Flap survival and functional outcomes in elbow soft tissue reconstruction: A 25-year systematic review

Free flap reconstruction of elbow soft tissue defects: Lessons learned from 15 years of experience

BACKGROUND

The elbow is a complex joint that is vital for proper function of the upper extremity. Reconstruction of soft tissue defects over the joint space remains challenging, and outcomes following free tissue transfer remain underreported in the literature. The purpose of this analysis was to evaluate the rate of limb salvage, joint function, and clinical complications following microvascular free flap coverage of the elbow.

METHODS

This retrospective case series utilized surgical logs of the senior authors (Stephen J Kovach and L Scott Levin) to identify patients who underwent microvascular free flap elbow reconstruction between January 2007 and December 2021. Patient demographics and medical history were collected from the medical chart. Operative notes were reviewed to determine the type of flap procedure performed. The achievement of definitive soft tissue coverage, joint function, and limb salvage status at 1 year was determined from postoperative visit notes.

RESULTS

Twenty-one patients (14 male, 7 female, median age 43) underwent free tissue transfer for coverage of soft tissue defects of the elbow. The most common indication for free tissue transfer was traumatic elbow fracture with soft tissue loss (n = 12, [57%]). Among the 21 free flaps performed, 71% (n = 15) were anterolateral thigh flaps, 14% (n = 3) were latissimus dorsi flaps, and 5% (n = 1) were transverse rectus abdominis flaps. The mean flap size was 107.5 cm2. Flap success was 100% (n = 21). The following postoperative wound complications were reported: surgical site infection (n = 1, [5%]); partial dehiscence (n = 5, [24%]); seroma (n = 2, [10%]); donor-site hematoma (n = 1, [5%]); and delayed wound healing (n = 5, [24%]). At 1 year, all 21 patients achieved limb salvage and definitive soft tissue coverage. Of the 17 patients with functional data available, 47% (n = 8) had regained at least 120 degrees of elbow flexion/extension. All patients had greater than 1 year of follow-up.

CONCLUSION

Microvascular free flap reconstruction is a safe and effective method of providing definitive soft tissue coverage of elbow defects, as evidenced by high rates of limb salvage and functional recovery following reconstruction.

Free peroneal artery perforator flap for reconstruction of traumatic limb soft tissue defects: A retrospective case series study

BACKGROUND

The free peroneal artery perforator (FPAP) flap is used for soft tissue defects after burns and trauma. However, the use of FPAP flaps to repair limb soft tissue defects for immediate reconstruction was rarely reported previously. Therefore, the purpose of this report is to evaluate free peroneal artery perforator flap to reconstruct traumatic limb soft tissue defects for immediate reconstruction.

PATIENTS AND METHODS

A total of 25 cases of limb soft tissue defects undergoing immediate reconstruction of FPAP flap transfer were retrospectively evaluated from January 2019 to June 2019 in our institute. The locations of defects included the palm (10 cases), finger (5 cases), foot (7 cases), ankle (2 cases) and wrist (1 case). The sizes of defect varied from 3 × 2 cm to 15 × 7 cm (54.1 cm2 in average). Flaps were harvested based on the peroneal perforator vessels, initially marked using hand-held Doppler.

RESULTS

Average size of harvested flap was 9.7 × 6.2 cm (ranging from 3.5 × 2 cm to 16 × 8 cm). All perforators were harvested from the peroneal artery and the arterial diameter ranged from 0.8 to 1.7 mm. The average pedicle length was 3.04 cm (range, 1.85-4.75 cm). Five vascular thrombosis were found including three cases of arterial thrombosis and two cases of venous thrombosis which were successfully salvaged by re-operation and vein graft. Satisfying functional outcome and acceptable appearance were achieved at 6 months or longer after surgery (range, 6-15 months, 12 months in average). All flaps survived at the end-point.

CONCLUSIONS

The FPAP flap is a reliable and thin fasciocutaneous flap, which can be used for repairing limb soft tissue defects. The FPAP flap can be used for covering defects with various appearances, locations, and sizes.

Modified lateral approach combined with medial percutaneous approach versus triceps tongue-shaped flap approach and bilateral triceps brachii approach for pin fixation in treatment of irreducible displaced pediatric supracondylar humeral fractures

To evaluate the clinical outcomes of the modified lateral approach combined with the medial percutaneous approach (MLACMPA) versus the triceps tongue-shaped flap approach (TTSFA) and the bilateral triceps brachii approach (BTBA) in the treatment of irreducible displaced supracondylar humeral fractures (SHFs) in children. Between March 2000 and July 2022, a total of 135 children who underwent open reduction and Kirschner wire cross internal fixation for irreducible displaced SHFs caused by trauma were retrospectively analyzed. According to the surgical approach, the patients were assigned to the TTSFA group (n = 36), the BTBA group (n = 40) and the MLACMPA group (n = 59). The duration of surgery, intraoperative blood loss, incision length, and elbow range of motion were compared. The 3 groups were similar in terms of mean age, sex distribution, and time from injury to operation. The duration of surgery, intraoperative blood loss, incision length and postoperative elbow range of motion in the MLACMPA group were significantly superior to those in the TTSFA group and BTBA group (P < .05). Compared the use of the TTSFA or the BTBA, using the MLACMPA for pin fixation in the treatment of irreducible displaced pediatric SHFs could significantly shorten the duration of surgery, reduce the operation trauma, facilitate earlier functional exercise of joints after operation and yield better elbow function.

Reconstruction of upper extremity soft tissue defects with free flaps

Aim: Many methods have been described in the literature for the reconstruction of upper extremity defects that may occur as a result of various etiological reasons. Among these methods, local or regional flaps are used quite frequently, and most defects can be successfully reconstructed. However, in some large and complex defects, technically more difficult free flap options may be unavoidable. In our study, we present our experience on upper extremity reconstruction with free flaps. Materials and Methods: Between 2015 and 2021, 9 patients (3 Female, 6 Male) underwent upper extremity reconstructions with free flaps. The ages of the patients ranged from 22 to 68 years. Our free flap choices included anterolateral thigh flap in 4 patients, latissimus dorsi free flap in 4 patients, and radial forearm free flap in 1 patient. Defects of patients were including dorsum of the hand in 3 patients, an amputation stump in 1 patient, the dorsum of the hand with the forearm in 2 patients, and the elbow with the forearm in 3 patients. Results: The radial artery was chosen as the recipient artery in all patients. The concomitant vein of the radial artery or the superficial venous system was used as the recipient vein. End-to-end anastomosis was performed in 6 patients and end-to-side anastomosis was performed in 3 patients. Arterial thrombosis was observed in 1 patient and venous thrombosis was observed in 1 patient. All vascular complications occurred in reconstructions with latissimus dorsi free flaps. Both patients were taken to early salvage surgery, the anastomoses were renewed and the flaps were salvaged. No additional complications were observed in other patients. There was no flap loss in our clinical series. Conclusion: Free flaps can be used safely for upper extremity soft tissue reconstructions in appropriate cases. Although it requires technical experience, we believe that perforator-based free flaps are quite advantageous due to minimal donor site problems and can be safely chosen as the first method in suitable patients.