記住我
ORIGINAL ARTICLE
Year : 2023 | Volume
: 31
| Issue : 1 | Page : 13-17
Reconstruction of fracture associated skin defects on olecranon with antegrade posterior interosseous artery flap
Selim Safali, Ali Ozdemir, Mehmet Afsin Karaoglan, Erkan Sabri Ertaş, Mehmet Ali Acar
Department of Orthopaedic and Traumatology, Medical Faculty, Selçuk University, Konya, Turkey
Correspondence Address:
Dr. Selim Safali
Department of Orthopaedic and Traumatology, Medical Faculty, Selçuk University, Konya
Turkey
Source of Support: None, Conflict of Interest: None
DOI: 10.4103/tjps.tjps_50_22
Context: The management of tissue defects of the olecranon after fractures of this region is challenging. Most cases require local or free flaps to obtain both soft-tissue reconstruction and wide range of motion of the elbow joint. Aim: The aim of this study is to describe the results of reconstruction of fracture-associated skin defects on the olecranon with posterior interosseous artery (PIA) flap. Settings and Design: We present our experience of using antegrade PIA flap for soft-tissue coverage of the olecranon region after fracture surgery. Materials and Methods: We retrospectively evaluated 11 cases who underwent reconstruction of the olecranon for soft tissue defect with PIA flap. We evaluated the extent of the soft-tissue defects and the harvested flaps, fracture fixation techniques, complications, patients' demographics, partial or total flap lost, number of perforators, time to reconstruction after injury, esthetic looking of reconstructed area, and donor site coverage. Results: The study included 11 patients (7 males and 4 females). The mean age was 35 years. The mean defect size was 15.4 cm2. The mean flap size was 20 cm2. Plates were used in six cases, tension band wiring in three cases, and external fixators in two cases for fracture fixation. Ten flaps survived completely. There was partial flap necrosis in one flap due to venous congestion. Infection, hematoma, and distal neurological deficits were not observed. Minimal morbidity occurred since the donor site was primarily closed in eight cases and skin graft in three cases. Good cosmetic outcome was achieved in all cases. We detected one perforator in one case, two perforators in five cases, three perforators in four cases, and four perforators in one case. Conclusion: Reconstruction with PIA flap is an effective, useful, and simple surgical technique for soft-tissue coverage on the olecranon region. The procedure involves a single step surgery, low donor site morbidity, and good cosmetic outcomes.
Keywords: Olecranon soft-tissue defects, perforator flap, posterior elbow, posterior interosseous artery flap
Elbow defects require reconstruction with resistant, elastic, and mobile tissue. Local flaps, regional flaps, and free flaps are options for reconstruction of soft-tissue defects of the olecranon.[1] Soft-tissue reconstruction surrounding the olecranon is always challenging after fractures.[2] This often requires soft-tissue reconstruction because of underlying triceps tendon, proximal ulna, elbow joint, and ulnar nerve. Open fractures, burns, infections, tumors, and surgery may be the cause of soft-tissue defects. Soft-tissue disorders and exposure of implants may occur due to surgery or trauma. Early reconstruction is crucial for elbow tissue defects to achieve good functional outcomes and to prevent infection.[3]
Reconstruction of olecranon defects should be reliable, quick, relatively simple and, should have minimal complications. Sometimes, local flaps can be insufficient for reconstruction and for satisfying requirements. Pedicled radial/ulnar artery forearm flaps require sacrificing a major artery of the hand. Free flaps require special equipment and microsurgical skills. The posterior interosseous artery (PIA) flap is a fasciocutaneous island flap vascularized by the PIA, which is not a major artery of the hand. Antegrade and reverse PIA flap types have been described before.[4],[5],[6] This flap has several advantages, such as providing thin, soft, and pliable skin with good color. This study aims to describe the results and evaluate the efficacy and reliability of reconstruction of the olecranon region with PIA flap which was performed on 11 cases.
Materials and MethodsAll procedures performed in studies involving human participants received ethical approval from the local institutional committee and were conducted in accordance with the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards.
We retrospectively reviewed the files of patients who underwent antegrade PIA flap reconstruction for soft-tissue defects on the olecranon after fracture surgery between January 2013 and June 2018 (n = 14). Patients who underwent reconstruction due to nonfracture causes (1 case after total elbow arthroplasty), out of follow-up (two patients) were excluded from the study. A total number of 11 cases with soft tissue defects of the olecranon were included in the study. Proximal ulna, triceps tendon or implants were exposed in all cases.
Surgical technique
All flap surgeries performed by the senior author. Supraclavicular brachial plexus block was performed in seven cases, and general anesthesia was required for four cases. A pneumatic tourniquet cuff was placed on the arm. Preoperative landmarks for PIA flap were determined by drawing a line between the lateral epicondyle and midpoint of the distal radioulnar joint [Figure 1] and [Figure 2]. Septocutaneous perforators of the flap were detected with a hand doppler (Dopplex SD2, Huntleigh Healthcare Ltd, Cardiff, UK) along the intermuscular septum between the extensor digiti minimi (EDM) and the extensor carpi ulnaris (ECU) and perforators were also marked on the skin. A distal skin island was designed. Debridement and measurement of the defect size were performed [Figure 1]. Defect size was measured with the elbow at full flexion to ensure closure of the tension-free wound. Width of the flap was planned to be smaller than 4 cm to allow primary closure of the donor site. The pivot point of the flap is the proximal piercing point of the PIA on the interosseous membrane. The pneumatic tourniquet cuff was inflated without draining the blood of the limb. Flap dissection began as previously described[6] by making markings of the essential flap at the donor site according to perforators. The first incision was made on the posterolateral side of the flap and was extended proximally. The fascia over the EDM and ECU was divided longitudinally. Flap dissection was performed from the radial to ulnar and distal to proximal side [Figure 3], to expose the pedicle and identify the perforators. The posterior interosseous nerve was preserved during pedicle dissection. After dissection was completed, the tourniquet was deflated. The artery was clamped on the distal side before ligation and after blood circulation of the flap was ensured, it was ligated. The flap was transferred to the defective site through the wide subcutaneous tunnel. Tension-free coverage/placement and vascularity of the flap was ensured with the elbow in full-flexion and full-extension. Then primary closure of donor site was performed [Figure 3] and [Figure 4].
Figure 1: Determining the defect size and planning the flap according to the defect
Figure 2: Determining the defect size and planning the flap according to the defectContraindications
As previously described by Choudry et al.,[7] contraindications for this flap include severe soft-tissue injury of the dorsal forearm, history of dorsal approach of the wrist, or defects >40 cm2. Furthermore, this flap is not used for tissue defects proximal to the olecranon, since the flap pedicle is not long enough.
Postoperative care and rehabilitation
Flap circulation was monitored at 1-h intervals during the first 24 h. The arm was elevated to prevent congestion. Patients who had no circulatory or additional problems within the first 48 h were discharged. Splints were used for 2 weeks to immobilize the elbow. Passive range of motion (ROM) exercises were initiated on the 2nd week after discharge. After the 3rd week, active ROM exercises were initiated.
Clinical evaluation
Demographic characteristics, flap survival, flap size, donor site-and flap-associated complications, number of perforators, time until reconstruction after injury, cosmetic outcome of the reconstructed site, and donor site coverage of the patients were assessed.
ResultsEleven cases (7 males and 4 females) were included in the study [Table 1]. The mean age of the patients was 35 years (range 19–64 years). All patients had a history of surgery after olecranon fracture. None of the patients had neurovascular injury, comorbid diseases, or had signs of infection. Six plates, two external fixators, and three tension bands were used for fracture stabilization. Tissue defects were on the right side in six patients and on the left side in five patients.
Mean defect size was 15.4 cm2[Table 1]. Maximum defect width was ≤4 cm in all patients. Mean flap size was 20 cm2. All patients were operated an average of 4 weeks after their first injury or operation. Mean operation time was 110 min (range 90–150 min). One perforator was detected in one case, two perforators in five cases, three perforators in four cases, and four perforators in one case with hand Doppler. Full flap survival was achieved in ten patients. Venous congestion occurred in two patients and one of them recovered after elevation of the elbow Case 5). Venous congestion caused partial flap necrosis in the other patient (Case 7). It fully resolved after debridement and no additional reconstructive surgery was needed. Cosmetic results were satisfactory [Figure 5]. It was good for eight patients, and acceptable for three patients. The donor site was closed with split-thickness skin graft in three cases with flap width of 4 cm. The donor site was closed primarily in the other 8 cases.
DiscussionMany surgical techniques have been previously described for the reconstruction of the elbow.[7] Among local muscle flaps, anconeus, flexor carpi ulnaris (FCU), brachioradialis (BR) and pedicled latissimus dorsi muscle flaps were previously used for reconstruction of soft tissue on the olecranon. Anconeus, FCU, and BR muscle flaps were used more often in the reconstruction of smaller defects, yielding satisfactory outcomes.[8],[9] It should be kept in mind that these flaps have a limited rotation arc, can create functional deficits, and may not provide acceptable coverage in large defects.[6] Although satisfactory results have been reported, FCU and BR flaps produce significant functional deficits in injured limbs.[6],[9] If the contiguous skin is in good health, local random flaps can be used for the reconstruction of small defects.[10] Another option, the pedicled latissimus dorsi muscle flap, has been preferred in the treatment of large and complex defects.[11] Distal end necrosis, functional loss, and large scar tissue are the most common complications of the pedicled latissimus dorsi muscle flap.[12] Radial and ulnar artery forearm flaps can be used in the reconstruction of elbow defects. Choudry et al. reported that radial and ulnar arterial sacrification, donor site morbidity, and cosmesis were significant problems.[7] Thoracoabdominal random flaps can also be used for reconstruction.[13] Hygiene, prolonged immobilization, two-stage procedures, and joint stiffness are major disadvantages of this flap.
Among the main advantages of the PIA flap are its thin and flexible structure and the fact that it does not require sacrificing one of the main arteries of the hand. In the present study, we evaluated functional and cosmetic results of antegrade PIA flap for the olecranon region after fracture surgery. As a result of our study, antegrade pia flap demonstrated successful functional and cosmetic results for the soft-tissue reconstruction of the mid-size defects of the elbow region. Except for venous congestion, no complications were detected. In the patient who developed venous congestion, it healed without the need for additional surgical procedures other than debridement. No complication was observed in the donor area and skin grafting was required in patients with a wide flap width.
Although there are many publications about the use of reverse PIA flap in hand defects,[14],[15] reports of the use of this flap to cover elbow defects are limited.[16],[17],[18] Penteado et al. first published a study regarding the use of antegrade PIA flap to cover elbow defects. They treated two patients with this flap and reported satisfactory outcomes.[4] Mazzer et al. and Gupta and Yenna reported successful outcomes which were containing four cases.[6],[19] Mazzer et al. expressed concern about the small size of the cutaneous perforators of PIA, if the flap was designed distally.[19]
Zaidenberg et al. described the distal perforators of the PIA in their cadaveric studies and also presented successful results of four clinical cases, they detected 3 or 4 perforators in their cadaveric study.[20] We detected four perforators in one case, three perforators in four cases, two perforators in five cases and one perforator in one case with hand Doppler. Perhaps, it depends on the Doppler's technical features.
Venous congestion is a common problem of this flap type and may cause flap loss. This problem was encountered in the literature, especially in reverse flow flap and total flap loss was reported in 3%−37% of cases.[4],[5],[15],[21] However, there is insufficient evidence for the formation of venous congestion due to the small number of studies related to the antegrade PIA flap. Many flap modifications were done to decrease the incidence of venous congestion, such as changes in flap design, avoiding tunneling of the flap, increasing the number of veins and number of perforators in the flap, medicinal leech therapy, and additional venous anastomosis.[15],[22],[23] In our study, venous congestion was observed in two (18%) patients. In one patient, venous congestion improved only with elevation, while partial flap necrosis was observed in the distal part of the flap in the other patient. After debriding the flap which developed necrosis, the patient's wound healed without the need for additional surgery. We do not perform additional venous anastomosis in pedicled fasciocutaneous flaps in our clinical routine. In the patient who developed venous congestion, performing additional venous anastomosis in the early period could reduce congestion and prevent flap necrosis. In the surgical technique used in the study, the antegrade PIA flap was transported to the olecranon region by passing through a subcutaneous tunnel in order to avoid additional incisions. Venous congestion would not have been encountered if the flap was delivered by performing z-plasties without tunneling. Since there is a bone implant under the flap, we avoid leech therapy to avoid the risk of infection.
Primary closure of the donor site is important in terms of cosmetic results. Zaidenberg et al. suggested primary closure of the donor site which is possible when the width is <3 cm in diameter.[20] Devale et al. reported that the pedicled radial artery forearm flap would yield better cosmetic results in patients with a defect larger than 4 cm, due to the fact that the donor site could not be closed.[24] In our study, the maximum flap width was 4 cm and the donor site was closed primarily in 8 cases, while split thickness skin graft was used in 3 cases. Cosmetic results were satisfactory in 2-year follow-up [Figure 6].
Our study has some limitations. It is a retrospective study with a small case series. Although only 11 cases were evaluated, it is the highest number of patients in the literature. The absence of a control group is another weakness of our study.
The antegrade PIA flap provides satisfactory outcomes for the treatment of defects on the posterior elbow. Clinical and anatomical studies show that this flap has a reliable anatomy and sufficient number of pedicles to reconstruct defects surrounding elbow. Thin and flexible flap structure, single stage reconstruction, no sacrificing of a major artery or muscle, short hospitalization time, early mobilization, low donor-site morbidity, and simple dissection of flap without microsurgical skills are the advantages of this flap. The most important disadvantage of this flap is its insufficiency in the reconstruction of large defects.
Conclusion
The antegrade PIA flap provides satisfactory outcomes for the treatment of defects on the posterior elbow. Clinical and anatomical studies show that this flap has a reliable anatomy and sufficient number of pedicles to reconstruct defects surrounding elbow. Thin and flexible flap structure, single stage reconstruction, no sacrificing of a major artery or muscle, short hospitalization time, early mobilization, low donor-site morbidity, and simple dissection of flap without microsurgical skills are advantages of this flap. The most important disadvantage of this flap is its insufficiency in the reconstruction of large defects.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
留言 (0)