Forequarter amputation entails surgical removal of entire upper extremity, scapula and clavicle. Several techniques of forequarter amputation have been described. The anterior approach has been the preferred technique of exploration of axillary vessels and brachial plexus. The posterior approach has been condemned to be unreliable and dangerous for most large tumor of the scapula and suprascapular area. We describe a surgical technique using posterior approach of exploration of major vessels for forequarter amputation of upper extremity in eight patients who presented with humeral-scapular tumor. There were six patients with osteosarcoma: three with tumor recurrent and three chemotherapy recalcitrant tumors with vessels involvement. One patient had massive fungating squamous cell carcinoma and another had recurrent rhabdomyosarcoma. Four patients had fungating ulcer and six patients had multiple pulmonary metastases at the time of surgery. The mean estimated blood transfusion was 900 ml (range 0-1600 ml) and two patients did not require transfusion. The duration of surgery ranged 2.5-6.0 hours (mean 3.8 hours). Two patients with known pulmonary metastases required post-operative intensive care monitoring. The mean duration of survival was 5.8 months. The posterior approach of exploring major vessels for forequarter amputation of upper extremity with musculoskeletal tumor is safe and reliable.
The brachial plexus at the infraclavicular level runs deeper compared to its course proximally, giving rise to impaired needle visualisation due to the steep angle of needle insertion with the current ultrasound-guided approach. A new posterior parasagittal in-plane ultrasound-guided infraclavicular approach was introduced to improve needle visibility. However no further follow up study was done.
A prospective randomized double-blind study was conducted which involved, 60 ASA 1-2, aged 18-65 years patients, who had elective or emergency orthopaedic surgeries of the upper limbs. They were randomly divided into two groups: Group I received 30 mls of 0.5% ropivacaine; and Group II received 0.5% levobupivacaine for infraclavicular brachial plexus block based on the coracoid approach. The onset time required for sensory block of all required dermatomes (C5-T1) and the onset time of motor block were documented. Based on the Visual Analogue Score, pain scores were recorded every 30 minutes during surgery and at the 6th hour. The mean onset time (SD) for sensory block with ropivacaine was 13.5 +/- 2.9 minutes compared to levobupivacaine at 11.1 +/- 2.6 minutes (p = 0.003). The onset time for motor block was 19.0 +/- 2.7 minutes in Group I compared to 17.1 +/- 2.6 minutes (p = 0.013) in Group II. Patients in both groups experienced both mild to moderate pain at the 6th hour. In conclusion, there were statistically significant differences in the onset-time for sensory and motor block. However, there was no statistically significant difference in terms of effectiveness of analgesia at the 6th hour. Although the clinical advantage of levobupivacine is not substantial, its safety profile becomes a major consideration in the choice of local anaesthetic for brachial plexus block where a large volume is required for an effective result.