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Hollins AW, Mithani SK. Advances in Soft Tissue Injuries Associated with Open Fractures. Hand Clin 2023; 39:605-616. [PMID: 37827613 DOI: 10.1016/j.hcl.2023.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/14/2023]
Abstract
Management of soft tissue injury is a key component in the overall treatment of upper extremity fractures. Hand surgeons must rely on their armamentarium for treating soft tissue deficits for functional outcomes. Understanding the role of fracture fixation and wound adjuncts, including negative pressure wound therapy and dermal regenerative templates, is the keys to success. In addition, detailed knowledge of local and free tissue options is essential for hand reconstruction.
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Affiliation(s)
- Andrew W Hollins
- Division of Plastic Surgery, Department of Surgery, Duke University Medical Center, Box 3974 Duke Medical Center, Durham, NC 27710, USA
| | - Suhail K Mithani
- Division of Plastic Surgery, Department of Surgery, Duke University Medical Center, 2301 Erwin Road, Durham, NC 27705, USA.
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Greco VE, Wroblewski A, Kharlamov A, Miller MC, Winek N, Hammarstedt JE, Regal S. "Safe dissection parameters of the anconeus rotational flap for soft tissue coverage at the elbow". Shoulder Elbow 2023; 15:436-441. [PMID: 37538523 PMCID: PMC10395408 DOI: 10.1177/17585732221095492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 01/28/2022] [Accepted: 04/03/2022] [Indexed: 08/05/2023]
Abstract
Background The anconeus is a small muscle located on the posterior elbow originating on the lateral epicondyle and inserting onto the proximal-lateral ulna that functions as an elbow extensor as well as dynamic stabilizer. The blood supply is tri-fold: medial/middle collateral artery (MCA), recurrent posterior interosseous artery (RPIA), and less commonly found, the posterior branch of the radial collateral artery. The anconeus has become a popular option for local soft tissue coverage about the elbow (distal triceps, olecranon, proximal forearm). The average defect size for consideration of local anconeus flap coverage is 5-7cm2. The aim of the study was to determine safe dissection parameters of the anconeus as well as map arterial pedicles to achieve successful local harvest of the muscle without devascularization. Materials and Methods 8 fresh frozen cadaveric arms (all male, average age 63 years - 4 left arms, 4 right arms) from scapula to fingertip were obtained. First, the radial, ulnar and axillary arteries were dissected and isolated. The radial and ulnar arteries were transected. 100cc normal saline was injected through the axillary artery, sequentially clamping the radial followed by the ulnar artery so that adequate flow could be seen through all vessels. 100cc mixture of Biodür and hardener (10:1) was mixed and injected into the axillary artery. We first allowed free flow through both the ulnar and radial vessels followed by clamping of these vessels. This allowed the pressure to build up and fill the smaller vessels in the arms. After injection, the axillary artery was then clamped and the specimens were left to harden for 24-48 h. After hardening, dissection was performed by making a curvilinear incision centred over the lateral epicondyle. The anconeus was identified and the interval between the anconeus and ECU was then confirmed. Measurements of the anconeus muscle were taken. Blunt dissection was carried between anconeus and ECU until the RPIA was identified and protected. We isolated the MCA by dissecting proximally. This was found to run with the nerve to the anconeus. Once this vessel had been protected, the muscle reflected from distal to proximal staying along its ulnar border. The branches of the RPIA were ligated and the dissection was continued proximally. Measurements of the distances of the RPIA, MCA were taken. Results The average distance of olecranon to muscle tip was 95.0mm. The average distance of lateral epicondyle (LE) to muscle tip was 90.8mm. The average distance of LE to olecranon was 49.8mm. The average location of the RPIA was 63.mm when measuring LE to vessel, 68.3mm when measuring olecranon to vessel, 18.3mm when measuring RPIA to muscle tip. The average RPIA diameter was 1.1mm and length was 36.4mm from the initial branching of the posterior interosseous artery. The average MCA diameter was 0.7mm. The posterior branch of the radial collateral artery was only found in 3/8 specimens. The RPIA and MCA were constant in all specimens. Dissection was safely carried to the border of the LE and olecranon without disruption of the MCA. CONCLUSIONS Our conclusions determined that if dissection of the anconeus is undertaken, the RPIA remains constant between the interval of the ECU as well as anconeus at an average distance of 18.3mm from the tip of the muscle measuring proximally; moreover, the MCA was constant in all specimens found directly between the LE and olecranon always running with the nerve to the anconeus. When dissecting and mobilizing to ensure preservation of the MCA, dissection should be taken from distal to proximal as well as dissecting along the ulnar border of the anconeus. Proximal dissection can be taken as proximal as the border of the LE and olecranon as that did not disrupt MCA blood supply.
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Affiliation(s)
- Victor E Greco
- Department of Orthopaedic Surgery, Allegheny General Hospital, Allegheny Health Network, 320 E North Avenue, Pittsburgh, PA 15212
| | - Andrew Wroblewski
- Department of Orthopaedic Surgery, Allegheny General Hospital, Allegheny Health Network, 320 E North Avenue, Pittsburgh, PA 15212
| | - Alexander Kharlamov
- Department of Mechanical Engineering and Materials Science, University of Pittsburgh, Pittsburgh PA
| | - Mark Carl Miller
- Department of Orthopaedic Surgery, Allegheny General Hospital, Allegheny Health Network, 320 E North Avenue, Pittsburgh, PA 15212
- Department of Mechanical Engineering and Materials Science, University of Pittsburgh, Pittsburgh PA
| | - Nathan Winek
- Department of Orthopaedic Surgery, Allegheny General Hospital, Allegheny Health Network, 320 E North Avenue, Pittsburgh, PA 15212
| | - Jon E Hammarstedt
- Department of Orthopaedic Surgery, Allegheny General Hospital, Allegheny Health Network, 320 E North Avenue, Pittsburgh, PA 15212
| | - Steven Regal
- Department of Orthopaedic Surgery, Allegheny General Hospital, Allegheny Health Network, 320 E North Avenue, Pittsburgh, PA 15212
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Kim BS, Jung KJ, Kim KB, Park SS. Treating AO Type C2-3 Distal Humerus Fractures With the Anconeus Flap Transolecranon Approach. Orthopedics 2022; 45:e326-e334. [PMID: 35947456 DOI: 10.3928/01477447-20220805-06] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
We evaluated the outcomes of precontoured locking plate fixation with the anconeus flap transolecranon (AFT) approach to treating AO type C2-3 comminuted intra-articular distal humerus (IDH) fractures among active patients. Thirty-six patients (age <65 years) with IDH fractures treated with precontoured distal humerus locking plate fixation were divided into 2 groups: group 1 (n=18; transolecranon [TO] approach) and group 2 (n=18; AFT approach). The radiographic examination included assessments of implant failure, fracture site union, and olecranon osteotomy site union. Clinical examination included assessments of operating time, range of motion (ROM), Mayo Elbow Performance Score (MEPS), Disability of the Arm, Shoulder and Hand (DASH) score, and complications. The mean follow-up time was 25.2 months (range, 18-79 months). The mean operating time was 134.3 minutes and was significantly longer for group 2 (AFT; 141.2 minutes) than for group 1 (TO; 124.2 minutes). The mean olecranon osteotomy site union time was significantly longer in group 2 (7.4 weeks) than in group 2 (4.0 weeks). Olecranon osteotomy site resorption occurred among 6 of 18 patients only in group 2. No significant difference in ROM (flexion, 130°; extension, -0.7°), MEPS (85.7 points), DASH score (20.0 points), or frequency of major complications (TO, 5; AFT, 6) was observed between the groups. Our results showed no advantage of the AFT approach over the TO approach, despite preserving the anconeus. Prospective randomized trials will be necessary to compare the AFT and TO approaches for treating comminuted IDH fractures. [Orthopedics. 2022;45(6):e326-e334.].
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Gangatharam S. Anconeus syndrome: A potential cause for lateral elbow pain and its therapeutic management-A case report. J Hand Ther 2021; 34:131-134. [PMID: 31492479 DOI: 10.1016/j.jht.2019.04.002] [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] [Received: 01/12/2019] [Revised: 04/05/2019] [Accepted: 04/10/2019] [Indexed: 02/03/2023]
Abstract
STUDY DESIGN This is a case report. INTRODUCTION Anconeus is a small, triangular muscle in the posterior aspect of the elbow, and it functions as weak elbow extensor and abducts the ulna during pronation. The contribution of anconeus muscle can cause lateral elbow pain, which is difficult to diagnose and treat. It also does not respond to the regular treatment for lateral epicondylitis. PURPOSE OF THE STUDY The purpose of this study was to report anconeus muscle irritation as a sole cause for lateral elbow pain. METHODS The patient was given an elbow splint for 4-6 weeks followed with eccentric and concentric strengthening to the elbow and wrist. RESULT At the end of week 9, the patient was pain-free. CONCLUSION The clients who are not responding with the usual treatment of lateral epicondylitis should be considered for any anconeus involvement.
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Abstract
Distal humerus fractures in the elderly population can be difficult to manage because of substantial articular comminution, poor bone quality, and soft tissue compromise. Important patient considerations for treatment include physiologic age, mental status, activity level, and independence with activities of daily living. Elderly patients may be reliant on their upper extremity as a weight-bearing limb when using a walker or rising to stand which creates additional demand. The goal of surgical treatment is to recreate a stable, painless elbow with a functional range of motion to preserve independence for daily activities and mobilization. The main surgical treatment options are open reduction and internal fixation and arthroplasty. Here, we discuss indications and operative goals in each clinical scenario.
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Cutler HS, Kelly D, Gross B, Rinehart D, Hull BR, Sanders D, Starr A, Sathy A. Increased articular exposure of the lateral elbow joint with the anconeus approach compared to the Kocher approach: a cadaver study. Arch Orthop Trauma Surg 2021; 141:917-923. [PMID: 32514835 DOI: 10.1007/s00402-020-03489-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 05/18/2020] [Indexed: 10/24/2022]
Abstract
INTRODUCTION The Kocher approach is the workhorse approach to the lateral elbow. However, the exposure is often limited, particularly for open reduction. The purpose of this study is to quantitatively compare the articular exposure of the anconeus and Kocher approaches to the lateral elbow. METHODS Eight surgical approaches (four Kocher and four Anconeus) were performed on four fresh cadavers. The right elbows of the first two specimens were dissected via the Kocher approach, and the left elbows via the anconeus approach. For the remaining two specimens, the laterality of the approaches was reversed. Access to key articular landmarks were assessed, including the capitellum, humeral trochlea, radial head, olecranon, coronoid process, and greater and lesser sigmoid notches of the ulna. A calibrated digital image was taken from the optimum surgeon's viewing angle of each approach, and these images were analyzed with ImageJ software (NIH, Bethesda, MD, USA) to calculate the area of exposed articular surfaces. RESULTS The average surface area exposed was 2.9 times greater with the anconeus approach compared with the standard Kocher approach (8.3 vs 3.1 cm2, p value 0.001). All key anatomic landmarks were directly visualized with the anconeus approach in each specimen. Visualization of the humeral trochlea, olecranon, coronoid process, and greater and lesser sigmoid notches of the ulna was not obtained in any of the Kocher approaches. DISCUSSION The Anconeus approach provides superior exposure of the lateral elbow joint compared with the Kocher approach. We recommend consideration of the anconeus approach for treatment of select traumatic injuries of the lateral elbow requiring increased access to the ulnohumeral and radiocapitellar joints.
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Affiliation(s)
- Holt S Cutler
- Department of Orthopaedic Surgery, UT Southwestern Medical Center, 5200 Harry Hines Boulevard, Dallas, TX, 75235, USA.
| | - Drew Kelly
- Department of Orthopaedic Surgery, UT Southwestern Medical Center, 5200 Harry Hines Boulevard, Dallas, TX, 75235, USA
| | - Bruno Gross
- Department of Orthopaedic Surgery, UT Southwestern Medical Center, 5200 Harry Hines Boulevard, Dallas, TX, 75235, USA
| | - Dustin Rinehart
- Department of Orthopaedic Surgery, UT Southwestern Medical Center, 5200 Harry Hines Boulevard, Dallas, TX, 75235, USA
| | - Brandon R Hull
- Department of Orthopaedic Surgery, UT Southwestern Medical Center, 5200 Harry Hines Boulevard, Dallas, TX, 75235, USA
| | - Drew Sanders
- Department of Orthopaedic Surgery, UT Southwestern Medical Center, 5200 Harry Hines Boulevard, Dallas, TX, 75235, USA
| | - Adam Starr
- Department of Orthopaedic Surgery, UT Southwestern Medical Center, 5200 Harry Hines Boulevard, Dallas, TX, 75235, USA
| | - Ashoke Sathy
- Department of Orthopaedic Surgery, UT Southwestern Medical Center, 5200 Harry Hines Boulevard, Dallas, TX, 75235, USA
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Brachioradialis muscle flap for posterior elbow defects: a simple and effective solution for the upper limb surgeon. J Shoulder Elbow Surg 2019; 28:1476-1483. [PMID: 31227467 DOI: 10.1016/j.jse.2019.03.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Revised: 03/12/2019] [Accepted: 03/13/2019] [Indexed: 02/01/2023]
Abstract
BACKGROUND Trauma, infection, and posterior surgical approach are the most frequent causes of soft tissue defects of posterior elbow. The brachioradialis (BR) muscle flap is a rotational muscular pedicled flap, and the dominant vascular pedicle arises from the radial recurrent artery in the proximal portion of the muscle. The aim of the study was to present the BR muscle flap as a simple, safe, and effective solution for the treatment of soft tissue defects of the posterior elbow. METHODS Five patients (3 males; mean age, 61.4 years; range, 40-73 years) with soft tissue defects of the posterior elbow underwent surgical treatment with the BR muscle flap. The causes of the defects were total elbow arthroplasty and postsurgical infection (n = 2), 1 patient with elbow arthrodesis due to neuropathic arthropathy, and postsurgical infection after open reduction and internal fixation of olecranon fractures (n = 2). All patients had a BR muscle flap and skin grafting. Orthopedic hardware was removed in 3 cases. RESULTS At the mean follow-up of 45 months (range, 26-61 months), all patients had viable and functional soft tissue coverage. All patients were free of infection, whereas 1 patient had a posterior elbow discomfort in daily activities. None of the patients reported wrist problems. CONCLUSIONS The BR muscle flap is a reliable solution, easy to harvest without requiring microsurgical expertise for small-size posterior elbow defects. It is a 1-stage procedure with no morbidity to the harvest site that provides stable and adequate coverage even in cases with postoperative infection.
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Lee DC, Kim JS, Roh SY, Lee KJ, Kim YW. Flap Coverage of Dysvascular Digits Including Venous Flow-Through Flaps. Hand Clin 2019; 35:185-197. [PMID: 30928050 DOI: 10.1016/j.hcl.2019.01.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
A dysvascular digit is defined as a threatened circulatory condition of a digit caused owing to multiple reasons, such as medical illness or trauma. A dysvascular digit always needs surgical manipulation of the vessel in trauma cases. The revascularization of the digit is a priority in such conditions, after which reconstruction of the defect is performed. In this article, the authors present and discuss the venous free flap, thenar free flap, toe plantar free flap, free style perforator flap, hypothenar free flap, and anconeus muscle free flap.
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Affiliation(s)
- Dong Chul Lee
- Department of Plastic and Reconstructive Surgery, Gwangmyeong Sungae General Hospital, 36, Digital-road, Gwangmyeong, Gyeonggi-do 14241, South Korea.
| | - Jin Soo Kim
- Department of Plastic and Reconstructive Surgery, Gwangmyeong Sungae General Hospital, 36, Digital-road, Gwangmyeong, Gyeonggi-do 14241, South Korea
| | - Si Young Roh
- Department of Plastic and Reconstructive Surgery, Gwangmyeong Sungae General Hospital, 36, Digital-road, Gwangmyeong, Gyeonggi-do 14241, South Korea
| | - Kyung Jin Lee
- Department of Plastic and Reconstructive Surgery, Gwangmyeong Sungae General Hospital, 36, Digital-road, Gwangmyeong, Gyeonggi-do 14241, South Korea
| | - Yong Woo Kim
- Department of Plastic and Reconstructive Surgery, Gwangmyeong Sungae General Hospital, 36, Digital-road, Gwangmyeong, Gyeonggi-do 14241, South Korea
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A new local muscle flap for elbow coverage-the medial triceps brachii flap: anatomy, surgical technique, and preliminary outcomes. J Shoulder Elbow Surg 2018; 27:733-738. [PMID: 29396099 DOI: 10.1016/j.jse.2017.11.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Revised: 11/11/2017] [Accepted: 11/14/2017] [Indexed: 02/01/2023]
Abstract
BACKGROUND The medial triceps brachii is vascularized by the middle collateral artery and the arterial circle of the elbow. This vascularization allows a distal pedicled use to cover soft tissue defects of the elbow. We report our experience using this flap to cover traumatic and postsurgical wounds. METHODS Patients who underwent a pedicled medial triceps brachii flap procedure between 2008 and 2015 were included. Data concerning characteristics of the patients, wound size, surgical technique, and complications were retrospectively reviewed. An independent observer examined patients and assessed outcome of the coverage procedure: wound healing, scar length, range of elbow motion, and patient satisfaction. RESULTS Eight patients were included (70.6 ± 17.7 years old at the time of surgery). All patients had serious comorbidities and risk factors of poor wound healing. Defects were due to postoperative healing complications (5 patients), skin necrosis secondary to an underlying olecranon fracture (1 patient), and direct open fractures (2 patients). Soft tissue defects had a median surface of 17 (14-22) cm2. The olecranon was exposed in 7 cases and the medial humeral epicondyle in 1 case. Mean procedure duration was 83 ± 14 minutes. There was no intraoperative or postoperative complication. All patients healed properly at 3 weeks of follow-up. No wound recurrence or surgery-related complication was reported after a median follow-up of 40.5 (21.5-69.5) months. CONCLUSION Favorable outcomes in all of our 8 patients make this flap an interesting option to cover small to medium-sized defects of the posterior aspect of the elbow.
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Wigton M, Friend M, Li Z. Circumferential Adipofascial Graft for Prevention of Recurrence of Posttraumatic Radioulnar Synostosis. J Hand Surg Am 2017; 42:1039.e1-1039.e6. [PMID: 29107381 DOI: 10.1016/j.jhsa.2017.09.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Accepted: 09/17/2017] [Indexed: 02/02/2023]
Abstract
Radioulnar synostosis can cause substantial loss of function, and surgical treatment can be challenging. Recurrence of the contracture related to scar or reformation of the synostosis is problematic. Several techniques have been described for prevention of recurrence. We present a technique utilizing a free wrap around adipofascial graft for interposition and circumferential coverage of the ulna after resection of the heterotopic bone. We believe this technique has the advantages of technical simplicity, secure interposition, and reliable outcomes.
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Affiliation(s)
- Michael Wigton
- Department of Orthopaedics, Wake Forest School of Medicine, Winston-Salem, NC
| | - Megan Friend
- Department of Orthopaedics, Wake Forest School of Medicine, Winston-Salem, NC.
| | - Zhongyu Li
- Department of Orthopaedics, Wake Forest School of Medicine, Winston-Salem, NC
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Abstract
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.
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Jeon BJ, Jwa SJ, Lee DC, Roh SY, Kim JS. The Anconeus Muscle Free Flap: Clinical Application to Lesions on the Hand. Arch Plast Surg 2017; 44:420-427. [PMID: 28946724 PMCID: PMC5621817 DOI: 10.5999/aps.2017.44.5.420] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Revised: 06/12/2017] [Accepted: 07/30/2017] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND It can be difficult to select an appropriate flap for various defects on the hand. Although defects of the hand usually must be covered with a skin flap, some defects require a flap with rich blood supply and adequate additive soft tissue volume. The authors present their experience with the anconeus muscle free flap in the reconstruction of various defects and the release of scar contractures of the hand. METHODS Ten patients underwent reconstruction of the finger or release of the first web space using the anconeus muscle free flap from May 1998 to October 2013. Adequate bed preparations with thorough debridement or contracture release were performed. The entire anconeus muscle, located at the elbow superficially, was harvested, with the posterior recurrent interosseous artery as a pedicle. The defects were covered with a uniformly trimmed anconeus muscle free flap. Additional debulking of the flap and skin coverage using a split-thickness skin graft were performed 3 weeks after the first operation. RESULTS The average flap size was 18.7 cm2 (range, 13.5-30 cm2). All flaps survived without significant complications. Vein grafts for overcoming a short pedicle were necessary in 4 cases. CONCLUSIONS The anconeus muscle free flap can be considered a reliable reconstructive option for small defects on the hand or contracture release of the web space, because it has relatively consistent anatomy, provides robust blood supply within the same operative field, and leads to no functional loss at the donor site.
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Affiliation(s)
- Byung-Joon Jeon
- Department of Plastic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seung Jun Jwa
- Department of Plastic Surgery, Gwangmyeong Sungae General Hospital, Gwangmyeong, Korea
| | - Dong Chul Lee
- Department of Plastic Surgery, Gwangmyeong Sungae General Hospital, Gwangmyeong, Korea
| | - Si Young Roh
- Department of Plastic Surgery, Gwangmyeong Sungae General Hospital, Gwangmyeong, Korea
| | - Jin Soo Kim
- Department of Plastic Surgery, Gwangmyeong Sungae General Hospital, Gwangmyeong, Korea
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Robinson PM, Li MKH, Dattani R, Van Rensburg L. The Boyd Interval: A Modification for Use in the Management of Elbow Trauma. Tech Hand Up Extrem Surg 2016; 20:37-41. [PMID: 26709569 DOI: 10.1097/bth.0000000000000112] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Surgical exposure of the radial head, proximal radius, capitellum, and proximal ulna can be achieved through several different approaches. The most commonly used are: the Kocher, Kaplan, and extensor digitorum communis splitting. Each of these approaches has its own limitations and dangers. In this article we describe a modified version of the less commonly used Boyd approach. We have used this approach with a transosseous lateral collateral ligament and annular ligament repair for operative treatment of fractures involving the radial head, proximal radius, proximal ulna including the coronoid, capitellum, and lateral column of the distal humerus. In our experience, the approach results in superior exposure of the lateral elbow while minimizing the risk of injury to the posterior interosseous nerve.
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Affiliation(s)
- Paul M Robinson
- *Department of Trauma and Orthopaedics, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK †Department of Trauma and Orthopaedics, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
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Effect of Anconeus Muscle Blocking on Elbow Kinematics: Electromyographic, Inertial Sensors and Finite Element Study. Ann Biomed Eng 2016; 45:775-788. [PMID: 27573695 PMCID: PMC5331076 DOI: 10.1007/s10439-016-1715-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Accepted: 08/15/2016] [Indexed: 12/30/2022]
Abstract
The specific contribution of the anconeus muscle to elbow function is still uncertain. This study aimed to investigate the effect on elbow kinematics and kinetics of blocking anconeus using lidocaine. Ten healthy volunteers performed experimental trials involving flexion–extension and supination–pronation movements in horizontal and sagittal planes. Inertial sensors and surface electromyography were used to record elbow kinematics and kinetics and electrical activity from the anconeus, biceps and triceps brachii before and after blocking anconeus. Moreover, a finite element model of the elbow was created to further investigate the contribution of anconeus to elbow kinematics. The electrical activity results from the trials before blocking clearly indicated that activity of anconeus was increased during extension, suggesting that it behaves as an extensor. However, blocking anconeus had no effect on the elbow kinematics and kinetics, including the angular velocity, net torque and power of the joint. The electrical activity of the biceps and triceps brachii did not alter significantly following anconeus blocking. These results suggest that anconeus is a weak extensor, and the relative small contribution of anconeus to extension before blocking was compensated by triceps brachii. The finite element results indicated that anconeus does not contribute significantly to elbow kinematics.
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Celli A. A new posterior triceps approach for total elbow arthroplasty in patients with osteoarthritis secondary to fracture: preliminary clinical experience. J Shoulder Elbow Surg 2016; 25:e223-31. [PMID: 27422461 DOI: 10.1016/j.jse.2016.04.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2015] [Revised: 03/23/2016] [Accepted: 04/05/2016] [Indexed: 02/01/2023]
Abstract
BACKGROUND During the past decade, total elbow arthroplasty (TEA) procedures have increased because of an increase in the number of trauma patients. Even though most current posterior approaches to the elbow provide excellent joint exposure, they involve the risk of extensor mechanism injury and of eventual insufficiency, particularly in patients with osteoarthritis (OA) secondary to fracture. I describe a new triceps exposure approach for TEA, the anconeus-triceps lateral flap, which has proved valuable in patients with distal humeral and olecranon fracture malunion, and its preliminary results at a minimum follow-up of 24 months. METHODS Twenty consecutive patients with OA due to distal humeral and olecranon fracture malunion underwent TEA by the anconeus-triceps lateral flap approach, which preserves the olecranon insertion of the medial portion of the triceps proper tendon. RESULTS At a mean follow-up of 33 months, the mean Mayo Elbow Performance Score rose from 41.3 to 94.3. The mean pain score on the visual analog scale fell from 7.1 to 1.1. There were no patients with insufficiency, secondary detachment of the triceps tendon, or grade 4 to 5 of the Medical Research Council scale. DISCUSSION These preliminary data suggest that preservation of the insertion of the medial portion of the triceps proper tendon enables earlier active rehabilitation. Moreover, the new approach provides optimum exposure of the olecranon also in patients with OA secondary to intra-articular fracture of the distal humerus and olecranon, where scarring and bone deformity usually hamper joint exposure.
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Affiliation(s)
- Andrea Celli
- Shoulder and Elbow Unit, Department of Orthopaedic Surgery, Hesperia Hospital, Modena, Italy.
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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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18
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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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Sun HJ, Zhang Y, Xia CL, Zhu WF, Wu JD. Applied anatomical study of the modified anconeus flap approach. Surg Radiol Anat 2015; 37:1049-54. [DOI: 10.1007/s00276-015-1483-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2014] [Accepted: 04/28/2015] [Indexed: 11/29/2022]
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Ruch DS, Orr SB, Richard MJ, Leversedge FJ, Mithani SK, Laino DK. A comparison of débridement with and without anconeus muscle flap for treatment of refractory lateral epicondylitis. J Shoulder Elbow Surg 2015; 24:236-41. [PMID: 25457781 DOI: 10.1016/j.jse.2014.09.035] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2014] [Revised: 08/25/2014] [Accepted: 09/12/2014] [Indexed: 02/01/2023]
Abstract
BACKGROUND Lateral epicondylitis is a common condition encountered by orthopedic surgeons. Whereas the majority of patients improve with conservative management, a small percentage will require surgery. The purpose of this study was to compare the clinical outcomes of surgical débridement of the common extensor origin alone with débridement combined with rotation of an anconeus muscle flap in patients who failed to respond to conservative management of chronic lateral epicondylitis. METHODS Fifty-seven patients who failed to respond to a minimum of 5 months of conservative treatment for lateral epicondylitis were retrospectively reviewed. Patients in group 1 were treated with open débridement of the common extensor origin. Patients in group 2 were treated with open débridement combined with rotation of an anconeus muscle flap. Outcome measures included elbow range of motion, grip strength, visual analog scale (VAS) for pain score, and Disabilities of the Arm, Shoulder, and Hand (DASH) score. Statistical analyses were performed by Student's t test with 95% confidence intervals. RESULTS At final follow-up, average DASH scores were significantly lower in group 2. There were no significant differences between the groups with regard to elbow range of motion or grip strength. VAS pain scores were significantly reduced in both groups. Preoperative VAS pain scores were significantly greater in group 2; however, at final follow-up, there was no significant difference between groups. There were no apparent complications in either group. CONCLUSIONS In addition to débridement of the common extensor origin, the rotation of an anconeus muscle flap may improve outcomes in cases of lateral epicondylitis that require operative intervention.
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Affiliation(s)
- David S Ruch
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Steven B Orr
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA.
| | - Marc J Richard
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Fraser J Leversedge
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Suhail K Mithani
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
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21
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Flexor carpi ulnaris muscle flap for soft tissue reconstruction after total elbow arthroplasty. Case Rep Surg 2014; 2014:798506. [PMID: 25400974 PMCID: PMC4220581 DOI: 10.1155/2014/798506] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2014] [Accepted: 09/18/2014] [Indexed: 11/26/2022] Open
Abstract
The soft tissue at the tip of the olecranon is very thin, leading to the frequent occurrence of wound complications after total elbow arthroplasty. To cover a soft tissue defect of the elbow, the flexor carpi ulnaris muscle flap is thought to be appropriate for reconstruction of the elbow with regard to its size, location, and blood supply. We got positive clinical results, so we report our experiences of using a flexor carpi ulnaris muscle flap for soft tissue reconstruction after total elbow arthroplasty.
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Sharpe F, Barry P, Lin SD, Stevanovic M. Anatomic study of the flexor carpi ulnaris muscle and its application to soft tissue coverage of the elbow with clinical correlation. J Shoulder Elbow Surg 2014; 23:82-90. [PMID: 24331124 DOI: 10.1016/j.jse.2013.07.057] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2013] [Revised: 07/16/2013] [Accepted: 07/28/2013] [Indexed: 02/01/2023]
Abstract
BACKGROUND The posterior elbow is prone to soft tissue loss that may require reconstructive methods for wound healing to be achieved. The flexor carpi ulnaris (FCU) muscle has been described for coverage in case reports and small series. Previous studies give conflicting anatomic findings about the dominant vascular pedicle for the FCU. METHODS Twenty-five cadaveric specimens were dissected. Pedicle location, number, and distance from the medial epicondyle were recorded along with the extent of posterior elbow coverage. Chart review was conducted during a 4-year period. Eight patients who underwent FCU rotational flap coverage were identified. Those flaps relied entirely on a single proximal pedicle. RESULTS The vascular pedicles from the ulnar artery or recurrent ulnar artery were identified in 24 of 25 specimens. The average distance from the tip of the medial epicondyle to the first pedicle was 5.7 cm (range, 3 to 10 cm). The length of muscle coverage proximal to the olecranon tip averaged 9.3 cm. The clinical follow-up of 7 patients requiring FCU rotational flaps for coverage of the posterior elbow showed that all flaps survived and provided adequate coverage for the defect. CONCLUSIONS The FCU rotational pedicle flap provides predictable coverage of small to medium-sized defects about the posterior elbow. Although it is relatively consistent, the proximal vascular pedicle does demonstrate some variability, which should be considered in planning surgery. The consistent distal extent of the FCU muscle belly provides wider proximal coverage of defects.
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Affiliation(s)
- Frances Sharpe
- Southern California Permanente Medical Group, Fontana, CA, USA
| | - Piers Barry
- Department of Orthopedics, University of Southern California, Keck School of Medicine, Los Angeles, CA, USA
| | - Steven D Lin
- Department of Orthopedics, University of Southern California, Keck School of Medicine, Los Angeles, CA, USA
| | - Milan Stevanovic
- Department of Orthopedics, University of Southern California, Keck School of Medicine, Los Angeles, CA, USA.
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Abstract
The elbow requires a durable and pliable soft-tissue envelope. Injuries, infections, or tumors that result in exposed tendon, bone, or implants require expedient soft-tissue coverage. Familiarity with various options for coverage can help tailor treatment to the defect size and minimize donor-site morbidity. In this article, emphasis is placed on muscle and fasciocutaneous flaps that have been shown to have reliable vascularity and predictable outcomes.
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Pereira BP. Revisiting the anatomy and biomechanics of the anconeus muscle and its role in elbow stability. Ann Anat 2013; 195:365-370. [DOI: 10.1016/j.aanat.2012.05.007] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2012] [Revised: 05/09/2012] [Accepted: 05/25/2012] [Indexed: 11/13/2022]
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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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Ng ZY, Lee SWJ, Mitchell JH, Fogg QA, Hart AM. Functional anconeus free flap for thenar reconstruction: a cadaveric study. Hand (N Y) 2012; 7:286-92. [PMID: 23997734 PMCID: PMC3418366 DOI: 10.1007/s11552-012-9412-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Restoration of thumb opposition when significant thenar soft tissue defects occur remains a considerable surgical challenge. While several clinical applications of the anconeus muscle have been developed, free functioning muscle transfer (FFMT) of the anconeus for thenar reconstruction has not been reported previously. This study therefore sought to describe anatomical features of the anconeus that would determine its suitability for use as a FFMT. METHODS The anconeus, its corresponding abductor pollicis brevis (APB), and the supplying neurovasculature in eight white British cadaveric upper extremities were identified and dissected. Measurements were performed using standard calipers and ImageJ 1.45d for a quantitative description of muscle architecture and the neurovasculature involved in the operative planning of the anconeus FFMT. RESULTS The mean measures of the anconeus were larger than those of the APB (anconeus/APB fiber length = 88.0 ± 9.9/57.7 ± 9.0 mm, area = 1,341.9 ± 230.4/987.7 ± 251.2 mm(2)). There was no significant difference between mean fiber angles (anconeus/APB = 70.5 ± 11.9°/78.4 ± 12.2°; p > 0.05) and neurovasculature (anconeus/APB: artery diameter = 1.9 ± 0.2/2.0 ± 0.5 mm, nerve diameter = 1.7 ± 0.3/2.1 ± 0.4 mm; p > 0.05). The length (31.3 ± 6.9 mm) and caliber (diameter = 1.9 ± 0.2 mm) of the vascular pedicle of the anconeus (recurrent posterior interosseous artery) and its venae comitans (diameter = 1.0 mm) are sufficient for microsurgical anastomosis. CONCLUSIONS The anatomic rationale of the anconeus FFMT for thenar reconstruction is sound and, compared to other FFMTs, may provide several advantages: reliable and matching anatomy, minimal donor site morbidity, and the potential to restore a greater degree of opposition and thus function in a one-stage procedure.
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Affiliation(s)
- Zhi Yang Ng
- />School of Medicine, University of Glasgow, Glasgow, G12 8QQ Scotland UK
| | - Sze Wei Justin Lee
- />School of Medicine, University of Glasgow, Glasgow, G12 8QQ Scotland UK
| | | | - Quentin A. Fogg
- />William Hunter Lectureship in Anatomy, School of Life Sciences, University of Glasgow, Glasgow, G12 8QQ Scotland UK
| | - Andrew M. Hart
- />Stephen Forrest Chair of Plastic Surgery, College of Medical Veterinary & Life Sciences, University of Glasgow, Glasgow, G12 8QQ Scotland UK , />Consultant Hand & Plastic Surgeon, Canniesburn Plastic Surgery Unit, Glasgow Royal Infirmary, 84 Castle Street, Glasgow, G4 0SF Scotland UK
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Davami B, Porkhamene G. Versatility of local fasciocutaneous flaps for coverage of soft tissue defects in upper extremity. J Hand Microsurg 2011. [PMID: 23204770 DOI: 10.1007/s12593-011-0040-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
Appropriate soft tissue coverage is of paramount importance for coverage of bone, joint, tendons, neurovascular structures, and hardware in upper extremity. In this article we have tried to renew the importance and simplicity of using the local fasciocutaneus flaps for coverage of shoulder, elbow and hand joints with showing the techniques in three examples. During a 5 year period,from 2004 to 2009, we have been treating soft tissue defects of the upper extremity over joints and hardware with local fasciocutaneous flaps. During this time we had 50 cases of exposed hardware, 20 over shoulder joint and 30 over olecranon. Also, we had 100 cases of exposed joints,30 over shoulder, 45 over olecranon 10 over wrist and 15 over finger joints. The etiology of exposed joints were 60 cases from burn, 10 from bursitis, 20 from traumatic injuries and the rest from other injuries such as animal bites.In this article we present 3 cases with the technique of operations and their associated figures: one exposed hardware at the shoulder treated by a distally based local fasciocutaneous flap,one exposed elbow joint due to flame burn treated by antecubital flap and the third case exposed bone and joint in the fifth and an example of fourth fingers treated by local fasciocutaneous flap from the same fingers. In these 150 cases we had 6 cases of superficial necrosis of the flaps which healed with supportive therapy. There was no cases of complete necrosis. 27 patients underwent revision of the dog-ear and were completely satisfied with the result. we present our experience of 150 case to prove that local fasciocutaneous flaps are versatile and can be used with good results if properly planned.
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Affiliation(s)
- Babak Davami
- Plastic Surgery Department, Tabriz Medical University, Sina Hospital, Azadi Street, Tabriz, Iran
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28
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Molinier F, Laffosse JM, Bouali O, Tricoire JL, Moscovici J. The anconeus, an active lateral ligament of the elbow: new anatomical arguments. Surg Radiol Anat 2011; 33:617-21. [PMID: 21225428 DOI: 10.1007/s00276-010-0767-5] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2010] [Accepted: 12/17/2010] [Indexed: 11/29/2022]
Abstract
PURPOSE As there are a few detailed anatomical studies of the active function of anconeus muscle in stabilizing the elbow, we aimed to look for anatomical features confirming its role as an active stabilizer of the humero-ulnar joint. METHODS Thirty fresh unembalmed elbows from 15 cadavers were dissected. We examined the anatomy, insertions, relationships and orientation of the muscle fibres of the anconeus. RESULTS The anconeus lies in a separate compartment from the other forearm muscles, but in continuity with the extensor (triceps) compartment of the arm. In all the cases, at its proximal extremity we observed continuity of muscle and tendon with the vastus lateralis of the triceps brachii. The muscle fibres run downward and backward, parallel to the fibres of vastus lateralis of the triceps, when the elbow is in extension. Its deep aspect adheres closely to the lateral joint capsule of the humero-ulnar joint. CONCLUSION The new anatomical characteristics of the anconeus revealed in this study make this muscle a digastric head of triceps brachii that coapts the ulna to the humerus and so reduces varus instability. The close relationships between triceps brachii and the anconeus on one hand and between the joint capsule and the anconeus on the other make the latter muscle an active lateral stabilizer of the elbow.
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Affiliation(s)
- François Molinier
- Laboratoire d'Anatomie, Faculté de Médecine Rangueil, 133, route de Narbonne, 31062, Toulouse Cedex, France.
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Abstract
Surgical exposures for complex injuries about the elbow are technically demanding because of the high density of neurologic, vascular, and ligamentous elements around the elbow. The posterior approaches (ie, olecranon osteotomy, triceps-reflecting, triceps-splitting, triceps-reflecting anconeus pedicle flap, paratricipital) include techniques used to navigate the area around the triceps tendon and anconeus muscle. These approaches may be extended to gain access to the entire joint. The ulnar nerve, the anterior and posterior capsules, and the coronoid process are addressed by means of a medial approach. Lateral approaches are useful in addressing pathology at the radial head, capitellum, coronoid process, and anterior and posterior capsules. These approaches may be combined to address complex pathology in the setting of fracture fixation, arthroplasty, and capsular release.
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30
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Lefemine V, Enoch S, Boyce DE. Surgical and reconstructive management of pressure ulcers. EUROPEAN JOURNAL OF PLASTIC SURGERY 2009. [DOI: 10.1007/s00238-008-0318-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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31
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Pollock JW, Athwal GS, Steinmann SP. Surgical exposures for distal humerus fractures: A review. Clin Anat 2008; 21:757-68. [DOI: 10.1002/ca.20720] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Jensen M, Moran SL. Soft tissue coverage of the elbow: a reconstructive algorithm. Orthop Clin North Am 2008; 39:251-64, vii. [PMID: 18374815 DOI: 10.1016/j.ocl.2007.12.009] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Soft tissue defects can occur for various reasons, but they are primarily due to trauma, tumor, and infection. Coverage choices may include primary closure, skin grafting, local cutaneous flaps, fasciocutaneous transposition flaps, island fascial or fasciocutaneous flaps, muscle or myocutaneous pedicled flaps, and microvascular free-tissue transfer. Despite the multitude of options for coverage, the authors have found four flaps to provide reliable coverage for most elbow deficits within their practice; these flaps are the latissimus dorsi flap, the radial forearm flap, the anconeus flap, and the free anterior lateral thigh flap. This article provides an overview of treatment options for elbow coverage, with specific emphasis on the use of these four specific flaps.
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Affiliation(s)
- Mark Jensen
- Department of General Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
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Choudry UH, Moran SL, Li S, Khan S. Soft-Tissue Coverage of the Elbow: An Outcome Analysis and Reconstructive Algorithm. Plast Reconstr Surg 2007; 119:1852-1857. [PMID: 17440365 DOI: 10.1097/01.prs.0000259182.53294.67] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Soft-tissue defects surrounding the elbow can be a challenging problem for the reconstructive surgeon. Multiple reconstructive options are available, but there are few published outcome studies. The authors performed an outcome analysis of soft-tissue coverage for elbow defects to determine the benefits and limitations of various reconstructive options in this problematic area. METHODS A retrospective review was performed of all elbow defects requiring flap coverage from 1988 to 2005. Patient demographics, defect characteristics, type of flaps used, complications, and long-term outcomes were analyzed. The t test was used for statistical comparison. RESULTS A total of 99 flaps were performed in 96 patients. Forty-seven percent of the defects were secondary to trauma. Sixty-six percent of the flaps used were pedicled flaps and 19 percent were free flaps. The most common pedicled flap used was the radial forearm flap, whereas the most commonly used free flap was the latissimus dorsi muscle flap. Reconstructive failures occurred in 10 percent of patients; these 10 patients required a second flap for limb salvage. The pedicled latissimus dorsi muscle flap had the highest complication rate (57 percent), with distal necrosis being the most frequent complication. The pedicled latissimus dorsi flap was associated with a higher complication rate when compared with the radial forearm flap (p = 0.01). CONCLUSIONS The pedicled latissimus was associated with a high rate of distal necrosis when it was used to cover defects distal to the olecranon. The authors recommend the use of the radial forearm flap or a free flap for soft-tissue coverage of defects lying over the proximal ulna.
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Affiliation(s)
- Umar H Choudry
- Rochester, Minn. From the Divisions of Plastic Surgery, Orthopedics, and General Surgery, Mayo Clinic
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34
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Kopp J, Polykandriotis E, Loos B, Seyhan H, Krickhahn M, Kneser U, Bach AD, Horch RE. Giant rodent ulcer of the elbow requiring defect coverage by preconditioned latissimus dorsi pedicled myocutaneous flap following excision. J Eur Acad Dermatol Venereol 2007; 21:252-4. [PMID: 17243966 DOI: 10.1111/j.1468-3083.2006.01827.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Abstract
The transolecranon approach for the treatment of distal humerus fractures and nonunions is commonly used. A complication of the standard osteotomy is denervation of the anconeus muscle, which provides dynamic stability to the lateral side of the elbow by preventing varus and posterolateral rotatory instability. This article describes the anconeus flap transolecranon (AFT) approach, which utilizes an internervous plane to preserve the anconeus muscle and a chevron-shaped osteotomy for maximal joint exposure. The approach is straightforward to perform with limited complications.
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Affiliation(s)
- George S Athwal
- Hand and Upper Limb Centre, St Joseph's Health Care, University of Western Ontario, London, ON, Canada.
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36
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Kalainov DM, Cohen MS. Posterolateral rotatory instability of the elbow in association with lateral epicondylitis. A report of three cases. J Bone Joint Surg Am 2005; 87:1120-5. [PMID: 15866979 DOI: 10.2106/jbjs.d.02293] [Citation(s) in RCA: 73] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- David M Kalainov
- Department of Orthopaedic Surgery, Northwestern University, Feinberg School of Medicine, Northwestern Center for Orthopedica, 676 North St. Clair, Suite 450, Chicago, Illinois 60611, USA
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37
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Mears SC, Zadnik MB, Eglseder WA. Salvage of Functional Elbow Range of Motion in Complex Open Injuries Using a Sensate Transposition Lateral Arm Flap. Plast Reconstr Surg 2004; 113:531-5. [PMID: 14758213 DOI: 10.1097/01.prs.0000101052.03932.54] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Complex open posterior elbow injuries pose three principal challenges to the reconstructive surgeon. First, the surgeon must provide stable soft-tissue closure over the joint/skeletal reconstruction. Second, the coverage must be thin and supple and promote the free gliding of the underlying structures. Finally, secondary and tertiary procedures must be anticipated beneath the flap, because a stiff, scarred, and adherent flap will only compromise these procedures. The results of 10 consecutive fasciocutaneous transposition lateral arm flaps for coverage of posterior elbow wounds are reported. This flap provides coverage that is thin and supple and that allows subsequent elevation for secondary procedures. Functionally, these flaps allowed for the development of an average arc of motion of 20 to 114 degrees and an average pronation-supination motion of 119 degrees.
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Affiliation(s)
- Simon C Mears
- Department of Orthopedic Surgery, R. Adams Cowley Shock Trauma Center, University of Maryland Medical Systems, Baltimore 21201, USA
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38
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Van Landuyt K, Hamdi M, Blondeel P, Monstrey S. The pyramidalis muscle free flap. BRITISH JOURNAL OF PLASTIC SURGERY 2003; 56:585-92. [PMID: 12946377 DOI: 10.1016/s0007-1226(03)00211-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The pyramidalis muscle is introduced as a new small muscle free flap, with description of its anatomy, the surgical technique and the clinical results in five different cases in which this flap was used to treat small recalcitrant wounds in the foot/ankle region. The pyramidalis muscle can be an alternative option in selective cases to reduce donor site morbidity as compared with more traditional free flaps.
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Affiliation(s)
- K Van Landuyt
- P/a Department of Plastic Surgery, University Hospital Gent, De Pintelaan 185, B-9000 Gent, Belgium.
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40
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Rubayi S, Kiyono Y. Flap surgery to cover olecranon pressure ulcers in spinal cord injury patients. Plast Reconstr Surg 2001; 107:1473-81. [PMID: 11335821 DOI: 10.1097/00006534-200105000-00026] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
In the quadriplegic patient, the periolecranon region is subjected to continuous and permanent mechanical shearing and pressure forces. As the sensation of this region is partially impaired secondary to the level of the spinal cord injury, this anatomical area is prone to develop bursitis and then a chronic open draining wound. This type of wound is refractory to conservative measures. Surgical closure of this functional area can represent a challenge to the plastic and reconstructive surgeon because not all of the surgical options available are suitable for spinal cord injury patients. Therefore, we describe our clinical experience, which consists of seven patients with traumatic complete quadriplegia treated between 1989 and 1998 (all patients were male) who presented with an open olecranon ulcer, septic bursitis, or aseptic bursitis, and who underwent surgical closure by direct closure, local arm fasciocutaneous flap, or cross-chest flap to cover the periolecranon soft-tissue defects. The follow-up period ranged from 3 months to 8 years (mean, 44 months). All types of flaps achieved wound closure without losing range of motion at the elbow; however, at 10 to 12 months after surgery, an olecranon pressure ulcer or septic bursitis recurred in three of seven patients. These three patients required surgical revision. The local fasciocutaneous rotational flap was found to be effective for closing periolecranon soft-tissue defects and can be reused in instances of recurrence. Patient education is essential to prevent re-ulceration in that functional area in the spinal cord injury patient.
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Affiliation(s)
- S Rubayi
- Rancho Los Amigos National Rehabilitation Center, University of Southern California, Downey, USA.
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