Partial sterno-costo-claviculectomy for Ewing's sarcoma of the medial clavicle (case report).

INTRODUCTION: Primary clavicle tumors are uncommon and account for <1 % of primary bone tumors. The majority of primary clavicle tumors are malignant. Approximately 1.4 % of all cases of Ewing's sarcoma occur in the clavicle. CASE PRESENTATION: Here, we report the case of a patient diagnosed with Ewing's sarcoma who received neoadjuvant chemotherapy and had an important reduction in the tumoral volume; second, the patient had undergone partial resection of the medial clavicle, first rib, and the sternum. DISCUSSION: The survival rate of patients with nonmetastatic lesions is 56-79 %. The clavicle is connected to major anatomical structures, which makes surgery challenging. Even if there is little morbidity after resection, these studies did not show the superiority of reconstruction. CONCLUSION: The location of Ewing's sarcoma in our patient indicated that the surgical approach was needed for large resection. The functional outcomes were excellent, with no signs of recurrence at the 2-year follow-up.

Open repair of a proximal left subclavian artery mycotic aneurysm with median claviculectomy.

Surgical repair of a subclavian artery mycotic aneurysm is dependent on aneurysm-specific characteristics and anatomic exposures could require sternotomy, thoracotomy, or supraclavicular incisions. Alternatively, a median claviculectomy can be used. We successfully performed a subclavian artery to axillary artery bypass with median claviculectomy in a 23-year-old man with multiple comorbidities. Postoperative Doppler ultrasound showed a patent left axillary artery with a palpable left radial artery, and the patient demonstrated full left shoulder range of motion without any significant deformities. This case suggests that a median claviculectomy can produce satisfactory outcomes in patients with subclavian artery mycotic aneurysms.

Clinical and functional outcome after partial or total claviculectomy without reconstruction for oncologic causes.

BACKGROUND: To achieve clear margins in rare malignant clavicular neoplasms, claviculectomy may become necessary. This study aimed to review clinical, functional, and oncologic outcomes following partial or total claviculectomy without reconstruction. METHODS: This study retrospectively included 15 patients from 2 tertiary sarcoma centers (mean age, 42.6 ± 20.3 years; 66.7% male patients). The median length of clinical and oncologic follow-up was 48.0 months (interquartile range [IQR], 24.0-83.5 months). Functional follow-up (Musculoskeletal Tumor Society score and QuickDASH score [short version of the Disabilities of the Arm, Shoulder and Hand questionnaire]) was available in 9 patients at a median of 36.0 months (IQR, 20.0-100.0 months). RESULTS: Of the 15 patients, 7 underwent total claviculectomy; 5, partial lateral claviculectomy; and 3, partial medial claviculectomy. No postoperative complications emerged. The median Musculoskeletal Tumor Society and QuickDASH scores at latest follow-up amounted to 26.0 points (IQR, 24.0-29.0 points) and 18.0 points (IQR, 11.0-22.0 points), respectively. Notably, scores tended to be lower in patients who underwent total claviculectomy (n = 2) in comparison to partial claviculectomy (n = 7). CONCLUSION: Satisfactory clinical and functional results can be achieved following partial or total claviculectomy without reconstruction, with a low complication rate and acceptable mid- to long-term function.

Clavicular Malignancies: A Borderline Surgical Management.

Nearly 1% of all bone cancers are primary clavicular tumors and because of their rarity, treating clinicians are unfamiliar with their diagnosis, classification, treatment options, and prognosis. In terms of preserving function and avoiding complications, clavicle reconstruction seems logical; however, further studies are needed to support this measure. Reconstruction techniques are difficult taking into account the anatomical structures surrounding the clavicle. When chest wall defects are present, a multidisciplinary team, including an orthopedist and thoracic and plastic surgeons, is of paramount importance for optimal surgical management. Malignant clavicle tumors may include primary and secondary malignancies and neighboring tumors with clavicular invasion. Surgical resection of complex thoracic tumors invading the clavicles can result in larger defects, requiring chest wall reconstruction, which is a substantial challenge for surgeons. Correct diagnosis with proper preoperative planning is essential for limiting complications. Post-resection reconstruction of the partial or total claviculectomy is important for several reasons, including maintaining the biomechanics of the scapular girdle, protecting the vessels and nerves, reducing pain, and maintaining the anatomical appearance of the shoulder. The chest wall resection and reconstruction techniques can involve either partial or full chest wall thickness, influencing the choice of reconstructive technique and materials. In the present paper, we aimed to synthesize the anatomical and physiopathological aspects and the small number of therapeutic surgical options that are currently available for these patients.

Multispecialty surgical management of large clavicular tumor: A case report.

INTRODUCTION: Primary and metastatic malignancies of the clavicle are extremely uncommon and difficult to treat. It carries a high morbidity rate. Total or partial claviculectomy is the recommended treatment option. PRESENTATION OF CASE: A 59-year-old male was admitted with a large left clavicular huge mass; biopsy showed poorly differentiated adenocarcinoma. Treatment started with chemoradiotherapy followed by complete excision of the tumor surgically. DISCUSSION: For treating this rare, difficult case, partial claviculectomy performed by a multispecialty team integrating three surgical skill sets: thoracic, ENT, and orthopedic surgeons, yields the best results. Clavicular carcinoma of known primary (CUP) is rare, and chemoradiotherapy showed preferable results in management. CONCLUSION: MDT reviews with surgeons, radiologists, pathologists, oncologists, and radiation oncologists are required in rare and complex cases of clavicular malignancy. Multispecialty surgical involvement is required for the safe excision of clavicular tumors with appropriate oncologic margins and fewer complications.

Partial Claviculectomy to Relieve Tracheal Compression in an Adult Male with Osteomesopyknosis.

BACKGROUND: The clavicle is a long bone that forms the anterior border of the thoracic inlet. Anatomic abnormalities of the clavicle can lead to compression of the innominate artery and trachea due to mass effect. These anatomic abnormalities can be amenable to surgical resection, which can provide complete resolution of symptoms. METHODS: We present a case of tracheal compression by the innominate artery in an adult man, caused by a clavicular abnormality due to an underlying bone mineralization disorder, corrected by partial resection of the right clavicle. RESULTS: The patient underwent successful open surgical resection of his right clavicular head leading to resolution of his tracheal compression by the innominate artery. CONCLUSIONS: We believe that this is the first description of tracheal compression due to osteomesopyknosis. This case demonstrates that compression of the innominate artery due to a clavicular abnormality can be safely corrected via open surgical resection.

Claviculectomy for exposure and redo repair of expanding, recurrent right subclavian aneurysm.

Subclavian artery aneurysms (SAAs) are rare, and their repair can be technically complex. We have reported the redo repair of a large, expanding, right SAA after primary repair consisting of total aortic arch replacement with bilateral subclavian artery ligation and bypass. The redo repair used claviculectomy to facilitate exposure, ligation of the right deep cervical and internal thoracic arteries from within the aneurysm sac, and revision of the previous axillary artery bypass that had thrombosed owing to the mass effect of the expanding SAA. Claviculectomy can facilitate repair of large SAAs that are poorly suited to more routine exposure approaches, with acceptable risk and functional outcomes.

Analysis of the clinical efficacy of tumor resection methods used in 20 patients with clavicular tumor.

BACKGROUND: To retrospectively analyze the tumor resection method used in 20 patients with clavicular tumors and evaluate its clinical efficacy. METHODS: A total of 9 patients with clavicular benign tumors underwent intracapsular resection, and 11 patients with clavicular malignant tumors underwent tumor resection from May 2012 to May 2017. Of the 11 patients, 5 underwent clavicular reconstruction using the plate-cement complex. Surgical efficacy was assessed using the Musculoskeletal Tumor Society, Constant-Murley, and American Shoulder and Elbow Surgeons shoulder outcome scores preoperatively until 12 months postoperatively. RESULTS: The average duration of follow-up care was 33.7 (12-71) months. Of the 20 patients, 3 patients died, 3 survived with tumor recurrence or metastasis, and 14 survived with no tumor recurrence. Among the 5 patients who underwent resection of malignant clavicular tumors and reconstruction, 2 underwent a re-operation because of a loose screw and plate displacement. In the functional assessment of the shoulder joint, patients with benign and malignant clavicular tumors showed significantly higher scores postoperatively compared with preoperative scores. For malignant clavicular tumors, no significant improvement was observed when comparing the non-reconstruction and reconstruction groups. CONCLUSIONS: Surgery is an optimal treatment for clavicular tumors. In patients with benign clavicular tumors, simple intracapsular resection can achieve a satisfactory prognosis. Reconstruction of a clavicular defect after resection of a clavicular malignant tumor is not recommended.

Medial claviculectomy for the treatment of recalcitrant central venous stenosis of hemodialysis patients.

OBJECTIVE: Outflow tract stenosis is the leading cause of hemodialysis access loss. Many lesions are highly resistant to endovascular treatment, necessitating open surgical intervention. We present our experience using medial claviculectomy for treatment of recalcitrant lesions at the thoracic outlet. METHODS: We retrospectively reviewed patients who underwent medial claviculectomy for dialysis-associated venous thoracic outlet syndrome at our institution between February 2013 and February 2018. Data collection included demographics, past medical history, access history, subsequent procedures, preoperative and postoperative brachial volume flows, and access use. RESULTS: We performed 25 medial claviculectomies in 25 patients with central venous stenosis. Four patients underwent concomitant central venous bypass and were excluded from this study. Twelve accesses were created at our institution; of these, the average access age was 41.6 months (±26.7 months). All patients previously underwent multiple angioplasty attempts to treat outflow stenosis and continued to have residual symptoms and poor fistula function. Medial claviculectomy with venolysis and angioplasty were performed to treat residual outflow stenosis at the level of the subclavian vein. Twenty-one patients had residual stenosis requiring angioplasty. Six patients had subclavian rupture requiring stent graft placement. All patients reported symptom improvement and immediate use of the fistula after medial claviculectomy. Nineteen (76%) patients reported complete resolution of symptoms after the procedure. Ultimately, eight (32%) ipsilateral arteriovenous accesses were lost, and six (24%) patients died in follow-up with patent, functional fistulas. Median length of follow-up was 17 months (interquartile range, 5-28 months). The 18-month primary patency and secondary patency with regard to subclavian vein interventions were 28% (95% confidence interval, 13.8%-56.1%) and 84% (95% confidence interval, 69.7%-100%), respectively. One patient required ligation for high-output cardiac failure. One patient had contralateral brachiocephalic jailing, which was corrected with kissing brachiocephalic stents. CONCLUSIONS: Medial claviculectomy is an effective treatment of recalcitrant central venous stenosis of the thoracic outlet. Balloon angioplasty or stent or stent graft placement is often necessary after extrinsic compression is alleviated and demonstrates acceptable secondary patency rates.

Is clavicular reconstruction imperative for total and subtotal claviculectomy? A systematic review.

BACKGROUND: The effects of clavicular reconstruction on total and subtotal claviculectomy are controversial. The aim of this study is to disclose the impact of clavicular reconstruction on the efficacy of this rare surgical procedure. METHODS: This is a systematic review of multiple medical databases for level I through IV evidence. RESULTS: Eleven studies (level IV) with a mean follow-up duration of 53 months (range, 12-156 months) met the inclusion criteria. There were 70 subjects (70 shoulders) including 36 male patients (51%), and the average age at operation was 30 years (range, 2-77 years). The etiology included tumors in 34 subjects (49%) and other disorders in 36 (51%). Of the patients, 41 (59%) underwent total claviculectomy whereas 29 (41%) underwent subtotal clavicular excision. Clavicular reconstruction was performed in 14 subjects (20%), with bone allograft in 8, autograft in 1, and a bone cement prosthesis in 5. Objective measurement disclosed compromised strength and mobility in aclaviculate limbs; however, no studies investigating clavicular reconstruction used similar means of measurement. Functional assessment scales implied global limb function following the 2 procedures was similar (American Shoulder and Elbow Surgeons score, P = .13; Constant score, P = .38). Claviculectomy with and without reconstruction resulted in a similar incidence of complications (P = .45); however, isolated claviculectomy was related to fewer further surgical procedures (P <.001) and faster recovery (P <.001). The 2 procedures were associated with similar satisfaction rates (P > .99). CONCLUSIONS: No evidence suggested clavicular reconstruction led to clinical outcomes superior to those of isolated claviculectomy. It is noteworthy that isolated excision of the clavicle was associated with a lower risk of further surgery and faster rehabilitation.

Non-union of a clavicle fracture: lateral fragment excision for brachial artery embolism.

A 67-year-old motorcyslist was admitted to hospital following a high-speed road traffic collision and found to have a left midshaft clavicle fracture and multiple ipsilateral rib fractures. He was treated conservatively and went on to have non-union of the clavicle. The non-union was managed non-operatively. The patient then re-attended the hospital with an acute ischaemic left hand 3 years after the original injury date. An arterial duplex scan confirmed a embolus to the brachial artery. A brachial embolectomy was urgently performed. A computed tomography scan showed non-union of the clavicle fracture and an inflammatory mass compressing the left subclavian artery, which was the focus of the embolic event. The clavicle non-union was managed operatively with lateral half claviculectomy. Immediately after clavicle excision, the vascular team performed reconstruction of the brachial artery. At follow-up,there was normal shoulder and hand function at outpatient clinic. A duplex scan confirmed good triphasic waveforms throughout the arteries of the left upper limb.

Long-term clinical outcomes, motion, strength, and function after total claviculectomy.

BACKGROUND: Total excision of the clavicle is rarely performed. No previous study has documented long-term outcomes with objective measurements of strength, motion, and patient-centered outcomes. We present the long-term consequences of total claviculectomy on shoulder girdle function, global upper extremity function, and overall general health. METHODS: Five total claviculectomy patients were evaluated at 2 time points (2005 and 2010, mean 4.8 and 9.4 years postoperatively) by use of the DASH, SF-36, Simple Shoulder Test, ASES, UCLA, HSS, and Constant shoulder scores. Isokinetic strength, clinical range of motion, and kinematic analysis were performed on each limb pair. RESULTS: All clinical scores allowing side-to-side comparison were poorer for the aclaviculate side, with significance reached for 2005 ASES scores and 2010 ASES, UCLA, HSS, and Constant scores. DASH scores and SF-36 scores were not significantly inferior to age- and sex-matched population norms. Deficits in strength were present in the aclaviculate limbs, with significance reached for adduction in 2005 and for forward flexion and external rotation in 2010. Kinematic and clinical range of motion analysis revealed scapular dyskinesis and significant deficits in external rotation in the aclaviculate limb. CONCLUSIONS: We found that the clavicle contributes to the strength, coordinated scapulohumeral rhythm, and overall range of motion of the shoulder girdle. Patients compensate for loss of the clavicle with minimal functional deficit. With time, patients gradually lose some compensatory ability as evidenced by deteriorating limb-specific, patient-centered outcome measures, diminished strength in certain planes of shoulder motion, and scapular dyskinesis at long-term follow-up. Despite objective deficits, these patients continue to have normal self-perceptions of overall health and global upper extremity function.

Combined ipsilateral neck and axillary lymphadenectomy for metastatic skin cancers: a case series and surgical tips.

In the absence of distant disease simultaneous skin cancer metastasis to neck and axillary lymph nodes necessitates both an axillary and neck en block lymphadenectomy. A combined ipsilateral neck and axillary lymph node dissection should involve an in-continuity dissection through the cervicoaxillary canal for optimal lymphatic and oncological clearance. Review of the literature reveals little published instruction on the procedure since the radical surgery performed by Bowden over 50 years ago. We present 4 cases where ipsilateral axillary and neck lymph node dissections were performed for metastatic melanoma and a case of apical axillary node dissection via a neck incision approach. Our surgical tips include performing apical axillary node dissection via the neck incision and consideration of clavicular osteotomy or clavicular excision. A transclavicular approach was taken in one patient who had an excellent functional outcome after a plate and screw fixation. One elderly patient required a middle third claviculectomy which reduced shoulder elevation but was not associated with functional impairment. We conclude the surgery is safe and associated with the usual morbidity ascribed with either an axillary or neck dissection undertaken in isolation. However, patients have a significant risk of disease relapse as would be expected due to the duel metastatic sites, multiple lymph node and neck involvement which are known to be independent poor prognostic factors on melanoma survival and relapse.