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

BACKGROUND: 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. METHODS: 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. RESULTS: We present a series of 5 cases managed with this principle. Soft tissue defects ranged in size from 4x9 cm (36 cm2) to 15x30 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 102degrees (range, 45degrees to 140degrees). CONCLUSIONS: 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.

Necrotising fasciitis and traditional medical therapy-- a dangerous liaison

<p><b>INTRODUCTION</b>Necrotising fasciitis is a disease associated with high morbidity and mortality, and multi-focal necrotising fasciitis is uncommon. We present 2 cases of concurrent necrotising fasciitis of contralateral upper and lower limbs.</p><p><b>CLINICAL PICTURE</b>Both presented with pain, swelling, bruising or necrosis of the affected extremities. Traditional medical therapy was sought prior to their presentation.</p><p><b>TREATMENT</b>After initial debridement, one patient subsequently underwent amputation of the contralateral forearm and leg. The other underwent a forearm amputation, but refused a below-knee amputation.</p><p><b>OUTCOME</b>The first patient survived, while the second died.</p><p><b>CONCLUSION</b>Traditional medical therapy can cause bacterial inoculation, leading to necrotising fasciitis, and also leads to delay in appropriate treatment. Radical surgery is needed to optimise patient survival.</p>