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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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Shafarenko MS, Baltzer HL. The Use of a Novel Chimeric Flexor Carpi Ulnaris and Ulnar Artery Flap for Elbow Coverage. Hand (N Y) 2023:15589447231219713. [PMID: 38159242 DOI: 10.1177/15589447231219713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Abstract
Elbow defects have a number of etiologies and present a difficult task for the reconstructive surgeon. A number of reconstructive options have been previously reported. We describe a case of a 54-year-old woman with a recurrent elbow defect secondary to prior trauma, surgical fixation, and infection. This was successfully managed with a novel chimeric flexor capri ulnaris and ulnar artery flap for coverage of the defect, which has not been previously described. This may serve as a useful guide for surgeons moving forward.
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Safali S, Ozdemir A, Karaoglan M, Ertaş E, Acar M. Reconstruction of fracture associated skin defects on olecranon with antegrade posterior interosseous artery flap. TURKISH JOURNAL OF PLASTIC SURGERY 2023. [DOI: 10.4103/tjps.tjps_50_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
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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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Bezirgan U, Yoğun Y, Bilgin SS, Armangil M. Anterolateral Thigh Flap Coverage for Large Posterior Defects of the Elbow. Indian J Orthop 2022; 56:2169-2175. [PMID: 36507210 PMCID: PMC9705611 DOI: 10.1007/s43465-022-00760-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 09/29/2022] [Indexed: 02/04/2023]
Abstract
Purpose This study highlights the advantages and disadvantages of Anterolateral Thigh (ALT) free flap using the brachial artery as the recipient vessel in large posterior defects of the elbow with early mobilization. Methods Eight patients with a soft tissue defect on the posterior elbow underwent reconstruction with an ALT free flap. Average age and follow-up were 29.5 years (range, 18-43 years) and 54 months (range, 35-76 months), respectively. All defects were on the posterior side, and brachial arteries on the anterior side were used as the recipient artery in all cases. Four defects were created by tumor excision, four were exposed with hardware after fixation of distal humeral and/or proximal ulna fractures. The dimensions of defects were between 80 and 352 cm2. Cases were evaluated according to function (ROM), complications, tissue quality anticipated from reconstruction and immobilization time after the reconstruction. Results All flaps except one survived and met the tissue quality anticipated from this reconstruction. In the bigger flaps, an apparent ugly scar at the donor site was the main problem. The flap on the posterior, and recipient artery on the anterior had no adverse effects on early motion of the elbow. Two cases with fractures had minimal restriction of elbow movement due to post-traumatic stiff elbow. There was one case of partial flap loss after myocardial infarction. After the patient was medically stable, the remaining distal defect was closed with a pedicled radial forearm flap. Conclusion ALT free flap has numerous advantages in covering defects at the posterior elbow such as being pliable, thin and durable skin, with a long and reliable pedicle reaching the brachial artery without causing any problem in early motion and surgical reconstruction can be easily completed in the supine position.
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Affiliation(s)
- Uğur Bezirgan
- Hand Surgery Unit, Orthopedics and Traumatology Department, Ibn’i Sina Hospital, Ankara University Faculty of Medicine, Sıhhiye, Ankara, Turkey
| | - Yener Yoğun
- Hand Surgery Unit, Orthopedics and Traumatology Department, Ibn’i Sina Hospital, Ankara University Faculty of Medicine, Sıhhiye, Ankara, Turkey
| | | | - Mehmet Armangil
- Hand Surgery Unit, Orthopedics and Traumatology Department, Ibn’i Sina Hospital, Ankara University Faculty of Medicine, Sıhhiye, Ankara, Turkey
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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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Ete G, Paul K, Akamanchi AK, Cordelia M J F, Agarwal S. Pedicled thoracodorsal artery perforator flap in the soft-tissue reconstruction of an acute traumatic cubital fossa defect. J Plast Reconstr Aesthet Surg 2022; 75:2070-2076. [PMID: 35365410 DOI: 10.1016/j.bjps.2022.02.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 01/12/2022] [Accepted: 02/15/2022] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Complex cubital fossa injuries with bony and vascular injuries are not an uncommon clinical presentation after trauma to the elbow. The revascularization of the upper limb by brachial artery repair with the venous graft is paramount, followed by immediate cover with a sturdy flap to salvage the limb. The use of local muscle and fasciocutaneous flaps is limited in the setting of vascular injury. The pedicled latissimus dorsi muscle flap and abdominal flaps are routinely used with few advantages. This article describes the use of a pedicled thoracodorsal artery perforator flap in the management of acute traumatic cubital fossa defect. MATERIAL AND METHODS A retrospective observational study was performed from September 2015 to December 2020 with patients who underwent the pedicled TDAP flap as a soft-tissue cover of cubital fossa injuries primarily. Patient variables, including the size of defect and flap, the number of perforators, the complications, and the outcome, were recorded. RESULTS Eleven patients were included in the study. The majority of the patients were males (n = 10) and presented with a history of trauma in a road traffic accident (n = 6) or because of a fall from height (n = 4). All of them (n = 11) had some form of bony injury. Seven patients in this group required brachial artery repair with an interposition vein graft successfully covered with a TDAP flap. There was a constant dominant musculocutaneous perforator about 10-13 cm from the apex of the axilla. At discharge, all flaps had settled well. On follow-up ranging from 2 months to 2 years, the patients reported satisfactory outcomes.
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Affiliation(s)
- Geley Ete
- Department of Plastic Surgery, Christian Medical College, Vellore, India
| | - Kingsly Paul
- Department of Plastic Surgery, Christian Medical College, Vellore, India
| | | | - Felix Cordelia M J
- Department of Plastic Surgery, Christian Medical College, Vellore, India
| | - Shwetha Agarwal
- Department of Plastic Surgery, Christian Medical College, Vellore, India.
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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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Reverse-Flow Versus Perforator Propeller Lateral Arm Flap for Elbow Reconstruction. Ann Plast Surg 2020; 84:535-540. [DOI: 10.1097/sap.0000000000002143] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Kang Y, Pan X, Wu Y, Ma Y, Liu J, Rui Y. Subacute reconstruction using flap transfer for complex defects of the upper extremity. J Orthop Surg Res 2020; 15:134. [PMID: 32264917 PMCID: PMC7140501 DOI: 10.1186/s13018-020-01647-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2020] [Accepted: 03/24/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Despite advances in microsurgical techniques of flap transfer, complex upper extremity trauma reconstruction remains a challenge for surgeons. This study aimed to present the outcomes in using flaps in the subacute reconstruction of complex upper extremity injuries. METHODS From July 2013 to December 2016, 35 patients ranging in age from 23 to 69 years with complicated upper extremity traumatic injuries were treated using flap reconstruction in subacute period. The number and causes of injury were 12 machine crush injuries, 18 machine strangulation injuries, two chainsaw accidents, two traffic accidents, and one incident of heavy bruising. Thirty-five patients underwent flap procedures, including 24 anterolateral thigh flaps (68.57%), five latissimus dorsi flaps (14.29%), and six lateral arm flaps (17.14%). Flap sizes ranged from 3 × 4 to 42 × 16 cm2. The mean time of flap reconstruction was 14 days (range 5-29). During postoperative follow-up, flap appearance, sensory recovery, scarring and satisfaction were assessed. RESULTS The overall flap survival rate was 94.3%.Two flaps developed partial necrosis, both of which were later treated with skin grafting. Traumatic wound infections occurred in three patients. All upper limb injuries were completely covered. The follow-up periods ranged from 18 to 62 months with an average of 2.9 months. All skin flap textures were soft with varying degrees of pigmentation. Flap sensory recovery was S1 in three cases, S2 in eight cases, S3 in 15 cases, and S4 in nine cases. There were no donor site complications other than three cases with scar hyperplasia. CONCLUSIONS The severe upper limb soft tissue defects still achieved satisfactory function and appearance with negligible complications and low amputation rates during the subacute period.
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Affiliation(s)
- Yongqiang Kang
- Department of Traumatic Orthopedics, Wuxi Ninth People's Hospital affiliated to Soochow University, NO.999 Liangxi Road, Wuxi City, 214062, Jiangsu Province, China
| | - Xiaoyun Pan
- Orthopaedic Institute, Wuxi Ninth People's Hospital affiliated to Soochow University, Wuxi, Jiangsu, China
| | - Yongwei Wu
- Department of Traumatic Orthopedics, Wuxi Ninth People's Hospital affiliated to Soochow University, NO.999 Liangxi Road, Wuxi City, 214062, Jiangsu Province, China
| | - Yunhong Ma
- Department of Traumatic Orthopedics, Wuxi Ninth People's Hospital affiliated to Soochow University, NO.999 Liangxi Road, Wuxi City, 214062, Jiangsu Province, China
| | - Jun Liu
- Department of Traumatic Orthopedics, Wuxi Ninth People's Hospital affiliated to Soochow University, NO.999 Liangxi Road, Wuxi City, 214062, Jiangsu Province, China
| | - Yongjun Rui
- Department of Traumatic Orthopedics, Wuxi Ninth People's Hospital affiliated to Soochow University, NO.999 Liangxi Road, Wuxi City, 214062, Jiangsu Province, China.
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Trasolini NA, Chidester J, Ghiassi A, Stevanovic M. Brachioradialis Flap With Vascularized Lateral Ulnar Collateral Ligament Reconstruction: A Case Report. Hand (N Y) 2020; 15:NP37-NP41. [PMID: 31014087 PMCID: PMC7076624 DOI: 10.1177/1558944719843632] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: Soft tissue defects about the elbow with concurrent ligamentous instability can be challenging to treat. Methods: We present a case report of a lateral elbow wound that resulted in lateral ulnar collateral ligament deficiency and posterolateral elbow instability. Results: We describe our technique of a modified brachioradialis rotational flap, in which the muscle is rotated to cover the soft tissue defect, while the vascularized brachioradialis tendon is used to simultaneously reconstruct the lateral ulnar collateral ligament. This procedure successfully restored posterolateral elbow stability at the time of wound coverage. Conclusion: Elbow soft tissue defects with associated ligamentous injuries can be treated using a modification of the brachioradialis rotational flap.
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Affiliation(s)
- Nicholas A. Trasolini
- University of Southern California, Los Angeles, USA,Nicholas A. Trasolini, Keck Medical Center, University of Southern California, 1520 San Pablo Street, Suite 2000, Los Angeles, CA 90033, USA.
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Collins J. Surgical intervention and customised dressings in an extremity wound caused by necrotising fasciitis: a case study. J Wound Care 2019; 28:S21-S27. [PMID: 31067168 DOI: 10.12968/jowc.2019.28.sup5.s21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Necrotising fasciitis can result in extensive loss of soft tissue and limb function. Therefore, surgical intervention requires a balance between extensive tissue removal and saving the limb. A 56-year-old male presented with necrotising fasciitis of the upper extremity. Debridement resulted in a full-thickness wound of the forearm and upper arm, an exposed olecranon and two proximally-based skin flaps. Reconstruction required multiple debridements to optimise the wound for skin grafting and to obtain flap adherence to underlying tissues of the upper arm. Conventional dressings over the flaps proved unsuccessful. Therefore, a customised versatile dressing to address each area of the wound was developed. Negative pressure wound therapy (NPWT) was applied over the exposed muscle (no exposed bone or tendon) of the lower arm and anterior upper arm; a hydropolymer foam dressing covered the elbow region. Closed incision negative pressure wound therapy (ciNPT) was applied over the incision on the posterior upper arm. Ultimately, complete wound closure was achieved, with normal/near-normal range of motion for all joints of the affected limb. There was complete take of skin grafts on the wrist, lower arm and anterior upper arm. ciNPT was effective in holding the incision together and promoting healing of the posterior upper arm, and the hydropolymer foam dressing aided with healing and coverage of the elbow region. In this case, healing of a large, complex upper extremity wound and restored limb function were achieved following use of a combination of surgical techniques and customisation of wound therapy modalities.
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Affiliation(s)
- Jessica Collins
- Plastic & Reconstructive Surgery, OasisMD Lifestyle Healthcare, San Diego, CA, US
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Naalla R, Chauhan S, Dave A, Singhal M. Reconstruction of post-traumatic upper extremity soft tissue defects with pedicled flaps: An algorithmic approach to clinical decision making. Chin J Traumatol 2018; 21:338-351. [PMID: 30579714 PMCID: PMC6354178 DOI: 10.1016/j.cjtee.2018.04.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2018] [Revised: 04/24/2018] [Accepted: 05/01/2018] [Indexed: 02/04/2023] Open
Abstract
PURPOSE Pedicled flaps are still the workhorse flaps for reconstruction of upper limb soft tissue defects in many centers across the world. They are lifeboat options for coverage in vessel deplete wounds. In spite of their popularity existing algorithms are limited to a particular region of upper limb; a general algorithm involving entire upper limb which helps in clinical decision making is lacking. We attempt to propose one for the day to day clinical practice. METHODS A retrospective analysis of patients who underwent pedicled flaps for coverage of post-traumatic upper extremity (arm, elbow, forearm, wrist & hand) soft tissue defects within the period of January 2016 to October 2017 was performed. Patients were divided into groups according to the anatomical location of the defects. The flaps performed for different anatomical regions were enlisted. Demographic data and complications were recorded. An algorithm was proposed based on our experience, with a particular emphasis made to approach to clinical decision making. RESULTS Two hundred and twelve patients were included in the study. Mean age was 27.3 years (range: 1-80 years), 180 were male, and 32 were female. Overall flap success rate was 98%, the following complications were noted marginal flap necrosis requiring no additional procedure other than local wound care in 32 patients (15%), partial flap necrosis requiring flap advancement or extra flap in 15 patients (7%), surgical site infection in 11 patients (5%), flap dehiscence requiring re-suturing in 5 patients (2.4%), total flap necrosis 4 patients (2%). CONCLUSION The proposed algorithm allows a reliable and consistent method for addressing diverse soft tissue defects in the upper limb with high success rate.
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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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Gandolfi S, Auquit-Auckbur I, Poirot Y, Bonmarchand A, Mouton J, Carloni R, Nseir I, Duparc F. Focus on anatomical aspects of soft tissue coverage options in elbow reconstruction: an updating review. Surg Radiol Anat 2018; 40:943-954. [DOI: 10.1007/s00276-018-2066-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Accepted: 07/05/2018] [Indexed: 11/30/2022]
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Forearm-Based Turnover Muscle Flaps for Elbow Soft-Tissue Reconstruction: A Comparison of Regional Coverage Based on Distal Flap Perfusion. Plast Reconstr Surg 2018; 142:152-157. [PMID: 29652763 DOI: 10.1097/prs.0000000000004472] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Elbow wounds pose a reconstructive challenge. Prior studies have described the vascular anatomy of both the brachioradialis and flexor carpi ulnaris muscle flaps. The goal of this study was to describe the distal flap perfusion of the flexor carpi radialis, with a direct comparison of the brachioradialis, flexor carpi ulnaris, and flexor carpi radialis muscle flaps for coverage around the elbow. METHODS Six fresh-frozen upper extremity specimens were dissected for brachioradialis, flexor carpi radialis, and flexor carpi ulnaris flaps. Vascular data from prior studies were combined with our anatomical measurements to determine the area of perfused coverage around the elbow for the brachioradialis and flexor carpi ulnaris. The flexor carpi radialis flap distal vascular perfusion was examined separately with transverse sections at 1-cm intervals after India ink injections to determine distal flap perfusion and elbow coverage. Perfusion data were plotted on x and y axes over the posterior elbow. RESULTS The brachioradialis muscle covered an average of 56 percent of the x axis and 7.4 percent of the y axis. The flexor carpi ulnaris muscle covered an average of 90 percent of the elbow along the x axis and 23.3 percent of elbow along the y axis. The flexor carpi radialis covered an average of 34 percent of the x axis and 4.8 percent of the y axis. CONCLUSION The flexor carpi ulnaris muscle provides the most versatile and robust coverage over the posterior elbow, followed by the brachioradialis muscle, which consistently provides coverage over the lateral epicondyle.
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Tabakan İ, Eser C, Gencel E, Kesiktaş E, Yavuz OM. Radial kollateral arter perforatör bazlı propellar flep ile dirsek bölgesi rekonstrüksiyonu. CUKUROVA MEDICAL JOURNAL 2018. [DOI: 10.17826/cumj.341429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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Kim HJ, Kim JY, Kee YM, Rhee YG. Total elbow arthroplasty under unfavourable soft tissue conditions. INTERNATIONAL ORTHOPAEDICS 2017; 42:367-374. [PMID: 29209741 DOI: 10.1007/s00264-017-3704-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Accepted: 11/21/2017] [Indexed: 11/25/2022]
Abstract
PURPOSE To evaluate the clinical and radiographic outcomes of patients with total elbow arthroplasty (TEA) and soft tissue reconstruction. METHODS We investigated six patients who underwent TEA and soft tissue reconstruction (two elbows with 1-stage surgery and four elbows with 2-stage surgery). The mean patient age at the time of the surgical procedure was 43.2 years; the mean follow-up duration was 88.2 months. RESULTS The mean pain visual analogue scale (VAS) during motion was improved from 6.3 pre-operatively to 0.7 at the last follow-up. The mean Mayo Elbow Performance Score (MEPS) improved from 26.7 pre-operatively to 81.7 at the last follow-up. The mean flexion-extension arcs of the 1- and 2-stage surgery groups increased from 12.5° and 13.8° pre-operatively to 72.5° and 100° at the last follow-up, respectively. The mean MEPS of the one and two stage surgery groups were 75 and 85, respectively, at the last follow-up. One of the six elbows had loosening on the simple radiograph at the last follow-up, and there were no cases with bushing wear. Three elbows needed additional skin debridement owing to wound complications (2/2 elbows in the 1-stage surgery group and 1/4 elbows in the 2-stage surgery group). CONCLUSIONS Under unfavorable soft tissue conditions, performing soft tissue reconstruction with TEA provides satisfactory functional improvement and pain relief. The two stage surgery provided a lower rate of wound complication and better elbow function than the one stage surgery, which led to high patient satisfaction post-operatively. LEVEL OF EVIDENCE Therapeutic Level IV.
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Affiliation(s)
- Hwan Jin Kim
- Shoulder & Elbow Clinic, Department of Orthopaedic Surgery, College of Medicine, Kyung Hee University, 1 Hoegi-dong, Dongdaemun-gu, Seoul, 130-702, Korea
| | - Jung Youn Kim
- Department of Orthopaedic Surgery, Hangang Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea
| | - Young Moon Kee
- Shoulder & Elbow Clinic, Department of Orthopaedic Surgery, College of Medicine, Kyung Hee University, 1 Hoegi-dong, Dongdaemun-gu, Seoul, 130-702, Korea
| | - Yong Girl Rhee
- Shoulder & Elbow Clinic, Department of Orthopaedic Surgery, College of Medicine, Kyung Hee University, 1 Hoegi-dong, Dongdaemun-gu, Seoul, 130-702, Korea.
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Wound breakdown reconstructed by reverse lateral arm flap after excision of heterotopic ossification of the elbow following severe burn injury: A case report. BURNS OPEN 2017. [DOI: 10.1016/j.burnso.2017.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Zimmer ZR, Horneff JG, Taylor RM, Levin LS, Kovach S, Mehta S. Evaluation and Treatment of Open Distal Humeral Fractures. JBJS Rev 2017; 5:01874474-201701000-00005. [PMID: 28135232 DOI: 10.2106/jbjs.rvw.16.00024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Zachary R Zimmer
- 1Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania2Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania3Department of Orthopaedic Surgery, University of Texas Health Science Center at Houston, Houston, Texas
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Maximizing Outcomes While Minimizing Morbidity: An Illustrated Case Review of Elbow Soft Tissue Reconstruction. PLASTIC SURGERY INTERNATIONAL 2016; 2016:2841816. [PMID: 27313886 PMCID: PMC4903136 DOI: 10.1155/2016/2841816] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/20/2015] [Accepted: 12/02/2015] [Indexed: 11/17/2022]
Abstract
Background. Injuries to the elbow have led to consequences varying from significant limitation in function to loss of the entire upper limb. Soft tissue reconstruction with durable and pliable coverage balanced with the ability to mobilize the joint early to optimize rehabilitation outcomes is paramount. Methods. Methods of flap reconstruction have evolved from local and pedicled flaps to perforator-based flaps and free tissue transfer. Here we performed a review of 20 patients who have undergone flap reconstruction of the elbow at our institution. Discussion. 20 consecutive patients were identified and included in this study. Flap types include local (n = 5), regional pedicled (n = 7), and free (n = 8) flaps. The average size of defect was 138 cm(2) (range 36-420 cm(2)). There were no flap failures in our series, and, at follow-up, the average range of movement of elbow flexion was 100°. Results. While the pedicled latissimus dorsi flap is the workhorse for elbow soft tissue coverage, advancements in microvascular knowledge and surgery have brought about great benefit, with the use of perforator flaps and free tissue transfer for wound coverage. Conclusion. We present here our case series on elbow reconstruction and an abbreviated algorithm on flap choice, highlighting our decision making process in the selection of safe flap choice for soft tissue elbow reconstruction.
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Camuzard O, Foissac R, Clerico C, Fernandez J, Balaguer T, Ihrai T, de Peretti F, Baqué P, Boileau P, Georgiou C, Bronsard N. Inferior Cubital Artery Perforator Flap for Soft-Tissue Coverage of the Elbow: Anatomical Study and Clinical Application. J Bone Joint Surg Am 2016; 98:457-65. [PMID: 26984913 DOI: 10.2106/jbjs.o.00760] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Soft-tissue defects surrounding the elbow can be a challenging problem for the orthopaedic surgeon. Reliable reconstruction with use of muscular flaps or even perforator flaps derived from the surrounding vessels has been described. The inferior cubital artery (ICA) is an indirect septocutaneous perforator branch that most frequently arises from the lateral side of the radial artery. The purposes of the present study were to characterize the capillary cutaneous perforators of the ICA and to evaluate the potential of a local perforator flap procedure for soft-tissue coverage of the elbow. METHODS Twenty fresh cadaveric forearms were dissected in order to describe the ICA anatomy, and in ten additional forearms the ICA was selectively injected with a red ink solution to detail the ICA vascular territory. For each artery, we recorded the site of origin, the diameter of the artery at its source, the course of the artery, and the number, type, and diameter of capillary cutaneous perforators. RESULTS A total of seventy-eight ICA capillary perforators were analyzed from the twenty dissected forearms: forty-six were in-transit capillary perforators, nineteen were terminal capillary perforators, and thirteen were musculocutaneous capillary perforators. Of these seventy-eight perforators, sixteen (21%) had a caliber of <0.5 mm and sixty-two capillary perforators (79%) had a caliber of ≥0.5 mm. Ten ICAs were selectively injected, and the mean size of all stained skin areas was 30.9 ± 11.9 cm(2). A perforator pedicled flap was readily feasible for all dissections. We also describe the case of a patient with a medial soft-tissue defect of the elbow that was covered with a pedicled perforator flap based on an ICA. The patient had satisfactory healing at two months. CONCLUSIONS The ICA flap is a reliable and useful flap for elbow soft-tissue reconstruction. CLINICAL RELEVANCE The perforator flap procedure is a major advancement in reconstructive surgery. One potential application of the perforator flaps is the use of tissue adjacent to a defect as a perforator-based island flap. The use of this tissue allows for thinner flaps to be tailored for more accurate reconstruction. A flap that depends on a perforator branch of the radial artery called the inferior cubital artery seems to be an excellent solution for soft-tissue coverage of the elbow.
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Affiliation(s)
- Olivier Camuzard
- Service de Chirurgie Réparatrice et de la Main (O.C., R.F., C.C., J.F., T.B., C.G.), Service de Traumatologie (F.de P., N.B.), and Service d'Orthopédie (P.B.), CHU de Nice, Nice, France Laboratoire d'Anatomie Humaine, Faculté de Médecine de Nice, Nice, France UMR E-4320 MATOs CEA/iBEB/SBTN-CAL, Université Nice Sophia Antipolis, Faculté de Médecine, Nice, France
| | - Rémi Foissac
- Service de Chirurgie Réparatrice et de la Main (O.C., R.F., C.C., J.F., T.B., C.G.), Service de Traumatologie (F.de P., N.B.), and Service d'Orthopédie (P.B.), CHU de Nice, Nice, France
| | - Cyril Clerico
- Service de Chirurgie Réparatrice et de la Main (O.C., R.F., C.C., J.F., T.B., C.G.), Service de Traumatologie (F.de P., N.B.), and Service d'Orthopédie (P.B.), CHU de Nice, Nice, France
| | - Jonathan Fernandez
- Service de Chirurgie Réparatrice et de la Main (O.C., R.F., C.C., J.F., T.B., C.G.), Service de Traumatologie (F.de P., N.B.), and Service d'Orthopédie (P.B.), CHU de Nice, Nice, France
| | - Thierry Balaguer
- Service de Chirurgie Réparatrice et de la Main (O.C., R.F., C.C., J.F., T.B., C.G.), Service de Traumatologie (F.de P., N.B.), and Service d'Orthopédie (P.B.), CHU de Nice, Nice, France
| | - Tarik Ihrai
- Service de Chirurgie Oncologique Réparatrice, CAL, Nice, France
| | - Fernand de Peretti
- Service de Chirurgie Réparatrice et de la Main (O.C., R.F., C.C., J.F., T.B., C.G.), Service de Traumatologie (F.de P., N.B.), and Service d'Orthopédie (P.B.), CHU de Nice, Nice, France Laboratoire d'Anatomie Humaine, Faculté de Médecine de Nice, Nice, France
| | - Patrick Baqué
- Laboratoire d'Anatomie Humaine, Faculté de Médecine de Nice, Nice, France
| | - Pascal Boileau
- Service de Chirurgie Réparatrice et de la Main (O.C., R.F., C.C., J.F., T.B., C.G.), Service de Traumatologie (F.de P., N.B.), and Service d'Orthopédie (P.B.), CHU de Nice, Nice, France
| | - Charalambos Georgiou
- Service de Chirurgie Réparatrice et de la Main (O.C., R.F., C.C., J.F., T.B., C.G.), Service de Traumatologie (F.de P., N.B.), and Service d'Orthopédie (P.B.), CHU de Nice, Nice, France
| | - Nicolas Bronsard
- Service de Chirurgie Réparatrice et de la Main (O.C., R.F., C.C., J.F., T.B., C.G.), Service de Traumatologie (F.de P., N.B.), and Service d'Orthopédie (P.B.), CHU de Nice, Nice, France Laboratoire d'Anatomie Humaine, Faculté de Médecine de Nice, Nice, France
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Dumitrascu DI, Georgescu AV. Pedicled perforator flaps for covering the elbow region. A case report. ACTA ACUST UNITED AC 2016; 88:560-2. [PMID: 26732233 PMCID: PMC4689252 DOI: 10.15386/cjmed-592] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Accepted: 10/05/2015] [Indexed: 11/23/2022]
Abstract
Covering the elbow soft tissue defects is a difficult task for the plastic surgeon. Because of, the important anatomical structures situated superficially and the high tendency for stiffness of the elbow, the reconstructive method must be chosen carefully. Traditionally the free flaps were the choice method for elbow reconstruction. In our department, we use the perforator pedicled flaps for covering elbow defects, as a viable alternative to the free microsurgical transfer. This paper presents a successful case of covering an elbow soft tissue defect in a male patient. By using a local pedicled flap we replaced "like with like" to obtain a very good cosmetic result. The lack of microsurgical anastomosis allowed an early physical therapy.
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Affiliation(s)
- Dinu I Dumitrascu
- Clinic for Plastic Surgery and Reconstructive Microsurgery, Rehabilitation Hospital, Iuliu Hatieganu University of Medicine, Cluj-Napoca, Romania
| | - Alexandru V Georgescu
- Clinic for Plastic Surgery and Reconstructive Microsurgery, Rehabilitation Hospital, Iuliu Hatieganu University of Medicine, Cluj-Napoca, Romania
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Clinical Outcomes of the Flexor Carpi Ulnaris Turnover Flap for Posterior Elbow Soft Tissue Defects. J Hand Surg Am 2015; 40:2358-63. [PMID: 26612633 DOI: 10.1016/j.jhsa.2015.09.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Revised: 09/02/2015] [Accepted: 09/08/2015] [Indexed: 02/02/2023]
Abstract
PURPOSE To report the clinical outcomes from 2 academic centers of the flexor carpi ulnaris (FCU) flap for coverage of posterior elbow soft tissue defects. METHODS We retrospectively reviewed 17 patients who underwent an FCU flap for posterior elbow wound reconstruction over an 8-year period at 2 academic centers. Outcome measures included visual analog score for pain; Disabilities of the Arm, Shoulder, and Hand score; Mayo Elbow Performance score; range of motion; wound healing; grip strength; and isokinetic dynamometry for wrist flexion. Wilcoxon signed-rank test was used to make side-to-side comparisons between the operative and nonsurgical extremities, and nonparametric statistical methods were used to analyze results. RESULTS All wounds healed successfully without need for revision surgery. Average visual analog, Disabilities of the Arm, Shoulder, and Hand, and Mayo Elbow Performance scores in the operative elbow were 1.8, 34, and 86, respectively. Average elbow arc of motion was 11° to 140° with 70° forearm pronation and 73° forearm supination. Compared with the nonsurgical side, grip strength on the operated side was 97% and wrist flexion peak torque was 89%. The operative limb had an average wrist flexion fatigue of 7%, compared with 22% for the nonsurgical arm. CONCLUSIONS Patients receiving an FCU flap had reliable healing, minimal pain, good functional outcomes, and no meaningful deficits in grip strength or wrist flexion strength. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Abstract
The elbow is a highly congruent trochoginglymoid joint allowing motion in both flexion-extension and pronosupination across 3 articulations. Therefore, treatment of fractures of the elbow can be technically challenging to manage, even after initial surgery. The posttraumatic elbow is prone to complications such as stiffness associated with heterotopic ossification, instability or subluxation (posterolateral rotatory instability and varus posteromedial instability patterns), and wound complications. This article discusses the pathoanatomy, prevention, and treatment of these complications.
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Affiliation(s)
- Emilie V Cheung
- Orthopedic Surgery, Stanford University, 450 North Broadway Street, MC 6342, Redwood City, CA 94304, USA.
| | - Eric J Sarkissian
- Department of Orthopaedic Surgery, Stanford University Hospital and Clinics, 300 Pasteur Drive, Room R144, Stanford, CA 94305-5341, USA
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Abstract
The elbow is particularly prone to trauma, and soft-tissue reconstruction can be challenging given the inherent motion, pressure, and lack of local tissue laxity. Small wounds and those without exposure of vital structures may be amenable to primary repair. Large wounds and those requiring more substantial structural or anatomic repair may require local, regional or free flap-based reconstruction. A comprehensive review of soft-tissue reconstruction of the elbow is provided to offer surgeons alternative options in complicated upper extremity wounds.
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Affiliation(s)
- Brian P. Kelley
- House Officer, Section of Plastic Surgery, The University of Michigan Health System
| | - Kevin C. Chung
- Professor of Surgery, Section of Plastic Surgery, Assistant Dean for Faculty Affairs, The University of Michigan Medical School
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28
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Gong X, Cui JL, Lu LJ. The medial arm pedicled perforator flap: application of phenomenon of one perforator perfusing multiple perforator angiosomes. Injury 2014; 45:2025-8. [PMID: 25294118 DOI: 10.1016/j.injury.2014.09.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2014] [Revised: 09/03/2014] [Accepted: 09/07/2014] [Indexed: 02/02/2023]
Abstract
BACKGROUND The medial arm is an optimal potential donor site for treating skin defects around the elbow. However, whether a reliable pedicled perforator flap could be harvested from the medial arm remains unanswered. The purpose of this study was to report the technique and our results using the medial arm pedicled perforator flaps. METHODS A total of eight flaps in seven patients underwent the medial arm pedicled perforator flaps to treat skin defects around the elbow. The flap was pedicled on one perforator 1.3±0.3mm in diameter within 3cm above the medial epicondyle. The flap size varied between 10 and 20cm in length and between 6 and 10cm in width. RESULTS Of the eight flaps in seven patients, seven flaps survived uneventfully except that one suffered venous insufficiency. Six patients were followed up for 1 month to 2 years. One patient was lost to follow-up after 7 days. The wounds in all patients healed satisfactorily. No deep wound infection and wound dehiscence developed. No revision surgery was performed in the survived flaps. CONCLUSIONS The survival of the medial arm pedicled perforator flap confirms the phenomenon of one perforator perfusing multiple perforator angiosomes in the medial arm, although this study has the retrospective clinical nature and limited number of the patients. The medial arm pedicled perforator flap is a useful tool to treat skin defects around the elbow.
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Affiliation(s)
- Xu Gong
- Department of Hand Surgery, The First Hospital of Ji Lin University, Chang Chun, Ji Lin 130021, China.
| | - Jian Li Cui
- Department of Hand Surgery, The First Hospital of Ji Lin University, Chang Chun, Ji Lin 130021, China.
| | - Lai Jin Lu
- Department of Hand Surgery, The First Hospital of Ji Lin University, Chang Chun, Ji Lin 130021, China.
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Andre A, Bonnevialle N, Grolleau JL, Mansat P. Soft-tissue coverage of olecranon with musculocutaneous flexor carpi ulnaris flap. Orthop Traumatol Surg Res 2014; 100:963-6. [PMID: 25459453 DOI: 10.1016/j.otsr.2014.09.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2013] [Revised: 07/20/2014] [Accepted: 09/11/2014] [Indexed: 02/02/2023]
Abstract
Coverage of the olecranon area is always challenging in traumatology. Because of the superficial situation of the bone, the absence of muscle, the thinness of the skin and the subcutaneous tissue locally, skin defects are not uncommon and can lead to exposure of hardware or prostheses. We report an original surgical technique using a musculocutaneous flap from the flexor carpi ulnaris (FCU) with a proximal pedicle to cover the olecranon area, detailing its limits and indications. The FCU flap has become our first-choice procedure to cover olecranon skin defects because of its low morbidity, its reliability, and its straightforward procedure, obviating the need for any microsurgery technique. Furthermore, it allows moving the elbow, immediately decreasing the risk of elbow stiffness.
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Affiliation(s)
- A Andre
- Unité de chirurgie réparatrice des membres, Institut de l'appareil locomoteur, CHU de Toulouse, place Baylac, 31059 Toulouse cedex, France.
| | - N Bonnevialle
- Unité de chirurgie réparatrice des membres, Institut de l'appareil locomoteur, CHU de Toulouse, place Baylac, 31059 Toulouse cedex, France
| | - J-L Grolleau
- Unité de chirurgie réparatrice des membres, Institut de l'appareil locomoteur, CHU de Toulouse, place Baylac, 31059 Toulouse cedex, France
| | - P Mansat
- Unité de chirurgie réparatrice des membres, Institut de l'appareil locomoteur, CHU de Toulouse, place Baylac, 31059 Toulouse cedex, France
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Microsurgical Pedicle Lengthening for Pedicled Thoracodorsal Artery Perforator Flap Transfer. Ann Plast Surg 2014; 73:174-6. [DOI: 10.1097/sap.0b013e31827100c2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
Elbow and forearm wounds have distinct reconstructive requirements, but both require a durable and pliable solution. Pedicle, free fasciocutaneous and muscle, and distant (2-stage) flaps have a role in wound reconstruction in these unique areas. This article presents practical surgical cases as a guide to soft tissue reconstruction of the elbow and forearm.
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Affiliation(s)
- Joshua M Adkinson
- Section of Plastic Surgery, Department of Surgery, University of Michigan Health System, 2130 Taubman Center, SPC 5340, 1500 East Medical Center Drive, Ann Arbor, MI 48109-5340, USA
| | - Kevin C Chung
- Section of Plastic Surgery, University of Michigan Medical School, 2130 Taubman Center, SPC 5340, 1500 East Medical Center Drive, Ann Arbor, MI 48109-5340, USA.
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Reconstruction of cubital fossa skin necrosis with radial collateral artery perforator-based propeller flap (RCAP). ANN CHIR PLAST ESTH 2014; 59:65-9. [DOI: 10.1016/j.anplas.2013.05.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2013] [Accepted: 05/22/2013] [Indexed: 11/23/2022]
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Hayn E. Successful treatment of complex traumatic and surgical wounds with a foetal bovine dermal matrix. Int Wound J 2013; 11:675-80. [PMID: 23452161 DOI: 10.1111/iwj.12028] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2012] [Revised: 11/15/2012] [Accepted: 12/10/2012] [Indexed: 01/01/2023] Open
Abstract
A foetal bovine dermal repair scaffold (PriMatrix, TEI Biosciences) was used to treat complex surgical or traumatic wounds where the clinical need was to avoid skin flaps and to build new tissue in the wound that could be reepithelialised from the wound margins or closed with a subsequent application of a split-thickness skin graft (STSG). Forty-three consecutive cases were reviewed having an average size of 79·3 cm(2) , 50% of which had exposed tendon and/or bone. In a subset of wounds (44·7%), the implantation of the foetal dermal collagen scaffold was also augmented with negative pressure wound therapy (NPWT). Complete wound healing was documented in over 80% of the wounds treated, whether the wound was treated with the foetal bovine dermal scaffold alone (95·2%) or when supplemented with NPWT (82·4%). The scaffold successfully incorporated into wounds with exposed tendon and/or bone to build vascularised, dermal-like tissue. The new tissue in the wound supported STSGs however, in the majority of the cases (88·3%); wound closure was achieved through reepithelialisation of the incorporated dermal scaffold by endogenous wound keratinocytes. The foetal bovine dermal repair scaffold was found to offer an effective alternative treatment strategy for definitive closure of challenging traumatic or surgical wounds on patients who were not suitable candidates for tissue flaps.
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Affiliation(s)
- Ernesto Hayn
- Plastic Surgery of Palm Beach, Wellington, FL, USA
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Abstract
Sweeping injuries of the elbow characterized by traumatic loss of medial or lateral epicondyles, collateral ligaments, and surrounding soft tissue result in loss of joint stability. Reconstruction of medial or lateral collateral ligaments is challenging due to loss of the cortical bone and the resultant difficulty in identifying the isometric attachment point. We describe a unique injury pattern and a surgical technique to restore joint stability using a bone tendon (Achilles) allograft. The technique was applied to 4 consecutive patients with a mean age of 35 (22-57) years and a mean follow-up of 20 months. Three patients with the lateral sweep injury had losses of the lateral epicondyle, lateral collateral ligament along with radial nerve palsy in 2. One patient with the medial sweep injury lost the medial epicondyle, medial collateral ligament, and had ulnar nerve palsy. All patients had an unstable ulnohumeral joint and underwent bone-tendon allograft (Achilles) reconstruction. The elbow joint was covered with a rotational radial forearm flap in 1 patient: myofasciocutaneous-free gracilis flap in 1 and rotational fasciomyocutaneous latissimus dorsi flap in 2 patients. One patient had an open reduction and internal fixation of distal third humerus shaft fracture, intercalary nerve grafting to the ulnar nerve, and repair of the brachial artery. At the final follow-up, average elbow motion was 115 degrees. Radiographic bone-to-bone healing was achieved in all patients. According to the American Shoulder and Elbow Surgeon's Assessment; average patient rated pain, function, and satisfaction scores were 3.4, 2.3, and 5, respectively. The average Disabilities of the Arm, Shoulder and Hand questionnaire score was 25. The use of bone-tendon allograft to reconstruct collateral ligaments of the elbow restored the elbow stability with a satisfactory functional outcome (evidence: level 4).
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Elbow reconstruction using island flap for burn patients. Arch Plast Surg 2012; 39:649-54. [PMID: 23233892 PMCID: PMC3518010 DOI: 10.5999/aps.2012.39.6.649] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2012] [Revised: 07/03/2012] [Accepted: 07/04/2012] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Deep burns of the elbow lead to soft tissue necrosis and infection, with exposure of deep structures. Adequate wound coverage of this area requires thin, pliable, and durable tissue, while optimal functional recovery requires early coverage and functional rehabilitation. We have found 3 types of island flaps that provide reliable coverage for the elbow. METHODS A retrospective study was performed on all patients who underwent flap coverage of an elbow defect at our hospital. The patients' data including age, sex, cause of injury, wound dimensions, timing of flap coverage, postoperative elbow motion, and complications were investigated. RESULTS Between 2001 and 2012, 16 patients were treated at our hospital. The mean age was 53.3 years. Three kinds of flaps were performed: 9 latissimus dorsi flaps, 4 lateral arm flaps, and 4 radial forearm flaps. The average defect size was 183.5 cm(2) (range, 28 to 670 cm(2)). Wound coverage was performed at mean duration of 45.9 days (range, 14 to 91 days). The mean postoperative active elbow flexion was 98° (range, 85° to 115°). Partial flap failure occurred in 1 latissimus dorsi flap. Minor complications included partial flap loss (11.8%), hematoma (23.5%), seroma (35.3%), and wound infection (5.9%). CONCLUSIONS Flap selection for elbow reconstruction is determined by the defect size and the extent of the adjacent tissue injury. Elbow reconstruction using an island flap is a single-staged, reliable, and relatively simple procedure that permits initiation of early rehabilitation, thereby improving a patient's functional outcome.
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Use of the fix and flap approach to complex open elbow injury: the role of the free anterolateral thigh flap. Arch Plast Surg 2012; 39:130-6. [PMID: 22783512 PMCID: PMC3385320 DOI: 10.5999/aps.2012.39.2.130] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2011] [Revised: 01/14/2012] [Accepted: 01/15/2012] [Indexed: 11/16/2022] Open
Abstract
Background Complex elbow injuries with associated nerve, muscle, or joint injury commonly develop post-inury stiffness. In order to preserve function, joint congruency, elbow stability and durable wound coverage must be achieved in a timely manner. Methods A retrospective review of patients who underwent orthopaedic fixation followed by free anterolateral thigh (ALT) flap soft tissue coverage was performed. Five patients were identified and included in this study. Results We present a series of 5 cases managed with this principle. Soft tissue defects ranged in size from 4×9 cm (36 cm2) to 15×30 cm (450 cm2) and were located either posteriorly (n=4) or anteriorly (n=1). Associated injuries included open fractures (n=3) and motor nerve transection (n=2). Wound coverage was achieved in a mean duration of 18.8 days (range, 11 to 42 day). There were no flap failures and no major complications. The mean postoperative active elbow motion was 102° (range, 45° to 140°). Conclusions In our small series we have highlighted the safety and utility of using the free ALT flap in complex elbow injuries. The ALT flap has many advantages which include abundant skin and subcutaneous tissue; vascularised vastus lateralis muscle that was used in our series to obliterate dead space, provide a vascular bed for nerve grafts and combat infection; and, access to fascia lata grafts for reconstruction of the triceps tendon.
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The "anconeus slide": rotation flap for management of posterior wound complications about the elbow. J Shoulder Elbow Surg 2011; 20:1310-6. [PMID: 21396832 DOI: 10.1016/j.jse.2010.11.031] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2010] [Revised: 11/18/2010] [Accepted: 11/27/2010] [Indexed: 02/01/2023]
Abstract
BACKGROUND Wound dehiscence at the tip of the olecranon is not an uncommon complication associated with surgical approaches to the elbow that involve a posterior skin incision. Various flaps have been described in the treatment of such soft tissue defects, but have associated morbidity. The "anconeus slide" rotation flap has low morbidity and is technically simple. In this study, we review the surgical technique and describe our experience with the anconeus rotation flap in 20 consecutive patients. METHODS The records of 20 patients who underwent an anconeus rotation flap by a single surgeon, from September 2006 to March 2010 were reviewed. The procedure was performed in the setting of total elbow arthroplasty (TEA) in 12 patients, revision total elbow arthroplasty in 3 patients, wound complications in 4 patients, and for an acute open distal humerus fracture in 1 patient. Patients were evaluated postoperatively for wound healing, pain, and postoperative Mayo Elbow Performance Scores (MEPS). RESULTS All 20 patients healed their surgical wounds completely. Postoperative MEPS scores averaged 79.3 (range, 50-100). CONCLUSION The anconeus rotational flap is a technically simple, reliable, and safe option for treatment of posterior wound complications about the elbow, and in the setting of primary and revision TEA when wound healing is a clinical concern. We recommend its use in patients who have either compromised posterior soft tissue coverage, triceps insufficiency, or factors associated with the potential for compromised wound healing.
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Jeon IH, Morrey BF, Anakwenze OA, Tran NV. Incidence and implications of early postoperative wound complications after total elbow arthroplasty. J Shoulder Elbow Surg 2011; 20:857-65. [PMID: 21641829 DOI: 10.1016/j.jse.2011.03.005] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2010] [Revised: 03/03/2011] [Accepted: 03/08/2011] [Indexed: 02/01/2023]
Abstract
HYPOTHESIS Other than an awareness, there is little detailed information regarding wound problems after total elbow arthroplasty. The purpose of this study was to (1) determine the incidence of wound complications after elbow arthroplasty, (2) document the long-term implications, (3) characterize risk factors, and (4) discuss a management strategy. We hypothesize that the incidence of this complication can be reduced with careful preoperative planning. MATERIALS AND METHODS We reviewed 1749 total elbow arthroplasties. The average patient age was 61.5 years (range; 30-91 years). Wound complications were diagnosed according to the criteria of the Centers for Disease Control and Prevention. RESULTS We identified and studied 97 patients (5.5%) from the 1749 procedures. The most common problems were delayed healing and drainage in 34 and wound hematoma in 33, of which 9 (27%) progressed to secondary deep infection. Of the 97 patients, 86 (88.7%) healed with the retention of the implant, 24 (∼25%) progressed to a septic elbow, and 11 (∼50%) required resection. Patients with rheumatoid arthritis represented 33% of the entire sample, but represented 45.8% of those with septic complications. Posttraumatic arthritis patients represented 58% of the entire sample and only 33% of those with septic problems (P < .05). CONCLUSIONS The overall incidence of serious wound complications was slightly less than anticipated; however, the significance was considerable. Patients with rheumatoid arthritis are most vulnerable. Persistent wound drainage showed a high correlation for deep infection and subsequent implant removal. Anticipation of potential problems and appropriate prophylactic management may avoid wound complications.
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Affiliation(s)
- In-Ho Jeon
- Department of Orthopedic Surgery, Asan Medical Center, School of Medicine, Ulsan University, Seoul, South Korea
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Payne DES, Kaufman AM, Wysocki RW, Richard MJ, Ruch DS, Leversedge FJ. Vascular perfusion of a flexor carpi ulnaris muscle turnover pedicle flap for posterior elbow soft tissue reconstruction: a cadaveric study. J Hand Surg Am 2011; 36:246-51. [PMID: 21276888 DOI: 10.1016/j.jhsa.2010.10.035] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2010] [Revised: 10/27/2010] [Accepted: 10/28/2010] [Indexed: 02/02/2023]
Abstract
PURPOSE The use of a pedicled flexor carpi ulnaris (FCU) muscle proximal turnover flap has been described previously for soft tissue reconstruction at the posterior elbow. Whereas consistent arterial supply to the FCU has been reported, the reliability of distal flap perfusion has not been confirmed. This study evaluated the vascular perfusion of an FCU turnover flap, based on the most proximal primary vascular pedicle that would permit a proximal turnover flap reconstruction to include the olecranon tip. METHODS In 12 fresh-frozen, proximal humeral human amputation specimens, the FCU flap was elevated from distal to proximal, preserving the most proximal primary vascular pedicle to the muscle belly that would permit flap coverage of the olecranon tip. The axillary artery was injected with India ink after ligation of radial and ulnar arteries at the wrist. After injection, each specimen was sectioned transversely at 0.5-cm increments to assess vascular perfusion of the muscle using loupe magnification. RESULTS The distance from the olecranon tip to the distal FCU muscle belly was 25.9 cm. The primary vascular pedicle that would facilitate creation of a proximal turnover flap was, on average, 5.9 cm distal to the olecranon tip. Perfusion of FCU muscle as measured distal to this primary pedicle was present in 50% to 100% of the muscle belly at an average of 8.9 cm beyond the pedicle. Perfusion of 25% to 50% of the FCU muscle belly was present at an average of 11.1 cm beyond the pedicle. Perfusion became less consistent (<25%) within the muscle belly at an average distance of 11.6 cm. CONCLUSIONS Use of a proximally based, pedicled FCU muscle turnover flap provides a reliable option for soft tissue reconstruction at the posterior elbow. We observed consistent arterial perfusion of the muscle flap when preserving a proximal vascular pedicle 5.9 cm distal to the olecranon tip.
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Affiliation(s)
- Diane E S Payne
- Department of Orthopaedic Surgery, Duke University, Durham, NC 27710, USA
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Immediate emergency free anterolateral thigh flap transfer for the mutilated upper extremity. Plast Reconstr Surg 2009; 123:1739-1747. [PMID: 19483573 DOI: 10.1097/prs.0b013e3181a65b00] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Immediate emergency free flaps are defined as flaps performed directly following emergency surgery due to the exposure of major reconstructed arteries, major nerves, bones, and tendons. The authors document their experience in using free anterolateral thigh flaps in the immediate reconstruction of complex upper extremity injuries. METHODS From January of 2000 to October of 2006, 12 patients ranging from 10 to 59 years old with complicated upper extremity traumatic injuries were treated with immediate emergency free anterolateral thigh flap transfers. These flaps were performed to cover the exposed vital structures. Flap sizes ranged from 30 x 15 to 8 x 6 cm. A variety of flap designs were used, including six flow-through flaps for upper limb revascularization and three tensor fasciae latae components for gliding planes of exposed repaired tendons. The operative times ranged from 7.2 to 12.1 hours, with an average operative time of about 9.6 hours. The hospital stay was from 13 to 34 days, with average stay of about 27.7 days. RESULTS All of the flaps survived. No re-exploration was required. Partial flap necrosis occurred in only one case. Traumatized wound infection occurred in three patients. CONCLUSIONS The anterolateral thigh flap has been popularized as the versatile flap for soft-tissue reconstruction. It has many advantages, including long pedicle length, large skin territory, flow-though and chimeric concept design, a two-team approach, and no need for changing the position. Thus, it is suitable as the immediate emergency flap for upper extremity salvage.
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Reconstruction of Postburn Antebrachial Contractures Using Pedicled Thoracodorsal Artery Perforator Flaps. Plast Reconstr Surg 2009; 123:1544-1552. [DOI: 10.1097/prs.0b013e3181a07439] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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