Introduction Oncologic resection around the elbow often results in large, complex tissue defects. Definitive reconstruction usually entails the use of allograft bone and/or alloprosthesis. Durable soft tissue coverage is critical since infection of bulk allograft is associated with a 50% limb loss rate. Although free tissue transfer is a highly effective and safe treatment option, it is not always necessary for these defects. In addition, the small risk of total free flap loss cannot be eliminated. The purpose of this study was therefore, to review our experience with the pedicled latissimus dorsi (LD) flap in providing stable and durable coverage of the elbow in this setting.

Methods This was a retrospective review of all patients in whom a pedicled LD flap was used to cover elbow reconstructions using prostheses or allografts from 1996 to 2004. Chart review and patient examinations were performed. Patient demographics, comorbid conditions, pathology, adjuvant treatment, defect characteristics, skin paddle dimensions and operative records were reviewed. Major and minor complications, range of motion, patient survival, and limb viability were evaluated as outcome variables.

Results Nine patients were identified during the study period (age range 6-75 years, mean age 38 years; 6 males and 3 females). Primary oncologic diagnosis included seven primary extremity tumors and one metastatic tumor. (renal cell) Intra-articular extension of the tumor into the elbow joint was seen in seven patients. Wide excision of the entire elbow was performed in eight patients with defects extending to the elbow and mid-forearm In two cases, a latissimus muscle flap alone was utilized, while 7 patients underwent myocutaneous flap transfer. The dimensions of the skin paddle ranged from 3.5 to 11cm in width (mean 6.5cm) and 11 to 35 cm in length (mean 24.7 cm); mean surface area was 142.0 cm2. Seven patients underwent allograft or alloprosthetic composite elbow reconstruction. One patient was reconstructed solely with a metallic prosthesis. No patients developed infections. Three patients had nonunions/delayed unions of their allografts. All were revised successfully using a new allograft or iliac crest bone graft. Two patients experienced partial skin flap necrosis requiring operative revision. All patients went on to heal without additional complications. Range of motion at the elbow was recorded for six of the eight patients. Motion recorded at the elbow ranged from 0 to 140 degrees with a mean of 117 degrees in flexion and a mean 33.3 degrees in extension. All patients with total elbow replacements demonstrated superior motion. As of their last documented follow up visits, no patients have gone on to amputation. The eight patients with primary extremity tumors are alive and without evidence of local tumor recurrence.

Conclusion The pedicled LD flap is an effective option for coverage of large complex elbow defects involving allograft and/or alloprosthesis reconstruction. While resections involving more distal portions of the arm are usually treated with free tissue transfer, the pedicled LD flap is our first choice for tumors involving the elbow. Use of the pedicled LD flap in complex elbow reconstructions provides ample well-vascularized soft tissue to minimize the risk of infection and maximize limb salvage.
View Synopsis (.doc format, 34.0 kb)