Function of the upper limbs after resection of the chest wall

Introduction. The study of the causes of decreased function of the upper limb (DFUL) after the chest wall resection has been the focus of only a few publications. Resection of the sternoclavicular joint and clavicle is an obvious reason for the DFUL. Other reasons are not so obvious - displacement of the pectoralis major muscle or its resection, intersection or resection of the trapezius or rhomboid muscles, large defect of the chest wall in the area covered with the scapula. The approach to reconstruction of the chest wall, i.e. the ability to prevent or reduce the degree of declined function.

Material and methods. In the N.N. Blokhin NMIC of Oncology from 2000 to 2019, 258 surgical procedures have been performed on primary and metastatic tumors localized on the chest wall. 123 patients (47.7%) suffered of functional disorders in upper limb postoperatively. The deterioration was due to the movement of the pectoralis major muscle or resection, after trapezius and/or rhomboid muscles were crossed or resected, after large defects of the chest wall in the area covered with the scapula, after interventions on the sternoclavicular joint. We used assessed the MSTS scale for assessment of the severity of DFUL. Mathematical accuracy was calculated using UTest Mann-Whitney, χ².

The results. The intersection or resection of the trapezius or rhomboid muscles did not lead to a significant DFUL. Resection of the pectoralis major muscle and its use as a displaced flap is only in rare cases accompanied by a DFUL of less than 80%. More severe DFUL had been in patients with a larger volume of resection of the pectoralis major muscle or after usage of counter pectoral flaps with excessive tension. Resections in the sternoclavicular joint area naturally led to DFUL up to 20% or more according to MSTS. Defects of the chest wall in the area covered by the scapula and adjacent areas, ranging from 50 cm² to 320 cm² (M_d=105 cm²), followed by DFUL 20% or more.

Conclusions. Interventions on the trapezius, rhomboid and pectoralis major muscles did not lead to a significant DFUL. In cases of interventions on the sternoclavicular joint, movable reconstruction with a low risk of instability should be performed. At the same time, the choice of reconstruction method remains the subject of research, as well as for the reconstruction of a defect in the area covered by the scapula.

1. Hongbin F, Jun F et al. Implantation of customized 3-D printed titanium prosthesis in limb salvage surgery: a case series and review of the literature. World Journal of Surgical Oncology. 2015;13:308.

2. Enneking W, Dunham W, Gebhardt M. A System for the Functional Evaluation of Reconstructive Procedures After Surgical Treatment of Tumors of the Musculoskeletal System. Clinical Orthopedics and Related Research. 1993;286:241-246.

3. Kennedy C, Beaton D, Smith P, Tang K, Van Eerd D, Hogg-Johnson S, Inrig T, Linton D, Couban R. Measurement properties of the QuickDASH (Disabilities of the Arm, Shoulder and Hand) Outcome Measure and cross-cultural adaptations of the QuickDASH: A systematic review: Quality of Life Research. 2013.

4. Charles SN. Displaced proximal humerus fractures. Part I. Classification and evaluation. J Bone Joint Surg. 1970;52A:1077-1089.

5. Davis AM, Wright JG, Williams JI, Bombardier C, Griffin A, Bell FtS. Development of a measure of physical function for patient with bone and soft tissue sarcoma. Quality of Life Research. 1996;5(5):508-516.

6. Davis AM, Williams JI, Bell S. Evaluating functional outcome in patients with lower extremity sarcoma. Clinical orthopaedics and related research. 1999;(358): 90-100.

7. Mansour KA, Powell RW. Modified technique for radical transmediastinal forequarter amputation and chest wall re-section. J Thorac Cardiovasc Surg. 1978;76:358-363.

8. Kuhn JA, Wagman LD, Lorant JA et al. Radical forequarter amputation with hemithoracectomy and free extended forearm flap. Ann Surg Oncol. 1994;1:353-359.

9. Losken A, Thourani VH, Carlson GW, Jones GE, Culbertson JH, Miller JI et al. A reconstructive algorithm for plastic surgery following extensive chest wall resection. Br J Plast Surg. 2004;57(4):295-302.

10. Микайлов ИМ, Засульский ФЮ. Хирургическое лечение метастатического поражения ключицы при семиноме. Травматология и ортопедия России. 2017;23(3):119-124.

11. Rubright J, Kelleher P. Long-term clinical outcomes, motion, strength, and function after total claviculectomy. J Shoulder Elbow Surg. 2014;23:236-244.

12. Cahueque M, Macias D. Reconstruction with non-vascular-ized fibular autograft after resection of clavicular benign tumor. Journal of orthopedics. 2015:255-259.

13. Bin Lin, Yong He, Yang Xu. Outcome of bone defect reconstruction with clavicle bone cement prosthesis after tumor resection: a case series study. BMC Musculoskeletal Disorders. 2014;15:183.

14. Kakwani RG, Matthews JJ. Rupture of the pectoralis major muscle: Surgical treatment in athletes. International Orthopedics (SICOT). 2007;31:159-163.

15. Mohammadreza G, Arash SV. Surgical Treatment of Pectoralis Major Tendon Rupture (Outcome Assessment). Asian Journal of Sports Medicine. 2014;5(2):129-135.

16. Joe B, Putnam J. Outcomes of Surgery for Chest Wall Sarcomas. Thoracic Surgery Clinic. 2010;20(4)535-542.

17. Sakai M, Yamaoka M. Subscapularis muscle flap for reconstruction of posterior chest wall skeletal defect. Int J Surg Case Rep. 2015;10:198-200.

18. Ahmada SB, Hoellwarthb J, Christiec N, Mcgough R. Radical resection of a giant rib osteosarcoma with complex chest wall reconstruction. International Journal of Surgery Case Reports. 2019;62:17-20.