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Latissimus dorsi free flap salvage of recurrent chronic osteomyelitis with simultaneous elbow interposition arthroplasty.

ABSTRACT: Chronic osteomyelitis is difficult to resolve and usually requires radical debridement, filling of dead space, and a well-vascularized tissue to cover the involved bone. In the tibia, this is frequently accomplished with free vascularized muscle transfer and success rates over 90% for cases of limited involvement but lower success for diffuse involvement. Elbow joints, with advanced arthritis but ineligible for total joint replacement, have been treated with interposition arthroplasty and varying degrees of success limited primarily by instability. A 46-year-old male presented with diffuse osteomyelitis of all three bones at the elbow joint and advanced articular destruction from septic arthritis. He had undergone more than ten previous surgeries without resolution of the osteomyelitis or restoration of elbow function over a 2-year period. Radical debridement followed by a latissimus dorsi free muscle flap interposed to the dead space and layered onto the bones as an interposition membrane was able to solve both of his problems. At 3 years postoperatively, there is no evidence of recurrent osteomyelitis, and the patient declares satisfaction with the daily functional performance of his elbow joint.

SUBMITTER: Henry M

PROVIDER: S-EPMC2528967 | biostudies-other | 2008 Mar

REPOSITORIES: biostudies-other

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Project description:BackgroundBreast reconstruction using the latissimus dorsi (LD) flap is one of the most popular and common breast reconstruction techniques among Asian patients. There are increasing numbers of cases wherein breasts need to be reconstructed to moderate to large sizes among the Asian population. Most reconstructive surgeons use abdominal-based flaps-such as the deep inferior epigastric perforator and transverse rectus abdominis myocutaneous flap, or LD flap with an implant-to supplement the volume. Here, we compare the usefulness of the boomerang LD (bLD) flap-a technique developed by modifying the design of the conventional extended LD flap-with that of the LD flap with implant (LDi).MethodsThis was a prospective cohort study including patients with breast cancer aged between 25 and 60 years who underwent unilateral total or skin/nipple-sparing mastectomy, or postmastectomy. The exclusion criteria were advanced breast cancer (stages 3 and 4); a history of cognitive impairment affecting ability to complete the self-reported questionnaire; a history of neurologic or musculoskeletal disorder; and a history of alcohol or drug abuse. Statistical analysis was performed, and correlations between the two technique types were analyzed [including age, body mass index, preoperative breast volume, operation time, flap elevation time, admission duration, adjuvant treatment (radiotherapy, chemotherapy), drain indwelling duration, and drain total sum volume].ResultsIn total, 85 patients who underwent immediate breast construction through the LDi group (n=63) or bLD group (n=25) techniques after total mastectomy between January 2015 and June 2022 were analyzed (mean age: LDi group, 46±7.7 years; bLD group, 45.6±7.8 years). We observed that the flap weight, operative time, mean admission duration, and drain indwelling duration were statistically significantly different in the bLD group (P<0.05). Body mass index, preoperative breast volume, specimen weight, flap elevation time, and drain total time were comparable between groups.ConclusionsBreast reconstruction using the bLD flap was found to be a suitable alternative technique for patients who desire an autologous tissue transfer (rather than an implant) but are contraindicated for abdominal-based flaps and do not mind long postoperative scars.

Project description:The latissimus dorsi flap (LDF) has gained popularity given its versatile nature and broad applicability in breast reconstruction. Its resurgence has been attributed to its ability to be enhanced using implant or high-volume fat grafting, rendering it a primary option for selected patients. The aim of this review is to tackle current indications and subjects of controversy regarding use of complete-autologous and implant-enhanced LDF in breast reconstruction. Also, a case-series showcasing the authors' experience with this versatile reconstructive option is presented. A search across Web of Science and PubMed MEDLINE from inception through January 3, 2023, was conducted. Articles reporting postoperative outcomes of autologous breast reconstruction with LDF were included. Regarding the case series, electronic medical records of patients who underwent total mastectomy and autologous breast reconstruction with LDF from January 2011 to December 2021 were retrospectively reviewed. Data on demographic and oncologic characteristics, and surgical characteristics and outcomes were extracted. Our review suggests that LDF is suitable for patients who lack alternative donor site, have a history of abdominoplasty or no access to microsurgery, smokers or obese. Latissimus dorsi (LD) harvesting has almost complete shoulder function recovery in the long-term. Thoracodorsal nerve division does not cause volume loss or animation deformity. Multisite multilayer fat grafting, beveling the edges of the skin paddle and fat, folding the LD muscle and plicating the paddle allow adequate projection and contour achievement. Our case-series included 234 reconstructions. Almost half of the patients had immediate fat transfer during reconstruction (51.3%). The rate of recipient site hematoma was 3.0%, seroma was 7.7%, wound disruption 32.1%, wound disruption events requiring unplanned procedures was 13.7%, and surgical site infection (SSI) was 12.4%. The LDF is reliable and safe for immediate or delayed breast reconstruction or salvage after reconstruction failure. Its versatility, reliable anatomy, easy dissection, and relative low complication rate have revived this modality as valuable opportunity for breast reconstruction in this era.

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Latissimus dorsi free flap salvage of recurrent chronic osteomyelitis with simultaneous elbow interposition arthroplasty.

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