18 Above-elbow and Below-elbow Amputations - …

1 18 Above-elbow and below -elbowAmputationsPaul Sugarbaker, Jacob Bickels and Martin MalawerOVERVIEWA bove-elbow Amputations are indicated for advanced soft-tissue and bone sarcomas of the forearm; below -elbowamputations are performed for such tumors of the forearm and the hand. The location of the tumor mass on themedial aspect of the distal arm and elbow joint, in close proximity to the main neurovascular bundle, may in largepart determine feasibility of a limb-sparing procedure. Above- and Below-elbow Amputations are performed toachieve wide surgical margins while preserving as much length as possible of the extremity.

2 The level ofamputation will vary with the location of the tumor in the forearm, at the elbow joint, and even at the lowerportion of the the procedure, muscle flaps are tapered and closed tautly in two layers over the cut ends of the bonesin order to facilitate mobility. A rigid dressing is applied immediately postoperatively to decrease pain and edemaand facilitate maturation of the Chapter 18 22/02/2001 08:33 Page 299 INTRODUCTIONA bove- and Below-elbow Amputations are rare pro-cedures because: (1) the distal arm, forearm, and armare relatively rare locations for soft-tissue and bonetumors.

3 (2) unlike tumors of the buttocks and lowerextremities, because of the fact that these locations areexposed, the tumors are noticed in relatively earlystages and in most cases are resectable; and (3)administration of preoperative chemotherapy, andespecially via the intra-arterial route or using isolatedlimb perfusion, significantly decreases tumor size andfacilitates a limb-sparing procedure. The feasibility oflimb-sparing was further augmented by the develop-ment of endoprosthetic devices that allow replacementof the distal humerus, proximal ulna, proximal radius,and even the distal radius, and which offer satisfactoryfunction.

4 Nonetheless, above- and Below-elbow amputationsretain a definitive role in the management of soft-tissueand bone tumors of the upper extremity (Figure ).These are required for tumors that cannot be removedwith a wide margin. However, rarely should a grade Isoft-tissue sarcoma that is not expected to metastasizebe initially treated by amputation. In this case, becauseof the efficacy of adjuvant radiation therapy, even amarginal margin is acceptable. Indications for above-and Below-elbow Amputations include: recurrencewas once considered a primaryindication for amputation.

5 The mere presence of arecurrent sarcoma is no longer an immediate indi-cation for an amputation. The capability to resect therecurrent tumor without compromising the functionof the extremity is the determining factor on whichthe decision to amputate is vascular involvement. The neurovascularbundle within the arm is tightly integrated in aclosed anatomic space. The cephalic vein usuallyprovides sufficient collateral flow if the brachial orthe axillary vein has to be sacrificed. However,although occasionally the tumor mass can bedelicately dissected off the brachial artery, in mostcases of vascular involvement the brachial artery isextensively encased and amputation is compact nature of the vascular supply to thewrist makes involvement of the radial and ulnararteries likely when a large tumor invades the volaraspect of the distal forearm.

6 In this instance theincidence of morbidity and failure associated withresection and reconstruction using a vascular graft ofone of these vessels is prohibitively high. nerve involvement. In general, one nerve aroundthe arm can be sacrificed and a two-nerve deficit istolerated. Sacrifice of the three major nerves leavesthe patient with a functionless extremity that isbetter off amputated. Nerve grafting for replacementof a section of the median, radial, or ulnar nerves isstill not associated with satisfactory soft-tissue contaminationas a result of apathologic fracture, or an inappropriate biopsy orresection attempt.

7 This is a frequent indication forbelow-elbow amputation; the anatomy of the handand lack of true biologic compartments allow bothlateral and longitudinal extension of the the tumor or along the biopsy tractmay negate a resection attempt, prohibit the use of aprosthetic device, and delay the administration ofadjuvant chemotherapy. Limb-sparing surgery isfeasible only if the infection is completely controlledprior to surgery, or if the infected tissues can becompletely removed at surgery. Musculoskeletal Cancer Surgery300 Figure Amputations are indicated foradvanced soft-tissue and bone sarcomas of the forearm.

8 Skinincisions and osteotomy sites for metaphyseal (high),diaphyseal, and supracondylar Above-elbow Chapter 18 22/02/2001 08:33 Page 300 Cancer patients who are candidates for an amputationface a unique psychological problem because not onlydo they face a threat to their lives, but they will also losetheir upper extremity. Besides an obvious aestheticdeficit, loss of the upper extremity, and especially thedominant one, has a profound functional , the rehabilitation of these patients begins atthe time of staging studies.

9 The entire health-care teammust develop a trusting and honest relationship withthe patient and include him or her at the early stages ofall decision making. Building upon this interaction, thepatient will be better able to accept the amputation andset realistic goals for return to a productive life. Thepatient's family, significant peers, and each member ofthe care team are crucial to this adjustment. All patients undergoing an amputation mayexperience phantom limb pain. This is not nearly sosevere with distal Amputations as it is with proximalamputations.

10 Nonetheless, it should be discussed withthe patient prior to surgery. The patient shouldunderstand that it is normal and that, if uncomfortable,can be effectively CONSIDERATIONSP atients requiring above- or Below-elbow amputationsfor a soft-tissue or primary bone sarcoma must undergocomplete staging in order to allow the surgeon todetermine the level of amputation and extent of soft-tissue resection. Complete staging allows determina-tion of full tumor extent and as a result the site for skinincision, shape of the flaps, and site of osteotomy.