Active Elbow Research Articles

The Effect of a Coronoid Prosthesis on Restoring Stability to the Coronoid-Deficient Elbow: A Biomechanical Study

The coronoid process has been recognized as a critical component in maintaining elbow stability. In the case of comminuted coronoid fractures, where repair is not possible or has failed, a prosthesis may be beneficial in restoring the osseous integrity of the elbow joint. The hypothesis of this in vitro biomechanical study was that a coronoid prosthesis would restore stability to the coronoid-deficient elbow. An anatomically shaped metallic coronoid prosthesis was designed and developed based on computed tomography-derived measurements and optimized to account for average cartilage thickness. Elbow kinematics and stability were determined for 8 cadaveric arms in active and passive elbow flexion in the varus, valgus, horizontal, and vertical positions using an elbow motion simulator. Varus-valgus angulation and internal-external rotation of the ulna relative to the humerus were quantified in the intact state, after collateral ligament sectioning and repair (control state), after a simulated 40% transverse coronoid fracture, and after implantation of the coronoid prosthesis. Internal rotation of the ulna increased with a 40% coronoid fracture in the horizontal and varus positions. Increases in varus angulation after coronoid fracture were also observed in the horizontal and varus positions, during active and passive flexion, respectively. Following implantation of the coronoid prosthesis, elbow kinematics were restored similar to control levels in all elbow positions. Our findings support our hypothesis that an anatomically shaped coronoid prosthesis would be effective in restoring stability to the coronoid-deficient elbow. This study provides evidence that the use of an anatomical implant restores stability to the coronoid-deficient elbow and rationale for further study and development of this method. For comminuted coronoid fractures, where repair is not possible or has failed, our research indicates that a prosthesis may be a feasible treatment option.

Distal triceps ruptures

Injury to the distal triceps is uncommon and often associated with anabolic steroid use, weight-lifting, or laceration. Eccentric loading of a contracting triceps has been implicated, particularly in professional athletes. Initial diagnosis may be difficult because a palpable defect is not always present. Pain and swelling may further limit the ability to evaluate strength and elbow range of motion. MRI may confirm the diagnosis and guide management. Treatment for incomplete tears with retained active elbow extension against resistance is nonoperative. Operative repair is indicated in active individuals with complete tears or incomplete tears with loss of strength. The results of operative repair are reported to be good to excellent and even operative repair of chronic tears can yield good results.

Anatomical and clinical substantiation of the long head of triceps transposition to restore active forearm flexion in patients with arthrogryposis

Purpose: to investigate anatomic features of the long head of triceps brachii in relation to its using as a pedicle flap for restoration of active forearm flexion in patients with arthrogryposis. Material and methods. Anatomical studies were performed on 15 fresh frozen human upper limbs from 9 cadavers. Arteries were perfused with radiopaque masses and following preparation, sectional roentgenography, morphometry of anatomical structures were carried. 29 patients with the lack of active elbow flexion aged from 8 months to 15 years were examined (clinical, neurological and physiological studies) and treated in Turner Scientific and Research Institute for Children's Orthopedics from 2008 to 2012. Results and conclusion. Anatomical studies demonstrated the possibility of transposition of the long head of triceps to forearm flexors position. The long head of triceps can be simply separated from the other two heads, it has independent innervation and blood supply, its vascular pedicle is easily identified, and length of extraorgan vessels and nerves is sufficient to transfer the muscle as a pedicle flap. Clinical study has shown the principal possibility and effectiveness of restoration of active forearm flexion in patients with arthrogryposis using the long head of triceps brachii.

Surgical treatment of brachial plexus posterior cord lesion: A combination of nerve and tendon transfers, about nine patients

Lesions of the posterior cord of the brachial plexus are rare. The symptoms are usually described as palsy of the deltoid and triceps brachii muscles and of the extensor muscles of the wrist, thumb and fingers. If there is no recovery, our strategy is to operate on these patients 6months after the injury using a combination of nerve and tendon transfers. We present a series of nine patients, two with a partial palsy and seven with a complete palsy of the posterior cord. We performed five nerve transfers to the axillary nerve, four using intercostal nerves and one using the ulnar nerve. Six patients benefited from a transfer to one of the nerves to the triceps brachii (medial or lateral head), five using the ulnar nerve and one using two intercostal nerves. We performed eight tendon transfers for radial palsy. The results demonstrated significant restoration of the deltoid muscle (grade 4 strength, mean active abduction of 120°). Active elbow extension was restored in all patients with an average strength measured at 5.6kg and 48% of the contralateral strength. All tendon transfers were successful with recovery of active wrist extension (40°), long fingers extension and thumb abduction and extension (12.5cm between the tips of index and thumb). With this method, we were able to restore function to the upper limb of patients who presented with debilitating palsy of the posterior cord of the brachial plexus.

Locked Elbow Joint Due to a Cartilage Flap Caused by Osteonecrosis of the Humeral Trochlea: A Case Report.

Although osteonecrosis of the humeral trochlea is a well-known complication of supracondylar humeral fractures in childhood, its frequency is relatively rare1. We report a case of a young boy with a locked elbow joint due to a cartilage flap caused by osteonecrosis of the humeral trochlea. Osteonecrosis was confirmed by follow-up radiographic examinations. The patient’s mother was informed that data concerning the case would be submitted for publication, and she provided consent. A ten-year-old boy was referred to our hospital with the symptom of locking during left elbow extension, which was accompanied with pain. The locking occurred suddenly when he turned a doorknob with the left hand. The medical history included a left supracondylar humeral fracture when he was five years old, which was treated conservatively by a local physician (Fig. 1). Fig. 1 Nondisplaced supracondylar fracture of the left elbow (arrow) when the patient was five years old. On the initial examination, no swelling or tenderness was observed in the left elbow. Although the active elbow flexion range was up to 137°, the active and passive extension loss was 75°, with painful locking. Passive extension induced pain on the posterolateral side of the lateral humeral condyle. The range of forearm motion was 90° for pronation and 80° for supination without limitation. Radiographs revealed an irregularly contoured ossification of the epiphysis in the lateral humeral condyle (Fig. 2-A), and computed tomography (CT) revealed irregular ossification of the medial trochlea (Fig. 2-B). Magnetic resonance imaging (MRI) revealed an abnormal low-intensity shadow on the T2-weighted …

Complications and revision rate compared by type of total elbow arthroplasty

This study evaluates the long-term results, including complication and revision rates, of different types of total elbow arthroplasty (TEA) with an average follow up of 13 years. Since 1984, a total of 84 primary TEAs have been performed in 77 patients at our institution. The patient's average age was 54.2 years. We performed unlinked TEA in 35 cases (Pritchard ERS since 1984 [n = 18], Kudo type 3 since 1991 [n = 17]), and semi-linked TEA in 49 cases (Pritchard Mark II since 1997 [n = 14], Coonrad-Morrey since 2001 [n = 35]). We assessed the patients for compliance to daily living guidelines (not to exceed 2.25 kg for repetitive lifting and 4.5 kg for single episode lifting), and followed up with them for an average of 13 years after primary TEA. We analyzed their results with regard to complication and revision rates as the type of TEA. The mean Mayo Elbow Performance Score (MEPS) improved from preoperative 34 points to postoperative 84 points. The active flexion-extension elbow motion increased from 25°-94° preoperative to 12°-130° postoperative. The overall complication rate was 44.0% (37/84 cases); the rate was statistically higher in the unlinked group (62.9%, 22/35 cases) than in the semi-linked group (30.6%, 15/49 cases). Theoverall revision rate was 27.4% (23/84 cases); the rate was higher in the unlinked group (34.3%, 12/35 cases) than in the semi-linked group (22.4%, 11/49 cases). Semi-linked TEA has better outcomes than unlinked TEA with respect to complication and revision rates; but continuous efforts to develop a new TEA design for longevity, improved cementing technique, and supporting activities of daily living are needed to reduce complication and revision rates in the future.

EMG and kinematic analysis of sensorimotor control for patients after stroke using cyclic voluntary movement with visual feedback.

BackgroundClinical scales are often used to evaluate upper-limb deficits. The objective of this study is to investigate the parameters during voluntary arm tracking at different velocities for evaluating motor control performance after stroke.MethodsEight hemiplegic chronic stroke subjects were recruited to perform voluntary movements of elbow flexion and extension by following sinusoidal trajectories from 30 deg to 90 deg at six velocities in the horizontal plane by completing 3, 6, 8, 12, 15, 18 flexion and extension cycles in 36 seconds in a single trial, and the peak velocities ranged from 15.7 to 94.2 deg/s. The actual elbow angle and the target position were displayed as real-time visual feedback. The angular displacement of the arm and electromyographic (EMG) signals of biceps and triceps were captured to evaluate the sensorimotor control of the affected and unaffected side.ResultsThe results showed significant differences in the root mean square error (RMSE), response delay (RD) and cocontraction index (CI) when the affected and unaffected sides were compared during the arm tracking experiment (P<0.05). RMSE decreased with the increase in the tracking velocities for the affected and unaffected sides. And CI and RD increased with the increase in the tracking velocities for both sides. There was significant correlation between average RMSE of the six velocities and Fugl-Meyer shoulder-elbow score for the eight poststroke subjects.ConclusionsThe method and parameters have potential for clinical use in quantitatively evaluating the sensorimotor deficiencies for patients after stroke about the accuracy of motion, response delay and cocontraction between muscle pairs.

Triceps Tendon Reconstruction Using Ipsilateral Palmaris Longus Autograft in Unrecognized Chronic Tears

Injury to the distal triceps tendon is uncommon and can be difficult to diagnose, especially when a partial rupture or tear occurs. In situations where an incomplete disruption to the musculotendinous unit occurs, a palpable defect or clear functional loss may not be present. Advanced imaging techniques, such as magnetic resonance imaging or ultrasound, can be used to confirm the diagnosis and define the extent of injury. The treatment of a complete rupture of the distal triceps tendon is repair or reconstruction, whereas the management of a patient with a partial triceps rupture is related to the pain, functional deficit, and expectations of the patient. This article presents 2 patients with chronic, near complete disruptions of the distal triceps tendon. In both patients, surgical reconstruction of the injured tendon was accomplished using ipsilateral palmaris longus autograft. This technique allows the treating surgeon to harvest the graft from the ipsilateral upper extremity. The palmaris autograft is then used to reconstruct the injured portion of the triceps tendon using a Pulvertaft weave technique through the intact triceps tendon and osseous tunnels within the proximal ulna. This technique allows for easy surgical setup and harvest of autograft tendon and provides a structurally sound technique for a tension-free reconstruction of the injured tendon. It also permits early postoperative elbow range of motion, with active elbow extension allowed at 6 weeks. The authors have used this technique successfully in the treatment of chronic partial tears of the distal triceps tendon.

Elbow Reconstruction Using Island Flap for Burn Patients

BackgroundDeep burns of the elbow lead to soft tissue necrosis and infection, with exposure of deep structures. Adequate wound coverage of this area requires thin, pliable, and durable tissue, while optimal functional recovery requires early coverage and functional rehabilitation. We have found 3 types of island flaps that provide reliable coverage for the elbow.MethodsA retrospective study was performed on all patients who underwent flap coverage of an elbow defect at our hospital. The patients' data including age, sex, cause of injury, wound dimensions, timing of flap coverage, postoperative elbow motion, and complications were investigated.ResultsBetween 2001 and 2012, 16 patients were treated at our hospital. The mean age was 53.3 years. Three kinds of flaps were performed: 9 latissimus dorsi flaps, 4 lateral arm flaps, and 4 radial forearm flaps. The average defect size was 183.5 cm2 (range, 28 to 670 cm2). Wound coverage was performed at mean duration of 45.9 days (range, 14 to 91 days). The mean postoperative active elbow flexion was 98° (range, 85° to 115°). Partial flap failure occurred in 1 latissimus dorsi flap. Minor complications included partial flap loss (11.8%), hematoma (23.5%), seroma (35.3%), and wound infection (5.9%).ConclusionsFlap selection for elbow reconstruction is determined by the defect size and the extent of the adjacent tissue injury. Elbow reconstruction using an island flap is a single-staged, reliable, and relatively simple procedure that permits initiation of early rehabilitation, thereby improving a patient's functional outcome.

Elbow flexion restoration using pedicled latissimus dorsi transfer in seven cases

PurposeThe aim of this study is to analyse the results of a series of pedicled latissimus dorsi transfers to restore elbow flexion. Moreover, we describe a new technique of distal fixation of the muscle to the proximal third of the ulnar diaphysis to increase the lever arm and improve strength. MethodsWe retrospectively reviewed seven patients aged from 18 to 49 years. Elbow flexion paralysis was secondary to destruction of the anterior arm compartment in four cases and to brachial plexus palsy in three cases. The humeral insertion of the latissimus dorsi was relocated on the coracoid process in five cases and not relocated in two cases. The patients were assessed using the Medical Research Council grading system, the maximum weight lifted by the wrist and the active elbow range of motion. ResultsAt the last follow-up (mean 26.6 months), five patients recovered M4 elbow flexion strength (0.5 to 8kg), one patient recovered M3 strength and the last transfer failed because of triceps brachii co-contractions. The mean active elbow flexion was 91° (range, 45 to 130°). Patients with destruction of the anterior arm compartment and particularly whose forearm was not paralyzed had better strength than patients with a brachial plexus palsy (3.25 versus 1kg). A skin island with the latissimus dorsi muscle flap was particularly useful in case of arm soft tissue defect. DiscussionA destroyed anterior compartment of the arm is a good indication for latissimus dorsi transfer to restore elbow flexion. The muscle is usually too weak in high brachial plexus palsy. Finally, the latissimus dorsi needs an objective, reproducible and reliable preoperative evaluation. Level of evidenceLevel IV.

Transfer of Nerve Branch to the Brachialis to Reconstruct Elbow Extension in Incomplete Tetraplegia: Case Report

We undertook a brachialis to triceps nerve transfer to restore elbow extension in a 53-year-old man 5 months after he sustained a spine injury that resulted in a central cord syndrome. Within 3 months of surgery, the patient had recovered active elbow extension and had M3 level strength, which increased to M4 and 5 kg of strength by 12 months postoperatively. Despite transferring an antagonist nerve for triceps reinnervation, the patient had no problems controlling active elbow flexion-extension. Harvesting the brachialis nerve caused no permanent decrease in elbow flexion strength.

Musculoskeletal growth in the upper arm in infants after obstetric brachial plexus lesions and its relation with residual muscle function

Denervation after obstetric brachial plexus lesion (OBPL) is associated with reduced musculoskeletal growth in the upper arm. The aim of this study was to investigate whether reduced growth of upper arm flexor and extensor muscles is related to active elbow function and humeral length. In this study, 31 infants age less than 6 months (mean age 4.3mo; range 2.1-5.9mo; 17 males; 14 females;) with unilateral OBPL (Narakas class I, 19; II, 3; III, 2; and IV, 7) treated at the VU medical centre, in whom neurosurgical reconstruction was considered were prospectively studied using magnetic resonance imaging of both arms at a mean age of 4.3 months. Humeral length and the cross-sectional area (CSA) of elbow flexor and extensor muscles were measured in both upper arms. Paresis of elbow function was estimated when the infants were a mean age of 4.5 months using the Gilbert score. Both flexor and extensor CSAs were significantly smaller on the affected side than on the unaffected side (88% [SD 32%], p=0.020, and 88% [SD 24%], p=0.001 respectively), as was humeral length (96% [SD 7%], p=0.005) (unaffected side 100% in all cases). There was no relation between the reduction in flexor and extensor CSA and residual muscle function. In 17 out of 31 patients, hypertrophy of flexor and/or extensor muscles was observed. Humeral length was not related to muscle parameters. Denervation has different effects on muscle growth and function as well as bone growth. In young infants with an OBPL, muscle size is not a predictor of muscle function. Flexion contractures of the elbow later in childhood may not be explained by a dominance of flexor muscle mass in infants.

Loss of large-diameter nerve sensory input changes perceived posture

Our previous studies (Inui et al. in J Physiol 589:5775-5784, 2011, Exp Brain Res 218:487-494, 2012) showed that a fully flexed or extended finger, wrist, and elbow became perceived as an extended or flexed 'phantom' hand and arm as ischemic anesthesia progressed. Here, we examined what happened if the wrist was fixed in full extension while the elbow was in full flexion before and during the anesthesia, and vice versa. Ten healthy participants demonstrated the perceived postures of their right wrist and elbow during an ischemic block of the right upper arm with the left hand and arm. If the actual wrist was fully extended while the actual elbow was fully flexed, then the perceived position of the wrist moved toward flexion and that of the elbow moved toward extension. Conversely, if the actual wrist was fully flexed while the actual elbow was fully extended, then the wrist was perceived to extend and the elbow was perceived to flex. Following the loss of the afferent signal coming from the main muscles acting at the two joints, the two perceived postures moved toward the opposite direction independently. The changes in the perceived postures are a shift in the body schema depending on the balance of the proprioceptive inputs that determine limb posture.

Fractures in Brief: Olecranon Fractures

Olecranon fractures are relatively common injuries, accounting for approximately 10% of upper extremity fractures in adults [26]. These fractures may result from a direct blow to the proximal ulna, or indirectly, via the forceful contraction of the triceps against resistance (typically, during a fall onto an outstretched hand). Less commonly, the olecranon may fracture when the elbow is hyperextended, as the bone is impacted against the olecranon fossa of the distal humerus. For unstable injuries, operative fixation typically is required. Even after recovery, loss of ROM is not uncommon. This article provides an overview of olecranon fractures in adults; therefore, discussion of olecranon fractures in skeletally immature patients is beyond the scope of this article.

FLUOROSCOPIC ANALYSIS FOR THE ESTIMATION OF IN VIVO ELBOW KINEMATICS: INFLUENCE OF 3D MODEL

The reliable knowledge that model-based three-dimensional (3D) fluoroscopy can provide about in vivo joints kinematics is essential to diagnose orthopedic pathologies, develop new prosthesis, and evaluate clinical procedures. To exploit 3D fluoroscopy for the analysis of elbow kinematics, its use was evaluated considering a single model for the forearm or two different models for the ulna and radius. Active elbow flexion-extension and prono-supination motor tasks of a healthy male subject were acquired by means of fluoroscopy. The 3D bone models were automatically aligned to the relevant projections. The pose estimation algorithm sought the tangency condition of the projection rays with the model surface, minimizing a cost function and exploiting an adaptive distance map. Five iterative guided alignments were performed to avoid the final convergence to a local minimum. The results highlighted the critical alignment of the ulna/radius model, particularly when prono-supination is performed. From the physiological motion patterns and given the values of the cost function, 3D fluoroscopy was proven to be applicable to the analysis of the elbow kinematics when single bone models for the ulna and radius are used.

Elbow Kinematics After Radiocapitellar Arthroplasty

Radiocapitellar arthroplasty has been proposed as a reconstructive option for combined radial head and capitellar deficiency. The purpose of this study was to assess the impact of radiocapitellar replacement on elbow kinematics. We hypothesized that with the medial collateral ligament (MCL) intact, radiocapitellar arthroplasty would replicate normal kinematics, and that a radiocapitellar arthroplasty would more closely approximate normal kinematics than an elbow with a deficient lateral column or with a deficient MCL. We tested 7 cadaveric arms in an upper extremity joint simulator. Each arm underwent computed tomographic scanning to aid implant size selection and computer-assisted implant insertion. We obtained kinematic data using an electromagnetic tracking system during elbow flexion. The capitellar and radial head implants were placed through an extended lateral epicondylar osteotomy. We sectioned the anterior bundle of the MCL, leaving the flexor-pronator mass intact. Outcomes of interest were varus-valgus and rotational kinematics of the ulnohumeral joint. The radiocapitellar arthroplasty showed no difference in kinematics compared with the postosteotomy control. The MCL-deficient elbow showed more valgus angulation and more external ulnar rotation than the control or radiocapitellar arthroplasty in the pronated, valgus loaded position. The deficient lateral column demonstrated increased external ulnar rotation kinematics during active elbow flexion. Radiocapitellar arthroplasty can restore normal elbow kinematics with the MCL intact. If the MCL is deficient, radiocapitellar arthroplasty does not restore normal kinematics. Radiocapitellar arthroplasty should be considered in cases of lateral column deficiency because it maintains normal elbow kinematics during active motion. Whereas radiocapitellar arthroplasty improves the stability of the MCL-deficient elbow with deficiency of the lateral column, reconstruction of the MCL may further improve normal kinematics.

Anterior Deltopectoral Approach for Axillary Nerve Neurotisation

To report outcome of axillary nerve neurotisation for brachial plexus injury through the anterior deltopectoral approach. Nine men aged 20 to 52 (mean, 27.8) years with brachial plexus injury underwent axillary nerve neurotisation through the anterior deltopectoral approach. Three of the patients had complete avulsion of C5-T1 nerve roots. The remaining 6 patients had brachial plexus injury of C5-C6 nerve roots, with associated subluxation of the glenohumeral joint, atrophy of the supraspinatus, deltoid and elbow flexors. They had no active shoulder abduction, external rotation, and elbow flexion. The pectoralis major and minor were cut and/or retracted to expose the underlying infraclavicular plexus. The axillary nerve was identified with respect to the available donor nerves (long head of triceps branch, thoracodorsal nerve, and medial pectoral nerve). In addition to the axillary nerve neurotisation, each patient had a spinal accessory nerve transferred to the suprascapular nerve for better shoulder animation. Patients were followed up for 24 to 30 (mean, 26) months. In the 3 patients with C5-T1 nerve root injuries, the mean active abduction and external rotation were 63 and 20 degrees, respectively, whereas the mean abduction strength was M3 (motion against gravity). In the 6 patients with C5-C6 nerve root injuries, the mean active abduction and external rotation were 133 and 65 degrees, respectively, whereas the strength of the deltoids and triceps was M5 (normal) in all. In 4 patients with the pectoralis major cut and repaired, the muscle regained normal strength. The anterior deltopectoral approach enabled easy access to all available donor nerves for axillary nerve neurotisation and achieved good outcomes.

Functional Outcome of Glenohumeral Fusion in Brachial Plexus Palsy: A Report of 54 Cases

The restoration of shoulder function is a major issue in brachial plexus palsy. Although several tendon and nerve transfers have been described, shoulder arthrodesis remains a reliable technique in this context. This study planned to compare surgical and functional outcomes of 2 glenohumeral arthrodesis bone graft techniques: massive subacromial corticocancellous versus cancellous only grafts. We reviewed 54 patients who had shoulder arthrodesis according to 2 parameters after a mean follow-up of 37 months. The primary outcome measure was the rate of fusion according to the surgical technique. A total of 26 patients received a massive subacromial corticocancellous bone autograft, and 28 patients received only cancellous bone. The secondary outcome measure was the range of scapulothoracic motion measured by a video-assisted method according to type of neurological lesion. Brachial plexus palsy was complete in 32 cases and partial in 22 cases. All patients had recovered active elbow flexion before undergoing shoulder arthrodesis. Of the 54 patients, 48 had no postoperative immobilization. The overall fusion rate was 76% after the first surgical procedure and 94% at last follow-up. Reoperation led to fusion in 10 cases, whereas 3 cases never fused. Pseudarthrosis rate after first surgery was 4% in the group with massive subacromial graft versus 43% in the group with cancellous bone graft. The mean range of motion was 59° in abduction (57° for complete palsy and 62° for partial palsy) with 42 cases 45° or greater. The mean range of motion was 48° in rotation (50° for complete palsy and 46° for partial palsy) with 35 cases 45° or greater. Shoulder fusion provided active abduction greater than 45° in more than 75% of cases and active rotation greater than 45° in almost 65% of cases. Using a massive subacromial graft significantly reduced pseudarthrosis rate (P < .001). Therapeutic III.

Discussion: Use of the Fix and Flap Approach to Complex Open Elbow Injury: The Role of the Free Anterolateral Thigh Flap

BackgroundComplex elbow injuries with associated nerve, muscle, or joint injury commonly develop post-inury stiffness. In order to preserve function, joint congruency, elbow stability and durable wound coverage must be achieved in a timely manner.MethodsA retrospective review of patients who underwent orthopaedic fixation followed by free anterolateral thigh (ALT) flap soft tissue coverage was performed. Five patients were identified and included in this study.ResultsWe present a series of 5 cases managed with this principle. Soft tissue defects ranged in size from 4×9 cm (36 cm2) to 15×30 cm (450 cm2) and were located either posteriorly (n=4) or anteriorly (n=1). Associated injuries included open fractures (n=3) and motor nerve transection (n=2). Wound coverage was achieved in a mean duration of 18.8 days (range, 11 to 42 day). There were no flap failures and no major complications. The mean postoperative active elbow motion was 102° (range, 45° to 140°).ConclusionsIn our small series we have highlighted the safety and utility of using the free ALT flap in complex elbow injuries. The ALT flap has many advantages which include abundant skin and subcutaneous tissue; vascularised vastus lateralis muscle that was used in our series to obliterate dead space, provide a vascular bed for nerve grafts and combat infection; and, access to fascia lata grafts for reconstruction of the triceps tendon.

Use of the Fix and Flap Approach to Complex Open Elbow Injury: The Role of the Free Anterolateral Thigh Flap

Complex elbow injuries with associated nerve, muscle, or joint injury commonly develop post-inury stiffness. In order to preserve function, joint congruency, elbow stability and durable wound coverage must be achieved in a timely manner. A retrospective review of patients who underwent orthopaedic fixation followed by free anterolateral thigh (ALT) flap soft tissue coverage was performed. Five patients were identified and included in this study. We present a series of 5 cases managed with this principle. Soft tissue defects ranged in size from 4×9 cm (36 cm(2)) to 15×30 cm (450 cm(2)) and were located either posteriorly (n=4) or anteriorly (n=1). Associated injuries included open fractures (n=3) and motor nerve transection (n=2). Wound coverage was achieved in a mean duration of 18.8 days (range, 11 to 42 day). There were no flap failures and no major complications. The mean postoperative active elbow motion was 102° (range, 45° to 140°). In our small series we have highlighted the safety and utility of using the free ALT flap in complex elbow injuries. The ALT flap has many advantages which include abundant skin and subcutaneous tissue; vascularised vastus lateralis muscle that was used in our series to obliterate dead space, provide a vascular bed for nerve grafts and combat infection; and, access to fascia lata grafts for reconstruction of the triceps tendon.