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Forequarter amputation

Forequarter amputation, also known as interscapulothoracic amputation, is a radical ablative surgical procedure that involves the complete removal of the entire upper extremity along with the shoulder girdle, including the clavicle, scapula, and associated periscapular muscles.^[1] This operation severs the subclavian artery and vein, brachial plexus, and key muscular attachments to achieve en bloc resection, typically via an anterior or posterior approach with skin flap closure.^[1] Historically, the procedure was first performed in 1808 by surgeon Ralph Cuming for severe trauma, with its initial oncologic application in 1836 by Dixie Crosby for a sarcoma of the shoulder; refinements by surgeons like Berger in 1887 and Littlewood in 1922 established modern techniques.^[1] Today, forequarter amputation is reserved for curative or palliative treatment of high-grade malignant tumors, such as sarcomas or carcinomas, originating in the proximal humerus, scapula, or axilla that infiltrate neurovascular structures and preclude limb-sparing options.^[2] Indications include unresectable lesions, recurrences after prior therapy, or severe functional impairment and pain unresponsive to conservative measures.^[1] The surgery, which averages about 2 hours in duration, generally achieves wide resection margins in over 90% of cases and requires minimal blood transfusion, with primary wound closure feasible in most patients.^[2] Complications are relatively low, encompassing minor issues like delayed wound healing (affecting around 17% of cases) and rare major events such as pneumothorax, though phantom limb pain remains a common long-term challenge.^[2] In curative settings for high-grade tumors, 5-year survival rates can reach approximately 39%, while palliative applications extend survival by an average of 11 months in advanced disease.^[2] Advances in imaging and adjuvant therapies have reduced its frequency, favoring reconstruction where possible, but it remains a vital salvage option for select aggressive malignancies.^[1]

Overview

Definition and types

Forequarter amputation, also known as interscapulothoracic amputation, is a radical surgical procedure involving the complete removal of the upper extremity, including the arm, scapula, clavicle, and portions of the chest wall such as the pectoral muscles and, in some cases, adjacent ribs when tumor extension requires it.^[3]^[4]^[5] This procedure is typically reserved for advanced malignancies of the shoulder girdle or upper arm that cannot be managed with limb-sparing techniques, aiming to achieve local tumor control.^[2] The classic form of forequarter amputation follows the traditional interscapulothoracic approach, excising the entire shoulder girdle en bloc to ensure wide margins around the tumor.^[4] Modified variants have been developed to optimize outcomes, such as those preserving additional skin or muscle flaps (e.g., fasciocutaneous deltoid flaps) for improved wound closure and prosthetic fitting, or incorporating transmediastinal access for extended chest wall resections in complex cases.^[6]^[7] These modifications focus on reducing morbidity while maintaining oncologic efficacy.^[8] Forequarter amputation can be performed in curative intent for localized aggressive tumors or palliatively to alleviate severe pain and functional impairment in advanced, unresectable disease.^[2] It is distinct from less extensive procedures like shoulder disarticulation, which removes only the arm at the glenohumeral joint while preserving the scapula and clavicle, thereby retaining some shoulder girdle stability.^[9]^[10]

Epidemiology and incidence

Forequarter amputation remains a rare surgical intervention, primarily indicated for advanced malignancies such as sarcomas involving the proximal upper extremity. Among patients with soft tissue sarcomas of the shoulder girdle, it is required in fewer than 5% of cases, while for primary bony sarcomas in this region, the rate ranges from 5% to 10%.^[4] In broader sarcoma cohorts, proximal major limb amputations, including forequarter procedures, occur in approximately 2.3% of cases treated at specialized centers.^[11] Historically, in the late 20th century, the incidence of proximal upper limb amputations for malignant tumors was estimated at about 1.4 per million population annually, based on data from regional registries.^[12] Demographically, forequarter amputation predominantly affects adults, with average patient ages ranging from 46 to 56 years across studies, aligning with peak incidences of sarcomas in the 40-70 age group.^[12]^[11] There is a notable male predominance, with male-to-female ratios of approximately 2:1 to 3:1, reflecting higher sarcoma rates in males for upper extremity tumors.^[12] The procedure is more common in regions with elevated prevalence of soft tissue or bone sarcomas, such as parts of Europe and North America, where access to oncologic care influences case detection; it is also linked to advanced breast cancer in some settings, though sarcomas account for the majority of indications.^[11] Trends indicate a marked decline in forequarter amputations in developed countries, driven by advancements in neoadjuvant chemotherapy, targeted therapies, and limb-salvage techniques that preserve function while achieving oncologic control.^[4] For instance, in the United States, historical data from the 1980s suggested 100-200 annual cases of proximal upper limb amputations, but contemporary estimates reflect fewer than 50, with overall amputation rates for sarcomas dropping below 5% due to improved multimodal treatments.^[13] This shift has reduced the procedure's frequency from a mainstay of curative intent in the mid-20th century to a primarily palliative or salvage option today.^[11]

Indications and preparation

Medical indications

Forequarter amputation, also known as interscapulothoracic amputation, is primarily indicated for locally advanced malignant tumors of the upper extremity and shoulder girdle that preclude limb-sparing surgery due to involvement of critical neurovascular structures.^[1] Common examples include soft tissue sarcomas originating in the shoulder girdle, osteosarcomas of the proximal humerus that are unresectable, and axillary lymph node metastases from recurrent breast cancer with extensive local invasion.^[14]^[15]^[16] Rare indications encompass severe trauma resulting in irreparable vascular and nerve damage to the upper limb, where no reconstructive options exist.^[1] Additionally, the procedure may be warranted for intractable infections, such as chronic osteomyelitis of the clavicle, scapula, or proximal humerus refractory to prolonged antibiotic therapy and debridement.^[15] Selection criteria typically involve tumors that invade the scapula, clavicle, or axillary neurovascular bundle—often exceeding 5 cm in size—rendering conservative resection impossible.^[17] The procedure is considered after failure of neoadjuvant radiation or chemotherapy to achieve tumor control, provided the patient demonstrates adequate fitness to tolerate major surgery.^[1] Preoperative staging, including imaging and biopsy, confirms the absence of distant metastases and local extent to justify amputation over palliation.^[14]

Preoperative evaluation

Preoperative evaluation for forequarter amputation involves a comprehensive multidisciplinary assessment to ensure patient suitability and optimize outcomes for this radical procedure, typically indicated for advanced sarcomas or other malignancies of the upper extremity and shoulder girdle. A team comprising oncologists, orthopedic or surgical oncologists, anesthesiologists, radiation oncologists, pathologists, and psychologists collaborates to evaluate the patient's overall health, tumor characteristics, and psychosocial readiness. This holistic approach helps determine if the patient can tolerate the extensive surgery and addresses potential barriers to recovery, such as functional limitations post-amputation.^[18]^[19] Diagnostic confirmation begins with a biopsy to verify malignancy, often using needle-core techniques to obtain tissue from the tumor site while minimizing contamination of potential resection margins. Staging follows the TNM classification system specific to soft tissue sarcomas, which assesses tumor size (T), nodal involvement (N), and metastasis (M) to guide prognosis and treatment planning; this is complemented by evaluation of comorbidities through cardiac stress testing, pulmonary function tests, and assessment of overall performance status to identify risks like cardiovascular or respiratory decompensation under anesthesia. These steps ensure the procedure is pursued only when less invasive options, such as limb-sparing surgery, are infeasible due to tumor extent.^[1]^[20]^[21] Preparation emphasizes informed consent, where patients receive detailed discussions on quality-of-life impacts, including loss of upper limb function, phantom limb pain, and prosthetic use, to facilitate realistic expectations. Nutritional optimization is pursued via preoperative screening with tools like serum albumin levels and dietary consultation to correct malnutrition, which is prevalent in cancer patients and correlates with higher complication rates in major amputations. Psychological counseling is integral, addressing body image concerns, anxiety, and depression through supportive therapy, as a significant proportion of amputees experience psychological disturbances that can impair rehabilitation adherence.^[22]^[23]

Anatomy and planning

Relevant anatomy

Forequarter amputation involves the removal of the entire upper extremity along with the shoulder girdle, necessitating a thorough understanding of the regional anatomy to ensure complete resection while preserving vital structures. The procedure targets the bony framework of the shoulder, including the clavicle, which forms the anterior boundary of the shoulder girdle and connects the upper limb to the axial skeleton; the scapula, a flat triangular bone that articulates with the humerus and clavicle to form the glenohumeral joint; the humerus; and portions of the first three ribs, which may be partially resected if tumor extension involves the chest wall.^[24]^[4]^[25] The soft tissues surrounding this region include major muscle groups that provide mobility and stability to the shoulder. The pectoralis major and minor muscles lie anteriorly, originating from the clavicle, sternum, and ribs, and inserting onto the humerus, serving as key landmarks for anterior dissection. Posteriorly, the latissimus dorsi originates from the thoracolumbar fascia and lower thoracic vertebrae, inserting on the humerus to facilitate arm adduction and extension, while the trapezius covers the superior aspect, arising from the occipital bone, nuchal ligament, and spinous processes of C7-T12, and inserting on the clavicle and scapula for scapular elevation and retraction. Additional muscles such as the serratus anterior and rhomboids contribute to scapular protraction and retraction, respectively, and are divided during the procedure. The axillary vessels, comprising the axillary artery (continuation of the subclavian artery) and vein, course through the axilla, supplying and draining the upper limb, while the brachial plexus—a network of nerves from C5-T1 roots—innervates the arm and shoulder muscles. Skin flaps are typically sourced from the posterior back (extending to the vertebral spines) and anterior chest (to the mid-sternum) to facilitate closure over the defect.^[24]^[26]^[4] Vascular and neural landmarks are critical for safe resection, with the subclavian artery and vein serving as primary ligation points, located medial to the anterior scalene muscle and beneath the clavicle, where they transition into the axillary vessels to supply the upper limb. The brachial plexus is divided at the root level (C5-T1), proximal to its formation behind the scalene muscles, to ensure complete neurovascular isolation while minimizing disruption to the lower trunk if possible. These anatomical considerations directly influence the determination of surgical margins to achieve oncologic clearance without compromising adjacent thoracic structures.^[25]^[24]^[4]

Surgical planning

Surgical planning for forequarter amputation begins with comprehensive imaging to delineate tumor extent and facilitate precise resection. Magnetic resonance imaging (MRI) is essential for assessing soft tissue involvement, including margins in the neck, paraspinal muscles, and chest wall, providing detailed visualization of tumor boundaries relative to critical structures.^[4] Computed tomography (CT) complements MRI by evaluating bony involvement, such as scapular or clavicular extension, and helps identify areas of tumor necrosis or circumferential spread.^[4] Positron emission tomography-computed tomography (PET-CT) plays a key role in detecting distant metastases, aiding in staging and determining candidacy for the procedure by assessing metabolic activity in potential sites like the lungs or bones.^[27] Margin planning prioritizes achieving negative surgical margins to optimize oncologic outcomes, typically aiming for 1-2 cm of healthy tissue around the tumor in soft tissue sarcomas, though wider margins may be pursued in high-risk cases involving the shoulder girdle.^[28] This involves careful evaluation of tumor proximity to vital structures, with angiography and venography used to assess vascular and brachial plexus involvement, guiding decisions on ligation versus preservation where feasible to minimize functional deficits.^[4] Customization of the procedure incorporates advanced tools for complex anatomies, such as 3D modeling derived from CT scans to create patient-specific virtual reconstructions, enhancing multidisciplinary planning among thoracic, oncologic, and plastic surgeons.^[29] Emerging technologies, including virtual reality (VR)-based surgical planning simulators as of 2024, allow for immersive preoperative rehearsal of resections to improve precision and team coordination.^[30] Intraoperative navigation may be employed in select cases to refine resection paths, while flap design for wound closure is tailored to defect size, often utilizing pedicled latissimus dorsi flaps to provide robust coverage over the chest wall, particularly in irradiated fields.^[4]

Surgical procedure

Anesthesia and positioning

Forequarter amputation is a major surgical procedure that necessitates general anesthesia to maintain hemodynamic stability and facilitate controlled ventilation, particularly given the potential for significant blood loss and fluid shifts.^[31] Multimodal general anesthesia, often induced with agents such as propofol, fentanyl, lidocaine, and rocuronium, is combined with endotracheal intubation using a double-lumen tube for lung isolation when required.^[31] Adjunctive regional anesthesia techniques, including interscalene brachial plexus blocks with continuous infusion of bupivacaine (0.175%), are routinely utilized to enhance postoperative analgesia and reduce opioid requirements.^[2] Other regional approaches, such as high thoracic erector spinae plane blocks or paravertebral blocks, may be employed for similar pain control benefits in select cases.^[32]^[33] Patient positioning is critical to ensure surgical access while minimizing risks of nerve injury and pressure sores. The standard approach involves placing the patient in the lateral decubitus position with the affected side upward, secured to the operating table at the hips using tape or a vacuum pack to maintain stability.^[4] An axillary roll is positioned under the dependent axilla to prevent brachial plexus compression, and additional padding, such as a sponge-rubber pad under the hip, is applied to protect against ischemic skin damage.^[4] The operative extremity is prepared and draped freely to allow manipulation, with intravenous lines and a Foley catheter secured prior to incision.^[4] Intraoperative monitoring is essential due to the procedure's risk of hemorrhage, with estimated blood loss typically ranging from 500 ml to 1 liter, though up to 2 liters in complex cases.^[34]^[2]^[35] Invasive arterial lines, such as radial artery cannulation, provide continuous blood pressure assessment, while central venous access via large-bore catheters (e.g., femoral two-lumen lines) enables rapid fluid resuscitation and transfusion.^[31] Core temperature is closely monitored and maintained above 35°C to mitigate coagulopathy risks, with hemoglobin levels tracked throughout to guide blood product administration, often including packed red blood cells and colloids like albumin.^[31] Blood conservation strategies, such as tranexamic acid administration, may be employed to reduce transfusion requirements.^[31]

Operative steps

Forequarter amputation is performed through either an anterior or posterior approach, with the posterior Littlewood technique often preferred for its reduced blood loss and improved exposure of the scapula. In the posterior approach, the patient is positioned laterally, and a cervicothoracic incision is made starting at the medial clavicle, extending along the clavicle to the acromion, curving posteriorly along the lateral border of the scapula to its inferior angle, and then medially 3-4 cm lateral to the spine midline; a pectoroaxillary incision joins this from the center of the clavicle inferolaterally along the deltopectoral groove, crossing the anterior axillary fold to meet the posterior incision at the lower third of the scapula's lateral border.^[36] Subcutaneous tissue and fascia are divided, and flaps are mobilized to expose the underlying muscles, clavicle, and shoulder girdle.^[9] The anterior approach involves a modified elliptical incision with its superior apex over the clavicle, inferolateral continuation to the midaxillary line, and posteriosuperior extension over the scapula, allowing dissection at the fascial level over the pectoralis major to expose and divide the clavicle at its proximal third.^[1] The resection begins with division of the muscular attachments to free the shoulder girdle. The trapezius and latissimus dorsi are transected first, followed by the omohyoid, levator scapulae, and rhomboids; the serratus anterior is detached after retracting the scapula, while the pectoralis major and minor, along with the short head of the biceps and coracobrachialis, are sectioned later in the sequence.^[36] The subclavian vessels are then isolated, clamped, doubly ligated, and divided, with the transverse cervical and scapular vessels also ligated to control bleeding; the subclavian artery is ligated and cut before the vein to minimize complications.^[36]^[1] The brachial plexus cords are sharply divided near their origin using a scalpel, with branches ligated proximally under traction to prevent neuromas.^[36]^[9] Osteotomy of the clavicle is performed near its sternal attachment using bone-cutting forceps or a Gigli saw after subperiosteal exposure, typically at the lateral margin of the sternocleidomastoid insertion; the scapula is then fully freed and removed en bloc with the upper extremity and detached muscles.^[36]^[9] Closure involves approximation of the anterior and posterior fasciocutaneous or myocutaneous flaps to achieve primary wound coverage, with excess skin excised to eliminate dog-ears; remaining muscles such as the pectoralis major and latissimus dorsi are sutured together for chest wall padding and contour.^[1]^[9] Closed suction drains are placed to manage potential fluid accumulation, followed by verification of hemostasis and application of a firm compression dressing to stabilize the flaps.^[36]

Postoperative care

Immediate management

Following forequarter amputation, patients are typically transferred to the intensive care unit (ICU) for close monitoring to ensure hemodynamic stability, given the significant blood loss and potential for cardiovascular instability associated with the procedure.^[31] Ventilator support may be required in cases involving chest wall resection, as this can compromise respiratory function due to altered thoracic mechanics and pain-related splinting.^[37] Pain management in the immediate postoperative period employs a multimodal approach to address acute surgical pain, residual limb pain, and the risk of phantom limb phenomena. This includes systemic opioids such as hydromorphone or fentanyl for breakthrough pain, regional nerve blocks (e.g., erector spinae plane or interscalene blocks with ropivacaine infusions), and adjuncts like ketamine to reduce opioid requirements.^[38] Patient-controlled analgesia (PCA) pumps are often utilized to allow titrated opioid delivery while minimizing oversedation. Wound care focuses on promoting healing of the large surgical defect, typically involving primary closure or flap reconstruction, with dressings applied to reduce edema, prevent infection, and facilitate granulation tissue formation.^[39] Early mobilization begins on postoperative day 1 to mitigate complications such as joint contractures and muscle atrophy, incorporating passive range-of-motion exercises for the remaining shoulder and upper body.^[40] Deep vein thrombosis (DVT) prophylaxis is standard for high-risk patients, using low-molecular-weight heparin (e.g., enoxaparin) alongside mechanical compression to counteract immobility-related risks.^[41] Potential complications, such as wound infection, require vigilant surveillance during this phase.^[39]

Long-term monitoring

Long-term monitoring after forequarter amputation focuses on detecting local recurrence, metastatic disease, and assessing functional adaptation to ensure optimal patient outcomes. Patients typically undergo clinical examinations and imaging studies at regular intervals to surveil for oncologic recurrence, with schedules tailored to tumor grade, size, and histology. For high-grade soft tissue sarcomas, follow-up includes physical exams every 3-6 months for the first 2-3 years, every 6 months for the next 2 years, and annually thereafter (up to 10 years or longer), with imaging (MRI or CT) of the amputation site and chest as indicated by risk, per NCCN guidelines (Version 1.2025).^[42] Functional assessments are integral to long-term monitoring, evaluating upper body adaptation and quality of life after loss of the shoulder girdle and arm. The Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire is commonly used to track upper extremity function, capturing patient-reported outcomes on daily activities, pain, and social roles with scores ranging from 0 (no disability) to 100 (severe disability).^[43] Regular administration of the DASH, often at annual visits or as needed, helps quantify improvements or persistent limitations, guiding supportive care adjustments without overlapping into rehabilitation protocols.^[44] Coordination of adjuvant therapies forms a key component of ongoing surveillance, determined by final pathology reports from the amputation specimen. Radiation therapy may be administered postoperatively for close or positive margins to enhance local control, while chemotherapy is considered for high-risk features such as high-grade tumors greater than 5 cm, typically initiated within weeks to months after surgery.^[13] Multidisciplinary review ensures these therapies align with recurrence risk, with monitoring extended up to 10 years or longer for late metastases.

Complications and risks

Intraoperative complications

Intraoperative complications during forequarter amputation primarily arise from the procedure's involvement of critical neurovascular structures in the shoulder girdle, necessitating vigilant surgical and anesthetic management to ensure patient stability. Hemorrhage represents the most immediate and potentially life-threatening risk, stemming from injury or ligation of major vessels such as the subclavian and axillary arteries and veins, which can lead to significant blood loss estimated at up to 1200 mL in reported cases.^[1]^[31] To address this, surgeons prioritize early proximal control through ligation of the subclavian artery followed by the vein, minimizing bleeding from collateral circulation, while transfusion protocols involving packed red blood cells maintain hemodynamic stability.^[1]^[31] Electrocautery and meticulous hemostasis further reduce intraoperative blood loss, with large-bore venous access essential for rapid fluid resuscitation.^[4] Nerve-related complications, particularly involving the brachial plexus, are inherent to the resection but can be exacerbated by inadvertent damage to anatomical variants during dissection, potentially setting the stage for neuromas or precursors to phantom limb pain.^[45] The plexus is intentionally transected at the level of its trunks or divisions, with proximal ligation employed to prevent retrograde nerve growth and reduce chronic pain risks.^[46]^[4] Intraoperative techniques such as cryoanalgesia applied to the proximal stump or placement of indwelling nerve sheath catheters for continuous brachial plexus blockade help mitigate acute neuropathic pain and long-term sequelae.^[45]^[47] Venous air embolism, while rare, can occur from disruption of central veins during exposure of the shoulder girdle, especially if the operative site is positioned above heart level, allowing air entry into the venous system and potential paradoxical embolization. Prevention focuses on surgical strategies like flooding the field with saline to displace air, Trendelenburg positioning to lower the site relative to the heart, and vigilant monitoring via end-tidal CO2 capnography or precordial Doppler ultrasound for early detection. In the event of embolism, immediate aspiration through central venous access and supportive ventilation are critical, as historical procedures without these measures occasionally resulted in fatal outcomes.^[48] Anesthesia safeguards, including secure intravenous lines to avoid air infusion, complement these efforts in one coordinated approach.^[31]

Postoperative complications

Postoperative complications following forequarter amputation often stem from the extensive nature of the procedure, which involves removal of the upper extremity and shoulder girdle, potentially leading to wound healing challenges, systemic issues, and long-term functional impairments. Wound-related complications are among the most frequent, primarily including infections, seroma formation, and flap necrosis. In a series of 40 patients undergoing radical amputations (30 forequarter and 10 hindquarter) for extremity tumors, 35% experienced wound complications such as cellulitis, abscesses, or partial flap necrosis overall, with 20% requiring surgical debridement (predominantly in hindquarter cases).^[49] These issues arise due to the large soft tissue defect and potential contamination during resection of the axilla and chest wall, often necessitating prolonged antibiotic therapy or additional interventions. Seroma, a collection of serous fluid in the surgical site, can also develop, contributing to delayed healing, though specific incidence rates for forequarter amputation are not well-documented in human studies and are more commonly reported in veterinary contexts. In one forequarter-specific series of 30 patients, delayed wound healing occurred in 17%.^[2] Systemic complications may include pulmonary issues and persistent pain syndromes. Pneumonia, particularly in cases involving chest wall resection, occurs due to impaired respiratory mechanics and postoperative immobility, with reported incidences of 4% in major lower limb amputations; preventive measures such as incentive spirometry and early mobilization are essential.^[50] Pneumothorax is a rare but serious pulmonary complication, reported in approximately 3% of forequarter cases.^[2] Chronic pain, including phantom limb pain, affects 84% of forequarter patients, with 23% experiencing severe, refractory symptoms that impact quality of life and may require multimodal management with opioids, neuromodulators, or nerve blocks.^[49] Functional deficits often result from the loss of shoulder girdle stability, leading to potential postural imbalances. Shoulder girdle instability can predispose patients to compensatory mechanisms that increase the risk of scoliosis, observed in case reports of unilateral upper limb amputees where trunk asymmetry develops over time.^[51] Long-term monitoring for spinal deformities is recommended, especially in younger patients.

Rehabilitation and outcomes

Physical rehabilitation

Physical rehabilitation following forequarter amputation aims to restore functional independence, prevent secondary complications, and enhance quality of life through structured therapeutic interventions tailored to the significant loss of upper extremity and shoulder girdle structures.^[52] This process involves a multidisciplinary approach, primarily led by physical and occupational therapists, focusing on compensatory strategies using the contralateral arm, trunk, and lower extremities.^[53] Rehabilitation is divided into distinct phases, beginning in the acute postoperative period and progressing toward advanced functional training. The acute phase, starting immediately after surgery, emphasizes wound care, pain control, and positioning to prevent contractures and edema in the chest wall and remaining shoulder structures. Therapists initiate gentle range-of-motion exercises for the contralateral arm and trunk, along with scar management techniques such as massage and silicone sheeting to promote healing and reduce hypersensitivity.^[52] Positioning protocols include elevation and supportive splinting to maintain neutral alignment and avoid shoulder hiking or scapular protraction on the affected side.^[54] In the intermediate phase, typically commencing around week 2 post-operation once wound stability is achieved, the focus shifts to strengthening the contralateral arm and core musculature to compensate for the lost limb. Physical therapy incorporates progressive resistance exercises for the intact upper extremity, trunk stabilization, and balance training to improve posture and prevent compensatory deformities like scoliosis.^[52] Occupational therapy addresses adaptations for activities of daily living (ADLs), teaching one-handed techniques for tasks such as eating and hygiene, often with environmental modifications like reachers or lowered shelving.^[53] This phase lasts 4-12 weeks, with emphasis on desensitization of the surgical site through graded compression and mobility exercises.^[52] The advanced phase, beginning approximately 3 months postoperatively, involves adaptive training for complex tasks like dressing and self-care, building on prior gains to achieve independent mobility and community reintegration. Therapists guide patients in energy-conserving strategies, bimanual simulations using the trunk, and vocational assessments to resume work or leisure activities.^[54] Overall goals include independent mobility by 3-6 months, with ongoing monitoring to sustain gains and address late-onset issues like muscle imbalances.^[52] Brief integration of prosthetic training may occur if applicable, but non-device exercises remain central to building resilience.^[52]

Prosthetic considerations and prognosis

Prosthetic devices for forequarter amputation are typically designed similarly to those for shoulder disarticulation, utilizing self-suspended sockets that conform to the residual thoracic contour, including the scapula and clavicle remnants, to provide stability without excessive harness reliance.^[9] These sockets can incorporate myoelectric control systems, where electromyographic signals from preserved chest wall muscles, such as the pectoralis major, enable intuitive operation of elbow, wrist, and terminal devices, often enhanced by targeted muscle reinnervation for improved signal specificity.^[55] However, prosthetic uptake remains relatively low among proximal upper limb amputees, primarily due to the high energy demands, cumbersome design, and preferences for cosmetic appearance over functional gains.^[9] Custom passive prostheses, focusing on aesthetic restoration through lightweight, skin-toned components, are frequently chosen to address body image concerns and facilitate social reintegration.^[55] Prognosis following forequarter amputation for soft tissue sarcomas varies by disease stage, with 5-year overall survival rates around 40%.^[56] Quality-of-life assessments indicate high levels of psychosocial adaptation in most survivors, enabling return to daily activities and employment, though approximately 25% experience significant depression risk, particularly in the first two years post-amputation, linked to functional loss and phantom pain.^[23] Key prognostic factors include tumor grade, where high-grade lesions (G2/G3) correlate with poorer outcomes and necessitate intensified adjuvant radiation; achievement of negative surgical margins (R0 resection), which is essential for local control and distant metastasis prevention; and adjuvant therapies such as radiotherapy (50-66 Gy) or chemotherapy for specific subtypes, which improve survival when margins are inadequate or disease is extensive.^[57]

History and societal aspects

Historical development

Forequarter amputation, also known as interscapulothoracic amputation, originated as a radical surgical procedure in the early 19th century. The first recorded forequarter amputation was performed in 1808 by British surgeon Ralph Cuming to treat a severe gunshot wound to the upper extremity.^[58] This traumatic indication marked the initial application of the technique, which involved complete removal of the upper limb, scapula, and clavicle to address irreparable damage. The procedure's oncological use followed shortly thereafter, with American surgeon Dixi Crosby reporting the first case in 1836 for a malignant osteosarcoma of the shoulder girdle, establishing its role in tumor resection where limb salvage was impossible.^[59] The technique gained prominence in the late 19th century through refinements by French surgeon Paul Berger, who in 1887 published a detailed description of the anterior surgical approach, emphasizing meticulous vascular control to reduce operative mortality.^[1] Berger's method, often termed Berger's operation, standardized the procedure and expanded its application beyond trauma to advanced malignancies, including sarcomas of the proximal humerus and scapula. During the early 20th century, forequarter amputation was increasingly adopted for recurrent or locally advanced breast cancer, with the first documented case reported in 1900 by surgeon Buchanan, reflecting the era's emphasis on en bloc resection influenced by pioneers like William Halsted and his radical mastectomy principles extended to shoulder girdle involvement.^[60] By the mid-20th century, forequarter amputation became a standard for high-grade bone and soft tissue sarcomas unresponsive to other interventions, though its frequency began to wane after the 1970s with the introduction of neoadjuvant chemotherapy and radiotherapy protocols that enabled limb-sparing surgeries.^[61] Usage dropped from approximately 32% of proximal upper extremity sarcoma cases in the 1970s to around 5% in contemporary series, prioritizing preservation of function and cosmesis. In the 1980s, reconstructive advancements incorporated vascularized myocutaneous flaps, such as latissimus dorsi or serratus anterior pedicled flaps, to enhance wound coverage and reduce postoperative complications like necrosis.^[62] These innovations build on earlier refinements, focusing on minimizing morbidity while maintaining oncologic efficacy. Forequarter amputation, involving the complete removal of the arm and shoulder girdle, profoundly affects patients' psychological well-being, often leading to post-traumatic stress disorder (PTSD), particularly in cases stemming from trauma such as accidents or combat, where prevalence rates among amputees range from 15% to 26%.^[63] Body dysmorphic concerns and distorted body image are also common, exacerbated by the visible and functional loss of the upper limb, which can trigger anxiety, reduced self-esteem, and feelings of mutilation or punishment.^[64] These effects are more pronounced in upper limb amputations due to their impact on self-expression, daily self-care, and social interactions, with depression affecting 21% to 35% of amputees in the first two years post-surgery.^[23] Patients frequently cope through peer support groups, which facilitate emotional adjustment by providing shared experiences and reducing isolation, as evidenced by programs like those offered by the Amputee Coalition.^[64] Psychological interventions, such as cognitive behavioral therapy (CBT), have demonstrated efficacy in addressing these issues by modifying maladaptive thoughts related to body image, pain, and loss, thereby improving adaptation during rehabilitation.^[23] Short-term psychotherapy and mindfulness techniques further support long-term mental health outcomes.^[65] Socially, forequarter amputation presents significant challenges, including reduced employment prospects, with return-to-work rates often below 50% due to physical limitations and employer biases.^[66] Insurance barriers compound these difficulties, as many plans impose annual caps on prosthetic coverage (ranging from $1,000 to $5,000) or deny claims by deeming advanced upper limb devices experimental or non-medically necessary, leading to substantial out-of-pocket costs; as of 2025, insurers continue to limit coverage for prosthetics, often questioning their medical necessity despite proven benefits.^[67]^[68] Visible amputations also foster stigma and discrimination, manifesting in social avoidance or altered interpersonal dynamics that hinder community reintegration.^[69] Culturally, representations of forequarter and similar major amputations in media often highlight war veterans, portraying them as resilient figures through poignant photography series and personal narratives that emphasize confidence and recovery, such as those capturing amputee soldiers posing with prosthetics.^[70] Advocacy organizations like the Amputee Coalition, founded in 1986, have played a pivotal role in addressing these impacts by establishing nationwide support networks, peer visitation programs, and awareness initiatives, including National Limb Loss Awareness Month since 2010, to promote inclusion and reduce societal barriers.^[71]

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Feb 9, 2009 · The rate of proximal major amputations in patients treated for sarcoma was 2.3% (37 out of 1597). Nineteen of the 45 patients with malignant ...
[12]
[PDF] AMPUTATION FOR TUMOR OF THE UPPER ARM
In a 10-year period 35 patients underwent a proximal amputation of the upper limb because of a malignant tumor. In 27 patients a forequarter amputation was ...
[13]
Incidence and Characterization of Major Upper-Extremity ... - NIH
The present study demonstrated an incidence of 347 trauma-related major upper-extremity amputations per year within the NTDB, or 46 cases per 100,000 trauma ...
[14]
Amputation in patients with extremity soft tissue sarcoma - NIH
Jan 11, 2024 · There were 22 cases of amputation in 596 STS patients and the amputation rate was 3.6% (22/596). Further, 1.8% (9/490) of patients with primary ...
[15]
Forequarter amputation: a safe rescue procedure in a curative and ...
Aug 15, 2016 · Forequarter amputation (FQA) is a surgical treatment of tumors in the upper extremity and shoulder girdle that infiltrate the neurovascular bundles.
[16]
Forequarter Amputation and Resection of Ribs 1–4 for Chronic ... - NIH
Aug 28, 2024 · Forequarter amputation is a surgical resection of the upper extremity, clavicle, and scapula that is usually performed for the treatment of trauma or malignant ...
[17]
Forequarter amputation for recurrent breast cancer - PMC
Apr 15, 2015 · Forequarter amputation is an aggressive treatment for recurrent breast cancer. Some patients with regional metastatic disease do benefit from forequarter ...
[18]
Multidisciplinary Management of Soft Tissue Sarcoma - PMC - NIH
The purpose of this paper is to review the principles and issues surrounding the diagnosis and treatment of soft tissue sarcoma.Missing: TNM | Show results with:TNM
[19]
https://jnccn.org/view/journals/jnccn/16/5/article-p536.xml
[20]
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May 11, 2024 · These guidelines review current evidence concerning management of soft-tissue sarcoma and provide recommendations to support best practice.Missing: TNM | Show results with:TNM<|control11|><|separator|>
[21]
Pre-Operative Rehabilitation Evaluation of the Dysvascular Patient ...
Apr 19, 2017 · Due to the increased comorbidities in this patient population, pre-operative rehabilitation evaluation by a multidisciplinary team is crucial to ...Missing: forequarter biopsy<|separator|>
[22]
Pre-operative Psychological Prep for Amputation Patients
Jun 5, 2025 · Good psychological preparation for amputation requires the provision of clear information, staff need to include patients in conversations about ...
[23]
Psychiatric understanding and treatment of patients with amputations
In addition, amputation can cause problems of sexual function as well as changes in body image, and these factors can cause psychological difficulties, such as ...
[24]
Upper Limb Amputation - StatPearls - NCBI Bookshelf
Transcarpal amputations are a common type of amputation and occur due to a variety of reasons including trauma, peripheral vascular issues, and infection. It is ...
[25]
Forequarter Amputation - Oncohema Key
Jul 22, 2016 · Forequarter amputation entails en bloc removal of the upper extremity together with the scapula and the lateral aspect of the clavicle.
[26]
Forequarter Amputation - Plastic Surgery Key
Jun 13, 2016 · Forequarter amputation is performed almost exclusively for tumors of the shoulder girdle or surrounding soft tissues that invade the glenohumeral joint.
[27]
FDG PET/CT in Initial Staging of Adult Soft-Tissue Sarcoma - NIH
FDG-PET/CT imaging predicts histopathologic treatment responses after the initial cycle of neoadjuvant chemotherapy in high-grade soft-tissue sarcomas.
[28]
Surgical margins in the management of extremity soft tissue sarcoma
Aug 30, 2018 · For most soft tissue sarcomas, it is justifiable to plan to resect a tumor with a margin of 1 to 2 cm of muscle or fat; it may also be ...Major classifications of... · Soft tissue sarcomas of special... · Recommendations
[29]
https://www.annalsthoracicsurgery.org/article/S0003-4975(21)00706-2/fulltext
[30]
Perioperative considerations of an extended forequarter amputation ...
Forequarter (interscapulothoracic) amputation is a radical surgical procedure involving removal of the entire upper extremity and shoulder girdle.Missing: definition | Show results with:definition<|control11|><|separator|>
[31]
High thoracic erector spinae plane block for forequarter amputation
Erector spinae plane block (ESP) is a relatively novel technique for managing patients with acute and chronic pain and postsurgical pain.
[32]
Perioperative analgesia for forequarter amputation in a child - PubMed
Mar 1, 2010 · We describe the management of postoperative pain for a 10-year-old girl who underwent forequarter amputation for osteosarcoma of the left ...
[33]
Posterior Approach for Forequarter Amputation (Littlewood Technique)
Sep 18, 2016 · The patient is placed in the lateral position, and the neck, chest, and whole upper limb are prepared and draped. Blood loss is minimal.
[34]
[PDF] Perioperative considerations of an extended forequarter amputation ...
Aug 27, 2020 · The surgical time of the procedure was 10 hours and 21 minutes. Estimated blood loss was 1200 ml. Urine output was 2850 ml. A total of two units ...
[35]
Perioperative Analgesia for Forequarter Amputation in a Morbidly ...
Sep 10, 2023 · We present a case of successful dual-level ESPB catheters combined with single shot interscalene block in a morbidly obese patient presenting for an upper ...Missing: anesthesia | Show results with:anesthesia
[36]
Perioperative Pain Management Strategies for Amputation - PubMed
Mar 1, 2017 · To review acute pain management strategies in patients undergoing amputation with consideration of preoperative patient factors, pharmacologic/interventional ...
[37]
Upper Limb Amputations | PM&R KnowledgeNow - AAPM&R
Mar 13, 2025 · Epidemiology. The primary cause of UE amputations is trauma, with about 75% stemming from work-related accidents like crush injuries, electrical ...
[38]
Immediate Postsurgical Management of Upper- Extremity Amputation
OCCUPATIONAL THERAPY. Occupational therapy is begun on the first postoperative day and is continued on a daily basis throughout the patients' entire hospital ...
[39]
Death and venous thromboembolism after lower extremity amputation
Enoxaparin and UH were both efficient and safe for the prophylaxis of DVT in patients submitted to lower extremity amputation. ... Early mobilization ...
[40]
How Long Should We Follow Patients With Soft Tissue Sarcomas?
Guidelines suggest that followup for low-grade soft tissue sarcomas should be every 3 to 6 months for 2 to 3 years and then annually.
[41]
Follow-up in soft tissue sarcomas - PMC - NIH
It is mandatory to follow-up patients every 3 months and perform careful history and physical examination (especially scars after surgery of the primary site) ...
[42]
Soft Tissue Sarcoma Treatment (PDQ®) - National Cancer Institute
Feb 21, 2025 · Follow-Up Testing. PET and CT imaging may have higher sensitivity than contrast-enhanced CT imaging when recurrent sarcoma is suspected. Late ...
[43]
Assessing physical function in adult acquired major upper-limb ...
Aug 27, 2011 · Conclusions: Upper-limb loss clearly affects physical function. DASH score limitation profiles may be useful in individual clinical assessments.Missing: forequarter | Show results with:forequarter
[44]
Disabilities of the Arm, Shoulder, and Hand Questionnaire
Oct 17, 2021 · The DASH is a 30-item patient-reported outcome measure utilized to assess symptoms and function of the entire upper extremity.Missing: forequarter amputation
[45]
Early application of cryoanalgesia to the brachial plexus prevents ...
Jul 13, 2022 · Early application of cryoanalgesia to the brachial plexus prevents development of phantom limb pain after traumatic forequarter amputation: A ...Missing: damage | Show results with:damage
[46]
Targeted Muscle Reinnervation and the Volar Forearm Filet Flap for ...
After forequarter amputation, the resection typically extends through the clavicle, and the brachial plexus is truncated at the level of the trunks or divisions ...
[47]
Nerve Sheath Catheter Analgesia for Forequarter Amputation in ...
Forequarter amputation (FQA) has been used for curative resection of locally advanced, high-grade tumours involving the shoulder girdle region and for ...Missing: general | Show results with:general
[48]
[PDF] The Forequarter Amputation
ectomy seemed necessary in order to define the indications more accurately ... Prof of Surgery Dartmouth Medical College, Prof of Anatomy Bellevue Hospital.
[49]
The Role of Radical Amputations for Extremity Tumors - NIH
Aug 11, 2011 · Forequarter amputation for malignant tumours of the upper extremity ... Local anesthetic infusion through nerve sheath catheters for analgesia ...<|separator|>
[50]
Preoperative risk factors for postoperative pneumonia following ...
Orthopedic surgical procedures have reported a postoperative pneumonia incidence ranging from 0.45% in cervical decompression, 4% in knee amputations, to as ...
[51]
Some Experience with Prosthetic Problems of Upper Extremity ...
Paralysis of the right arm had developed in 1952, and forequarter amputation was performed in March 1953. ... Examination showed marked scoliosis (the left ...Missing: instability | Show results with:instability
[52]
[PDF] VA/DoD CLINICAL PRACTICE GUIDELINE FOR THE ...
VA/DoD Clinical Practice Guideline. (2022). The Management of Upper Limb Amputation Rehabilitation. Washington, DC: U.S. Government Printing Office.
[53]
[PDF] Chapter 3 REHABILITATION OF THE UPPER LIMB AMPUTEE
Forequarter amputations and shoulder disarticu- lations usually result from tumor resection. This disabling amputation diminishes biscapular abduc- tion by one ...
[54]
Rehabilitation management for a patient with a radical forequarter ...
A forequarter amputation is a resection of the chest wall, indicated for primary bone and soft tissue tumours, involving the shoulder girdle, axilla and chest ...
[55]
Upper Extremity Amputations and Prosthetics - PMC - PubMed Central
Upper extremity amputations are most frequently indicated by severe traumatic injuries. The location of the injury will determine the level of amputation.
[56]
Forequarter amputation for malignancy | Request PDF - ResearchGate
Aug 6, 2025 · Complications after forequarter amputation include ... Most postoperative complications are due to wound infection and flap necrosis.
[57]
Soft Tissue Sarcomas of the Arm – Oncosurgical and Reconstructive ...
Feb 22, 2016 · Complete tumor resection is the most important prognostic factor for local and distant disease control (8, 9). If local tumor control is not ...<|control11|><|separator|>
[58]
Case Report “Whoops” fixation of proximal humerus pathological ...
Forequarter amputation (interscapulothoracic amputation) entails the surgical removal of the entire upper extremity and shoulder girdle, including the scapula ...Missing: modalities | Show results with:modalities
[59]
Forequarter amputation for malignant tumours of the upper extremity
Forequarter (interscapulothoracic) amputation was first performed by Ralph Cuming in 1808. The first oncological forequarter amputation was reportedly ...
[60]
Curative use of forequarter amputation for recurrent breast cancer ...
Nov 18, 2014 · Here, we report a case of forequarter amputation for curative treatment of axillary recurrent breast cancer, together with a literature review.Missing: planning | Show results with:planning
[61]
Major Limb Amputations and Prosthetics - Musculoskeletal Key
Sep 5, 2018 · Although the amputation of a digit is by far more common, major upper extremity amputations account for up to 25% of all amputations.
[62]
Forequarter Amputation Combined With Chest Wall Resection
Forequarter amputation in combination with chest wall resection is a feasible and potentially curative treatment for malignant tumors of the shoulder girdle.
[63]
Combining Surgical Innovations in Amputation Surgery—Robotic ...
Dec 7, 2023 · The objective was to evaluate if a robotically harvested rectus abdominis (RA) transplant is a feasible procedure to improve soft-tissue ...
[64]
(PDF) Prevalence of Post Traumatic Stress Disorder after Amputation
Aug 7, 2025 · Available estimates of previous studies also suggest that between 15% and 26% of individuals with limb loss might experience PTSD. [22,23,28,29] ...Missing: forequarter | Show results with:forequarter
[65]
Emotional and Psychological Reactions to Amputation - Physiopedia
A number of body image-related problems may be frequently experienced following amputation such as anxiety and sexual impairment and/or dysfunction. Mutilation ...
[66]
Psychiatric understanding and treatment of patients with amputations
May 11, 2021 · To improve the patient's adaptation, psychological interventions such as short-term psychotherapy, cognitive behavioral therapy, mindfulness ...<|control11|><|separator|>
[67]
[PDF] A preliminary examination of the relationship between employment ...
Jul 7, 2009 · The study found that employment decreased from 75% to 43.5% after amputation. Few amputees used services for pain, and few services were ...
[68]
Health insurers are increasingly limiting coverage for prosthetic ...
Dec 19, 2024 · Many insurance plans impose caps on durable medical equipment (DME), including prosthetics, with annual limits ranging from $1,000 to $5,000.<|separator|>
[69]
[PDF] The importance of stigma theory for clinical decisions related to ...
Dec 6, 2022 · Social stigma surrounding amputations is real. It changes the quality of interactions not only between the patient and their physician but also ...
[70]
War veteran amputees captured in powerful shots by photographer ...
Nov 13, 2015 · A photographer who took a series of poignant shots of male and female war veterans who have lost limbs in service has seen his efforts turned into a hardcover ...
[71]
About Us - Amputee Coalition
Welcome to the Amputee Coalition (AC)! Since 1986, we have been the leading national organization supporting people who have limb loss and limb difference.