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McGraw JR, Sulkar RS, Bascone CM, Othman S, Mauch JT, Naga HI, Levin LS, Kovach SJ. Free flap reconstruction of elbow soft tissue defects: Lessons learned from 15 years of experience. Microsurgery 2024; 44:e31163. [PMID: 38530145 DOI: 10.1002/micr.31163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 01/10/2024] [Accepted: 02/15/2024] [Indexed: 03/27/2024]
Abstract
BACKGROUND The elbow is a complex joint that is vital for proper function of the upper extremity. Reconstruction of soft tissue defects over the joint space remains challenging, and outcomes following free tissue transfer remain underreported in the literature. The purpose of this analysis was to evaluate the rate of limb salvage, joint function, and clinical complications following microvascular free flap coverage of the elbow. METHODS This retrospective case series utilized surgical logs of the senior authors (Stephen J Kovach and L Scott Levin) to identify patients who underwent microvascular free flap elbow reconstruction between January 2007 and December 2021. Patient demographics and medical history were collected from the medical chart. Operative notes were reviewed to determine the type of flap procedure performed. The achievement of definitive soft tissue coverage, joint function, and limb salvage status at 1 year was determined from postoperative visit notes. RESULTS Twenty-one patients (14 male, 7 female, median age 43) underwent free tissue transfer for coverage of soft tissue defects of the elbow. The most common indication for free tissue transfer was traumatic elbow fracture with soft tissue loss (n = 12, [57%]). Among the 21 free flaps performed, 71% (n = 15) were anterolateral thigh flaps, 14% (n = 3) were latissimus dorsi flaps, and 5% (n = 1) were transverse rectus abdominis flaps. The mean flap size was 107.5 cm2. Flap success was 100% (n = 21). The following postoperative wound complications were reported: surgical site infection (n = 1, [5%]); partial dehiscence (n = 5, [24%]); seroma (n = 2, [10%]); donor-site hematoma (n = 1, [5%]); and delayed wound healing (n = 5, [24%]). At 1 year, all 21 patients achieved limb salvage and definitive soft tissue coverage. Of the 17 patients with functional data available, 47% (n = 8) had regained at least 120 degrees of elbow flexion/extension. All patients had greater than 1 year of follow-up. CONCLUSION Microvascular free flap reconstruction is a safe and effective method of providing definitive soft tissue coverage of elbow defects, as evidenced by high rates of limb salvage and functional recovery following reconstruction.
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Affiliation(s)
- J Reed McGraw
- Division of Plastic Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Reena S Sulkar
- Division of Plastic Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Corey M Bascone
- Division of Plastic Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sammy Othman
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Northwell Health, Great Neck, New York, USA
| | - Jaclyn T Mauch
- Section of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Hani I Naga
- Division of Plastic, Reconstructive, Oral, and Maxillofacial Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - L Scott Levin
- Division of Plastic Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Orthopaedic Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Stephen J Kovach
- Division of Plastic Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Orthopaedic Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Kahramangil B, Pires G, Ghaznavi AM. Flap survival and functional outcomes in elbow soft tissue reconstruction: A 25-year systematic review. J Plast Reconstr Aesthet Surg 2021; 75:991-1000. [PMID: 34961697 DOI: 10.1016/j.bjps.2021.11.091] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 11/14/2021] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Different elbow flap reconstructions have been described in the literature. We aim to define the optimal flap technique based on defect size and etiology. METHODS A systematic review was undertaken using the terms "(Elbow reconstruction) AND ((Soft tissue) OR (flap))". Flaps were grouped under fasciocutaneous (FCF), muscular (MF), distant pedicled (DPF), and free flaps (FF). The primary outcome was flap survival. The secondary outcomes were postoperative complications and range of motion (pROM). RESULTS Twenty articles with 224 patients were included. Defect sizes were small (<10 cm2) (18%), medium (10-30 cm2) (23%), large (30-100 cm2) (43%), and massive (>100 cm2) (16%). Etiologies included trauma (26%), burn contractures (26%), infection (26%), hardware coverage (16%), and others (6%). FCF (54%) was the preferred flap followed by MF (28%), DPF (13%), and FF (5%). The rate of flap necrosis was 4% and that of other complications was 10%. The postoperative range of motion (pROM) (reported in 154 patients) was >100°, 50-100°, and <50° in 82%, 17%, and 1% of the cases, respectively. Small defects were most commonly reconstructed with MFs (83%), medium defects were reconstructed with MFs (52%) or FCFs (46%), and large defects were reconstructed with FCFs (91%). Massive defects predominantly required DPFs (60%) and FFs (26%). FCFs were the most common reconstruction method for burn contractures (84%), infections (55%), and traumatic defects (51%). Hardware coverage was predominantly performed using MFs (86%). No difference in complications and pROM was found between flap techniques. CONCLUSION Elbow flap reconstruction can be performed using different techniques. FCFs are the most commonly used reconstruction method. MFs are useful for smaller defects and hardware coverage. DPFs and FFs are needed for massive injuries.
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Affiliation(s)
- Bora Kahramangil
- Department of General Surgery, Cleveland Clinic Florida, Weston, FL, United States
| | - Giovanna Pires
- Florida Atlantic University Schmidt College of Medicine, Boca Raton, FL, United States
| | - Amir M Ghaznavi
- Department of Plastic Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, Weston, FL 33331, United States.
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Almerey TA, Oliver JD, Jorgensen MS, Rinker BD, Farres HA, Hakaim AG, Forte AJ. Upper extremity reconstruction following open surgical repair of giant arteriovenous fistula aneurysm: clinical case and systematic review of the literature. ACTA BIO-MEDICA : ATENEI PARMENSIS 2020; 91:e2020093. [PMID: 33525257 PMCID: PMC7927515 DOI: 10.23750/abm.v91i4.8472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 05/22/2019] [Indexed: 11/24/2022]
Abstract
Background: Nearly 30% of arteriovenous fistulas (AVFs) located in the upper extremity for hemodialysis access result in short- and long-term adverse effects, such as rupture, necessitating emergent surgical management and extensive soft-tissue reconstruction. With this systematic review, we aimed to compile all reported open surgical techniques used for complicated AVF repair in the upper extremity, the respective soft-tissue reconstructive outcomes, and vascular patency rates at final follow-up. Methods: Using Ovid Medline/PubMed databases, we conducted a review of the English-language literature on AVF aneurysm surgical management in the upper extremity, filtered for relevance to open surgical technique and outcomes in vascular patency after aneurysmal repair at long-term follow-up (≥6 months postoperatively). We include a detailed case of surgical removal of a giant AVF aneurysm and subsequent flap elevation and reconstruction of the upper extremity. Results: Of 150 articles found in the initial search, 19 (from 2010-2017) met inclusion criteria. From the reviewed studies, 675 patients underwent open surgical repair of AVF aneurysm in the upper extremity. Surgical approaches included partial-to-full aneurysm excision, interposition graft, tubularized extracellular matrix, sutured and stapled aneurysmorrhaphy, and stent graft. Rates of vascular patency at repair site ranged from 47% to 100%, with a pooled average of 78% at 6 months or longer postoperatively. Conclusions: For plastic and hand surgeons, aneurysmal ligation and excision is feasible even in severe cases and is associated with overall good vascular and soft-tissue reconstructive outcomes in the upper extremity. (www.actabiomedica.it)
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Affiliation(s)
- Tariq A Almerey
- Division of General Surgery, Mayo Clinic Florida, Jacksonville, FL.
| | | | | | - Brian D Rinker
- Division of Plastic Surgery and Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic Florida, Jacksonville, FL.
| | - Houssam A Farres
- Division of Vascular Surgery, Mayo Clinic Florida, Jacksonville, FL.
| | - Albert G Hakaim
- Division of Vascular Surgery, Mayo Clinic Florida, Jacksonville, FL.
| | - Antonio Jorge Forte
- Division of Plastic Surgery and Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Jacksonville, Florida.
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Naalla R, Chauhan S, Dave A, Singhal M. Reconstruction of post-traumatic upper extremity soft tissue defects with pedicled flaps: An algorithmic approach to clinical decision making. Chin J Traumatol 2018; 21:338-351. [PMID: 30579714 PMCID: PMC6354178 DOI: 10.1016/j.cjtee.2018.04.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2018] [Revised: 04/24/2018] [Accepted: 05/01/2018] [Indexed: 02/04/2023] Open
Abstract
PURPOSE Pedicled flaps are still the workhorse flaps for reconstruction of upper limb soft tissue defects in many centers across the world. They are lifeboat options for coverage in vessel deplete wounds. In spite of their popularity existing algorithms are limited to a particular region of upper limb; a general algorithm involving entire upper limb which helps in clinical decision making is lacking. We attempt to propose one for the day to day clinical practice. METHODS A retrospective analysis of patients who underwent pedicled flaps for coverage of post-traumatic upper extremity (arm, elbow, forearm, wrist & hand) soft tissue defects within the period of January 2016 to October 2017 was performed. Patients were divided into groups according to the anatomical location of the defects. The flaps performed for different anatomical regions were enlisted. Demographic data and complications were recorded. An algorithm was proposed based on our experience, with a particular emphasis made to approach to clinical decision making. RESULTS Two hundred and twelve patients were included in the study. Mean age was 27.3 years (range: 1-80 years), 180 were male, and 32 were female. Overall flap success rate was 98%, the following complications were noted marginal flap necrosis requiring no additional procedure other than local wound care in 32 patients (15%), partial flap necrosis requiring flap advancement or extra flap in 15 patients (7%), surgical site infection in 11 patients (5%), flap dehiscence requiring re-suturing in 5 patients (2.4%), total flap necrosis 4 patients (2%). CONCLUSION The proposed algorithm allows a reliable and consistent method for addressing diverse soft tissue defects in the upper limb with high success rate.
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Brachioradialis Flap for Soft Tissue Coverage of Posterior Elbow Wounds: Case Report and Surgical Technique. Tech Hand Up Extrem Surg 2018; 23:2-5. [PMID: 30395081 DOI: 10.1097/bth.0000000000000209] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The posterior aspect of the elbow is an area prone to chronic wound complications due to its prominence and the tensile forces resulting from elbow range of motion. In situations in which local wound care fails, various options for soft tissue coverage are available, including the anconeus, lateral arm, radial forearm, extensor carpi radialis longus, and flexor carpi ulnaris flaps. Each option offers unique considerations depending on the complexity and extent of the soft tissue defect. In situations in which coverage of a large defect is required, or when primary soft tissue coverage options fail, an alternative option is the brachioradialis rotational muscle flap. We present a review of the literature, case report, and surgical technique using the brachioradialis muscle for coverage of a large posterior elbow wound after failure of an anconeus flap.
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Bowen CM, Landau MJ, Badash I, Gould DJ, Patel KM. Primary tumors of the hand: Functional and restorative management. J Surg Oncol 2018; 118:873-882. [DOI: 10.1002/jso.25202] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Accepted: 07/23/2018] [Indexed: 11/09/2022]
Affiliation(s)
- Chase M. Bowen
- Division of Plastic and Reconstructive Surgery; Keck School of Medicine of the University of Southern California; Los Angeles California
| | - Mark J. Landau
- Division of Plastic and Reconstructive Surgery; Keck School of Medicine of the University of Southern California; Los Angeles California
| | - Ido Badash
- Division of Plastic and Reconstructive Surgery; Keck School of Medicine of the University of Southern California; Los Angeles California
| | - Daniel J. Gould
- Division of Plastic and Reconstructive Surgery; Keck School of Medicine of the University of Southern California; Los Angeles California
| | - Ketan M. Patel
- Division of Plastic and Reconstructive Surgery; Keck School of Medicine of the University of Southern California; Los Angeles California
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Gandolfi S, Auquit-Auckbur I, Poirot Y, Bonmarchand A, Mouton J, Carloni R, Nseir I, Duparc F. Focus on anatomical aspects of soft tissue coverage options in elbow reconstruction: an updating review. Surg Radiol Anat 2018; 40:943-954. [DOI: 10.1007/s00276-018-2066-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Accepted: 07/05/2018] [Indexed: 11/30/2022]
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Devale MM, Munot RP, Bhansali CA, Bhaban ND. Awkward defects around the elbow: The radial recurrent artery flap revisited. Indian J Plast Surg 2017; 49:357-361. [PMID: 28216816 PMCID: PMC5288911 DOI: 10.4103/0970-0358.197235] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Background: Soft tissue defects on the posterior aspect of the elbow are commonly seen in patients treated with internal fixation for fractures around the elbow joint. An axial flap based on the radial recurrent artery (RRA) is very useful for such defects, especially if a posterior midline arm incision has been taken for skeletal fixation. The aim of this study is to describe the usefulness of RRA flap (based on the RRA) in the management of such defects. Materials and Methods: We present a retrospective analysis of 4 cases managed with the RRA flap for soft tissue reconstruction of defects around the elbow joint at our institute from January 2015 to August 2016. All the patients were males with a history of exposed implant following internal fixation of olecranon/distal humerus fracture. The size of defects ranged from 4 cm × 4 cm to 7 cm × 5 cm. Results of the analysis are presented here. Results: All flaps survived completely. There was no infection, hematoma or distal neurovascular deficit. There was minimal donor site morbidity. Conclusion: The RRA flap is a useful, simple flap for defects around the elbow joint in select patients providing one stage, reliable, cosmetically acceptable coverage.
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Affiliation(s)
- Maksud M Devale
- Department of Plastic Surgery, Lokmanya Tilak Municipal Medical College, Mumbai, Maharashtra, India
| | - Rohit P Munot
- Department of Plastic Surgery, Lokmanya Tilak Municipal Medical College, Mumbai, Maharashtra, India
| | - Chirag A Bhansali
- Department of Plastic Surgery, Lokmanya Tilak Municipal Medical College, Mumbai, Maharashtra, India
| | - Neeraj D Bhaban
- Department of Plastic Surgery, Lokmanya Tilak Municipal Medical College, Mumbai, Maharashtra, India
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9
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Mascaró P. A. RECONSTRUCCIÓN DE TEJIDOS BLANDOS DE LA EXTREMIDAD SUPERIOR. REVISTA MÉDICA CLÍNICA LAS CONDES 2016. [DOI: 10.1016/j.rmclc.2016.01.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Griffin M, Hindocha S, Malahias M, Saleh M, Juma A. Flap decisions and options in soft tissue coverage of the upper limb. Open Orthop J 2014; 8:409-14. [PMID: 25408782 PMCID: PMC4235084 DOI: 10.2174/1874325001408010409] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2014] [Revised: 08/25/2014] [Accepted: 09/12/2014] [Indexed: 11/22/2022] Open
Abstract
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.
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Affiliation(s)
| | - Sandip Hindocha
- Department of Plastic Surgery, Whiston Hospital, Merseyside, L35 5DR, UK
| | - Marco Malahias
- Department of Plastic Surgery. Good Hope Hospital, West Midlands, UK
| | - Mohamed Saleh
- Department of Plastic Surgery, Ain Shams University. Egypt
| | - Ali Juma
- Department of Plastic Surgery, Countess of Chester Hospital, UK
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Abstract
Elbow and forearm wounds have distinct reconstructive requirements, but both require a durable and pliable solution. Pedicle, free fasciocutaneous and muscle, and distant (2-stage) flaps have a role in wound reconstruction in these unique areas. This article presents practical surgical cases as a guide to soft tissue reconstruction of the elbow and forearm.
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Affiliation(s)
- Joshua M Adkinson
- Section of Plastic Surgery, Department of Surgery, University of Michigan Health System, 2130 Taubman Center, SPC 5340, 1500 East Medical Center Drive, Ann Arbor, MI 48109-5340, USA
| | - Kevin C Chung
- Section of Plastic Surgery, University of Michigan Medical School, 2130 Taubman Center, SPC 5340, 1500 East Medical Center Drive, Ann Arbor, MI 48109-5340, USA.
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12
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Abstract
Many options exist for reconstruction of the posterior elbow/olecranon area following wound formation. Careful early wound management is crucial to ensure successful outcomes following reconstruction. Local and regional options are preferred methods for soft tissue coverage in this region. Common flap options include the reversed lateral arm flap, the radial forearm flap, posterior interosseous artery flap, brachioradialis muscle flap, flexor carpi ulnaris flap, and the latissimus flap. The advantages and disadvantages of these flap options are discussed in this review.
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The Pedicled Reverse-Flow Lateral Arm Flap for Coverage of Complex Traumatic Elbow Injuries. Ann Plast Surg 2013; 71:37-9. [DOI: 10.1097/sap.0b013e318248b627] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Soft-tissue coverage for upper extremity injuries. CURRENT ORTHOPAEDIC PRACTICE 2013. [DOI: 10.1097/bco.0b013e318265dee4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Akinci M, Ay S, Kamiloglu S, Erçetin O. LATERAL ARM FREE FLAPS IN THE DEFECTS OF THE UPPER EXTREMITY — A REVIEW OF 72 CASES. ACTA ACUST UNITED AC 2012; 10:177-85. [PMID: 16568511 DOI: 10.1142/s0218810405002784] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2004] [Accepted: 09/01/2005] [Indexed: 11/18/2022]
Abstract
Lateral arm flaps are versatile in the use of upper extremity moderate-sized defects with little morbidity and with acceptable cosmesis. The conditions are outlined in a series of 74 lateral arm flaps performed on 72 patients and the results are given. Five patients were operated on as emergencies, 12 were operated within the first 72 hours of injury and 57 patients were treated electively. Skin defects were between 6 × 4 cm and 20 × 9 cm . Five (7%) flaps were lost due to venous thrombosis, three that sustained a high-voltage electric burn. Two other patients that were treated for a high-voltage electric burn had a successful revision of the anastomosis site in the early post-operative duration. One flap was abandoned due to very thin pedicle and obesity of the patient. A higher failure rate is encountered most frequently with the cases of high-voltage electric burn. To deal with this problem, a modified approach such as an extended approach and/or including the forearm skin to the flap is recommended during the flap harvest. For a longer pedicle to be anatomized more proximally, perforator flaps with longer pedicles may be used as an alternative.
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Affiliation(s)
- M Akinci
- Ankara Hand Surgery Center, Department of Hand Surgery, Güven Hospital, Ankara, Turkey.
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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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Prantl L, Schreml S, Schwarze H, Eisenmann-Klein M, Nerlich M, Angele P, Jung M, Füchtmeier B. A safe and simple technique using the distal pedicled reversed upper arm flap to cover large elbow defects. J Plast Reconstr Aesthet Surg 2008; 61:546-51. [PMID: 17618845 DOI: 10.1016/j.bjps.2007.05.015] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2006] [Revised: 11/30/2006] [Accepted: 05/22/2007] [Indexed: 11/24/2022]
Abstract
The reconstruction of large soft-tissue defects at the elbow is hard to achieve by conventional techniques and is complicated by the difficulty of transferring sufficient tissue with adequate elasticity and sensate skin. Surgical treatment should permit early mobilisation to avoid permanent functional impairment. Clinical experience with the distal pedicled reversed upper arm flap in 10 patients suffering from large elbow defects is presented (seven male, three female; age 40-70 years). The patient sample included six patients with chronic ulcer, two with tissue defects due to excision of a histiocytoma, and one patient with burn contracture. In the two cases of histiocytoma, defect closure of the elbow's ulnar area was achieved by using a recurrent medial upper arm flap. In the eight other patients we used a flap from the lateral upper arm with a flap rotation of 180 degrees. Average wound size ranged from 4 to 10 cm, average wound area from 30 to 80 cm(2). Flap dimensions ranged from 15 x 8 cm for the lateral upper arm flap to 29 x 8 cm for the medial upper arm flap. The inferior posterior radial and ulnar collateral arteries are the major nutrient vessels of the reversed lateral and medial upper arm flaps. Perforating vessels are identified preoperatively using colour Doppler ultrasonography. Flap failure did not occur. Secondary wound closure became necessary due to initial wound healing difficulties in one patient. Mean operation time was 1.5 h and mean follow-up period 12 months. Good defect coverage with tension-free wound closure was achieved in all cases. Stable defect coverage led to long-term wound stability without any restriction of elbow movement. The lateral and medial upper arm flaps represent a safe and reliable surgical treatment option for large elbow defects. The surgical technique is comparatively simple and quick.
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Affiliation(s)
- L Prantl
- Department of Plastic Surgery, University Hospital, Regensburg, Germany.
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Pedicled and free radial forearm flaps for reconstruction of the elbow, wrist, and hand. Plast Reconstr Surg 2008; 121:887-898. [PMID: 18317137 DOI: 10.1097/01.prs.0000299924.69019.57] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND A single surgeon's experience with 67 pedicled and free radial forearm flaps for reconstruction of the elbow, wrist, and hand was analyzed retrospectively. METHODS Fifty-seven pedicled (43 reverse and 14 antegrade flow) and 10 free radial forearm flaps were performed in 66 patients, including seven fascial flaps and one osteocutaneous flap. Indications involved soft-tissue coverage of the elbow (n = 11), dorsal wrist and hand (n = 24), palmar wrist and hand (n = 12), and thumb amputations (n = 5); after release of thumb-index finger web space contractures (n = 6) and radioulnar synostosis (n = 2); before toe-to-thumb transfers (n = 3); for reconstruction following tumor excision (n = 13); and for wrapping of the median, ulnar, and radial nerves for traction neuritis (n = 5). RESULTS Primary healing of the soft-tissue defect of the elbow, wrist, and hand was successful in 95 percent of patients. There was one flap dehiscence, partial loss of two reverse radial forearm flaps, and complete loss of one free radial forearm flap. Eleven donor sites were closed primarily and 56 were covered with a split-thickness skin graft. No patients complained specifically of cold intolerance of the hand or dysesthesias in the superficial radial nerve or lateral antebrachial nerve distribution. CONCLUSIONS This is the largest reported series of radial forearm flaps for reconstruction of the upper extremity. The authors believe the antegrade pedicled radial forearm flap is the optimal flap for coverage of defects around the elbow, and the reverse radial forearm flap is the optimal choice for coverage of moderate-sized defects of the wrist and hand.
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Saint-Cyr M, Langstein HN. Reconstruction of the hand and upper extremity after tumor resection. J Surg Oncol 2006; 94:490-503. [PMID: 17061282 DOI: 10.1002/jso.20486] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
This article reviews the surgical options available for reconstruction of the upper extremity following tumor resection. In order to achieve maximum function and limb salvage a multidisciplinary approach to patient care is emphasized. With proper preoperative planning, salvage of limb form and function can be accomplished in over 95% of cases. Successful reconstruction is measured by preservation of patient health, limb function, limb sensation and cosmesis and stable wound coverage. Important adjuncts to reconstruction include adequate postoperative splinting and aggressive rehabilitation to maximize long-term upper extremity function.
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Affiliation(s)
- Michel Saint-Cyr
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
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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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Koschnick M, Bruener S, Germann G. Free tissue transfer: an advanced strategy for postinfection soft-tissue defects in the upper extremity. Ann Plast Surg 2003; 51:147-54. [PMID: 12897517 DOI: 10.1097/01.sap.0000058495.72795.b9] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Surgical treatment of severe, necrotizing infections frequently leave compound defects that require complex reconstructive procedures. In the upper extremity, local flap coverage is limited because of the size of the lesions. Regarding the results of early microsurgical coverage of complex postinfectious defects of the lower extremity, the goal of this study was to evaluate the role of free tissue transfer in the treatment of severe infections in the upper extremity. Between 1994 and 1999, 24 patients with major defects as a result of severe necrotizing infections in the upper extremity underwent free tissue transfer. Parameters assessed included the success of infection control, flap survival rate, salvage of the extremity, and an outcome analysis by the Disability of Arm-Shoulder-Hand score and a visual analog scale. Patient age ranged from 17 to 75 years (average age, 50.8 years). Previous treatment of 11 patients in outlying hospitals included 4.2 operative procedures and a delay of admission to the authors' unit of 89 days. The average defect size after debridement was 10.0 x 14.4 cm. Twenty-four free flaps including 16 muscle or musculocutaneous flaps, 4 chimeric flaps from the subscapular system, and 4 osteocutaneous flaps were performed for reconstruction. The overall flap survival was 95.8%. One temporalis fascia flap (TPF) was lost as a result of vascular thrombosis, and three flaps underwent successful revision of the anastomoses. Eight patients required further minor surgical treatment. The Disability of Arm-Shoulder-Hand score yielded an average of 41.5 points, which represents a moderate impairment of activities of daily living. Visual analog scale assessment demonstrated an overall high satisfaction (9.5 points; range, 1-10 points). The data demonstrate that even in severe necrotizing infections resulting in complex acute or chronic defects, limb salvage and infection control can be achieved successfully with radical debridement and early free tissue transfer.
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Affiliation(s)
- Martin Koschnick
- Department of Plastic-Hand and Reconstructive Surgery, Burn Center, BG-Trauma Center, University of Heidelberg, Ludwigshafen, Germany.
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Duteille F, Rocchi L, Dautel G, Merle M. Le lambeau antécubital : intérêt dans les pertes de substance du coude. Étude anatomique et expérience de cinq cas cliniques. ANN CHIR PLAST ESTH 2001. [DOI: 10.1016/s0294-1260(01)80004-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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