Soft-tissue coverage of the elbow

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Delayed Abdominal Flap for Upper Extremity Soft Tissue Coverage

Unlike other body parts, the upper extremity has critical structures close to the skin, making soft tissue injuries more complex. These injuries can result from various causes, including trauma and necrotizing soft tissue infections, necessitating reconstruction. Historically, pedicled flaps from the groin and abdomen were commonly used for upper extremity reconstruction, but they had limitations, such as the need for flap division and debulking, patient discomfort, and stiffness. Free flap reconstruction has become the preferred method, but it still faces challenges like patient and facility issues, the absence of recipient vessels after injury, and multi-surface wounds. This case report describes a 67-year-old patient with a severe necrotizing soft tissue infection in the right upper extremity. After multiple debridement procedures, the patient underwent hand amputation and soft tissue coverage using an abdominal wall-based flap. The objectives of achieving stable soft tissue coverage while preserving maximal length of the upper extremity were successfully achieved, and the patient expressed satisfaction with the outcomes. Inadequate management of upper extremity wounds can lead to amputation and psychological distress. The reconstructive ladder is used to approach upper extremity soft tissue defects, with free tissue transfer being the standard for larger defects. However, abdominal flaps still have indications when free tissue transfer is not feasible or contraindicated. It is imperative that plastic surgeons have these techniques in their armamentarium to provide a service to the ever more complex patient with an upper extremity wound.

The Use of a Novel Chimeric Flexor Carpi Ulnaris and Ulnar Artery Flap for Elbow Coverage

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.

Anterolateral Thigh Flap Coverage for Large Posterior Defects of the Elbow

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.

Pedicled thoracodorsal artery perforator flap in the soft-tissue reconstruction of an acute traumatic cubital fossa defect

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.

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

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.

Brachioradialis Flap With Vascularized Lateral Ulnar Collateral Ligament Reconstruction: A Case Report

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.

Anterolateral Thigh Flap-the Optimal Flap in Coverage of Severe Elbow Injuries

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.

Brachioradialis muscle flap for posterior elbow defects: a simple and effective solution for the upper limb surgeon

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.

Antegrade Posterior Interosseous Flap for Nonhealing Wounds of the Elbow: Anatomical and Clinical Study

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.

A new local muscle flap for elbow coverage-the medial triceps brachii flap: anatomy, surgical technique, and preliminary outcomes

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.

Bipedicle Flaps for Posterior Elbow Reconstruction

Chronic posterior elbow soft tissue defects often require soft tissue reconstruction because of exposure of the underlying triceps tendon and proximal ulna. Current options for soft tissue coverage require sacrifice of a local muscle or microsurgery. The purpose of this study is to evaluate patient and surgical outcomes after reconstruction of small-sized to medium-sized (<50 cm) posterior elbow defects with bipedicle advancement flaps. A retrospective chart review was performed for 3 patients who underwent posterior elbow reconstruction with bipedicle flaps. The etiology of the soft tissue elbow defect was chronic infected olecranon bursitis (n=2) and exposed olecranon plate after open fracture (n=1). Patient comorbidities included: diabetes, CREST (Calcinosis, Raynaud phenomenon, Esophageal dysmotility, Sclerodactyly, Telangiectasia) syndrome, and rheumatoid arthritis. The mean patient age at time of reconstruction was 44 years (39 to 51 y), and the mean area of soft tissue defect was 39.3 cm (24 to 54 cm) after debridement of involved tissue. All patients had positive intraoperative cultures and were treated with culture-directed long-term intravenous antibiotics. There were no surgical complications or flap loss. All patients had reepithelialization of the donor site by postoperative week 8 and stable soft tissue coverage of the elbow after surgery at final follow-up with full preoperative elbow range of motion. This technique offers a simple, reliable solution for soft tissue coverage of the posterior elbow using excess local tissue for primary closure of posterior elbow wounds with minimal donor-site morbidity.

Perforator-based propeller flaps reliability in upper extremity soft tissue reconstruction: a systematic review

Current data on upper extremity propeller flaps are poor and do not allow the assessment of the safety of this technique. A systematic literature review was conducted searching PubMed, EMBASE, and the Cochrane Library electronic databases, and the selection process was adapted from the preferred reporting items for systematic reviews and meta-analysis statement. The final analysis included ten relevant articles involving 117 flaps. The majority of flaps were used for the hand, distal wrist, and elbow. The radial artery perforator and ulnar artery perforator were the most frequently used flaps. The were 7% flaps with venous congestion and 3% with complete necrosis. No difference in complications rate was found for different flaps sites. Perforator-based propeller flaps appear to be an interesting procedure for covering soft tissue defects involving the upper extremities, even for large defects, but the procedure requires experience and close monitoring.

LEVEL OF EVIDENCE

II.

Maximizing Outcomes While Minimizing Morbidity: An Illustrated Case Review of Elbow Soft Tissue Reconstruction

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.

Soft-Tissue Coverage for Elbow Trauma

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.

Soft-tissue coverage of olecranon with musculocutaneous flexor carpi ulnaris flap

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.

Flap decisions and options in soft tissue coverage of the upper limb

Soft tissue deficiency in the upper limb is a common presentation following trauma, burns infection and tumour removal. Soft tissue coverage of the upper limb is a challenging problem for reconstructive surgeons to manage. The ultimate choice of soft tissue coverage will depend on the size and site of the wound, complexity of the injury, status of surrounding tissue, exposure of the vital structures and health status of the patient. There are several local cutaneous flaps that provide adequate soft tissue coverage for small sized defects of the hand, forearm and arm. When these flaps are limited in their mobility regional flaps and free flaps can be utilised. Free tissue transfer provides vascularised soft tissue coverage in addition to the transfer of bone, nerve and tendons. Careful consideration of free flap choice, meticulous intraoperative dissection and elevation accompanied by post-operative physiotherapy are required for successful outcomes for the patient. Several free flaps are available for reconstruction in the upper limb including the groin flap, anterolateral flap, radial forearm flap, lateral arm flap and scapular flap. In this review we will provide local, regional and free flap choice options for upper limb reconstruction, highlighting the benefits and challenges of different approaches.

Flap reconstruction of the elbow and forearm: a case-based approach

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.