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Section 2: Upper Limb
maintained, and these determine the
surgical technique. First, the ultra-short
transhumeral amputation is based on
an intact “chevron” region, which is the
skin and muscle of the deltoid region.
The ability to bias a chevron-shaped
flap of skin, subcutaneous tissue, and
full-thickness deltoid muscle to bone
makes the ultra-short transhumeral
amputation an attractive option. The
true shoulder disarticulation can be
performed with a lateral chevron region flap, a posterior flap, or an axillary-based flap of durable undersurface
tissue. When possible, the axillary flap
is preferred because there is no muscle
to atrophy over the osseous structures
and durable padding is provided for
an articulating or a cosmetic prosthesis. The forequarter amputation can be
based on a posterior periscapular flap or
an anterior pectoralis flap. If neoplasm
is an indication for amputation, the absolute necessity to achieve wide margin
means that these classic flaps may not be
available, so regional rotational or free
flaps become essential. The latissimus
dorsi rotational flap, either ipsilateral
or contralateral, is preferred for defect
coverage. Free tissue from the amputated limb is sometimes necessary for
coverage if tumor irradiation has been
performed.
10,11
Alternatives to Amputation
As noted earlier, shoulder-level amputation should be a last resort because 90%
of tumor resections and infections can
be treated with limb salvage procedures.
These limb-salvage techniques involve
resecting the proximal humerus, the glenoid with or without the main body of
the scapula, and the entire or only part of
the clavicle. This procedure, which was
first described in 1928, is commonly
referred to as the Tikhoff-Linberg re
section and is the basis for maintaining
function and movement in the distal
upper limbs while allowing resection
of tumor or infection in the shoulder
region. The procedure was modified
-
in 1977 by Ralph Marcove to include
preservation of the uninvolved scapula despite extensive proximal humeral
and glenoid resection.
12-14
lawar
introduced the most useful
12-15
In 1991, Ma-
classification system for shoulder-level
deficits and reconstruction. When considering structural loss and replacement
or the need to amputate, the author of
this chapter finds Malawar’s system to
be most user-friendly.
12-14
The system
was later modified according to a classification from the Musculoskeletal Tumor
Society (MSTS) (Figure 2).
The requirements for limb salvage
are a free tumor plane adjacent to the
axillary neurovascular bundle, the
chest wall, or the lymph nodes
16,17
or
indications in palliative cases where
amputation is not justified because of
extensive chest wall involvement.8 After the surgical team understands the
defect, it is important to be aware of the
goal of achieving a periarticular shoulder reconstruction that can provide a
mobile but stable axis for elbow and
wrist rotation, which allows placement
of the hand in space. Reconstruction
can involve the use of allograft, endoprosthesis, autograft fibular, and even
pasteurized autograft or combinations
of these to provide fusion or an articulating shoulder. Most surgeons facile
with shoulder resection prefer a stable
fusion for a young laborer and a mobile
endoprosthetic or allograft prosthetic
composite for an older individual.
Forequarter or
Interscapulothoracic
Amputation
Indications
The indications for forequarter amputations are soft-tissue sarcoma arising in
the axilla beneath the pectoral muscle
or the scapula with adherence to the
chest wall, osteosarcoma and highgrade chondrosarcoma with extension
into the axilla and invading the brachial
plexus and the great vessels, and primary tumors arising in the chest wall
Figure 2
etal Tumor Society classication of skeletal
resections about the shoulder girdle. At least
one-half of the region must be resected to be
so designated. S1 = the blade or spine of the
scapula, S2 = the ac romion-glenoi d cavity complex (the gleno id cavity must be removed ), S3 =
the proximal ep iphysis of the humerus, S4 = the
proximal metaphysis of the humerus, and S5 =
the proximal part of the diaphysis of the humerus. (Reproduced with permission from the
Mayo Foundation for Education and Research,
Rochester, MN.)
Illustration of the Musculoskel-
and involving structures of the thoracic
inlet or the axilla.
6,8 ,16-18
Case reports of
mycosis fungoides illustrate that proximal amputation can be necessary in
life-threatening infections of the upper
extremity. Palliation in malignant carcinoma, where plexopathy is intolerable,
also can be an indication.
Technique
The forequarter amputation is the preferred ablative procedure for extensive
tumor or infection in which invasion
of the brachial plexus, the chest wall,
or the axilla makes shoulder disarticulation impossible (Figure 3). This ampu
tation uses anterior- or posterior-based
local flaps. If forequarter amputation is
indicated, the flap often is determined
by pathology, and the surgical procedure is an adaptation of both anteriorand posterior-based flaps; however, a
bias for one or the other often exists.
Most forequarter amputations can be
-
Atlas of Amputations and Limb Deciencies, Fourth Edition © 2016 American Academy of Orthopaedic Surgeons
272
Chapter 22: Amputations About the Shoulder: Surgical Considerations
Figure 3
major muscle. D, Section of the vessels and nerves after transecting the subclavius. E, Section of the medial scapular muscles. F, Closure. (Reproduced with permission from Tooms RE: Amputations of the upper extremity, in Crenshaw AH, ed: Campbell’s Operative Orthopaedics, ed 8. St. Louis,
MO, Mosby-Year Book, 1992, pp 771-721.)
Illustrations of anterior vascular exposure with a posterior-based ap. A, Skin incision. B, Clavicle resection. C, Lifting the pectoralis
© 2016 American Academy of Orthopaedic Surgeons Atlas of Amputations and Limb Deciencies, Fourth Edition
273
Section 2: Upper Limb
Figure 4
posteriorly (B), and dissection can proceed either medially over the middle clavicle or posteriorly over the scapular ap based on the preference of
the surgeon. C and D, When the tumor is not encasing the vessels, the posterior ap is created, and posteromedial dissection is done rst because this
is often the most tedious part of the procedure. E, After the posteromedial angle has been elevated away from vertebral remnant muscles along the
medial scapula, most of the scapular blood supply and the suprascapular neurovascular bundle can be visualized by pulling dorsally on the scapula.
F, The clavicular osteotomy is performed. With most of the procedure completed and the limb still vascularized, “spare parts” can be harvested if
required. G, The subclavian artery is controlled and ligated, with the plexus in view. H, Silk ties are placed before cleanup to help identify structures
that will require nerve catheter inlay. I, Closure before application of the wound vacuum, with nerve catheters emanating from the skin.
performed by fashioning a posterior
skin flap, although an anterior flap is
an alternative.
dure revolves around whether ligation
of the subclavian artery and the brachial
plexus is managed from the anterior by
osteotomy of the clavicle or from the
posterior after dividing the muscles from
the medial and superior scapula, which
facilitates identification of the neurovascular structures through traction and
allows ligation from within. The author
Atlas of Amputations and Limb Deciencies, Fourth Edition © 2016 American Academy of Orthopaedic Surgeons
274
Intraoperative photographs of anterior vascular exposure with a posterior-based ap. The incisions are outlined anteriorly (A) and
10,18
The surgical proce-
of this chapter prefers a modification of
the two approaches, whereby a posterior
full-thickness skin flap is fashioned, but
the subclavian vessels and the plexus
are managed anteriorly. Before the procedure begins, it should be determined
if there is need for free tissue rather than
skin graft over viable muscle. This is
necessary because the vascularity for
a distal filet flap must be preserved
when proximal dissection is performed,
making subclavian ligation the last step
performed before the limb is delivered
to the back table.
The patient is positioned in the “sloppy” lateral decubitus position with a
beanbag pliable enough to allow bias
anteriorly and posteriorly (by manually
tilting the patient over the bag) as the
amputation proceeds. If multiple assistants are not available, a limb positioning
system often is helpful in keeping the
limb elevated and under tension to facilitate dissection (Figure 4).
Chapter 22: Amputations About the Shoulder: Surgical Considerations
Incision
Skin flaps are marked along the bony
prominence of the clavicle and the
scapular spine to allow elevation of the
posterior flap from the glenohumeral
articulation to the medial border of the
scapula. The large teardrop exposure
outline begins with an anterior limb that
centers on the middle third of the clavicle. The posterior incision traverses the
lateral acromion full thickness to fascia
overlying the latissimus, the trapezius,
and the infraspinatus. The two incisions
meet deep in the axilla based on the patient’s pathophysiology.
Deep Dissection
The sternocleidomastoid and deltoid
muscles are elevated off the middle
third of the clavicle, and the middle
third is osteotomized with a saw. The
sub clavius muscle is identified and
transected to reveal the subclavian
artery and the brachial plexus. The
subclavian artery is isolated but not
ligated if distal harvesting of “spare
parts” will be necessary; otherwise,
the author of this chapter controls and
quickly ligates the artery and vein and
proceeds to nerve identification and
transection. Nerve transection is done
sharply, but the perineural ends are
tagged with polydioxanone suture in
the event targeted muscle reinnervation (TMR) is an option and to facilitate
the placement of intraoperative neural
catheters. After the brachial plexus has
been ligated, attention is turned to the
posterior limb. From the full-thickness
skin flap that was created, the medial
border of the scapula is identified; an
Israel retractor can pull the large posterior flap toward the midline, and a bone
hook can be used to put tension on the
scapula. The trapezius, rhomboid, and
levator muscles are divided to reveal
the subscapularis muscle covering the
scapula. Next, the medial angle muscles
are released from the medial scapula
in the following order: the latissimus
and trapezius superficially, followed by
the deep rhomboid and levator scapulae
muscles. This is best accomplished with
a Bovie electrocautery to manage the
periscapular plexus. Care is taken to
identify and ligate the branches of the
transverse cervical and scapular arteries
coursing around the scapula. The serratus muscles are then divided by pulling
the scapula posterolaterally with a bone
hook to reveal the subscapularis and
place the forelimb on stretch. After this
is complete, there is usually only the
need to ligate the suprascapular fossa
and the anterior trapezius, which are ligated several centimeters away from the
tumor. The axillary incisions are then
connected, and the limb is delivered
to the back table. The pectoral fascia
is sewn to the trapezial and the rhomboid fascia after large suction drains (18
French round or pediatric chest tubes)
are placed inferoaxillary and cervicoscapularly, in line with the incisions,
with one under the pectorals and one in
line with the vertebral dissection. Incisional negative-pressure wound dressings are used, and a large, well-padded
circumferential elastic compressive
wrap is applied.
Posterior Vascular Isolation
With an Anterior Flap
Posterior vascular isolation with an
anterior flap is also known as the
Littlewood technique.9 The patient is
positioned in a sloppy lateral decubitus position on a beanbag. The clavicle and the scapula are marked, and
the clavicle becomes the basis for the
skin incisions. First, a full-thickness
skin and subcutaneous incision begins
along the medial border of the scapula
and runs the length of this bone along
the superior margin, over the top of the
accordion, and finally proceeds distally
along the posterolateral acromion. The
distal limb is in line with the surgical
neck of the scapula and continues distally along the axillary border of the
scapula to the distal angle, where the
incision is curved medial to a point
approximately 5 cm from the midline
of the back. Next, the posterior incision is directed anteriorly to meet the
anterior incision in the axilla. The anterior incision is then started along the
medial border of the clavicle and runs
laterally to the deltopectoral groove,
where it runs just lateral but in line
with this relationship. The skin incision is then curved inferiorly along the
pectoral border in the axilla to meet
the posterior axillary incision. The surgeon must carefully create a large fullthickness skin and subcutaneous flap
to the fascia, which has been elevated
medially off the scapular muscles to
1 cm medial of the medial border of
the scapula, and a clavipectoral flap.
This flap can include the pectorals if
the tumor is biased much posteriorly.
Release of the medial angle muscles
proceeds in the manner described for a
forequarter amputation, with the same
technique used to divide the serratus
muscles. Blunt dissection is next carried to the omohyoid and subclavius
muscles, which are divided under direct visualization. Soft tissue is bluntly
freed from the undersurface of the clavicle, and the forelimb is placed under
tension by an anterolaterally directed
moment to put the plexus and subclavian vessels on stretch. The vessels are
double ligated, and the plexus trunks
are divided sharply after tagging each
separately for TMR or intraoperative
intraneural catheters. The pectoral
muscles are then divided, and the limb
is removed to the back table. The pectoral fascia is sewn to trapezial and rhomboid fascia after large suction drains
are placed inferoaxillary and cervicoscapularly in line with the incisions,
one under the pectorals and one in line
with the vertebral dissection (Figures
5 and 6). Patients with large, posterior
high-grade sarcoma require an anterior flap. Incisional negative- pressure
wound dressings are used, and a large,
well-padded circumferential elastic
compressive wrap is applied.
© 2016 American Academy of Orthopaedic Surgeons Atlas of Amputations and Limb Deciencies, Fourth Edition
275
Section 2: Upper Limb
Figure 5
terior ap. The skin incision is brought more medial on the dorsal limb and more lateral anteriorly.
The dissection proceeds posterior to anterior under the scapula while placing the arm in adduction and internal rotation to bring the scapula into “chicken wing” prominence. (Reproduced with
permission from Tooms RE: Amputations of the upper extremity, in Crenshaw AH, ed: Campbell’s
Operative Orthopaedics, ed 8. St. Louis, MO, Mosby-Year Book, 1992, pp 711-721.)
Exploration of the Anterior
Cervical Triangle
Either vascular management or a skin
flap swung superiorly can be used to
facilitate exploration of the cervical triangle; however, it is preferable to plan
a teardrop incision with a posterior
flap and anterior vascular management
Illustration of the posterior vascular access forequarter amputation based on an an-
when cervical triangle management
is required. The sternocleidomastoid
muscle is divided as it inserts along the
clavicle and the junction between the
internal jugular vein and the subclavian
vein. The trunks of the brachial plexus are exposed and divided. Cervical
lymph nodes are dissected, ligated, and
sent to pathology to verify clear margins
and to aid in deciding if brachytherapy
or external beam adjuvant therapy is
needed. The internal jugular vein and
the common carotid artery are inspected
for humeral invasion and reconstruction
as necessary.
19
En Bloc Chest Wall Excision
The thoracic entry interspace is chosen
distal enough to allow cephalic mobilization and removal of tumor from structures to be preserved. Posterior ribs are
divested of periosteum longitudinally,
and the neuromuscular bundles are
ligated beneath. Ribs are divided with
a saw, rib cutters, or a Gigli saw, and
the chest wall is opened wide with rib
spreaders. The lung parenchyma is then
inspected for pulmonary metastases. If
the lung is the solitary site of metastases
and the metastases are localized, they
can be resected with wide local excision
to preserve viable lung tissue. The surgeon should then reach as cephalad as
possible around the lung with the other
hand in the cervical triangle to assess for
thoracic inlet metastases or to control
midline bleeding in patients with traumatic injury.
8
If a portion of the chest wall is to be
removed with the forelimb, a median
sternotomy is required, and the posterior chest wall dissection is thereby connected to the anterior chest wall block.
Internal mammary vessels are ligated at
the lowest interspace, and the sternum
is split with a saw to the corresponding level. The medial clavicle is divested of remaining soft tissues superiorly
because the medial clavicle will need
to be removed after the sternotomy to
facilitate identification of the first rib.
Finally, the first rib is skeletonized with
the electrocautery as it attaches to the
manubrium. The strap, sternohyoid, and
sternothyroid muscles are divided to expose the innominate vein. The trunk of
the subclavian artery and vein that were
ligated during the forelimb ablation are
traced medial to their junction with the
Atlas of Amputations and Limb Deciencies, Fourth Edition © 2016 American Academy of Orthopaedic Surgeons
276
Chapter 22: Amputations About the Shoulder: Surgical Considerations
Figure 6
seen. B, T1-weight MRI of the tumor. Note the very large feeder vessels as the dark ow voids and the tumor comprising most of the deltoid. C, Photograph shows the shoulder area after closure. The patient was treated with a forequarter amputation with an anterior ap.
vertebral artery and then double ligated again; this is best accomplished by
dissecting the artery and the vein from
within the thorax. At this point, this
chapter’s author prefers to leave the
cords of the brachial plexus long to the
trunk level for TMR, even if the chest
wall is to be resected. The medial and
posterior scalene muscles are then divided to complete the chest wall resection.
If the tumor is on the left side, care must
be taken to preserve the left vagus and
phrenic nerves and ligate the thoracic
duct. Chest tubes are placed. The chest
wall is reconstructed with a polymethyl
methacrylate polypropylene mesh plate.
Adjuncts for Coverage
Usually, substantial defects can be
managed with local or regional flaps;
however, large posterior exophytic tumors, radiation fibrosis, and chest wall
or rib invasion preclude local coverage.
Free-tissue transfer is the only option
in these instances. This can be accomplished in a separate procedure by
elaborating the contralateral latissimus
dorsi muscle and skin grafting after a
rest interval with negative-pressure vacuum wound therapy. A modified, free
forearm filet flap with healthy, well-vascularized, nonirradiated tissue for coverage is another option. Cordeiro et al10
described use of the volar musculature
with fasciocutaneous extensions based
on the brachial artery and a single vein.
In their series, the flap size averaged
25 × 30 cm, and the pedicle ranged from
A, Photograph of a large, high-grade pleomorphic sarcoma of the right shoulder. Necrosis of the skin and subcutaneous tissue can be
10 to 15 cm, easily tying into the subclavian, innominate, or carotid arteries.
Most of the amputation is performed
with the subclavian vessels isolated but
intact and the distal limb still perfused.
Fasciocutaneous flaps are raised in the
subfascial plane on the dorsum of the
forearm. After the extensor carpi ulnaris
is reached medially and the first dorsal
compartment is reached laterally, dissection is carried to bone subperiosteally
and beneath all of the flexor muscles.
Distally, the median and ulnar nerves
along with the radial and ulnar arteries are ligated at the wrist. Proximally,
everything is divided at the elbow, and
the interosseous vessel is identified and
ligated as it leaves the radial artery. The
brachial pedicle is dissected proximal
to the flap in the utilitarian medial arm
exposure, at a length dictated by the amputation. This technique is an extremely
effective approach for patients with very
poor soft-tissue envelopes.
10,11,2 0
of anterior, middle, and posterior deltoid signals is possible, providing three
sites for myoelectric control. When
available, the chevron flap with deltoid
muscle and regional skin is projected
for coverage. The typical skin incisions
follow the deltopectoral interval to the
deltoid insertion. The incision is then
curved bluntly over the lateral arm to
the posterior deltoid border. The incision is then carried proximally to the
deltoid-latissimus junction.
After a full-thickness incision has
been made to fascia in all planes, the
initial dissection proceeds in the standard deltopectoral interval, which is
familiar to most surgeons. The anterior
deltoid conjoined tendon with the pectorals is then identified and transected,
and a Bovie electrocautery is used to
elaborate the broad deltoid insertion off
the humerus from anterior to posterior.
The latissimus dorsi is divided off the
humerus, and both the latissimus dorsi
and the pectoralis major are tagged for
Modified and True
Shoulder Disarticulation
Because of improved body symmetry
and prosthetic fitting, the ultra-short
transhumeral amputation is preferred
over a true shoulder disarticulation or
a forequarter amputation (Figure 7). A
short residual limb can provide the prosthetist with the necessary surface area
for fitting a device that uses voluntary
motion to actuate an externally powered
gripper, and it is extremely powerful
when paired with TMR. Differentiation
later reattachment.
Attention is then turned to the brachial vessels, which are quickly located
by reaching into the proximal anterior
incision and using a cautery to cut the
conjoined tendon of the coracobrachialis. The author of this chapter then identifies the length of the vascular pedicle
necessary to perfuse deltoid skin or provide an easy docking site for a filet flap
in the event of catastrophic trauma or
exophytic tumor invasion of the deltoid
region. The nerves of the brachial plexus
© 2016 American Academy of Orthopaedic Surgeons Atlas of Amputations and Limb Deciencies, Fourth Edition
277
Section 2: Upper Limb
Figure 7
chevron ap. The deltoid is elevated, the rotator cu is left intact, and the humerus is transected at
the surgical ne ck. The latissimus dor si and pectoralis musc les are suture imbricated i nto the residual
humerus for balanced adduction and abduction.
are identified and cut sharply with a
No. 10 blade and allowed to retract under tension after being tagged with
polydioxanone suture if TMR becomes
an option. The humerus is osteotomized
with a saw at the level of the surgical
neck. Much like the adductor myodesis
of the transhumeral amputation, careful
attention must be paid to reattaching
the pectoral and deltoid muscles. The
rotator cuff attachments on the humerus
are maintained with the procedure, and
the residual humerus will abduct and
externally rotate. Careful balancing can
be achieved by transferring and tensioning the latissimus dorsi and pectoralis
muscles as well as splitting the trapezius
if necessary. If the soft tissues have been
stripped by traumatic injury or sacrificed because of tumor, arthrodesis with
AO 7.3-mm cannulated screws into the
glenoid is still preferable for contouring
compared with excision of the proximal
fragment.
If it becomes necessary to perform
a true shoulder disarticulation, most
Illustration of a modied shoulder disarticulation skin incision with a traditional
of the surgical procedures proceed as
previously described. After the deltoid
myocutaneous flap has been dissected
off the lateral two-thirds of the humerus, the pectoral muscle is resected and
tagged for reattachment into the glenoid.
The coracobrachialis tendon is isolated
with a right-angled forceps and transected to provide access to the axillary
brachial artery takeoff and the brachial
plexus. The axillary artery is double ligated, and the individual components
of the brachial plexus are transected
sharply after tagging with polydioxanone suture for later identification if
TMR is an option. The shoulder capsule
is placed on stretch, and the anterior
joint space is entered, allowing direct
inside-to-outside division of the superior, inferior, and posterior capsule to deliver the limb. The pectoralis major and
latissimus dorsi are then sutured to the
rotator cuff and the capsule remnants
to fill the glenoid. No ablation of the
glenoid cartilaginous surface is necessary, but a taut sling with remaining soft
tissues is paramount to avoid a painful
bursa that can develop if the envelope
is mobile and floppy. Suture anchors
to secure the dead space are helpful in
avoiding this complication. The deltoid
fascia is secured to the axillary fascia
over an anterior and posterior drain in
line with the skin incisions, and an incisional negative-pressure vacuum wound
dressing is applied. A compressive
shoulder dressing is fashioned either
with a circumferential elastic wrap or a
commercially available fabric hook-andloop fastener shoulder wrap dressing.
If the deltoid is not available for coverage, another secondary flap of the
axillary skin and subcutaneous tissues
is equally durable. This flap requires
management of eccrine sweat glands
and laser hair ablation. However, in
most individuals, this added manipulation is a minor inconvenience compared
with the durability of the axillary flap.
If the axillary flap is used, two modifications to the ultra-short transhumeral
amputation and the true shoulder disarticulation can be applied. First, the
skin incision starts in the deltopectoral
groove just under the clavicle, as in the
chevron flap, and then is carried over the
medial arm just over the cephalic vein.
It traverses posteriorly toward the triceps at the level of the deltoid insertion
and then courses superiorly along the
posterior border of the deltoid and over
the acromioclavicular joint to meet the
deltopectoral limb. The whole deltoid is
dropped inferolaterally by dissecting it
along with lateral skin and likely tumor.
The axillary/brachial artery is controlled
as previously described, and the humerus is lifted laterally from the wound by
dividing the supraspinatus and superior capsule sequentially anteriorly and
posteriorly in the true shoulder disarticulation. If amenable, the humerus is
osteotomized at the surgical neck. If the
ultra-short transhumeral amputation is
possible, which is usually unlikely if
sacrifice of the deltoid is required, then
the axillary soft tissues are sewn into the
Atlas of Amputations and Limb Deciencies, Fourth Edition © 2016 American Academy of Orthopaedic Surgeons
278
Chapter 22: Amputations About the Shoulder: Surgical Considerations
proximal incision. In the true shoulder
disarticulation, where the deltoid is not
available, the pectoralis and latissimus
dorsi are brought into the gleaned fossa, and the accordion is osteotomized,
as is the coracoid process if needed to
contour the bony prominences. A compressive dressing is applied over an incisional negative-pressure vacuum wound
dressing and suction drains.
Postoperative Management
When possible, nerve catheters are
placed in the perineurium under direct
visualization to facilitate postoperative
regional anesthesia. Large-caliber suction drains are used to evacuate the dead
space and emanate from the skin in line
with incisions in the event a tumor mar
gin is positive and requires reexcision.
Gabapentin is given the morning of surgery preoperatively and continued postoperatively, titrating to a dose of 30 mg
three times per day. Amitriptyline (25
mg) is started the night of surgery and
titrated to 50 mg at bedtime. Patients
are monitored in the intensive care unit
(overnight at a minimum) because the
neuromodulators often can be sedating
and care must be taken to avoid oversedation. An incisional negative-pressure
wound dressing is applied in the surgical
suite and removed on postoperative day
5. Compressive elastic wraps are applied
in a circumferential fashion to prevent
hematoma or seroma. Desensitization
therapy is started on postoperative day
2, and mirror therapy is added as soon
as the patient is discharged to a regular
monitoring protocol.
-
Complications
Current developments in transfusion
practices, the use of local and intravenous hemostatic agents, and improvements in surgical critical care have
considerably reduced the morbidity
and mortality of shoulder disarticulations and forequarter amputations.2
However, the life span of many of these
patients is often short because of the
disease processes that necessitated the
proximal upper limb amputation. Major
complications are common, and every
effort should be made to prevent them.
Complications can be divided into the
following groups: early postoperative,
near-term oncologic, and long-term
body asymmetry and prosthetic.
Early complications include cardiopulmonary and wound issues. Infection
at the wound site should be managed
aggressively, and every effort should be
made to prevent hematoma or seroma
formation. The incisional negativepressure wound dressing is removed
after 5 days, but the deep suction drains
should be maintained until the effluent
is less than 30 mL per shift (usually 8
hours) for a 24-hour period. Skin edge
and flap necrosis is always a possibility in preoperatively irradiated wounds,
and perioperative hyperbaric oxygen
therapy should be considered for any
wound (preexisting, postoperative, or
fibrosis resulting from radiation) at risk
of infection.
Phantom limb sensations and
nerve-related pain must be managed
aggressively by an occupational therapy team experienced in caring for
patients with upper limb amputations.
An aggressive regional anesthesia team
aids in this process. If wound complications are eminent, every effort should
be made for early provision of regional
or free-oxygenated tissue in the form of
contralateral latissimus dorsi or rectus
abdominis free flaps to expedite wound
healing and enable the patient to resume chemotherapy. A chronic draining
wound requires aggressive treatment,
and alternative coverage is vital to prevent severe complications.
Near-term oncologic complications
include local recurrence and metastases
or repeat infection in a patient with a
prior life-threatening infection. These
complications can be mitigated intraoperatively with wide local excision of lesions. At times, when a completely clear
margin is impossible to obtain or local
recurrence is a substantial risk, careful
consideration should be given to adjuvant treatment with brachytherapy or
postoperative external beam radiation.
Late complications include “high
shoulder” in a patient with a proximal
upper limb amputation, postural scoliosis, and issues with prosthesis wear (Fig-
ure 8). The normal upright posture of
a patient with a forequarter amputation
is inhibited by a lack of scapulothoracic
tension, muscle imbalance, and the lack
of arm weight. The patient lists to the
uninvolved side because the unopposed
tension of the muscles that normally elevate the forelimb acts against the weight
of the arm.21 For this reason, postural
physical therapy is started immediately in conjunction with desensitization
and mirror therapies to combat body
asymmetry issues. Postural scoliosis
is problematic, especially in skeletally
immature patients. Postural asymmetry
can often lead to scoliosis and occipital
headaches caused by prosthesis wear,
contralateral trapezial tension, and ipsilateral unopposed shoulder elevators.21
Every effort should be made to facilitate an early and aggressive multidisciplinary physical therapy approach.
Limb Salvage Alternatives
to Shoulder-Level
Disarticulation
Many limb-salvage techniques avoid
shoulder disarticulation;
ever, it may be difficult to match the
pathology to the indicated technique.
Approximately 90% of tumors about the
shoulder and the periscapular region
can be treated with limb salvage.1 In patients with infection or tumor, the risk
of local recurrence should be weighed
against the benefits of limb salvage. In
cases of trauma, the functionality of the
reconstructed limb and the patient’s
quality of life must be weighed against
the psychological benefit of definitive
amputation surgery.
Indications for limb salvage include a
viable soft-tissue envelope distal to the
7,9,17, 22-2 4
how-
© 2016 American Academy of Orthopaedic Surgeons Atlas of Amputations and Limb Deciencies, Fourth Edition
279
Section 2: Upper Limb
shoulder with normal nerve function
below the elbow or the ability to perform
tendon transfers to augment specified
functions. With modern techniques,
these so-called internal amputations
are extremely viable procedures and
result in improved quality of life compared with amputation. In a study by
Figure 8
procedure. Slight postural scoliosis and a high shoulder can be seen. B, Photograph of a bodycapture forequarter prosthesis. Despite the modern design, many patients elect not to use such a
prosthesis because of its bulk.
A, Clinical photograph of a patient with a forequarter amputation 3 years after the
Wada et al,24 the internal amputation
or “shoulder resection” group achieved
a mean MSTS functional score between
68% and 72%. The limiting factor in any
reconstruction after shoulder-level resection is the amount of abductor present, which is dependent on contracting
the trapezius and sliding the remaining
scapula over the chest wall. Distal grip
is usually maintained, but limb girdle
strength is substantially compromised.
Several limb salvage techniques are
available for the treatment of patients
with catastrophic soft-tissue and osseous loss if the distal motor nerves are
preserved (Figures 9 and 10).
Tikhoff-Linberg Resection
The en bloc upper humeral interscapulothoracic resection, also known as
the Tikhoff-Linberg procedure, is the
basis for limb salvage in patients with
catastrophic loss of the shoulder (Fig-
ure 11). The Malawar classification system aids in understanding the defects
and planning reconstruction. Generally,
reconstruction after resection takes the
form of arthrodesis; endoprosthetic replacement; osteoarticular allograft; and
autogenous grafts, such as the autograft
fibula or clavicle pro humeri.
25,26
The
prerequisites for the procedure are that
the tumor does not extend into the axillary neuromuscular bundle, the chest
wall, or the lymphatic system.
16
Patients are positioned in the sloppy
lateral decubitus position, but some
physicians prefer to slightly jackknife
the bed with a reverse Trendelenburg position to facilitate an almost
sideways beach-chair posture. This
Figure 9
A, Preoperative AP radiograph of the left arm. The gunshot wound was débrided and irrigated several times during the patient’s evacuation from the
combat area. Antibiotic beads were placed in an eort to prevent infection and achieve limb salvage. B, Intraoperative photograph of the arm. Note
the excellent mus cle bed and attachm ent to major humeral fragm ents. The forceps is poi nting to the identied and pro tected radial ner ve. C, Perioperative oblique ra diograph of the upper limb a fter reconstruction with a tumor endoprosthesis, el bow fusion, and a free inner vated latissimus dorsi ap.
Atlas of Amputations and Limb Deciencies, Fourth Edition © 2016 American Academy of Orthopaedic Surgeons
280
Images from a soldier who was injured by a high-velocity gunshot, resulting in massive proximal humerus, deltoid, and elbow loss.
Chapter 22: Amputations About the Shoulder: Surgical Considerations
Figure 10
of resect ion. A, Typ e I, intra-articular p roximal humeral resec tion (shown, type I-A : abductors retaine d; not shown, type I- B: abductor resec ted) B, Type
II, partial scapulectomy (shown, type II-A: abductors retained; not shown, type II-B: abductors resected). C, Type III, intra-articular total scapulectomy
(shown, type III-A: abductors retained; not shown, type III-B: abductors resected). D, Type IV, extra-articular scapular and humeral head resection
(shown, type IV-B: abductors resected; not shown, type IV-A: abductors retained). E, Type V, extra-articular humeral and glenoid resection (shown,
type V-B: abductors resected; not shown, type V-A: abductors retained). F, Type VI, extra-articular humeral and total scapula resection (shown, type
VI-B: abductors resected; not shown, type VI-A: abductors retained).
position readily facilitates the Mercedes incision that is often required to
better visualize tumors of the shoulder
while facilitating preservation of the
axillary/brachial medial arm contents
and periscapular dissection. The initial limb of the incision starts longitudinally over the suprascapular fossa
and branches just proximal to the acromioclavicular joint to the anterior and
posterior limbs. The anterior limb approximates the deltopectoral approach
to the shoulder, with the exception that
Illustrations of the Malawar classication for intercalary shoulder resections. The abductors can be retained or resected in each type
the coracoid process is osteotomized
early or the conjoined tendon is cut
to deliver the axillary neuromuscular
bundle. The anterior incision is carried
distally as far as necessary to facilitate
a humeral transection at least 2 cm
away from the tumor. After the dissection has projected the medial arm
structures, it is usually possible for the
surgeon to reach laterally and anteriorly over the humerus to the interval
between the biceps and the brachialis
to identify and protect the radial nerve.
Attention is then turned to the posterior limb of the incision, which curves
posterolaterally over the surgical neck
of the scapula. Through this incision, it
is possible to mobilize a massive posterior soft-tissue envelope for a complete
scapulectomy alone or in combination
with extracapsular humeral resection
(Malawar type III or VI). After the brachial artery and the plexus have been
protected and the periscapular muscles
have been sectioned, the deltoid and trapezius are cauterized in a manner that
© 2016 American Academy of Orthopaedic Surgeons Atlas of Amputations and Limb Deciencies, Fourth Edition
281
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