Forequarter (Interscapulothoracic) Amputation

Indication. An unresectable malignant tumour of the shoulder girdle — most often a high-grade bone or soft-tissue sarcoma (osteosarcoma, chondrosarcoma, malignant peripheral nerve sheath tumour, synovial sarcoma, or a soft-tissue sarcoma of the axilla/proximal arm) — that cannot be removed with a clear margin while leaving a viable, innervated and useful limb. The decisive anatomical reason is involvement of the axillary neurovascular bundle: once a tumour encases the axillary artery and vein or the cords of the brachial plexus, limb salvage is impossible. Less common indications are massive local recurrence after limb-salvage, severe uncontrollable infection, and a catastrophically injured (mangled) limb beyond reconstruction. Assess resectability and stage the patient before committing. Before offering an amputation, the sarcoma MDT must establish:

• Local extent — MRI of the shoulder girdle and axilla to map the tumour against the axillary vessels, brachial plexus, chest wall and glenohumeral joint. The key question is whether the neurovascular bundle is encased.
• Distant disease — CT chest (and often whole-body staging) for pulmonary metastases, the commonest site of spread.
• Histology and grade — a representative biopsy (planned so the tract is excised with the specimen).
• The Enneking surgical stage — most curative forequarter amputations are performed for a high-grade (Stage II) tumour that has broken out of its compartment (Stage IIB). The one decision that matters — is limb salvage genuinely impossible? Limb-salvage (an extra-articular scapulothoracic / Tikhoff-Linberg resection with endoprosthetic reconstruction) is now the default for most high-grade shoulder-girdle sarcomas and gives comparable survival to amputation when margins are clear. Forequarter amputation is reserved for the situations below.

Consent honestly and specifically: loss of the limb and shoulder contour; the scar and a flail shoulder; phantom sensation and phantom-limb pain (which most patients experience); a small risk of flap necrosis needing further surgery or a skin graft; the cosmetic and limited functional role of a prosthesis; and the prognosis dictated by the underlying tumour. Setup. General anaesthesia, large-bore venous access, arterial line, cross-matched blood and a urinary catheter — this is major blood-loss surgery. The patient is placed in a semi-lateral position that allows the anterior (clavicle, deltopectoral, axilla) and posterior (vertebral border of the scapula, chest wall) incisions to be reached without re-prepping. The whole forequarter, hemithorax and upper abdomen are prepped. Antibiotic prophylaxis at induction.

The goal: remove the entire upper limb together with the scapula and the lateral clavicle in one block, with a clear oncological margin, by gaining early control of the subclavian vessels, dividing the brachial plexus, detaching the scapula from the chest wall, and closing the large defect with healthy fasciocutaneous flaps. The exposure below is the clavicle-first anterior (Berger) approach, completed with a posterior scapular-release — the technique taught because it delivers proximal vascular control before the specimen is disturbed.

Rehabilitation and recovery | Phase | Timing | Focus | Management | |-------|--------|-------|------------| | 1 | 0–2 weeks | Wound healing, pain control, drains | Bed to chair; chest physiotherapy; multimodal analgesia for phantom pain; drains out when output low | | 2 | 2–6 weeks | Wound maturation, posture, breathing | Gentle neck and trunk range; posture re-education; scar massage as it heals | | 3 | 6–12 weeks | Prosthesis and return to function | Lightweight cosmetic shoulder cap fitted; graded return to daily activities | | 4 | 3–6 months | Adaptation and independence | Occupational therapy, driving assessment, psychological support, return to work where possible | Operative mortality is low but not zero in this often-palliative population, and most patients are discharged within one to two weeks. Long-term survival is governed by the underlying tumour and the resection margins rather than by the amputation itself. A functional myoelectric prosthesis is rarely successful after forequarter amputation because the shoulder girdle and brachial plexus are gone, so prosthetic effort is directed at cosmesis and comfort. Complications

Epidemiology. Forequarter amputation is now uncommon. Improvements in limb-salvage surgery, neoadjuvant chemotherapy and endoprosthetic reconstruction mean that the great majority of high-grade shoulder-girdle sarcomas are treated without amputation, and the procedure is performed in only a small minority of sarcoma patients today — increasingly for palliation rather than cure. Pathoanatomy. The axillary artery continues from the subclavian artery at the outer border of the first rib and runs through the axilla, giving the thoracoacromial, lateral thoracic, subscapular and circumflex branches, before becoming the brachial artery at the lower border of teres major. It travels with the axillary vein within the axillary sheath, surrounded by the cords of the brachial plexus. Proximally the subclavian vessels arch over the first rib — which is why dividing the clavicle delivers safe access for proximal control. The scapula is tethered to the chest wall by trapezius above, latissimus dorsi below, levator scapulae and the rhomboids along its vertebral border, and serratus anterior on its costal surface; dividing these frees the girdle. The anatomical reason limb salvage fails is direct: a tumour of the proximal humerus, scapula or axilla that invades this neurovascular bundle cannot be resected with a clear margin while preserving a viable, innervated, useful limb.

Key evidence. The Malawer classification of shoulder-girdle resections frames the decision: progressively more radical resections (Types I to VI) move from limb-salvage resections toward forequarter amputation, so amputation sits at the extreme end of a ladder whose lower rungs preserve a functional limb. Modern outcomes series (Bickels, Wittig and colleagues) show that with careful patient selection — reserving amputation for true neurovascular encasement, non-reconstructable limbs and palliation — local control and survival are comparable to historical limb-salvage outcomes, and palliative forequarter amputation reliably relieves pain and improves quality of life in appropriately selected patients. Phantom-limb pain, reviewed comprehensively by Flor, remains the dominant long-term morbidity and the focus of peri-operative prevention.