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McGraw JR, Sulkar RS, Bascone CM, Othman S, Mauch JT, Naga HI, Levin LS, Kovach SJ. Free flap reconstruction of elbow soft tissue defects: Lessons learned from 15 years of experience. Microsurgery 2024; 44:e31163. [PMID: 38530145 DOI: 10.1002/micr.31163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 01/10/2024] [Accepted: 02/15/2024] [Indexed: 03/27/2024]
Abstract
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.
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Affiliation(s)
- J Reed McGraw
- Division of Plastic Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Reena S Sulkar
- Division of Plastic Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Corey M Bascone
- Division of Plastic Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sammy Othman
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Northwell Health, Great Neck, New York, USA
| | - Jaclyn T Mauch
- Section of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Hani I Naga
- Division of Plastic, Reconstructive, Oral, and Maxillofacial Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - L Scott Levin
- Division of Plastic Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Orthopaedic Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Stephen J Kovach
- Division of Plastic Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Orthopaedic Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Greco VE, Wroblewski A, Kharlamov A, Miller MC, Winek N, Hammarstedt JE, Regal S. "Safe dissection parameters of the anconeus rotational flap for soft tissue coverage at the elbow". Shoulder Elbow 2023; 15:436-441. [PMID: 37538523 PMCID: PMC10395408 DOI: 10.1177/17585732221095492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 01/28/2022] [Accepted: 04/03/2022] [Indexed: 08/05/2023]
Abstract
Background The anconeus is a small muscle located on the posterior elbow originating on the lateral epicondyle and inserting onto the proximal-lateral ulna that functions as an elbow extensor as well as dynamic stabilizer. The blood supply is tri-fold: medial/middle collateral artery (MCA), recurrent posterior interosseous artery (RPIA), and less commonly found, the posterior branch of the radial collateral artery. The anconeus has become a popular option for local soft tissue coverage about the elbow (distal triceps, olecranon, proximal forearm). The average defect size for consideration of local anconeus flap coverage is 5-7cm2. The aim of the study was to determine safe dissection parameters of the anconeus as well as map arterial pedicles to achieve successful local harvest of the muscle without devascularization. Materials and Methods 8 fresh frozen cadaveric arms (all male, average age 63 years - 4 left arms, 4 right arms) from scapula to fingertip were obtained. First, the radial, ulnar and axillary arteries were dissected and isolated. The radial and ulnar arteries were transected. 100cc normal saline was injected through the axillary artery, sequentially clamping the radial followed by the ulnar artery so that adequate flow could be seen through all vessels. 100cc mixture of Biodür and hardener (10:1) was mixed and injected into the axillary artery. We first allowed free flow through both the ulnar and radial vessels followed by clamping of these vessels. This allowed the pressure to build up and fill the smaller vessels in the arms. After injection, the axillary artery was then clamped and the specimens were left to harden for 24-48 h. After hardening, dissection was performed by making a curvilinear incision centred over the lateral epicondyle. The anconeus was identified and the interval between the anconeus and ECU was then confirmed. Measurements of the anconeus muscle were taken. Blunt dissection was carried between anconeus and ECU until the RPIA was identified and protected. We isolated the MCA by dissecting proximally. This was found to run with the nerve to the anconeus. Once this vessel had been protected, the muscle reflected from distal to proximal staying along its ulnar border. The branches of the RPIA were ligated and the dissection was continued proximally. Measurements of the distances of the RPIA, MCA were taken. Results The average distance of olecranon to muscle tip was 95.0mm. The average distance of lateral epicondyle (LE) to muscle tip was 90.8mm. The average distance of LE to olecranon was 49.8mm. The average location of the RPIA was 63.mm when measuring LE to vessel, 68.3mm when measuring olecranon to vessel, 18.3mm when measuring RPIA to muscle tip. The average RPIA diameter was 1.1mm and length was 36.4mm from the initial branching of the posterior interosseous artery. The average MCA diameter was 0.7mm. The posterior branch of the radial collateral artery was only found in 3/8 specimens. The RPIA and MCA were constant in all specimens. Dissection was safely carried to the border of the LE and olecranon without disruption of the MCA. CONCLUSIONS Our conclusions determined that if dissection of the anconeus is undertaken, the RPIA remains constant between the interval of the ECU as well as anconeus at an average distance of 18.3mm from the tip of the muscle measuring proximally; moreover, the MCA was constant in all specimens found directly between the LE and olecranon always running with the nerve to the anconeus. When dissecting and mobilizing to ensure preservation of the MCA, dissection should be taken from distal to proximal as well as dissecting along the ulnar border of the anconeus. Proximal dissection can be taken as proximal as the border of the LE and olecranon as that did not disrupt MCA blood supply.
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Affiliation(s)
- Victor E Greco
- Department of Orthopaedic Surgery, Allegheny General Hospital, Allegheny Health Network, 320 E North Avenue, Pittsburgh, PA 15212
| | - Andrew Wroblewski
- Department of Orthopaedic Surgery, Allegheny General Hospital, Allegheny Health Network, 320 E North Avenue, Pittsburgh, PA 15212
| | - Alexander Kharlamov
- Department of Mechanical Engineering and Materials Science, University of Pittsburgh, Pittsburgh PA
| | - Mark Carl Miller
- Department of Orthopaedic Surgery, Allegheny General Hospital, Allegheny Health Network, 320 E North Avenue, Pittsburgh, PA 15212
- Department of Mechanical Engineering and Materials Science, University of Pittsburgh, Pittsburgh PA
| | - Nathan Winek
- Department of Orthopaedic Surgery, Allegheny General Hospital, Allegheny Health Network, 320 E North Avenue, Pittsburgh, PA 15212
| | - Jon E Hammarstedt
- Department of Orthopaedic Surgery, Allegheny General Hospital, Allegheny Health Network, 320 E North Avenue, Pittsburgh, PA 15212
| | - Steven Regal
- Department of Orthopaedic Surgery, Allegheny General Hospital, Allegheny Health Network, 320 E North Avenue, Pittsburgh, PA 15212
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Fadel ZT, Ashi MB, Magram WS. Case report: reverse lateral arm flap in a patient with previously harvested radial artery. Case Reports Plast Surg Hand Surg 2022; 9:169-172. [PMID: 35873923 PMCID: PMC9302009 DOI: 10.1080/23320885.2022.2099395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
The radial artery supplies various locoregional flaps used for elbow reconstruction. A reverse lateral arm flap is a reliable choice, despite sacrificing the radial artery in some cases. We describe using a reverse lateral arm flap for elbow soft tissue reconstruction in a patient with a previously harvested radial artery.
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Affiliation(s)
- Zahir T. Fadel
- Division of Plastic Surgery, Department of Surgery, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Mohammed B. Ashi
- Department of Plastic and Reconstructive Surgery, National Guard Hospital, Jeddah, Saudi Arabia
| | - Weaam S. Magram
- Division of Plastic Surgery, Department of Surgery, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
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Pawar MD, Sahasrabudhe P, Panse N, Bindu AR, Phulwer RD. Management of Posttraumatic Posterior Elbow Defects by Nonmicrosurgical Reconstruction. Indian J Plast Surg 2022; 55:251-261. [PMID: 36325085 PMCID: PMC9622223 DOI: 10.1055/s-0042-1750372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Introduction
Reconstruction of posterior defects is challenging due to the quality and uniqueness of the excess skin at the elbow that is durable, thick, pliable, and without much subcutaneous tissue. The goal of reconstruction is to cover the elbow defects with a durable skin cover that will facilitate full passive range of motion. In this era of microsurgery, free tissue transfer is feasible for almost any defect. However, in this article, we discuss various locoregional and pedicled flap options and the protocol followed at our institute to tackle posttraumatic posterior elbow defects.
Materials and Methods
This is a retrospective analysis of 48 patients with posttraumatic posterior elbow defects admitted from January 2012 to February 2020. Posterior elbow defects were assessed according to the size and location and managed with a nonmicrosurgical reconstruction.
Results
Of 48 patients, 32 were managed with nonmicrosurgical flaps. Eighteen patients had large defects and 14 had small defects. Reverse lateral forearm flap was the workhorse flap for defect coverage. Of 32 flaps, nine developed complications; however, no patient had total flap necrosis.
Conclusion
Posterior elbow defects are a difficult problem to tackle. To achieve optimal results, all patients with elbow trauma should be attended and managed by orthopaedic and plastic surgeons in collaboration for optimal results. We believe that most of these defects can be resurfaced by nonmicrosurgical reconstruction with proper planning and execution and their utility cannot be understated.
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Affiliation(s)
- Manoj Dinkar Pawar
- Department of Plastic & Reconstructive Surgery, B.J. Government Medical College and Sassoon Hospital, Pune, Maharashtra, India
| | - Parag Sahasrabudhe
- Department of Plastic & Reconstructive Surgery, B.J. Government Medical College and Sassoon Hospital, Pune, Maharashtra, India
| | - Nikhil Panse
- Department of Plastic & Reconstructive Surgery, B.J. Government Medical College and Sassoon Hospital, Pune, Maharashtra, India
| | - Ameya Rajan Bindu
- Department of Plastic & Reconstructive Surgery, B.J. Government Medical College and Sassoon Hospital, Pune, Maharashtra, India
| | - Rohit Dagadu Phulwer
- Department of Plastic & Reconstructive Surgery, B.J. Government Medical College and Sassoon Hospital, Pune, Maharashtra, India
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Beyer GA, Dua K, Shah NV, Scollan JP, Newman JM, Mithani SK, Koehler SM. Upper Extremity Free Flap Transfers: An Analysis of the National Surgical Quality Improvement Program Database. J Hand Microsurg 2022; 14:245-250. [DOI: 10.1055/s-0040-1717828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
Abstract
Introduction We evaluated the demographics, flap types, and 30-day complication, readmission, and reoperation rates for upper extremity free flap transfers within the National Surgical Quality Improvement Program (NSQIP) database.
Materials and Methods Upper extremity free flap transfer patients in the NSQIP from 2008 to 2016 were identified. Complications, reoperations, and readmissions were queried. Chi-squared tests evaluated differences in sex, race, and insurance. The types of procedures performed, complication frequencies, reoperation rates, and readmission rates were analyzed.
Results One-hundred-eleven patients were selected (mean: 36.8 years). Most common upper extremity free flaps were muscle/myocutaneous (45.9%) and other vascularized bone grafts with microanastomosis (27.9%). Thirty-day complications among all patients included superficial site infections (2.7%), intraoperative transfusions (7.2%), pneumonia (0.9%), and deep venous thrombosis (0.9%). Thirty-day reoperation and readmission rates were 4.5% and 3.6%, respectively. The mean time from discharge to readmission was 12.5 days.
Conclusion Upper extremity free flap transfers could be performed with a low rate of 30-day complications, reoperations, and readmissions.
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Affiliation(s)
- George A. Beyer
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York, Downstate Medical Center, Brooklyn, New York, United States
| | - Karan Dua
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York, Downstate Medical Center, Brooklyn, New York, United States
| | - Neil V. Shah
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York, Downstate Medical Center, Brooklyn, New York, United States
| | - Joseph P. Scollan
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York, Downstate Medical Center, Brooklyn, New York, United States
| | - Jared M. Newman
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York, Downstate Medical Center, Brooklyn, New York, United States
| | - Suhail K. Mithani
- Department of Plastic, Maxillofacial, and Oral Reconstructive Surgery, Duke University Medical Center, Durham, North Carolina, United States
| | - Steven M. Koehler
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York, Downstate Medical Center, Brooklyn, New York, United States
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Guntur P, Satria O, Wahyudi M. Wide resection and reconstruction of giant cell tumor of the distal humerus with favorable outcomes in 3 months: A case report. Int J Surg Case Rep 2022. [PMCID: PMC9168117 DOI: 10.1016/j.ijscr.2022.107155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Introduction and importance A giant cell tumor is a locally aggressive tumor with low-risk progression into malignant and rarely metastasize, but a high risk of recurrence and notable disturbance of bony architecture in peri-articular locations. Wide resection provides a more advantageous therapy option, but the functional outcome is often hampered. Case presentation A 36-years old woman came with a lump on the left elbow as chief of complaint since a year ago that kept growing bigger with pain, local tenderness, and limited motion. She underwent several examinations and was diagnosed with a giant cell tumor in the distal humerus. Wide excision and reconstruction surgery using megaprosthesis, rotational flap, nerve graft, and skin graft were done. After 3 months follow-up, the patient had favorable functional outcomes. Clinical discussion The primary aim of treating giant cell tumors is wide resection with good functional than cosmesis outcomes. This manner was common and expected to reduce the potential risk of infection. Conclusion Reconstruction with megaprosthesis, nerve and skin graft, is a reasonable option after wide resection of the giant cell tumor in the left humerus with favorable functional outcomes within 3 months compared with other treatment modalities. A giant cell tumor is a locally aggressive tumor with high recurrence rate. Wide resection removes the entire mass, but may hamper functional outcome. Reconstruction using megaprosthesis, nerve and skin graft may be used. Reconstruction results in satisfactory outcome with lower recurrence rate.
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Affiliation(s)
- Putera Guntur
- Corresponding author at: Department of Orthopaedic and Traumatology, Faculty of Medicine Universitas Indonesia, Fatmawati General Hospital, Jl. RS Fatmawati Raya no. 4, Jakarta Selatan, Jakarta 12430, Indonesia.
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Macken AA, Lans J, Miyamura S, Eberlin KR, Chen NC. Soft-tissue coverage for wound complications following total elbow arthroplasty. Clin Shoulder Elb 2021; 24:245-252. [PMID: 34875731 PMCID: PMC8651597 DOI: 10.5397/cise.2021.00409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 08/20/2021] [Indexed: 11/25/2022] Open
Abstract
Background In patients with total elbow arthroplasty (TEA), the soft-tissue around the elbow can be vulnerable to soft-tissue complications. This study aims to assess the outcomes after soft-tissue reconstruction following TEA. Methods We retrospectively included nine adult patients who underwent soft-tissue reconstruction following TEA. Demographic data and disease characteristics were collected through medical chart reviews. Additionally, we contacted all four patients that were alive at the time of the study by phone to assess any current elbow complications. Local tissue rearrangement was used for soft-tissue reconstruction in six patients, and a pedicle flap was used in three patients. The median follow-up period was 1.3 years (range, 6 months–14.7 years). Results Seven patients (78%) underwent reoperation. Four patients (44%) had a reoperation for soft-tissue complications, including dehiscence or nonhealing of infected wounds. Five patients (56%) had a reoperation for implant-related complications, including three infections and two peri-prosthetic fractures. At the final follow-ups, six patients (67%) achieved successful wound healing and two patients had continued wound healing issues, while two patients had an antibiotic spacer in situ and one patient underwent an above-the-elbow amputation. Conclusions This study reports a complication rate of 78% for soft-tissue reconstructions after TEA. Successful soft-tissue healing was achieved in 67% of patients, but at the cost of multiple surgeries. Early definitive soft-tissue reconstruction could prove to be preferable to minor interventions such as irrigation, debridement, and local tissue advancement, or smaller soft-tissue reconstructions using local tissue rearrangement or a pedicled flap at a later stage.
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Affiliation(s)
- Arno A Macken
- Orthopedic Hand and Upper Extremity Service, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Jonathan Lans
- Orthopedic Hand and Upper Extremity Service, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Satoshi Miyamura
- Orthopedic Hand and Upper Extremity Service, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Kyle R Eberlin
- Plastic, Reconstructive and Hand Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Neal C Chen
- Orthopedic Hand and Upper Extremity Service, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Kahramangil B, Pires G, Ghaznavi AM. Flap survival and functional outcomes in elbow soft tissue reconstruction: A 25-year systematic review. J Plast Reconstr Aesthet Surg 2021; 75:991-1000. [PMID: 34961697 DOI: 10.1016/j.bjps.2021.11.091] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 11/14/2021] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Different elbow flap reconstructions have been described in the literature. We aim to define the optimal flap technique based on defect size and etiology. METHODS A systematic review was undertaken using the terms "(Elbow reconstruction) AND ((Soft tissue) OR (flap))". Flaps were grouped under fasciocutaneous (FCF), muscular (MF), distant pedicled (DPF), and free flaps (FF). The primary outcome was flap survival. The secondary outcomes were postoperative complications and range of motion (pROM). RESULTS Twenty articles with 224 patients were included. Defect sizes were small (<10 cm2) (18%), medium (10-30 cm2) (23%), large (30-100 cm2) (43%), and massive (>100 cm2) (16%). Etiologies included trauma (26%), burn contractures (26%), infection (26%), hardware coverage (16%), and others (6%). FCF (54%) was the preferred flap followed by MF (28%), DPF (13%), and FF (5%). The rate of flap necrosis was 4% and that of other complications was 10%. The postoperative range of motion (pROM) (reported in 154 patients) was >100°, 50-100°, and <50° in 82%, 17%, and 1% of the cases, respectively. Small defects were most commonly reconstructed with MFs (83%), medium defects were reconstructed with MFs (52%) or FCFs (46%), and large defects were reconstructed with FCFs (91%). Massive defects predominantly required DPFs (60%) and FFs (26%). FCFs were the most common reconstruction method for burn contractures (84%), infections (55%), and traumatic defects (51%). Hardware coverage was predominantly performed using MFs (86%). No difference in complications and pROM was found between flap techniques. CONCLUSION Elbow flap reconstruction can be performed using different techniques. FCFs are the most commonly used reconstruction method. MFs are useful for smaller defects and hardware coverage. DPFs and FFs are needed for massive injuries.
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Affiliation(s)
- Bora Kahramangil
- Department of General Surgery, Cleveland Clinic Florida, Weston, FL, United States
| | - Giovanna Pires
- Florida Atlantic University Schmidt College of Medicine, Boca Raton, FL, United States
| | - Amir M Ghaznavi
- Department of Plastic Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, Weston, FL 33331, United States.
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Gerakopoulos E, Colegate-Stone T, O'Connor EF, Rose V. The use of the anterolateral thigh vascular free flap in complex open elbow fractures after major trauma - An illustrated report of an interesting case. Trauma Case Rep 2021; 34:100463. [PMID: 34258369 PMCID: PMC8259302 DOI: 10.1016/j.tcr.2021.100463] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/13/2021] [Indexed: 11/28/2022] Open
Abstract
Major trauma may result in severe open elbow fractures with significant soft tissue injury and skin loss. Reconstruction of those defects can be complicated and inadequate cover can result in severely limited functional outcome. The free anterolateral thigh flap (ALT) is one of the ways to reconstruct those defects. Its utilisation in severe complex open elbow fractures is recently being increased due to its advantages. The purpose of this article is to present an interesting case where the ALT flap was used with success in a challenging situation of a severe elbow bony, ligamentous and soft tissue injury. Our case has demonstrated that the ALT flap presents an effective method in treating successfully severe open elbow fractures, and its advantages include 1)large amount of available skin and subcutaneous tissue for coverage of the elbow joint without creating strictures, 2)potential of using the vascularised vastus lateralis muscle to minimise the residual dead space in order to prevent infection and as a vascular bed for nerve grafting and 3) the ability to harvest fascia lata grafts and use them to reconstruct ligamentous and tendinous injuries. We recommend the use of the vascularised ALT flap when treating severe open elbow fractures.
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Koteswara Rao Rayidi V, Prakash P, Srikanth R, Sreenivas J, Swathi K. Anterolateral Thigh Flap-the Optimal Flap in Coverage of Severe Elbow Injuries. Indian J Plast Surg 2020; 52:314-321. [PMID: 31908370 PMCID: PMC6938428 DOI: 10.1055/s-0039-3401470] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Accepted: 10/15/2019] [Indexed: 10/25/2022] Open
Abstract
Introduction Traditionally, the latissimus dorsi muscle with or without skin paddle has been the flap of choice for coverage of elbow defects. The ALT flap has found application in elective upper limb defects on account of it's ability to be tailor made for individual defects. Our series of 10 cases shows the advantages of using this flap for acute trauma defects. Materials and Methods Consecutive 10 cases of severe elbow injuries, involving varying amounts of the lower arm and proximal forearm underwent debridement followed by coverage using the free anterolateral thigh flap. Nine of 10 arterial anastomosis were done end to side to the brachial artery and venous anastomosis to the veins accompanying the artery. Seven of these patients had long bone fractures and elbow dislocations, stabilised using external fixator. Four patients needed primary muscle or tendon repair and nerve repair or graft. Results There was 1 total flap loss, intraoperatively where a TFL flap had been used in a 71 year-old patient. Nine of 10 had successful wound coverage. Using Jupiter criteria, 2 had excellent, 3 had good, 3 had fair, and 1 had poor outcome. Conclusion This consecutive series of moderate and severe elbow injuries demonstrates that the ALT flap should be considered as the flap of first choice, specifically when there is a need.
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Affiliation(s)
| | - Panagatla Prakash
- Department of Plastic Surgery, Nizams Institute of Medical Sciences, Hyderabad, India
| | - R Srikanth
- Department of Plastic Surgery, Nizams Institute of Medical Sciences, Hyderabad, India
| | | | - Karavattula Swathi
- Department of Plastic Surgery, Nizams Institute of Medical Sciences, Hyderabad, India
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Brachioradialis muscle flap for posterior elbow defects: a simple and effective solution for the upper limb surgeon. J Shoulder Elbow Surg 2019; 28:1476-1483. [PMID: 31227467 DOI: 10.1016/j.jse.2019.03.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Revised: 03/12/2019] [Accepted: 03/13/2019] [Indexed: 02/01/2023]
Abstract
BACKGROUND Trauma, infection, and posterior surgical approach are the most frequent causes of soft tissue defects of posterior elbow. The brachioradialis (BR) muscle flap is a rotational muscular pedicled flap, and the dominant vascular pedicle arises from the radial recurrent artery in the proximal portion of the muscle. The aim of the study was to present the BR muscle flap as a simple, safe, and effective solution for the treatment of soft tissue defects of the posterior elbow. METHODS Five patients (3 males; mean age, 61.4 years; range, 40-73 years) with soft tissue defects of the posterior elbow underwent surgical treatment with the BR muscle flap. The causes of the defects were total elbow arthroplasty and postsurgical infection (n = 2), 1 patient with elbow arthrodesis due to neuropathic arthropathy, and postsurgical infection after open reduction and internal fixation of olecranon fractures (n = 2). All patients had a BR muscle flap and skin grafting. Orthopedic hardware was removed in 3 cases. RESULTS At the mean follow-up of 45 months (range, 26-61 months), all patients had viable and functional soft tissue coverage. All patients were free of infection, whereas 1 patient had a posterior elbow discomfort in daily activities. None of the patients reported wrist problems. CONCLUSIONS The BR muscle flap is a reliable solution, easy to harvest without requiring microsurgical expertise for small-size posterior elbow defects. It is a 1-stage procedure with no morbidity to the harvest site that provides stable and adequate coverage even in cases with postoperative infection.
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Kish AJ, Pensy RA. The Mangled Extremity: An Update. CURRENT SURGERY REPORTS 2019. [DOI: 10.1007/s40137-019-0226-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Antegrade Posterior Interosseous Flap for Nonhealing Wounds of the Elbow: Anatomical and Clinical Study. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2018; 6:e1959. [PMID: 30881783 PMCID: PMC6414117 DOI: 10.1097/gox.0000000000001959] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Accepted: 08/08/2018] [Indexed: 11/26/2022]
Abstract
Background: The posterior interosseous artery (PIA) flap has been widely reported to cover defects at the dorsal aspect of the hand. However, the use of this flap to cover elbow defects has been rarely reported. The purpose of this study was to analyze the anatomical feasibility of the PIA flap to cover elbow soft-tissue defects and, additionally, to review the clinical outcomes of patients treated with this flap. Methods: An anatomical study was performed on 14 cadaveric specimens to assess the number of PIA perforators at the distal third of the forearm, along with the distance of the perforators from the ulnar styloid. Additionally, the pedicle distance from the pivot point to the lateral epicondyle was recorded. A clinical study in 4 patients with elbow soft-tissue defects treated with the antegrade PIA was also performed to assess viability and clinical outcomes. Results: A mean of 3 perforators (range, 2–4) of the PIA were found in the distal third of the forearm. The pedicle distance from the pivot point to the lateral epicondyle was 10 cm (range, 8–11.5 cm). In the clinical study, all cases treated with the antegrade PIA flap showed satisfactory outcomes without loss of the flap or significant partial necrosis. Conclusion: In this limited series, the antegrade PIA flap has shown to be a reliable and effective alternative for treatment of soft-tissue defects at the elbow. The PIA perforators in the distal forearm and the pedicle length allow the flap to easily reach the elbow.
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A new local muscle flap for elbow coverage-the medial triceps brachii flap: anatomy, surgical technique, and preliminary outcomes. J Shoulder Elbow Surg 2018; 27:733-738. [PMID: 29396099 DOI: 10.1016/j.jse.2017.11.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Revised: 11/11/2017] [Accepted: 11/14/2017] [Indexed: 02/01/2023]
Abstract
BACKGROUND The medial triceps brachii is vascularized by the middle collateral artery and the arterial circle of the elbow. This vascularization allows a distal pedicled use to cover soft tissue defects of the elbow. We report our experience using this flap to cover traumatic and postsurgical wounds. METHODS Patients who underwent a pedicled medial triceps brachii flap procedure between 2008 and 2015 were included. Data concerning characteristics of the patients, wound size, surgical technique, and complications were retrospectively reviewed. An independent observer examined patients and assessed outcome of the coverage procedure: wound healing, scar length, range of elbow motion, and patient satisfaction. RESULTS Eight patients were included (70.6 ± 17.7 years old at the time of surgery). All patients had serious comorbidities and risk factors of poor wound healing. Defects were due to postoperative healing complications (5 patients), skin necrosis secondary to an underlying olecranon fracture (1 patient), and direct open fractures (2 patients). Soft tissue defects had a median surface of 17 (14-22) cm2. The olecranon was exposed in 7 cases and the medial humeral epicondyle in 1 case. Mean procedure duration was 83 ± 14 minutes. There was no intraoperative or postoperative complication. All patients healed properly at 3 weeks of follow-up. No wound recurrence or surgery-related complication was reported after a median follow-up of 40.5 (21.5-69.5) months. CONCLUSION Favorable outcomes in all of our 8 patients make this flap an interesting option to cover small to medium-sized defects of the posterior aspect of the elbow.
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