LATISSIMUS DORSI MUSCULOCUTANEOUS FREE FLAP

IN AN EMERGENCY OPERATION: A CASE REPORT TRANSPLANTATION TO SALVAGE BELOW-ELBOW AMPUTATION

TAKAFUMI NAITO, M.D., MSAMlCHl USUI, M.D., YOSHlHlKO TSUCHIDA, M.D., SEllCHl ISHII, M.D., MASAMITSU KANEKO, M.D.

We used a free latissimus dorsi musculocutaneous flap (LD m-c flap) to cover a large skin defect at the stump of a fore- arm in an emergency operation.

The patient we discuss is a 52-year-old man. Amputation at the distal one third of the left forearm occurred after catch- ing his hand and wrist in a machine. The amputated left hand was severely damaged and there were wide skin defects. The function of the elbow joint was well preserved. Both the

radius and ulna were cut 7 cm distal from the elbow joint. A 20 x 8 cm square of LD m-c flap was transplanted to the stump of the forearm. The flap survived without incident. The range of motion of the elbow joint was from 20" to 85". The prosthesis was well fitted to the stump, and the patient re- turned to his workshop 9 months after injury.

0 1996 Wiley-Liss, Inc. MICROSURGERY 17:155-157 1996

0 1996 Wiley-Liss, Inc. MICROSURGERY 17:155-157 1996

We used a free latissimus dorsi musculocutaneous flap (LD m-c flap) to cover a large skin defect at the stump of a forearm in an emergency operation. The prosthesis was ap- plied 2 months after injury, and the patient returned to his workshop 9 months after injury with a good stump fitting well to the prosthesis.

CASE REPORT A 52-year-old man visited our clinic 1 hour after am-

putation at the distal one-third of the left forearm after catching his hand and wrist in a machine. The amputated left hand was severely damaged (Fig. 1A,B), and thus re- plantation was not indicated. The muscles in the forearm were severely avulsed, and there were wide skin defects from the middle of the anterior upper arm to the distal

From the Departments of Traumatology and Critical Care Medicine (T.N., M.K.) and Orthopedic Surgerj (M.U., Y.T.. S.I.) Sapporo Medical University, Sap- poro, Japan.

Address reprint requests to Dr Takafurni Naito, Department of Traumatology and Critical Care Medicine, Sapporo Medical University, South 1, West 16, Chuoku, Sapporo 060, Japan.

Received for publication January 11, 1996: revision accepted April 30, 1996.

0 1996 Wiley-Liss, Inc.

forearm (Fig. 1C). Fortunately, the function of the elbow joint was well preserved. Both the radius and ulna were cut 7 cm distal from the elbow joint, but there was a large defect of soft tissue in the anterior portion of the elbow joint and the stump. At first, we planned to use the palm skin flap of the amputated forearm, but the size of the palm skin was somewhat small for covering the skin defects, and ves- sels of the palm skin were severely damaged. Therefore, we harvested a 20 x 8 cm square of free LD m-c flap from the right side. This flap was transplanted to the stump of the forearm. The thoracodorsal artery was anastomosed to the radial artery, and the comitant vein was anastomosed to the subcutaneous vein of the forearm. The residual skin defects on the upper arm were covered with a meshed split- thickness skin graft. Close postoperative temperature mon- itoring was performed on the flap. The flap survived with- out incident (Fig. 2A).

The patient started rehabilitation for application of a below-elbow prosthesis 21 days after injury. The permanent prosthesis was applied 2 months after injury. At 5 months after the injury, defatting and skin plasty of the flap were performed (Fig. 2B). By 7 months after the injury the range of motion of the elbow joint was from 20" to 85", with a

156 Naito et al.

Figure 1. A, B: The preoperative condition of the amputated hand. The muscles in the forearm were avulsed from radius and ulna. The radial and ulnar artery and median and ulnar nerve were avulsed. C: Residual condition of the left upper extremity. Massive skin defect was observed in the anterior aspect of the distal upper arm and the distal forearm.

good appearance of the stump. The prosthesis was well fitted to the stump, and the patient returned to his workshop 9 months after injury (Fig. 3).

Figure 2. A: Postoperative free LD m-c flap covering the stump and anterior aspect of the elbow joint. 8: Nine months after surgery, the stump is in good condition. Defatting and skin plasty were performed 5 months after surgery.

DISCUSSION A below-elbow prosthesis is far more functional than an

above-elbow one. For a forearm prosthesis, at least 7 cm of forearm length with a 100" arc motion of the elbow is de- sirable. There are several reports of the successful coverage of a large skin defect of a forearm amputation stump using a distant flap' or free f l a ~ . ~ . ~ Jones et al.4 reported a fore- arm amputation similar to ours. They successfully closed the stump by using a free LD muscle flap with a split- thickness skin graft, which was performed 12 days after the injury. They also noted that a free LD muscle flap offers the distinct advantage of covering a large skin and soft tissue defect at the amputation stump and that the free LD m-c flap has considerable potential when soft tissue is needed to cover a massive skin defect.

In our case, we succeeded in making a useful amputa- tion stump using free LD m-c flap transplantation. Further- more, the patient could start rehabilitation 21 days after injury, because we performed primary closure of the stump in an emergency operation. It was difficult to estimate the

Emergency Free Flap for Forearm Amputation 157

amount of skin needed at the primary closure site of the stump using the LD m-c flap, because the injured limb showed swelling and edema at the emergency operation. Preoperative design of the flap is important. If the harvested flap is not large enough to cover the skin defect, the residual defect can be covered by a split-thickness skin graft. After the edema of the damaged tissue subsides, the grafted split- thickness skin graft may be resected. In our case, we har- vested an 8-cm-wide skin flap and covered the stump pri- marily without free skin grafting.

Another problem of an LD m-c flap is a pressure sore, which may occur on the flap due to lack of sensation. How- ever, there were no sores, on the flap from the prosthesis when we checked the patient at 9 months after surgery. The free LD m-c flap is useful for covering a massive soft tissue and skin defect at the forearm amputation stump in an emer- gency surgery.

REFERENCES 1 . Burstein FD, Salomon JC, Stahl RS: Elbow joint salvage with the

transverse rectus island flap: A new application. Plastic Reconstr Surg

2. Brones MF, Wheeler ES, Lesavoy MA.: Restoration of elbow flexion and arm contour with the latissimus dorsi myocutaneous flap. Plastic Reconstructive Surg 69:329, 1982.

3. Sbitany U, Wray RC Jr: Use of the rectus abdominis muscle flap to reconstruct an elbow defect. Plast Reconstr Surg 77:988-989, 1986.

4. Jones ML, Antonio S, William TX. Blair F: Salvage of a below-elbow amputation stump with a free latissimus dorsi muscle flap: A case report. J Hand Surg [Am] 19-A:207-208, 1994.

84:492-497, 1989.

Figure 3. Range of motion of the left elbow joint while wearing the prosthesis. Extension (A) and flexion (6) of elbow joint.