//

Forequarter amputation for chondrosarcoma

    Overview

    Learn the Forequarter amputation for chondrosarcoma surgical technique with step by step instructions on OrthOracle. Our e-learning platform contains high resolution images and a certified CME of the Forequarter amputation for chondrosarcoma surgical procedure.
    Forequarter amputation removes the upper limb, scapula and lateral shoulder girdle en-bloc to achieve eradication of malignant tumours when limb-salvage is not possible.
    Chondrosarcoma (CS) is the second most common primary bone tumour and the most common in adults. These range from low to high grade malignant cartilage tumours which may metastasise to the lungs. They are relatively insensitive to chemo- or radiotherapy meaning that surgery is the principal intervention. Five year survival ranges from 99% for low grade to 24% for dedifferentiated chondrosarcomas. Achieving adequate surgical margins to ensure the tumour is excised-bloc is the guiding oncological principle to avoid local recurrence; local recurrence is associated with metastasis and death. Therefore, in patients in whom limb-salvage is impossible due to tumour encroachment on nerves, blood vessels and joints, amputation may regrettably be the optimal oncological treatment for their chondrosarcoma.
    Patients should undergo detailed pre-operative staging and counselling prior to surgery, including pre-operative assessment at a limb-fitting centre to aid post-operative rehabilitation.



    Indications

    INDICATIONS:
    The indications for forequarter amputation include primary bone and soft-tissue sarcomas or metastatic bone tumours of the proximal humerus, shoulder girdle or axilla with neuro-vascular involvement where limb-salvage is not considered possible. The indication may be for curative disease control or to palliate severe pain or tumour fungation.
    SYMPTOMS & ASSESSMENT:
    Patients usually present with pain and swelling for weeks or months around the shoulder associated with limitation of motion and possibly radicular symptoms into the upper limb.
    INVESTIGATION:
    All patients should have detailed pre-operative investigations to identify the extent of disease. Locally plain radiographs and MRI to cover the entire tumour would be necessary. Systemically, staging the extent of disease with chest CT to exclude pulmonary metastases is mandatory and whole body imaging which may include whole body scintigraphy, MRI or PET-CT depending upon the primary tumour. The histological diagnosis must be confirmed with a pre-operative biopsy of the tumour. CT angiography may be useful to confirm vascular involvement which may indicate forequarter amputation or be useful to plan pre-operative embolisation of highly vascular tumours (e.g. renal cell or thyroid metastases). All investigations should be discussed in a specialist bone sarcoma MDT prior to forequarter amputation.
    OPERATIVE ALTERNATIVES:
    If limb-salvage is not possible then there are no surgical alternatives. If limb-salvage is possible but vascular structures are enveloped by the tumour then resection and vascular reconstruction may be possible in select circumstances.
    NON-OPERATIVE ALTERNATIVES:
    Radiotherapy may be considered for patients with radio-sensitive primary or metastatic tumours, but chondrosarcomas are radio-insensitive and are considered a surgical disease with no real non-operative alternatives to surgical excision.
    CONTRAINDICATIONS:
    Surgical contraindications include extensive tumours invading the chest wall when negative surgical margins may not be achievable or in metastatic cases where the extent of disease would not offer a survival advantage. Medical contraindications include patients who are not fit enough to withstand such a major physiological insult.

    Setup

    Patients are positioned in the lateral decubitus position using props to hold the patient on the table. We use a vacuum surgical bean bag positioner. The affected limb is left free to be moved during the surgery. Patients would have full intra-operative monitoring in place including arterial line, intra-venous antibiotic prophylaxis, air blanket warming and four units of packed red cells available.
    The skin is prepared using alcoholic chlorhexidine and draped using Ioban incisional drapes from the midline of the thorax anteriorly to the midline posteriorly. The incisions are marked prior to incisional draping, which form a teardrop shaped incision apexing at the mid-clavicle.

    Operation – 1

    Pre-operative radiograph left proximal humerus demonstrating soft-tissue mass with calcification indicative of high-grade chondrosarcoma.

    Pre-operative coronal T2 weighted MRI showing high signal extra-osseous extension of the chondrosarcoma medial and lateral to the proximal humeral metaphysis.

    Pre-operative axila T2 weighted MRI again showing the extra-osseous mass medially abutting the axilliary neuromuscular sheath. Consequently attempted reaction and limb-salvage would risk local recurrence which is associated with metastasis and death.

    Position the patient and mark the skin incisionThe incision is marked posteriorly and anteriorly forming an elliptical shape which has its apex at the mid-clavicle and runs along the deltopectoral groove, inferior to the axilla and over the mid-scapula as shown.

    The anterior incision is marked as described along the deltopectoral groove from the mid-clavicle.

    Prep and drape the surgical fieldAfter skin preparation and draping, Ioban incisional drapes are placed over the surgical field. The forearm is isolated with a bag but lies free so that the limb can be positioned optimally throughout the operation for access and exposure.

    Anterior skin incision first to achieve vascular controlThe anterior approach is utilised first to approach the subclavian neurovascular bundle first to achieve vascular control. By lighting the vessels initially this will help to minimise peri-operative blood loss.

    Identify the deltopectoral intervalThe deltopectoral interval is identified to find the (CV) cephalic vein which is used to trace to the axiliary vein that it leads to. Fibres of the (DM) deltoid are visible lateral to the cephalic vein.

    Subperiosteal dissection of the clavicleThe (C) clavicle is identified and dissected subperiosteally. The (T) trapezius is evident posteriorly.

    At the mid portion of the clavicle two small Hohmann’s retractors are placed subperiosteally prior to osteotomy.

    Clavicular osteotomyThe osteotomy is performed by passing a Gigli saw with a Roberts or Lahey angled clamp at the mid clavicle.

    The lateral portion of the osteotomised clavicle is shown elevated using a Langenback’s retractor to reveal the subclavius muscle.

    The (S) subclavian vein is dissected to expose any branches. The subclavian vein is a direct continuation of the axillary vein, which passes under the pectoralis minor muscle, and is renamed as the subclavian vein once it passes the lateral border of the first rib. At this point, the superficial vein known as the ‘cephalic vein’ has joined the axillary vein.
    The vein now ascends to the medial border of anterior scalene muscle. From here it joins with the internal jugular vein to form the brachiocephalic vein.

    Control of the subclavian vein is achieved by passing sutures under the vein.

    Ligate the subclavian veinThe vein is ligated proximally and distally before division.

    The artery is controlled by passing a suture under the subclavian artery.
    The subclavian artery arises on the left side of the body directly from the aortic arch and from the brachiocephalic trunk on the right. Both course above the cervical pleura and between the anterior and medial scalene muscles. It enters the axilla between the first rib and the clavicle and becomes the axillary artery.

    Ligate the subclavian arteryThe (S) subclavian artery is ligated proximally and distally prior to division.

    Once the artery is tied off proximally and distally divide the vessel with a blade as shown.

    Next develop the rest of the anterior approach towards the axilla and latissimus dorsi, the (D) deltoid and (P) pectoralis minor are highlighted for orientation.

    Complete the axillary skin incision With the (A) arm flexed forward, extend the skin incision under the (Ax) axilla towards the inferior angle of the scapula.

    The incision is deepened through the fascia and onto the (LD) latissimus dorsi.

    Deepen the posterior incision to the scapulaExtend the incision cranially over the scapula

    Release the scapula off the thoracic cageElevate the inferior angle of the (S) scapula off the thorax by releasing the teres minor and major off the lateral scapula border and any residual fibres of latissimus dorsi present.

    Next release the muscles off the medial border of the (S) scapula including rhomboids, serratus anterior and levator scapulae to reach the scapula spine and trapezius.

    Continue the incision over the shoulder girdle to join the anterior incision and incise the trapezius muscle beneath the skin. In the photograph the clavicular osteotomy is stabilised by the assistant’s hand to prevent damage to the great vessels when the shoulder is protracted.

    Operation – 2

    Deepen the incision through the (T) trapezius to access the chest wall deep to the scapula.

    Identify the brachial plexusElevate the lateral portion of the (C) clavicle to facilitate exposure of the brachial plexus.

    Ligate the brachial plexusLigate and incise the cords of the (BP) brachial plexus. The lateral, medial and posterior cord titles describe their anatomical location relation to the axillary artery.

    Elevate the upper limb from the chest wall to dissect the remaining soft-tissues.

    Release the rotator cuff muscles from the scapular spineAbduct the arm and incise the remainder of the supraspinatus and infraspinatus muscles from the scapular spine. Both are innervated by the suprascapular nerve (C5-6).

    The resected specimen prior to histological analysis.

    Opposing view of the resected specimen.

    Careful haemostasis is achieved prior to closure.

    Surgical drains are inserted cranially and caudally. Haematomas and serums are common post-operative sequelae.

    The wound is closed in layers with clips to skin. The vacuum drains are evident caudally. Vacuum drains assist in minimising the risk of haematoma and seroma.

    Post-operative chest radiograph showing the absent upper limb, scapula and lateral shoulder girdle and highlighting the level of mid-clavicular osteotomy.

    Post Operative

    HDU level care and observation
    IV antibiotics for 24 hours
    VTE prophylaxis to include low molecular weight heparin for 2 weeks and mechanical foot pumps whilst in bed and above the knee stockings for 6 weeks
    Interscalene nerve catheter for 3 days
    Titrate dose of pregabalin or gabapentin to minimise phantom limb pain
    Remove drains when output is <80ml/24 hours
    Routine blood tests
    Await histological analysis

    Recommended Reading

    Overall ten year survival for axial and appendicular chondrosarcoma is approximately 70%. The incidence of local recurrence is 26% and metastasis 32% (https://pdfs.semanticscholar.org/b0b7/d284cd20ce1bdc6b705eb2f571c465c65e68.pdf)
    Independent risk factors predictive of survival include extracompartmental spread, development of local recurrence and high histological grade. Independent risk factors for local recurrence include inadequate surgical margins and tumour size greater than 10 cm. Surgical excision with an oncologically wide margin provides the best prospect both for cure and local control in these patients.
    Recent and as yet unpublished local research has shown that a minimum surgical margin of 4mm is required to minimise the risk of local recurrence and optimise survival chances, which in this case was considered unlikely with attempted limb-salvage given the pre-operative MRI scan highlighting the proximity of the axilliary sheath.
    Overall ten year survival for axial and appendicular chondrosarcoma is approximately 70%. The incidence of local recurrence is 26% and metastasis 32% (https://pdfs.semanticscholar.org/b0b7/d284cd20ce1bdc6b705eb2f571c465c65e68.pdf)
    Independent risk factors predictive of survival include extracompartmental spread, development of local recurrence and high histological grade. Independent risk factors for local recurrence include inadequate surgical margins and tumour size greater than 10 cm. Surgical excision with an oncologically wide margin provides the best prospect both for cure and local control in these patients.
    Recent and as yet unpublished local research has shown that a minimum surgical margin of 4mm is required to minimise the risk of local recurrence and optimise survival chances, which in this case was considered unlikely with attempted limb-salvage given the pre-operative MRI scan highlighting the proximity of the axilliary sheath.

    Reference

    • orthoracle.com

    Tags:

    You might be interested in

    Dark mode powered by Night Eye