A New Method of Limb Salvage and Functional Upper Limb Reconstruction

doi:10.4236/mps.2012.24019

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Modern Plastic Surgery, 2012, 2, 80-82

http://dx.doi.org/10.4236/mps.2012.24019 Published Online October 2012 (http://www.SciRP.org/journal/mps)

A New Method of Limb Salvage and Functional Upper

Limb Reconstruction

Ruka Shimizu1, Kazuo Kishi1, Hideo Morioka2, Hiroo Yabe2

1Department of Plastic and Reconstructive Surgery, Keio University School of Medicine, Tokyo, Japan; 2Department of Orthopaedic

Surgery, Keio University School of Medicine, Tokyo, Japan.

Email: [email protected]

Received July 18th, 2012; revised August 17th, 2012; accepted September 17th, 2012

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 h er 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

1. Introduction

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. In cases where limb salvage is cho-

sen, various tissues including muscle, skin, and bone may

be required depen di n g o n the extent o f the defect .

In such cases, flaps based on the thoracodorsal artery

will fulfill most of the closure requirements. Large flaps

may be created around this artery, which supplies the

latissmus dorsi (LD) muscle, serratus anterior muscle,

and ribs. Flaps from this area may be structured to in-

corporate varying amounts of bone and muscle as indi-

cated by the defect. The ribs are primarily supplied by

the intercostal artery, which anastomoses with the thora-

codorsal artery in the LD muscle [1,2]. The option to

incorporate bone and soft tissue in a single pedicle has

made flaps from the thoracodorsal system popular in

reconstruction of the maxillofacial region [3,4]. The LD

is also frequently used to functionally reconstruct the

elbow joint [5- 10] .

In the present report, we describe a patient in whom a

large defect involving most of the upper arm and gleno-

humeral joint was reconstructed with the combined vas-

cularized rib-latissmus dorsi flap, resulting in successful

limb salvage.

2. Case Report

A 33-year-old woman with a right proximal humeral

chondrosarcoma underwent a radical tumor resection that

included the proximal half of the humerus, the shoulder,

the lateral one third of the clavicle, the deltoid muscle,

the triceps brachii muscle, the proximal two thirds of the

biceps brachii muscle, and the overlying skin (Figure

1(a)).

We planned the reconstruction using a vascularized

rib-latissmus dorsi flap based on the thoracod orsal artery

system (Figure 1(b)). The ninth and tenth ribs were

raised with the ninth intercostal artery (Figure 1(c)). The

ribs were partially cut with a bone saw to straighten them

and placed facing each other, then fixed with surgical

wire. They were then fixed to the residual humerus with

a titanium plate and sutured to an artificial ligament

(Leeds-Keio ligament). The other side of the artificial

ligament was fixed to the remnant of the clavicle (Fig-

ures 1(d) and (e)). The insertion of the LD was sutured

to the remnant of the biceps brachii, and the origin of the

LD was sutured to the dissected shoulder with 3 - 0 po-

lyglactin 910 (Vycryl, Ethicon Inc., Somerville, NJ)

A New Method of Limb Salvage and Functional Upper Limb Reconstruction 81

Artificial

ligame nt

Titanium plate

Figure 1. (a) Defect following resection of the tumor. The axillary artery, axillary vein, and axillary nerve were maintained.

The distal one third of the biceps brachii was preserved. C: clavicle, S: scapula, AA: axillary artery, B: biceps brachii; (b)

Design of the flap. The ninth and tenth ri bs were included in the flap; (c) View from the deep side after raising the flap; (d)

Schematic view of the reconstruction. The ribs and residual clavicle were sutured to the Leeds-Keio ligament; (e) The ribs

and residual humerus bone were fixed with a titanium plate. AL: artificial ligament. P: titanium plate; (f) Schematic view of

the setting of the LD. The thoracodorsal nerve was preserved and the origin of the LD was sutured to the remnant of the

shoulder. The insertion of the LD was sutured to the remnant of the biceps brachii; (g), (h) Front and side views five years

postoperatively. X-ray image of the reconstructed upper arm. The fused ribs are nearly straight; (i), (j) The maximum flexion

of the elbow was 120 degrees, and function of the hand was almost completely intact.

(Figure 1(f)). The flap healed without any necrosis. The

flexion of the elbow recovered shortly after the surgery.

Six months postoperatively, non-union was observed

between the ribs and the humerus. Thus a free bone graft

was added around the non-union. Five years after the

primary operation, the ribs were nearly straight (Figures

1(g) and (h)). The function of the hand was preserved,

and the flexion of the elbow was possible to 120 degrees

(Figures 1(i) and (j)).

3. Discussion

This is the first report describing the use of a combined

vascularized rib-LD flap for the reconstruction of a muscle

and bone defect simultaneously following a radical resection

involving most of the upper arm and glenohumeral joint.

If the shoulder joint is preserved, its function may be

improved by multiple muscle transfer [11]. It is still not

possible, however, to completely reconstruct a functional

shoulder joint at the time of radical resection involving

the joint. In such cases where some distal neuromuscular

function in the arm or hand may be possible, merely re-

storing the function of elbow flexion results in significant

improvements in a patient’s quality of life. In an upper

limb reconstruction, the LD muscle is frequently used to

restore elbow flexion [5-10,12]. In the cases requiring

reconstruction of the biceps brachii, transfer of the LD

without disrupting its innervation will restore elbow

flexion. In the present case, the functional recovery of the

biceps brachii muscle was observed in the early postop-

erative period. Only one third of the patient’s biceps

brachii muscle was retained. Therefore, much of the elbow

flexion was mediated by the transposed LD muscle.

When reconstructing the long bones, the fibula is fre-

quently used [8,13,14]. The lower leg, however, lacks

sufficient soft tissue to reconstruct large muscular defects

that may also be present. The vascularized rib is also

sometimes chosen for reconstruction of the long bones

[15,16]. Use of a rib permits the concurrent reconstruc-

tion of soft tissue defects with the LD muscle, particu-

larly when restoration of elbow flexion is also desired.

The curve of the rib sometimes limits its use in long bone

reconstruction. The rib may be straightened, however, by

A New Method of Limb Salvage and Functional Upper Limb Reconstruction

creating a glass stick fracture and suturing the rib to-

gether in a fashion that straightens it but does not com-

promise its strength.

The ability of the reconstructed shoulder joint to sup-

port the weight of the arm was another concern in our

case. The Leed-Keio ligament is made of polyester woven

into an open mesh-like structure [17]. After implantation,

longitudinally aligned collagen-fiber bundles with spin-

dle-shaped nuclei form over the polyester matrix [18,19].

Use of this material permitted the strength of the artificial

joint to be preserved even after five years in our case.

Our report illustrates that the combined vascularized

rib-LD flap is useful in the reconstruction of large soft

tissue and bony defects that involve the upper limb and

the glenohumeral joint.

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