A New Method of Limb Salvage and Functional Upper Limb Reconstruction

Ruka Shimizu, Kazuo Kishi, Hideo Morioka, Hiroo Yabe

Department of Orthopaedic Surgery, Keio University School of Medicine, Tokyo, Japan.
Department of Plastic and Reconstructive Surgery, Keio University School of Medicine, Tokyo, Japan.

DOI: 10.4236/mps.2012.24019                

Abstract

Amputation is frequently used to treat malignant tumors invading into the shoulder joint. When the vessels and major nerves of the upper arm are preserved, however, the limb may be salvaged with a combined osseous, myocutaneous flap. We reconstructed large defects, which included the shoulder joint, using a vascularized rib-latissmus dorsi combined flap. Ribs were connected via the ninth or tenth posterior intercostal artery. Several slits were cut in the ribs, and the rib was glass stick fractured to straighten it. The thoracodorsal nerve was preserved and the latissmus dorsi muscle was transferred to the defect previously occupied by the biceps humerus. The ribs were connected to the residual clavicle via a Leeds-Keio artificial ligament. The flaps completely engrafted. The patient was able to flex her elbow relatively early postoperatively. The function of the hand was preserved intact. In conclusion, the combined vascularized rib-latissmus dorsi flap is useful for patients who require functional or bony reconstruction of large defects involving the shoulder joint.

Keywords

Shoulder; Vascularized Rib; Latissmus Dorsi; Elbow Flexion; Limb Salvage

Conflicts of Interest

The authors declare no conflicts of interest.

References

[1]	K. Kawamura, H. Yajima, Y. Tomita, Y. Kobata, K. Shigematsu and Y. Takakura, “Restoration of Elbow Function with Pedicled Latissimus Dorsi Myocutaneous Flap Transfer,” Journal of Shoulder and Elbow Surgery, Vol. 16, No. 1, 2007, pp. 84-90. doi:10.1016/j.jse.2006.03.006
[2]	K. Onishi and Y. Maruyama, “Compound Rib-Latissimus Dorsi Osteomusculocutaneous Flap in Reconstruction of the Upper Arm,” Annals of Plastic Surgery, Vol. 36, 1996, pp. 191-194. doi:10.1097/00000637-199608000-00014
[3]	C. H. Lin, F. C. Wei, L, S, Levin, J. Su, K. F. Fan, W. L. Yeh and D. T. Hsu, “Free Composite Serratus Anterior and Rib Flaps for Tibial Composite Bone and Soft-Tissue Defect,” Plastic and Reconstructive Surgery, Vol. 99, No. 6, 1997, pp. 1656-1665. doi:10.1097/00006534-199705000-00028
[4]	M. D. Vekris, A. E. Beris, M. G. Lykissas, A. V. Korompilias, A. D. Vekris and P. N. Soucacos, “Restoration of Elbow Function in Severe Brachial Plexus Paralysis via Muscle Transfers,” Injury, Vol. 39, No. 3, 2008, pp. S15-S22. doi:10.1016/j.injury.2008.06.008
[5]	L. De Smet, “The Latissimus Dorsi Flap for Reconstruction of a Paralysed Deltoid,” Acta Chirurgica Belgica, Vol. 104, 2004, pp. 328-329.
[6]	K. Fujikawa, F. Iseki and B. B. Seedhom, “Arthroscopy after Anterior Cruciate Reconstruction with the Leeds-Keio Ligament,” Journal of Bone & Joint Surgery, British Volume, Vol. 71, No. 4, 1989, pp. 566-570.
[7]	Y. Maruyama, K. Onishi, Y. Iwahira, Y. Okajima and M. Motegi, “Free Compound Rib-Latissimus Dorsi Osteomusculocutaneous Flap in Reconstruction of the Leg,” Journal of Reconstructive Microsurgery, Vol. 3, No. 1, 1986, pp. 13-18. doi:10.1055/s-2007-1007032
[8]	T. Schoeller, G. Wechselberger, H. Hussl and G. M. Huemer, “Functional Transposition of the Latissimus Dorsi Muscle for Biceps Reconstruction after Upper Arm Replantation,” Journal of Plastic, Reconstructive & Aesthetic Surgery, Vol. 60, No. 7, 2007, pp. 755-759. doi:10.1016/j.bjps.2006.11.032
[9]	D. C. Sundaresh, D. Gopalakrishnan and N. Shetty, “Vascularised Rib Graft Defects of the Diaphysis of the Humerus in Children. A Report of Two Cases,” Journal of Bone & Joint Surgery, British Volume, Vol. 82, 2000, pp. 28-32. doi:10.1302/0301-620X.82B1.9678
[10]	S. Yazar, C. H. Lin adn F. C. Wei, “One-Stage Reconstruction of Composite Bone and Soft-Tissue Defects in Traumatic Lower Extremities,” Plastic and Reconstructive Surgery, Vol. 114, No. 6, 2004, pp. 1457-1466. doi:10.1097/01.PRS.0000138811.88807.65
[11]	J. E. Aviv, M. L. Urken and C. Vickery, H. Weinberg, D. Buchbinder and H. F. Biller, “The combined latissimus dorsi-scapular free flap in head and neck reconstruction,” Archives of Otolaryngology—Head & Neck Surgery, Vol. 117, No. 11, 1991, No. 1242-1250. doi:10.1001/archotol.1991.01870230058008
[12]	S. O’Ceallaigh, K. S. A. Mehboob Ali and T. P. F. O’Connor, “Functional Latissimus Dorsi Muscle Transfer to Restore Elbow Flexion in Extensive Electrical Burns,” Burns, Vol. 31, No. 1, 2005, pp. 113-115. doi:10.1016/j.burns.2004.06.017
[13]	E. Nomura, M. Inoue and H. Sugiura, “Histological Evaluation of Medial Patellofemoral Ligament Reconstructed Using the Leeds-Keio Ligament Prosthesis,” Biomaterials, Vol. 26, No. 15, 2005, pp. 2663-2670. doi:10.1016/j.biomaterials.2004.07.053
[14]	C. H. Lin, F. C. Wei, H. C. Chen and D. C. Chuang, “Outcome Comparison in Traumatic Lower-Extremity Reconstruction by Using Various Composite Vascularized Bone Transplantation,” Plastic and Reconstructive Surgery, Vol. 104, No. 4, 1999, pp. 984-992. doi:10.1097/00006534-199909040-00013
[15]	T. D. Pierce and M. M. Tomaino, “Use of the Pedicled Latissimus Muscle Flap for Upper-Extremity Reconstruction,” Journal of the American Academy of Orthopaedic Surgeons, Vol. 8, No. 5, 2000, pp. 324-331.
[16]	Y. K. Tu, C. Y. Yen, W. L. Yeh, I. C. Wang, K. C. Wang and W. N. Ueng, “Reconstruction of Posttraumatic Long Bone Defect with Free Vascularized Bone Graft: Good Outcome in 48 Patients with 6 Years’ Follow-Up,” Acta Orthopaedica Scandinavica, Vol. 72, No. 4, 2001, pp. 359-364. doi:10.1080/000164701753542014
[17]	P. D. Kim and K. E. Blackwell, “Latissimus-Serratus-Rib Free Flap for Oromandibular and Maxillary Reconstruction,” Archives of Otolaryngology—Head and Neck Surgery, Vol. 133, No. 8, 2007, pp. 791-795. doi:10.1001/archotol.133.8.791
[18]	P. J. Stern and J. P. Carey, “The Latissimus Dorsi Flap for Reconstruction of the Brachium and Shoulder,” The Journal of Bone & Joint Surgery, Vol. 70, No. 4, 1988, pp. 526-535.
[19]	S. Zaffagnini, G. M. Marcheggiani Muccioli, V. Chatrath, A. Bondi, V. De Pasquale, D. Martini, B. Bacchelli and M. Marcacci, “Histological and Ultrastructural Evaluation of Leeds-Keio Ligament 20 Years after Implant: A Case Report,” Knee Surgery, Sports Traumatology, Arthroscopy, Vol. 16, No. 11, 2008, pp. 1026-1029. doi:10.1007/s00167-008-0608-9