Closure of Persistent, Small, Posterior Elbow Soft Tissue Defects Using a Rotation Flap: A Retrospective Study

Treating soft tissue defects occurring over the posterior elbow is challenging. Purpose: This study aimed to evaluate the long-term outcomes of using rotation flaps for soft tissue defects over the posterior elbow. Methods: A retrospective study was conducted among patients who had sustained posterior elbow defects and underwent rotation flap under local anesthesia between January 2, 2011, and December 31, 2014. Patient inclusion criteria stipulated the soft tissue defect had to be small (<12 cm²), was the result of wound dehiscence following posterior approach surgery immediately following trauma, and had failed to heal using nonsurgical treatment or primary closure. Patients with an active infection, malignancies, a defect of any etiology other than trauma, or incomplete operative data were excluded. Patient demographics, medical history, operative reports, and outcomes were abstracted. Flap failure and surgical complications were monitored for a minimum of 2 years after surgery. Range of motion (ROM; 0˚ to normal 130˚) and Mayo Elbow Performance Scores (MEPS) were evaluated and recorded before surgery and after 2 years’ follow-up and included evaluating pain, ROM, stability, and daily function. Patient, wound, surgical, and wound healing variables were compared between the flap survival and flap failure/complication groups using Mann-Whitney U and chi-squared tests. The Wilcoxon signed-rank test was used to compare pre- and postoperative MEPS and elbow ROM. Results: Thirty (30) patients (13 male, 17 female; mean age 55 ± 15.6 [range 19–74] years) had complete records. Eighteen (18) flaps were created using the transolecranon approach, and 12 rotation flaps involved an olecranon fracture; 24 flaps survived and 6 patients experienced flap failure/complications (wound dehiscence or infection). Mean procedure duration was 25.6 ± 10.1 minutes. All defects were located over the olecranon with exposed bone or hardware. Mean defect size was 7.4 cm² ± 2.9 cm², the average defect duration was 60.4 (range 31–89) days, average time to wound healing was 21.9 ± 11.5 days, and mean follow-up time was 29.4 (range 24–56) months. All flaps successfully survived without recurrence. Mean pre- and postoperative MEPS were significantly different (56.4 vs. 90.2 points; P <.001). ROM did not differ significantly between mean preoperative range (extension 9.8˚ ± 3.2˚ and flexion 116.7˚ ± 10.2˚) and mean final follow-up range (extension 9.6˚ ± 2.6˚ and flexion 118.5˚ ± 11.3˚; P = .459). Conclusion: Rotation flap surgery performed under local anesthesia may offer a simple and safe option in the treatment of small (<12 cm²) trauma-related defects over the posterior elbow. More research is needed to develop evidence-based guidelines for optimal approaches to posterior elbow soft tissue defect closure techniques.

Orthopedic surgeons face considerable challenges when treating soft tissue defects over the posterior elbow. Defects can occur following trauma, infection, burns, and chronic bursitis of the olecranon. Case series and retrospective studies have shown treatment can be difficult even for small-sized defects, especially in cases of exposed bone, tendon, or hardware.^1-5 Variables used for determining defect coverage options include the size of the defect, quality of soft tissues, tissue scarring, medical comorbidities, and surgical expertise; defect size is a key consideration.^1-3 Various methods can be used to cover soft tissue defects over the posterior elbow, but outcomes are difficult to compare because most studies are small case series, and functional outcomes are determined by the underlying abnormality noted before surgery, not by surgical methods.⁵ For small-sized defects, local or distant flaps such as anconeus (extensor of the elbow originated from the lateral epicondyle of the humerus and inserted into the proximal ulna), brachioradialis (the flexor of the elbow originated from the lateral supracondylar ridge of the humerus and inserted into the styloid process of radius), or the flexor carpi ulnaris ([FCU] flexor of the wrist originated from the medial epicondyle of humerus and olecranon of ulna and inserted into the carpal bone and ligaments) are commonly reported options.^3-5 However, these techniques are unavoidably accompanied by potential donor site morbidity and require meticulous techniques and general anesthesia.^4-8

A local rotation flap also is an option for elbow defects. Local rotation flaps have the advantage of low morbidity, and they are easier to perform and require less anesthesia; however, the procedure is limited to patients with relatively good vascularity and tissue mobility.^3,7,9 Thus far, the clinical application or indication with respect to defect size has not been well reported.

The purpose of this retrospective study was to evaluate the long-term (>2 years) outcomes of a rotation flap technique performed under local anesthesia for small-sized (<12 cm²) soft tissue defects over the posterior elbow following elbow trauma.

The Institutional Review Board of the authors’ hospital approved the study, and all patients were informed and consented in writing to participate after deciding to have surgery. A retrospective review of patients who had sustained posterior elbow defects and underwent rotation flap under local anesthesia between January 2, 2011, and December 31, 2014, was conducted. Drawing from a review of the literature,^8-10 soft tissue defects were classified based on the size of the defect as large (>55 cm²), medium (12–55 cm²), or small (<12 cm²). Patient inclusion criteria stipulated the soft tissue defect had to be small (<12 cm²), have occurred as the result of wound dehiscence associated with the posterior approach for surgical treatment of elbow trauma, and had failed to respond to conservative treatment such as secondary healing using artificial dermal matrix or primary closure. Patients with an active infection, malignancy, inadequate operative data, and/or a defect of any etiology other than trauma were excluded.

Patients were classified into 2 groups: 1) flap survival without complications, or 2) flap failure with/without complications. Complications were defined as surgery-related wound problems, including infection and/or dehiscence requiring prolonged antibiotics and/or additional surgical interventions including debridement or skin grafts (not flap procedures). Flap failure was defined as wound breakdown requiring reoperation or conversion to more complicated flap techniques during the follow-up period.

Patient demographic characteristics, medical records, and operative reports in the electronic medical record were reviewed. Patient age, gender, medical diagnosis, surgical method used at the time of injury, comorbidities, soft tissue defect size, operative time, and time to healing were abstracted. Flap failure and surgical complications were monitored for a minimum of 2 years after surgery. All patients underwent physical examination for range of motion (ROM; normal 0˚ to 130˚). In addition, Mayo Elbow Performance Scores (MEPS) were evaluated and recorded before surgery by evaluating pain, ROM, stability, and daily function. MEPS and ROM were measured for the elbow joint in all patients using a standard goniometer at the 2-year follow-up. All data were entered to a spreadsheet, and serial numbers were used to protect patient identity.

Surgical technique. All patients underwent the operation under local anesthesia, and no tourniquets were used during the flap surgery. One (1) surgeon performed all procedures. The patient was placed in the supine position, with the arm draped across the chest. The flap was designed in a semicircular shape from the apex of the wound dehiscence and was 3 to 4 times the size of the defect (see Figure 1). Depending on the skin elasticity over the posterior elbow region, the size and direction of advancement (medially or laterally from the defect) of the flap were determined. The adipofascial flap then was raised and dissected, and meticulous care was taken to preserve the medial antebrachial cutaneous nerve at the medially designed flap. The flap was elevated and then rotated into the defect (see Figure 2) and loosely inset without tension. Skin laxity allowed direct closing at the donor site in all cases. If excessive skin tension was noted during skin closure, the backcut technique was used to reduce the skin tension. A well-padded long arm splint was applied for 2 weeks, keeping the elbow at 80˚ of flexion. Once wound healing was confirmed (ie, viable without complications), sutures were removed after 2 weeks, and the patient was instructed to perform elbow ROM exercises. Rehabilitation was performed until the ROM was as measured before surgery.

Statistical analysis. Collected data were entered into a statistical analysis program (SPSS Inc) for calculation. Patient, wound, surgical, and wound healing variables were compared between the flap survival and failure/complication groups using Mann-Whitney U and chi-squared tests. The Wilcoxon signed-rank test was used to compare pre- and postoperative MEPS and elbow ROM.

Of the 48 patients who underwent surgery, 9 had a defect other than trauma and 3 had an active infection; those 12 were excluded from the study. Four (4) patients were lost to follow-up, and 2 patients died. Thus, 30 patients (13 males, 17 females; mean age 55 ± 15.6 [range 19–74] years) returned for clinical and radiographic evaluations. The most common medical comorbidities were hypertension (15, 50%), diabetes mellitus (14, 46.7%), and chronic renal disease (5, 16.7%). Seven (7) patients were taking immunosuppressive medications (see Table 1a and b). No significant difference in baseline demographic characteristics or medical record information was noted between the groups (see Table 2).

Of the 30 rotation flaps created, 18 were used in the setting of open reduction and plate fixation for a distal humerus fracture using the transolecranon approach; 12 osteotomies were fixed using a 3.5 mm diameter locking compression olecranon plate (LCP Olecranon Plate; DepuySynthes), and 6 involved tension band wiring. The other 12 rotation flaps involved an olecranon fracture; 6 osteotomies were fixed using a locking compression olecranon plate, and 6 patients had tension band wiring. All defects were located over the olecranon with exposed bone or hardware. The mean defect size was 7.4 cm² ± 2.9 cm² (range 3–12 cm²), and the average duration of the defect was 60.4 (range 31–89) days. An average of 2.2 operations had been performed before the rotation flap surgery; 17 patients had undergone direct wound closure several times, and 1 had undergone skin grafting following failed negative pressure wound therapy. The mean follow-up period was 29.4 (range 24–56) months.

The mean duration of the surgery was 25.6 ± 10.1 (range 15–48) minutes. All 24 flaps successfully survived without recurrence; 6 patients experienced flap failure/complications (wound dehiscence or infection). Wound healing occurred in all patients within an average of 21.9 ± 11.5 (range 9–49) days after surgery. The MEPS collected at the last follow-up showed significant improvement over the preoperative MEPS (mean preoperative score, 56.4 points; mean final follow-up score, 90.2 points; P <.001). The ROM at the final follow-up was not significantly different from the preoperative ROM (mean preoperative range: extension 9.8˚ ± 3.2˚ and flexion 116.7˚ ± 10.2˚; mean final follow-up range: extension 9.6˚ ± 2.6˚ and flexion 118.5˚ ± 11.3˚; P = .459). No reoperations or conversions to other flap techniques were noted. Complications related to the procedure occurred in 6 patients; 4 developed wound dehiscence and 2 developed superficial wound infections. No flap failure occurred. The complications were treated using repeated sharp/surgical wound debridement and intravenous antibiotics, and no wound issues were noted through to the last follow-up. The initial mean defect size was significantly smaller in the flap survival group (n = 24; size 6.5 ± 2.7 cm2) compared to the failure/complication group (n = 6; 10.7 ± 1.5 cm²; P = .001). Figure 3 and Figure 4 depict examples of the cases.

The proper option for the coverage of soft tissue defects over the posterior elbow often is determined by defect size, quality of vascular supply, elasticity of soft tissues, tissue scarring, medical comorbidities, surgical expertise, and vital structures involved.^1-3,11 For large defects, recent retrospective studies^12-14 recommended radial forearm or free flaps, including the transfer of the latissimus dorsi muscle, as viable treatment options. Although various reconstructive options, including local fasciocutaneous or muscle flaps, are available for small to medium-sized defects,^5,9,11,15,16 these are somewhat complicated procedures with high morbidity that require meticulous technique and general anesthesia.^3,4,13,16

The rotation flap technique presented in this study provided good coverage for small soft tissue defects over the posterior elbow and generated satisfactory outcomes with regard to wound healing and elbow joint function. In addition, this technique has the advantage of being quick and simple to perform. However, this option is limited by the size of the defect because its blood supply is based only on perfusion through the dermal or subdermal plexus. Therefore, determining the indication for rotation flap surgery with respect to the size of the defect might be essential.
In their retrospective study of 17 patients who underwent a FCU flap for posterior elbow wound reconstruction, Bayne et al¹ concluded defects appropriate for the FCU flap should be <4 cm in width. The present study adds to the literature by showing rotation flaps are useful for skin defects smaller than 12 cm².

ll patients, including those with flap failure/complications had good clinical outcomes without functional deficits of the elbow, which may potentially occur in any flap procedure as evidenced by the postoperative MEPS and ROM of the elbow joint. Few studies have evaluated the functional outcomes associated with the use of flap surgeries. Elhassan et al² published a series describing 20 patients who underwent local pedicled anconeus flap surgery. Their retrospective report of outcome measures assessed at the final follow-up showed a mean MEPS of 90 and a subjective elbow value (SEV) of 95 (a completely normal elbow presents with a SEV of 100%; extreme pain and no function present as an SEV of 0%). Similarly, the retrospective study by Fleager and Cheung⁶ that evaluated outcomes for anconeus slide rotation flap surgery for 20 patients reported a mean MEPS of 79.3 following surgery. These results are similar to the present study, which found the final MEPS increased to 90.2 after rotation flap. However, in the previous studies, various degrees of functional loss were noted, and various types of flap technique were found to be associated with potential donor site morbidity.^3,12,15-19 Although several authors have demonstrated no significant difference in function of the involved joint after muscle was harvested (particularly in the setting of FCU and anconeus local flaps), clear conclusions are not forthcoming due to the relatively small study samples^1,2 and the absence of prospective, randomized, controlled clinical studies. Fleager and Cheung⁶ also noticed that despite good wound coverage and functional outcomes, surgeons should use caution regarding the overuse of the local muscle flap because of potential donor site morbidity.    

In the present study, microvascular technique was not required for coverage, and the mean duration of the operation was 25.6 minutes; thus, all patients could undergo surgery with local anesthesia. In their 10-patient retrospective study, Prantl et al³ reported a mean operation time of 1.5 hours for the distal pedicled reversed-upper arm flap procedure for elbow defects (average wound size ranged from 4 cm to 10 cm); however, the method of anesthesia was not described.³ Compared to a flap that requires microvascular technique, the rotation flap procedure is a simple and timesaving operation. Furthermore, for smaller defects, the technical ease and decreased operation time may be particularly advantageous for elderly patients with multiple medical problems and for surgeons with limited experience.

This study has several limitations. The number of cases is somewhat small, limiting the ability to generalize the optimal indication of this technique; a prospective, controlled study design or a larger database would be required. One (1) surgeon performed all operations, which may bias the outcomes per his/her skill. The defect size alone should not solely determine wound closure method; quality of soft tissue, present tissue scarring, and surrounding skin laxity also may allow variability in rotation flaps that could conceivably cover soft tissue defect. In addition, the retrospective nature of the study has inherent weaknesses. For example, the varying severity of injuries in each patient could yield a divergent effect on wound healing. Furthermore, a detailed definition of the state of patient comorbidities (such as HbA1C level and peripheral neuropathy) was not available in the authors’ database. Direct comparison between the rotation flap and other reconstructive methods would clarify the effectiveness of the present procedure for soft tissue defects over the posterior elbow, as well verify the advantages and disadvantages this approach offers.

Rotation flap surgery was found to be a potentially useful treatment option for small defects over the posterior elbow. This study presented a relatively homogeneous cohort, because the defects resulted from wound dehiscence following surgery using a posterior approach for elbow trauma, and all patients underwent rotation flap surgery. All patients who underwent this surgical procedure achieved wound healing and satisfactory clinical outcomes. This approach has the advantage of being relatively quick and simple to use and does not require extensive microsurgical technique or general anesthesia. Research comparing this technique to other methods is warranted.

All authors are attending physicians at their respective facilities: Dr. Kang, Department of Orthopaedic Surgery, Chungbuk National University Hospital, Cheongju, Korea; Dr. Kim, Department of Orthopaedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea. Dr. Park , Dr. Jeong, Dr. Cha, and Dr. Kim, Department of Orthopaedic Surgery, Chungbuk National University Hospital. Please address correspondence to: Ji-Kang Park, MD, 776 1 Sunhwan-ro, Seowon-gu, Cheongju, Korea 28644; email: carm0916@hanmail.net.