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Reconstruction of the Distal Humerus and Elbow Joint Using a Pedicled Scapular Flap: Case Report
SCIENTIFIC ARTICLE
Reconstruction of the Distal Humerus and Elbow Joint Using a Pedicled Scapular Flap: Case Report Peter Nthumba, MD, Susan George, MD, Michael Jami, Partick Nyoro Loss of elbow function resulting from major bone loss negatively affects quality of life and leaves limited options for reconstruction and restoration of function. To overcome this disabling problem, we reconstructed the distal humerus of a child in a single stage using a scapular flap based on the angular branch of the thoracodorsal artery as a pedicled flap. We also reconstructed the proximal ulna using an iliac crest bone graft with dermal graft interposition arthroplasty, which enabled the restoration of useful elbow function. (J Hand Surg 2013;38A:1150–1154. Copyright © 2013 by the American Society for Surgery of the Hand. All rights reserved.) Key words Elbow joint, distal humerus, reconstruction, pedicled scapular flap.
HRONIC OSTEOMYELITIS IS a difficult clinical problem, and even with the advances of modern medicine, treatment continues to pose major challenges to clinicians, especially in the developing world. Limb trauma from hostilities as well as from domestic, industrial, and motorized vehicular accidents expose large numbers of people to the danger of developing this complication.1,2 Chronic osteomyelitis may also spread from an anatomically contiguous infected part, most commonly septic arthritis. Untreated or unresolved acute osteomyelitis from a hematogenous source may become chronic. A complication of chronic osteomyelitis in children that is difficult to manage is the formation of an extensive sequestrum, sometimes involving an entire long bone. While surgical debridement of infected tissue and the use of appropriate antibiotics are the recommended treatment for osteomyelitis, in children with extensive sequestrum, sequestrectomy should be delayed until sufficient involucrum has been formed, to preserve bone stability and length. Premature debridement of
C
From the Plastic, Reconstructive, and Hand Surgery Unit, AIC Kijabe Hospital, Kijabe, Kenya; and the Department of Plastic Surgery, Vanderbilt University Medical Center, Nashville, TN. Received for publication June 22, 2012; accepted in revised form March 8, 2013. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Peter M. Nthumba, MD, Plastic, Reconstructive, and Hand Surgery Unit, AIC Kijabe Hospital, Kijabe 00220, Kenya; e-mail: [email protected]. 0363-5023/13/38A06-0014$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2013.03.027
1150 䉬 © ASSH 䉬 Published by Elsevier, Inc. All rights reserved.
such a sequestrum may lead to partial or complete loss of bone.2,3 Chronic osteomyelitis of the humerus is well reported.2,4 In contrast, this report focuses on the challenges of reconstructing the distal humerus and elbow joint in a 12-year-old child, 10 years after loss of the distal humerus and elbow joint from destruction by infection and surgical intervention. CASE PRESENTATION A 12-year-old girl was brought to the Plastic Surgery Outpatient Clinic because of a deformed left arm. She described an inability to use the left hand to do anything without the other hand assisting in positioning it (Fig. 1). When she was 2 years of age, she developed septic arthritis of the left elbow followed by chronic osteomyelitis of the distal humerus. Surgical debridement led to the loss of the distal half of the humerus with destruction of the proximal ulna and elbow joint (Fig. 2). The neurological exam was normal, as were hand, wrist, and shoulder functions. She had no elbow joint and was unable to reach her mouth with this hand. Radiographs revealed absence of the distal half of the humerus. The olecranon process and trochlear notch of the ulna appeared deformed and poorly developed, but were difficult to assess both radiographically and clinically. We harvested a pedicled composite flap of scapula (based on the angular branch) and latissimus dorsi musculocutaneous flap (based on the thoracodorsal vessels).
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1151
FIGURE 1: Preoperative photograph of patient attempting to bring her hand to her mouth.
We achieved osteosynthesis of the 12-cm segment of scapula to the proximal humerus with plate and screws (Fig. 3). We reconstructed the dysplastic trochlear notch and olecranon process with an iliac crest bone graft, and achieved osteosynthesis with Kirschner wires. The neojoint surface was lined with a dermal graft. The latissimus dorsi was attached to the distal ulna to provide cover for the reconstructed olecranon process and to lengthen the triceps mechanism. An external fixator held the elbow at 90° flexion for 6 weeks. Then, the extremity was placed in a sling for 4 weeks, during which time the patient was allowed controlled elbow exercises within the sling. After 4 weeks, the elbow was stable against varus, valgus, and flexion-extension stress tests. Active forearm rotation was 60° in each direction, and active elbow motion was from 30° to 160°, which enabled the patient to reach her mouth, back, head, and lower extremities and perform all aspects of personal hygiene, hence achieving painless and near-normal upper extremity function (Fig. 4). At 6 months postoperatively, although it was short, the humerus had remodeled, assuming a shape similar to that of the distal humerus (Fig. 5). DISCUSSION The elbow has a critical role in upper extremity function. It positions the hand appropriately for the performance of activities of daily living. Loss of elbow function therefore has a profound effect on the quality of life for the individual.
FIGURE 2: Preoperative radiograph showing dysplastic proximal ulna and missing distal humerus.
Most reports on elbow dysfunction relate largely to arthritis and its management. In many such patients, interposition arthroplasty has been used to relieve pain and improve elbow function.5 Loss of elbow function resulting from extensive bone loss leaves limited options for reconstruction. Although total elbow arthroplasty is a viable option for the adult, practical options for elbow reconstruction in younger patients are almost nonexistent. Elbow arthrodesis presents a major challenge in the setting of considerable bone loss and would be unacceptable for a young, growing child. Cavadas et al6 reported a series of patients with massive bone loss treated with free fibular or iliac crest bone flaps for reconstruction of the distal humerus. A second free flap was used if the proximal ulna was also missing. Evans and Luethke7 reported using a free lateral scapula flap with a tailored latissimus dorsi to reconstruct the proximal ulna in a patient who had sustained a gunshot injury. The muscle provided soft tissue cover for the defect, and the reconstruction restored excellent elbow function. The scapula has been used mainly as a free flap for the reconstruction of mandibular and maxillary defects,8 although it has also been used as a pedicled flap for mandible and proximal humerus reconstruction.9 –11
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FIGURE 3: A Intraoperative picture of lateral scapular and latissimus dorsi musculocutaneous flaps before insetting. Arrow a indicates the angle of scapula, arrowhead b is the upper part of the scapula flap, arrowhead c is the latissimus dorsi musculocutaneous component of the flap, and arrow d is the thoracodorsal vascular pedicle. B Surgical procedure: lateral scapular flap based on the angular branch of the thoracodorsal vessels with latissimus dorsi musculocutaneous flap. The distal part of the neo-humerus is the angle of scapula. C Immediate postoperative radiograph. The neo-olecranon process is held in place by 2 large Kirschner wires, while a smaller Kirschner wire holds the distal neo-humerus in place within the joint.
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FIGURE 4: A The patient’s hand reaches above her head. B At 3 months after surgery, she is able to reach her mouth. C The patient is able to reach her back and can perform perineal hygiene.
Developmentally, the scapula ossifies from 7 centers, including 1 at the inferior angle, which remains cartilaginous until age 16 years, when it ossifies. Inclu-
sion of the entire inferior angle of the scapula in a flap, as in the patient reported here, would thus be expected to ensure continued longitudinal growth of the flap.
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tissue. Gradual loading stress may have caused scar tissue remodeling, and hence strength and stability. In addition, we believe that growth and lengthening of the neo-humerus led to tightening of the musculature and soft tissues around the elbow joint, effectively enhancing elbow joint stability. Our experience with this single case suggests that scar tissue in the growing child may be sufficient to provide elbow joint stability, obviating the need for ligament reconstruction. Particularly in resource-poor settings, and when feasible, single-stage reconstruction has benefits over those requiring multiple procedures. The technique described here offers an excellent option for the reconstruction of massive bone loss about the elbow. REFERENCES
FIGURE 5: Postoperative radiograph at 6 months. The scapula resembles a distal humerus, and the radiolucency distally indicates a large cartilage mass.
Furthermore, the muscle forces acting on the flap lead to remodeling of the neo-humerus in line with its new functions, because it is subjected to different loads during use. As hypothesized, the scapular flap remodeled into a distal neo-humerus structure (Fig. 5). In their series of 5 patients with massive bone loss about the elbow, Cavadas et al6 demonstrated return of excellent function after the restoration of elbow joint anatomy and the use of interposition arthroplasty. All 5 patients had delayed ligament reconstruction for stability.6 We had informed our patient and guardian that there might be the need to secondarily reconstruct collateral ligaments to ensure elbow stability. After removing the external fixator and initiating physical therapy, however, the elbow joint proved stable and has remained so, even with increased loading over time. The patient currently uses the limb freely for all of her daily activities. The stability is most likely the result of scar
1. Kaplan SL. Osteomyelitis in children. Infect Dis Clin N Am. 2005; 19(4):787–797. 2. Beckles VL, Jones HW, Harrison WJ. Chronic haematogenous osteomyelitis in children: a retrospective review of 167 patients in Malawi. J Bone Joint Surg Br. 2010;92(8):1138 –1143. 3. Spiegel DA, Penny JN. Chronic osteomyelitis in children. Tech Orthop. 2005;20(2):142–152. 4. Chhabra AB, Golish SR, Pannunzio ME, Butler TE Jr, Bolano LE, Pederson WC. Treatment of chronic nonunions of the humerus with free vascularized fibula transfer: a report of thirteen cases. J Reconstr Microsurg. 2009;25(2):117–124. 5. Froimson AI, Morrey BF. Interposition arthroplasty of the elbow. In: Morrey BF, ed. Master Techniques in Orthopaedic Surgery: the Elbow. Vol. 105. Philadelphia: Lippincott Williams and Wilkins; 2002:391– 408. 6. Cavadas PC, Landin L, Thione A, Ibañez J, Nthumba P, Roger I. Reconstruction of massive bone losses of the elbow with vascularized bone transfers. Plast Reconstr Surg. 2010;126(3):964 –972. 7. Evans GR, Luethke RW. A latissimus/scapula combined myo-osseous free flap based on the subscapular artery used for elbow reconstruction. Ann Plast Surg. 1993;30(2):175–179. 8. Brown J, Bekiroglu F, Shaw R. Indications for the scapular flap in reconstructions of the head and neck. Br J Oral Maxillofac Surg. 2010;48(5):331–337. 9. Nthumba PM. Use of the osteo-muscular dorsal scapular flap in reconstruction of mandibular defects. Ann Plast Surg. 2013;70(1): 553–556. 10. Pinsolle V, Tessier R, Casoli V, Martin D, Baudet J. The pedicled vascularised scapular bone flap for proximal humerus reconstruction and short humeral stump lengthening. J Plast Reconstr Aesthet Surg. 2007;60(9):1019 –1024. 11. Yadav P, Rajput R. Pedicled transfer of vascularized scapular bone graft to the humerus. Plast Reconstr Surg. 2001;107(1):140 –142.
JHS 䉬 Vol A, June
Reconstruction of the Distal Humerus and Elbow Joint Using a Pedicled Scapular Flap: Case Report Peter Nthumba, MD, Susan George, MD, Michael Jami, Partick Nyoro Loss of elbow function resulting from major bone loss negatively affects quality of life and leaves limited options for reconstruction and restoration of function. To overcome this disabling problem, we reconstructed the distal humerus of a child in a single stage using a scapular flap based on the angular branch of the thoracodorsal artery as a pedicled flap. We also reconstructed the proximal ulna using an iliac crest bone graft with dermal graft interposition arthroplasty, which enabled the restoration of useful elbow function. (J Hand Surg 2013;38A:1150–1154. Copyright © 2013 by the American Society for Surgery of the Hand. All rights reserved.) Key words Elbow joint, distal humerus, reconstruction, pedicled scapular flap.
HRONIC OSTEOMYELITIS IS a difficult clinical problem, and even with the advances of modern medicine, treatment continues to pose major challenges to clinicians, especially in the developing world. Limb trauma from hostilities as well as from domestic, industrial, and motorized vehicular accidents expose large numbers of people to the danger of developing this complication.1,2 Chronic osteomyelitis may also spread from an anatomically contiguous infected part, most commonly septic arthritis. Untreated or unresolved acute osteomyelitis from a hematogenous source may become chronic. A complication of chronic osteomyelitis in children that is difficult to manage is the formation of an extensive sequestrum, sometimes involving an entire long bone. While surgical debridement of infected tissue and the use of appropriate antibiotics are the recommended treatment for osteomyelitis, in children with extensive sequestrum, sequestrectomy should be delayed until sufficient involucrum has been formed, to preserve bone stability and length. Premature debridement of
C
From the Plastic, Reconstructive, and Hand Surgery Unit, AIC Kijabe Hospital, Kijabe, Kenya; and the Department of Plastic Surgery, Vanderbilt University Medical Center, Nashville, TN. Received for publication June 22, 2012; accepted in revised form March 8, 2013. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Peter M. Nthumba, MD, Plastic, Reconstructive, and Hand Surgery Unit, AIC Kijabe Hospital, Kijabe 00220, Kenya; e-mail: [email protected]. 0363-5023/13/38A06-0014$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2013.03.027
1150 䉬 © ASSH 䉬 Published by Elsevier, Inc. All rights reserved.
such a sequestrum may lead to partial or complete loss of bone.2,3 Chronic osteomyelitis of the humerus is well reported.2,4 In contrast, this report focuses on the challenges of reconstructing the distal humerus and elbow joint in a 12-year-old child, 10 years after loss of the distal humerus and elbow joint from destruction by infection and surgical intervention. CASE PRESENTATION A 12-year-old girl was brought to the Plastic Surgery Outpatient Clinic because of a deformed left arm. She described an inability to use the left hand to do anything without the other hand assisting in positioning it (Fig. 1). When she was 2 years of age, she developed septic arthritis of the left elbow followed by chronic osteomyelitis of the distal humerus. Surgical debridement led to the loss of the distal half of the humerus with destruction of the proximal ulna and elbow joint (Fig. 2). The neurological exam was normal, as were hand, wrist, and shoulder functions. She had no elbow joint and was unable to reach her mouth with this hand. Radiographs revealed absence of the distal half of the humerus. The olecranon process and trochlear notch of the ulna appeared deformed and poorly developed, but were difficult to assess both radiographically and clinically. We harvested a pedicled composite flap of scapula (based on the angular branch) and latissimus dorsi musculocutaneous flap (based on the thoracodorsal vessels).
PEDICLED SCAPULAR FLAP
1151
FIGURE 1: Preoperative photograph of patient attempting to bring her hand to her mouth.
We achieved osteosynthesis of the 12-cm segment of scapula to the proximal humerus with plate and screws (Fig. 3). We reconstructed the dysplastic trochlear notch and olecranon process with an iliac crest bone graft, and achieved osteosynthesis with Kirschner wires. The neojoint surface was lined with a dermal graft. The latissimus dorsi was attached to the distal ulna to provide cover for the reconstructed olecranon process and to lengthen the triceps mechanism. An external fixator held the elbow at 90° flexion for 6 weeks. Then, the extremity was placed in a sling for 4 weeks, during which time the patient was allowed controlled elbow exercises within the sling. After 4 weeks, the elbow was stable against varus, valgus, and flexion-extension stress tests. Active forearm rotation was 60° in each direction, and active elbow motion was from 30° to 160°, which enabled the patient to reach her mouth, back, head, and lower extremities and perform all aspects of personal hygiene, hence achieving painless and near-normal upper extremity function (Fig. 4). At 6 months postoperatively, although it was short, the humerus had remodeled, assuming a shape similar to that of the distal humerus (Fig. 5). DISCUSSION The elbow has a critical role in upper extremity function. It positions the hand appropriately for the performance of activities of daily living. Loss of elbow function therefore has a profound effect on the quality of life for the individual.
FIGURE 2: Preoperative radiograph showing dysplastic proximal ulna and missing distal humerus.
Most reports on elbow dysfunction relate largely to arthritis and its management. In many such patients, interposition arthroplasty has been used to relieve pain and improve elbow function.5 Loss of elbow function resulting from extensive bone loss leaves limited options for reconstruction. Although total elbow arthroplasty is a viable option for the adult, practical options for elbow reconstruction in younger patients are almost nonexistent. Elbow arthrodesis presents a major challenge in the setting of considerable bone loss and would be unacceptable for a young, growing child. Cavadas et al6 reported a series of patients with massive bone loss treated with free fibular or iliac crest bone flaps for reconstruction of the distal humerus. A second free flap was used if the proximal ulna was also missing. Evans and Luethke7 reported using a free lateral scapula flap with a tailored latissimus dorsi to reconstruct the proximal ulna in a patient who had sustained a gunshot injury. The muscle provided soft tissue cover for the defect, and the reconstruction restored excellent elbow function. The scapula has been used mainly as a free flap for the reconstruction of mandibular and maxillary defects,8 although it has also been used as a pedicled flap for mandible and proximal humerus reconstruction.9 –11
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FIGURE 3: A Intraoperative picture of lateral scapular and latissimus dorsi musculocutaneous flaps before insetting. Arrow a indicates the angle of scapula, arrowhead b is the upper part of the scapula flap, arrowhead c is the latissimus dorsi musculocutaneous component of the flap, and arrow d is the thoracodorsal vascular pedicle. B Surgical procedure: lateral scapular flap based on the angular branch of the thoracodorsal vessels with latissimus dorsi musculocutaneous flap. The distal part of the neo-humerus is the angle of scapula. C Immediate postoperative radiograph. The neo-olecranon process is held in place by 2 large Kirschner wires, while a smaller Kirschner wire holds the distal neo-humerus in place within the joint.
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FIGURE 4: A The patient’s hand reaches above her head. B At 3 months after surgery, she is able to reach her mouth. C The patient is able to reach her back and can perform perineal hygiene.
Developmentally, the scapula ossifies from 7 centers, including 1 at the inferior angle, which remains cartilaginous until age 16 years, when it ossifies. Inclu-
sion of the entire inferior angle of the scapula in a flap, as in the patient reported here, would thus be expected to ensure continued longitudinal growth of the flap.
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tissue. Gradual loading stress may have caused scar tissue remodeling, and hence strength and stability. In addition, we believe that growth and lengthening of the neo-humerus led to tightening of the musculature and soft tissues around the elbow joint, effectively enhancing elbow joint stability. Our experience with this single case suggests that scar tissue in the growing child may be sufficient to provide elbow joint stability, obviating the need for ligament reconstruction. Particularly in resource-poor settings, and when feasible, single-stage reconstruction has benefits over those requiring multiple procedures. The technique described here offers an excellent option for the reconstruction of massive bone loss about the elbow. REFERENCES
FIGURE 5: Postoperative radiograph at 6 months. The scapula resembles a distal humerus, and the radiolucency distally indicates a large cartilage mass.
Furthermore, the muscle forces acting on the flap lead to remodeling of the neo-humerus in line with its new functions, because it is subjected to different loads during use. As hypothesized, the scapular flap remodeled into a distal neo-humerus structure (Fig. 5). In their series of 5 patients with massive bone loss about the elbow, Cavadas et al6 demonstrated return of excellent function after the restoration of elbow joint anatomy and the use of interposition arthroplasty. All 5 patients had delayed ligament reconstruction for stability.6 We had informed our patient and guardian that there might be the need to secondarily reconstruct collateral ligaments to ensure elbow stability. After removing the external fixator and initiating physical therapy, however, the elbow joint proved stable and has remained so, even with increased loading over time. The patient currently uses the limb freely for all of her daily activities. The stability is most likely the result of scar
1. Kaplan SL. Osteomyelitis in children. Infect Dis Clin N Am. 2005; 19(4):787–797. 2. Beckles VL, Jones HW, Harrison WJ. Chronic haematogenous osteomyelitis in children: a retrospective review of 167 patients in Malawi. J Bone Joint Surg Br. 2010;92(8):1138 –1143. 3. Spiegel DA, Penny JN. Chronic osteomyelitis in children. Tech Orthop. 2005;20(2):142–152. 4. Chhabra AB, Golish SR, Pannunzio ME, Butler TE Jr, Bolano LE, Pederson WC. Treatment of chronic nonunions of the humerus with free vascularized fibula transfer: a report of thirteen cases. J Reconstr Microsurg. 2009;25(2):117–124. 5. Froimson AI, Morrey BF. Interposition arthroplasty of the elbow. In: Morrey BF, ed. Master Techniques in Orthopaedic Surgery: the Elbow. Vol. 105. Philadelphia: Lippincott Williams and Wilkins; 2002:391– 408. 6. Cavadas PC, Landin L, Thione A, Ibañez J, Nthumba P, Roger I. Reconstruction of massive bone losses of the elbow with vascularized bone transfers. Plast Reconstr Surg. 2010;126(3):964 –972. 7. Evans GR, Luethke RW. A latissimus/scapula combined myo-osseous free flap based on the subscapular artery used for elbow reconstruction. Ann Plast Surg. 1993;30(2):175–179. 8. Brown J, Bekiroglu F, Shaw R. Indications for the scapular flap in reconstructions of the head and neck. Br J Oral Maxillofac Surg. 2010;48(5):331–337. 9. Nthumba PM. Use of the osteo-muscular dorsal scapular flap in reconstruction of mandibular defects. Ann Plast Surg. 2013;70(1): 553–556. 10. Pinsolle V, Tessier R, Casoli V, Martin D, Baudet J. The pedicled vascularised scapular bone flap for proximal humerus reconstruction and short humeral stump lengthening. J Plast Reconstr Aesthet Surg. 2007;60(9):1019 –1024. 11. Yadav P, Rajput R. Pedicled transfer of vascularized scapular bone graft to the humerus. Plast Reconstr Surg. 2001;107(1):140 –142.
JHS 䉬 Vol A, June