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

Abstract

Introduction Traditionally, the latissimus dorsi muscle with or without skin paddle has been the flap of choice for coverage of elbow defects. The ALT flap has found application in elective upper limb defects on account of it’s ability to be tailor made for individual defects. Our series of 10 cases shows the advantages of using this flap for acute trauma defects.

Materials and Methods Consecutive 10 cases of severe elbow injuries, involving varying amounts of the lower arm and proximal forearm underwent debridement followed by coverage using the free anterolateral thigh flap. Nine of 10 arterial anastomosis were done end to side to the brachial artery and venous anastomosis to the veins accompanying the artery. Seven of these patients had long bone fractures and elbow dislocations, stabilised using external fixator. Four patients needed primary muscle or tendon repair and nerve repair or graft.

Results There was 1 total flap loss, intraoperatively where a TFL flap had been used in a 71 year-old patient. Nine of 10 had successful wound coverage. Using Jupiter criteria, 2 had excellent, 3 had good, 3 had fair, and 1 had poor outcome.

Conclusion This consecutive series of moderate and severe elbow injuries demonstrates that the ALT flap should be considered as the flap of first choice, specifically when there is a need.

Keywords

anterolateral thigh flap - elbow injuries - acute trauma

• References

• 1 Kelley BP, Chung KC. Soft tissue coverage for elbow trauma. Hand Clin 2015; 31 (04) 693-703
• 2 Stevanovic M, Sharpe F. Soft-tissue coverage of the elbow. Plast Reconstr Surg 2013; 132 (03) 387e–402e [PubMed: 23584626]
• 3 Levin LS. The reconstructive ladder. An orthoplastic approach. Orthop Clin North Am 1993; 24 (03) 393-409 [PubMed: 8101984]
• 4 Farber GL, Taylor KF, Smith AC. Pedicled thoracoabdominal flap coverage about the elbow in traumatic war injuries. Hand (N Y) 2010; 5 (01) 43-48
• 5 Pierce TD, Tomaino MM. Use of the pedicled latissimus muscle flap for upper-extremity reconstruction. J Am Acad Orthop Surg 2000; 8 (05) 324-331
• 6 Longo UG, Franceschi F, Loppini M, Maffulli N, Denaro V. Rating systems for evaluation of the elbow. Br Med Bull 2008; 87 (01) 131-161
• 7 Lister G, Scheker L. Emergency free flaps to the upper extremity. J Hand Surg Am 1988; 13 (01) 22-28
• 8 Ninkovic M, Deetjen H, Ohler K, Anderl H. Emergency free tissue transfer for severe upper extremity injuries. J Hand Surg [Br] 1995; 20 (01) 53-58
• 9 Hallock GG. The utility of both muscle and fascia flaps in severe upper extremity trauma. J Trauma 2002; 53 (01) 61-65
• 10 Harvey EJ, Aponte R, Levin LS. Application of the island pedicle latissimus dorsi flap for soft tissue coverage of the elbow. Can J Plast Surg 1999; 7 (01) 23-26
• 11 Ma CH, Tu YK, Wu CH, Yen CY, Yu SW, Kao FC. Reconstruction of upper extremity large soft-tissue defects using pedicled latissimus dorsi muscle flaps–technique illustration and clinical outcomes. Injury 2008; 39 (Suppl. 04) 67-74
• 12 Hacquebord JH, Hanel DP, Friedrich JB. The pedicled latissimus dorsi flap provides effective coverage for large and complex soft tissue injuries around the elbow. Hand (N Y) 2018; 13 (05) 586-592
• 13 Stevanovic M, Sharpe F, Thommen VD, Itamura JM, Schnall SB. Latissimus dorsi pedicle flap for coverage of soft tissue defects about the elbow. J Shoulder Elbow Surg 1999; 8 (06) 634-643
• 14 Jutte DL, Rees R, Nanney L, Bueno R, Lynch JB. Latissimus dorsi flap: a valuable resource in lower arm reconstruction. South Med J 1987; 80 (01) 37-40
• 15 Derderian CA, Olivier WA, Baux G, Levine J, Gurtner GC. Microvascular free-tissue transfer for traumatic defects of the upper extremity: a 25-year experience. J Reconstr Microsurg 2003; 19 (07) 455-462
• 16 Chen HC, Tang YB, Mardini S, Tsai BW. Reconstruction of the hand and upper limb with free flaps based on musculocutaneous perforators. Microsurgery 2004; 24 (04) 270-280
• 17 Wang HT, Fletcher JW, Erdmann D, Levin LS. Use of the anterolateral thigh free flap for upper-extremity reconstruction. J Hand Surg Am 2005; 30 (04) 859-864
• 18 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 (06) 1852-1857
• 19 Chui CH, Wong CH, Chew WY, Low MH, Tan BK. Use of the fix and flap approach to complex open elbow injury: the role of the free anterolateral thigh flap. Arch Plast Surg 2012; 39 (02) 130-136
• 20 Morrey BF, Askew LJ, Chao EY. A biomechanical study of normal functional elbow motion. J Bone Joint Surg Am 1981; 63 (06) 872-877
• 21 Spindler N, Al-Benna S, Ring A. et al. Free anterolateral thigh flaps for upper extremity soft tissue reconstruction. GMS Interdiscip Plast Reconstr Surg DGPW 2015; 4: 1-8 10.3205/iprs000064, ISSN 2193–8091