Distant Pedicled Flaps for Elbow Coverage- a Systematic Review

Abstract

Coverage of elbow defects can be challenging for reconstructive surgeons. The intended reconstruction not only has to cover and protect the underlying structures but also allow for smooth functioning of the joint. Even in the era of microsurgery, certain defects are not amenable to reconstruction with regional flaps or free flaps. Pedicled flaps from the abdomen play a critical role in such cases to salvage the elbow and hence the limb. While there are multiple such flaps mentioned, a systematic review is lacking. This systematic review aims to look at all the pedicled flaps from the abdomen to the elbow reported in the literature. After an extensive search of multiple databases, 159 articles were obtained, of which 31 were selected. The flaps reported in the selected articles were grouped into muscle/ musculocutaneous or skin/fasciocutaneous flaps. While the latissimus dorsi appeared to be the most utilized flap overall to cover the defect in the elbow region, paraumbilical perforator-based flaps were the most common among the fasciocutaneous flaps. This review highlights the commonly used flaps, and discusses the advantages and disadvantages of each. In view of the considerable overlapping names of various fasciocutaneous flaps, we offer a nomenclature for better communication and understanding.

Keywords

• Elbow
• Reconstruction
• Pedicled flap

Dirsek Bölgesi Defektlerinin Onarımında Uzak Pediküllü Flepler: Sistematik Derleme

Abstract

Dirsek bölgesi defektlerinin kapatılması rekonstrüktif cerrahlar için kendine özgü çeşitli güçlükler içerir. Amaçlanan rekonstrüksiyon sadece allta yatan yapıları örterek korumakla kalmamalı, aynı zamanda dirsek ekleminin sorunsuz hareketine de izin vermelidir. Mikrocerrahi cağında bile bazı defektlerin bölgesel ya da serbest fleplerle onarımı olanaklı olmayabilir. Bu tip olgularda abdomenden hazırlanan pediküllü flepler dirseğin ve dolayısı ile ve ekstremitenin kurtarılmasında çok önemli bir rol oynarlar. Bu amaçla pek cok flep tanımlanmış olsa da bu konu üzerine yazılmış derlemelerin sayısı kısıtlıdır. Bu sistematik derlemenin amacı literatürde dirsek bölgesi defektlerinin onarımı için abdomen bölgesinden hazırlanan flepleri konu alan çalışmaları gözden geçirmektir. Bu amaçla çesitli veri bankalarının kapsamlı taraması sonucu bulunan 159 makalenin 31 tanesi seçildi. Seçilen makalelerde bahsi geçen flepler kas / muskulokutan ya da cilt/ fasyokutan flepler olarak sınıflandırıldı. Genel olarak, latissimus dorsi flebi dirsek bölgesi fleplerinin kapatılması için kullanılan en yaygın flep olarak ortaya çıksa da, paraumblikal perforatörlere baze flepler en sık kullanılan fasyokütan flepler idi. Bu derleme, en sık kullanılan flepleri ortaya koyup bunların kullanımı ile ilgili avantaj ve dezavantajları tartışmaktadır. Farklı fasyokütan flepleri tanımlamak için kullanılan terimler arasında karışıklığa yol açacak derecede bir örtüşme olduğundan, bu fleplerin daha iyi anlaşılması ve daha iyi iletişim için yeni bir tanımlama şablonu da sunulmuştur.

Keywords

• Dirsek
• Rekonstrüksiyon
• pediküllü flep

References

1. 1. 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(6):1852–1857.
2. 2. Kelley BP, Chung KC. Soft-Tissue Coverage for Elbow Trauma. Hand Clin. 2015;31(4):693–703.
3. 3. 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(6):634–643
4. 4. Jensen M, Moran SL. Soft tissue coverage of the elbow: a reconstructive algorithm. Orthop Clin North Am. 2008;39(2):251–vii.
5. 5. Khan KS, Kunz R, Kleijnen J, Antes G. Five steps to conducting a systematic review. J R Soc Med. 2003;96(3):118–121
6. 6. Hallock GG, Dingeldein GP. The Thoracoepigastric Flap as an Alternative for Coverage of the Burned Elbow. J Burn Care & Rehab.1982;3(6),393–396.
7. 7. Davis WM, McCraw JB, Carraway JH. Use of a direct, transverse, thoracoabdominal flap to close difficult wounds of the thorax and upper extremity. Plast Reconstr Surg. 1977;60(4):526–533.
8. 8. Seitchik SH, Granick MS, Solomon MP, Berman AT. Posttraumatic upper extremity wound coverage utilizing the extended deep inferior epigastric flap. Ann Plast Surg. 1992;28(5):465–471

9. 9. O’Shaughnessy KD, Rawlani V, Hijjawi JB, Dumanian GA. Oblique pedicled paraumbilical perforator-based flap for reconstruction of complex proximal and mid-forearm defects: a report of two cases. J Hand Surg Am. 2010;35(7):1105–1110
10. 10. Naduthodikayil P, Bhandari L, Sreedhar SL. Pedicled Oblique Para-Umbilical Perforator (OPUP) Flap for Upper Limb Reconstruction. J Hand Surg Asian Pac Vol. 2016;21(2):229–233.
11. 11. Ramadevi V. Pedicle Thoracoumbilical Flap for Soft Tissue Coverage Defects Around Elbow Region. IOSR J Dent & Med Sci. 2019;18(2):2327.
12. 12. Farber GL, Taylor KF, Smith AC. Pedicled thoracoabdominal flap coverage about the elbow in traumatic war injuries. Hand (N Y). 2010;5(1):43–48.
13. 13. Yunchuan P, Jiaqin X, Sihuan C, Zunhong L. Use of the lateral intercostal perforator-based pedicled abdominal flap for upper-limb wounds from severe electrical injury. Ann Plast Surg. 2006;56(2):116–121
14. 14. Pirela-Cruz MA, Reddy KK, Higgs M. Soft tissue coverage of the elbow in a developing country. Tech Hand Up Extrem Surg. 2007;11(3):214–220
15. 15. Fisher J. External oblique fasciocutaneous flap for elbow coverage. Plast Reconstr Surg. 1985;75(1):51–61
16. 16. Leena J. Islanded Parascapular Flap: An Above Elbow Stump Cover. Anaplastology. 2015; 4(1): 144.
17. 17. Reyad KA, Talal RS. Bilateral Combined Groin and Hypogastric Flap for Coverage of Extremely Huge Combined Hand, Forearm and Elbow Defects. Egypt, J. Plast. Reconstr. Surg. 2019; 43(3) 545-547.
18. 18. Ooi A, Ng J, Chui C, Goh T, Tan BK. Maximizing Outcomes While Minimizing Morbidity: An Illustrated Case Review of Elbow Soft Tissue Reconstruction. Plast Surg Int. 2016;2016:2841816.
19. 19. Schottstaedt ER, Larsen LJ, Bost FC. Complete muscle transposition. J Bone Joint Surg Am. 1955;37-A(5):897–919.
20. 20. Zancolli E, Mitre H. Latissimus dorsi transfer to restore elbow flexion. An appraisal of eight cases. J Bone Joint Surg Am. 1973;55(6):1265–1275
21. 21. 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(1):37–40.
22. 22. Nicoli F, Orfaniotis G, Lazzeri D, et al. The latissimus dorsi-groin-lymph node compound flap: A comprehensive technique with three features including skin coverage, restoration of motor function, and prevention of upper limb lymphedema. Microsurgery. 2016;36(8):689– 694.
23. 23. Sbitany U, Wray RC Jr. Use of the rectus abdominis muscle flap to reconstruct an elbow defect. Plast Reconstr Surg. 1986;77(6):988–989
24. 24. Burstein FD, Salomon JC, Stahl RS. Elbow joint salvage with the transverse rectus island flap: a new application. Plast Reconstr Surg.