Use of the fix and flap approach to complex open elbow injury: the role of the free anterolateral thigh flap

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.

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.

Innovative adaptation of the "spare tissues concept" applied for olecranon coverage of a severe burn patient: A case report

BACKGROUND

The management of bone exposure in patients with extensive burns could be a challenge due to the lack of healthy tissue. In such cases, it could be interesting to use any still healthy tissue initially destined for amputation and use it to cover up another site. We present the case of a sever burn patient for whom we used the only healthy palmar hand skin to cover an olecranon exposure.

CLINICAL CASE DESCRIPTION

A 38-year-old man has been admitted in burn victim unit with extensive deep burns on 60% of the total body surface. An exposure of the left olecranon was appeared occurring on a burned area, with absence of healthy local tissues available for coverage. Concomitantly a trans-radial amputation was indicated because of severe digits burns leading to an impossibility to preserve the function of the hand. A palmar skin area was healthy leading to harvested this palmar skin flap pedicled on ulnar vessels. Early post-operative healing was satisfactory and no vascular suffering of the flap has been observed with a total healing at three weeks.

CONCLUSION

In any patient the spare tissues concept should be keep in mind when amputation is indicated simultaneously with a problematic of loss of substance coverage to a proximity area. In this case of severe burn patient, we used a palmar skin flap pedicled on the ulnar vessels to cover an olecranon exposure.

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.

Reconstruction of a malignant soft tissue tumor around the elbow joint using a frozen autograft treated with liquid nitrogen, in combination with a free anterolateral thigh flap: A report of two cases

We present two cases of malignant soft tissue tumor around the elbow joint treated with en bloc resection, in which reconstruction using a frozen autograft technique in combination with a free anterolateral thigh flap offered reliable method for limb salvage and good recovery of elbow function.

The Waterfall Fascia Lata Interposition Arthroplasty "Grika Technique" as Treatment of Posttraumatic Osteoarthritis of the Elbow in a High-Demand Adult Patient: Validity and Reliability

Introduction

The elbow interposition arthroplasty is a very common procedure performed mainly on active young patients who need great functionality and for whom total joint replacement is contraindicated and arthrodesis is noncompliant. We are going to demonstrate a case of a 34-year-old male suffering from malunion of the distal humerus, elbow stiffness, and manifest signs of arthrosis of the dominant limb, treated with the IA Grika technique at a 5-year follow-up.

Patients and Methods

The chosen criteria to evaluate the injured side and the uninjured side during the clinical and radiological follow-up were the objective function and related quality of life, measured by the Mayo Elbow Performance Score (MEPS), and postoperative complications. To assess flexion and supination forces and elbow muscular strength, a hydraulic dynamometer was used.

Results

At a 5-year follow-up, the results were excellent as during the first year.

Conclusions

The Grika technique is a valid and feasible option in the treatment of elbow injuries.

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.

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.