Tikhoff Procedure: Understanding This Radical Surgical Intervention

What is the Tikhoff procedure?

The Tikhoff procedure, also known as the interscapulothoracic resection or forequarter amputation, is a highly complex and radical surgical intervention involving the en bloc removal of the upper extremity, including the scapula, clavicle, and the entire arm, along with associated musculature and neurovascular structures.

Understanding the Tikhoff Procedure

The Tikhoff procedure represents one of the most extensive resections performed in orthopedic oncology. It is a disarticulation surgery, meaning it involves separating the limb at a joint, in this case, the shoulder girdle, from the torso. This procedure is named after Dr. Ivan Tikhoff, a Russian surgeon who first described it in the early 20th century. While initially performed for various severe conditions, its primary indication today is the treatment of aggressive malignant tumors originating in or extensively involving the shoulder girdle.

Anatomical Considerations

The shoulder girdle is a highly complex anatomical region, comprising the scapula (shoulder blade), clavicle (collarbone), and the proximal humerus (upper arm bone), articulating with the sternum and ribs. The Tikhoff procedure involves the removal of these bony structures along with the extensive network of muscles that attach to them (e.g., deltoid, trapezius, latissimus dorsi, rotator cuff muscles), and the critical neurovascular bundles (brachial plexus, subclavian artery and vein) that supply the arm and hand.

Key Structures Removed:

• Scapula: The entire shoulder blade.
• Clavicle: The collarbone, often including its articulation with the sternum.
• Proximal Humerus: The upper portion of the arm bone, or the entire humerus and the rest of the arm.
• Associated Musculature: Major muscles of the shoulder, chest, and back that attach to the removed bones.
• Neurovascular Structures: Portions of the brachial plexus and major blood vessels to the arm.

The removal of these structures significantly alters the biomechanics of the upper torso, impacting stability, posture, and the potential for prosthetic fitting.

Indications for the Procedure

The Tikhoff procedure is typically a last-resort option, considered when limb-sparing surgery is not feasible due to the size, location, or aggressiveness of a tumor.

Primary Indications:

• Malignant Tumors: Primarily high-grade sarcomas (e.g., osteosarcoma, chondrosarcoma, Ewing sarcoma, soft tissue sarcomas) that involve the scapula, proximal humerus, or clavicle.
• Extensive Local Invasion: When the tumor has invaded critical neurovascular structures or surrounding vital tissues, making a less radical resection impossible to achieve clear margins.
• Recurrent Tumors: In cases where previous limb-sparing surgeries have failed, and the tumor has recurred aggressively.

The goal of the procedure is to achieve complete tumor removal (R0 resection) to maximize the chances of local disease control and improve survival rates, even at the cost of significant functional impairment.

The Surgical Process

The Tikhoff procedure is a lengthy and intricate operation requiring a highly skilled surgical team.

Key Surgical Steps:

1. Patient Positioning and Incision: The patient is typically positioned laterally or semi-prone. A large incision is made to expose the shoulder girdle and surrounding tissues.
2. Vascular and Neural Control: The subclavian artery and vein, and the brachial plexus, are carefully identified, ligated (tied off), and transected (cut) to control bleeding and separate the limb's neurovascular supply.
3. Muscle and Bone Dissection: The extensive musculature attaching the shoulder girdle to the torso is meticulously dissected and detached. The clavicle is disarticulated from the sternum, and the scapula is separated from the rib cage.
4. En Bloc Resection: The entire involved shoulder girdle and upper extremity are removed as a single unit, ensuring wide tumor-free margins.
5. Reconstruction (if applicable): While not always possible or indicated, some cases may involve soft tissue reconstruction using local flaps to cover the large defect, or rarely, a prosthetic shoulder girdle may be attempted, though functional outcomes are limited.
6. Wound Closure: The remaining tissues are carefully approximated, and the wound is closed, often with drains to manage fluid accumulation.

The surgery is associated with significant blood loss and requires extensive post-operative monitoring.

Post-Operative Recovery and Rehabilitation

Recovery from a Tikhoff procedure is prolonged and challenging, requiring a multidisciplinary approach.

Immediate Post-Operative Period:

• Pain Management: Extensive pain control is crucial, often involving patient-controlled analgesia (PCA) or regional nerve blocks.
• Wound Care: Meticulous wound care is essential to prevent infection and promote healing of the large surgical site.
• Monitoring: Close monitoring for complications such as hemorrhage, infection, and flap compromise (if reconstruction was performed).

Rehabilitation Phases:

• Early Mobilization: Focus on trunk mobility, deep breathing exercises, and preventing deconditioning of the remaining limbs.
• Prosthetic Training: For patients who are candidates, evaluation and fitting for a cosmetic or functional prosthesis may begin. Training focuses on donning/doffing, care, and basic operation of the prosthesis.
• Compensatory Strategies: Learning new ways to perform activities of daily living (ADLs) using the unaffected arm and trunk.
• Strengthening and Conditioning: Strengthening of the remaining core and upper body musculature to improve balance and functional independence.
• Psychological Support: Significant psychological support is vital to help patients cope with the dramatic change in body image and function.

Physical and occupational therapists play a critical role in guiding patients through this demanding rehabilitation process, focusing on maximizing independence and quality of life.

Functional Outcomes and Long-Term Considerations

The functional outcome following a Tikhoff procedure is a complete loss of the affected upper extremity.

Expected Limitations:

• Complete Loss of Arm Function: Patients will have no use of the arm on the operated side.
• Balance and Posture Changes: The removal of significant mass can affect balance and lead to postural deviations.
• Activities of Daily Living: Significant adaptations are required for tasks such as dressing, bathing, and eating.
• Vocational and Recreational Impact: Return to previous work or hobbies may be challenging or impossible.

Potential Complications:

• Infection
• Hemorrhage
• Nerve damage (to remaining structures)
• Phantom limb pain
• Deep vein thrombosis (DVT) and pulmonary embolism (PE)
• Psychological distress

Patients often learn to adapt remarkably well, utilizing their dominant unaffected arm and developing compensatory movements. Assistive devices and modifications to the home and workplace are frequently necessary to enhance independence.

Conclusion

The Tikhoff procedure is a radical, life-saving surgery for aggressive shoulder girdle malignancies. While it results in the complete loss of an upper extremity, it offers a chance for definitive tumor control when no other options exist. Understanding the profound anatomical implications, the complex surgical process, and the extensive rehabilitation required is crucial for both patients and healthcare professionals. The focus of post-operative care shifts from limb preservation to maximizing the patient's functional independence and overall quality of life through adaptive strategies and comprehensive support.