Improved shoulder contour following forequarter amputation with an osteomyocutaneous free flap from the amputated extremity: two cases

Defect Coverage after Forequarter Amputation—A Systematic Review Assessing Different Surgical Approaches

Autologous fillet flaps are a common reconstructive option for large defects after forequarter amputation (FQA) due to advanced local malignancy or trauma. The inclusion of osseous structures into these has several advantages. This article therefore systematically reviews reconstructive options after FQA, using osteomusculocutaneous fillet flaps, with emphasis on personalized surgical technique and outcome. Additionally, we report on a case with an alternative surgical technique, which included targeted muscle reinnervation (TMR) of the flap. Our literature search was conducted in the PubMed and Cochrane databases. Studies that were identified were thoroughly scrutinized with regard to relevance, resulting in the inclusion of four studies (10 cases). FQA was predominantly a consequence of local malignancy. For vascular supply, the brachial artery was predominantly anastomosed to the subclavian artery and the brachial or cephalic vein to the subclavian or external jugular vein. Furthermore, we report on a case of a large osteosarcoma of the humerus. Extended FQA required the use of the forearm for defect coverage and shoulder contour reconstruction. Moreover, we performed TMR. Follow-up showed a satisfactory result and no phantom limb pain. In case of the need for free flap reconstruction after FQA, this review demonstrates the safety and advantage of osteomusculocutaneous fillet flaps. If the inclusion of the elbow joint into the flap is not possible, we recommend the use of the forearm, as described. Additionally, we advocate for the additional implementation of TMR, as it can be performed quickly and is likely to reduce phantom limb and neuroma pain.

Forequarter Amputation and Reconstructive Options

OBJECTIVE

This study aimed to present the results of a series of forequarter amputations (FQAs) and to evaluate the reconstructive methods used.

SUMMARY BACKGROUND DATA

Although FQA has become a rare procedure in the era of limb-sparing treatment of extremity malignancies, it is a useful option when resection of a shoulder girdle or proximal upper extremity tumor cannot be performed so as to retain a functional limb.

METHODS

Thirty-four patients were treated with FQA in 1989 to 2017. Various reconstructive techniques were used, including free fillet flaps from the amputated extremity.

RESULTS

All patients presented with intractable symptoms such as severe pain, motor or sensory deficit, or limb edema. Seventeen patients were treated with palliative intent. Chest wall resection was performed in 9 patients. Free flap reconstruction was necessary for 15 patients, with 11 free flaps harvested from the amputated extremity. There was no operative mortality, and no free flaps were lost. In curatively treated patients, estimated 5-year disease-specific survival was 60%. Median survival in the palliatively treated group was 13 months (1-35 months).

CONCLUSIONS

Limb-sparing treatment is preferable for most shoulder girdle and proximal upper extremity tumors. Sometimes, FQA is the only option enabling curative treatment. In palliative indications, considerable disease-free intervals and relief from disabling symptoms can be achieved. The extensive tissue defects caused by extended FQA can be safely and reliably reconstructed by means of free flaps, preferably harvested from the amputated extremity.

Forequarter Amputation and Immediate Reconstruction with a Free Extended Humeral-Radial Forearm Flap

A forequarter amputation is a radical ablative surgical procedure that includes the entire upper extremity with its shoulder girdle. We present a 53-year-old woman with a solid slow growing tumor in her right shoulder of 15 x 20 cm in diameter. Resection and immediate reconstruction with a free radial forearm flap extended from the distal third of the arm to the midpalmar region, taking the humeral artery and the cephalic vein as a main peddicle. The final outcome is shown at six weeks after the surgery.

Curative use of forequarter amputation for recurrent breast cancer over an axillary area: a case report and literature review

Axillary recurrence of breast cancer that involves the brachial neurovascular bundle is uncommon. However, for many patients with such recurrence, forequarter amputation can play a palliative role in relieving excruciating pain and paralysis of the upper limb. Further, for those patients who do not have distant metastasis or other local-regional recurrence, forequarter amputation provides a chance for a cure. Only a few case reports of curative amputations for recurrent breast cancer are present in the literature. Here, we report a case of forequarter amputation for curative treatment of axillary recurrent breast cancer, together with a literature review. To date, we have followed the patient for three years after amputation, during which there has been no evidence of recurrence or metastasis. Although radical resection is feasible, it can be accompanied by surgical wound complications and psychosocial stress. Therefore, an organized multidisciplinary approach is needed to ensure the success of radical resection.

Forequarter amputation combined with chest wall resection: a single-center experience

BACKGROUND

Forequarter amputation combined with chest wall resection is a rarely performed procedure. Six patients were treated for advanced malignancies with this operation in our institution since 1993. Uncontrollable pain, lymphedema, loss of function of the affected limb and, in some patients, localized ulceration of the tumor at the time of presentation, provided the indication for the operation. All patients underwent radical amputation of the upper limb and the structures of the shoulder girdle, in combination with resection of the thoracic chest wall in an extent of 2 to 7 ribs.

METHODS

Chest wall reconstruction was achieved by implantation of a polytetrafluoroethylene patch (n=5) or a combination of a metal implant (Stratos System R, MedXpert GmbH, Heitersheim, Germany) and a polytetrafluoroethylene patch (n=1). Myocutaneous coverage of the defects was achieved by use of pedicled flaps from adjacent tissue (n=3) or by free myocutaneous flaps harvested from the amputated forearm (n=3).

RESULTS

No perioperative mortality occurred; however, significant morbidity was seen after the use of the free forearm flaps based on occurring vascular problems. All 3 patients had to undergo surgical revision of the flap. Survival ranged from 5 to 50 months (median=23.5 months) with 3 patients still alive at the time of this investigation.

CONCLUSIONS

Forequarter amputation in combination with chest wall resection is a feasible and potentially curative treatment for malignant tumors of the shoulder girdle with invasion of the chest wall. The operation results in immediate palliation and long-term survival can be obtained in selected cases.