Coracobrachialis Myofascial Flap

Abstract

Background Synovio-cutaneous fistulae (SCF) are a rare but known complication after joint trauma, inflammation, or infection. Practitioners with first-hand experience treating this complication are limited. To date, treatment methodology has not been standardized, which may, in part, account for high recurrence rates. The coracobrachialis muscle (CBM) has been established as a feasible muscle flap. However, there is limited literature with respect to its potential applications and no literature regarding its use for management of glenohumeral SCF. Rationale for selection and utilization of the CBM for this purpose is presented. Methods Pertinent literature is reviewed. The article presents a case of a 48-year-old white man with a persistent SCF located at the superior incisional margin after revision of a rotator cuff repair, following failed conservative management. Definitive treatment included culture, excision of the fistula tract, and a CBM flap over the exposed joint space followed by a V-Y type advancement flap to close the wound. The drain was removed postoperatively at 1 week. Gentle range of motion was started at 2 weeks. Results Range of motion was satisfactory after the procedure. The patient had no recurrence of the fistula, and no morbidity was noted at the donor site at 1-year follow-up. Discussion Treatment strategies should begin with culture to determine the presence of a sterile versus infected SCF. Infected SCF should be treated with an appropriate culture-sensitive course of antibiotics. A trial of immobilization may be the next step in management. SCF should be distinguished from persistent SCF, which may help guide management. Those fistulae that persist past 14 days of immobilization should receive consideration for definitive treatment utilizing a muscle flap to provide tension-free water-tight closure. Local irrigation, excision of the fistula tract, and debridement alone, with or without primary closure, has been associated with a high recurrence rate. Conclusion The CBM can be used as a myofascial flap with multiple advantageous attributes and minimal resultant morbidity from use. It can be used as a primary treatment strategy for glenohumeral SCF and should be considered principally in cases of conservative management failure.