A New Method for Elbow Arthrodesis for Soft-tissue Coverage: The Use of Biceps Brachii Muscle Flap.
Elbow arthrodesis is a fixing method of the elbow in proper positions by different methods to reduce the pain and prevent amputation of the extremity.  It is performed in cases with chronic infection, posttraumatic arthritis, acute traumatic nonreconstructable elbow injuries, and the failure of total elbow prosthesis.  The most important causes of these complications include surgical morbidity and poor anatomical structure of the soft tissue of the elbow joint from soft tissue.
Although different methods are described in the literature, elbow arthrodesis is a rarely applied procedure due to difficulty, limited indication, and high complication rate. The most important causes of these complications include surgical morbidity and poor anatomical structure of the soft tissue of the elbow joint from soft tissue.
In this article, we have presented a case of gunshot injury that underwent elbow arthrodesis and tissue coverage by the way of reconstruction with biceps brachii muscle flap. The aim of this article is to present a reconstruction technique with biceps brachii muscle flap which is a novel method to reduce the complications due to plate-screw applications and to discuss the advantages of this technique in elbow arthrodesis.
A 27-year-old male who had right radioulnar fracture and defect of 1/3 distal humerus due to gunshot injury about 1 year ago was referred to the orthopedics and traumatology clinic after the application of intramedullary nail and external fixator to the radius and ulna [Figure 1a and b]. In neurological examination, the patient was found to have radial nerve deficit with normal median and ulnar nerve findings. On electromyography examination, transmission rate in the ulnar and median nerves was normal, but no transmission could be obtained in the radial nerve. Radial and ulnar arterial flows were found to be triphasic in the Doppler ultrasonography. Approximately 1 month after the first visit, the second operation was planned with the purpose of proper bone reduction. In the second operation, intramedullary nails were removed; pseudoarthrosis areas in fracture lines in radius and ulna were removed. Intramedullary nails and 3.5-mm plate were placed to radius and ulna, respectively. Autografts which were taken from the iliac crest were transferred the fracture lines in both bones [Figure 1c].
Long arm plaster was applied, and drains were removed in the first postoperative day. The patient had wound site infection approximately 3 weeks later, and he was operated for the third time for debridement. Infection was observed to be localized to the fascia, and unhealthy tissues were debrided. The patient was treated with intravenous teicoplanin 400 mg t.i.d for 7 days, and wound infection was recovered completely. The patient was discharged from the hospital with a long arm splint. Humeroulnar arthrodesis and pseudoarthrosis surgery for distal 1/3 humeral defect were planned approximately 45 days after the third operation.
Anatomy and surgical technique
The biceps brachii is a two-headed muscle located in the anterior compartment of the arm. The short head originates from the supraglenoid tubercle of the scapular bone and the short head originates from the coracoid process, attaches to the radial tuberosity through the common tendon and to the deep fascia of the forearm through aponeurosis bicipitalis.
The innervation is provided by the musculocutaneous nerve. It is the most powerful supinator muscle and most important flexor muscle of the forearm. It is a Type V muscle flap according to the Mathes-Nahai classification. It has one dominant vascular pedicle and multiple secondary vascular pedicles. The middle and distal perforator arteries originated from brachial artery supply blood to the both heads of muscle. The middle perforator arteries feed 60% of the muscle by entering the muscle approximately 5-8 cm below the anterior axillary fold and the distal perforator arteries feed the remaining 40% of the muscle. When the dominant vascular pedicle is sacrificed to the Type V muscle flaps, the secondary vascular pedicles feed the muscle. [3-5]
Operation was performed in the left lateral decubitus position, and the layers were passed through longitudinally from posterior of the right elbow, and pseudoarthrosis line was reached. The ulnar nerve was preserved by dissection. It was observed that the radial nerve was cut off and the distal part of radial nerve was not found at the level of the elbow. After the pseudoarthrosis line was cleaned, fibular bone graft and grafts transferred from iliac crest were placed to the distal part of humerus and olecranon. Arthrodesis was performed with 110[degrees] plate and screws of 3.5 and 4.5 mm in size. The plaques in ulnar bone were covered with regional muscles [Figure 2a]. Afterward, the distal pedicle of lateral head of the muscle was reached by dissecting distally by entering about 10 cm superior from the antecubital region between the two heads of biceps brachii muscle. Approximately 8 cm portion of the lateral head of the biceps brachii muscle was transferred over the distal perforator to the most prominent part of the plaque o the elbow and below the scarred skin area [Figures 2b-d and 3]. Vacuum drains were placed and skin cuts were sutured with careful bleeding control. An external fixator was used to fix the elbow joint and to prevent the muscle flap from compression. Intravenous cefazolin 1 g b.i.d. was administered for 1 week postoperative. Although venous insufficiency was present at the incisional side of the dermal flaps in the elbow joint postoperatively [Figure 4a and b], venous insufficiency was recovered, and primary skin repair was completed at follow-up. The external fixator was removed after 2 months as the patients did not have wound site infection or plaque-screw exposition [Figure 4c and d]. Tendon transfer was scheduled after confirmation of bone callus formation on X-ray which is a sign of bone healing at 9th month of the postoperative period in the patient with radial nerve deficit [Figure 4e and f]. Informed consent was obtained.
Anatomically weak soft-tissue structure of the extensor side of the elbow increases the risk of complication in elbow arthrodesis. Possible complications of elbow arthrodesis include infection, bone graft loss, nonunion, delayed union, fractures, and skin loss due to bone and plaque irritation. 
Proper soft-tissue coverage of the plaque, screw and efficient treatment of infections are important to reduce the risk of complication, especially in posttraumatic patients and in patients with chronic osteomyelitis.
Muscle and muscle-skin flaps together with appropriate antibiotherapy are excellent reconstructive options in the treatment of unhealthy soft tissue and bone and prosthesis infections. By increasing the tissue perfusion, muscle flaps lead to better oxygenation and increased penetration of antibiotics to the tissue. In addition, muscle flaps significantly reduce bacterial load compared with fasciocutaneous flaps. 
In the literature, debridement and reconstruction with muscle flaps in addition to appropriate antibiotherapy were recommended in the treatment of osteomyelitis and prosthetic infections. [8-10] This case was operated four times after the gunshot injury and debrided due to wound site infection in the third operation. Although more aggressive surgical procedure was performed in the fourth operation, no sign of wound site infection or discharge were detected at the follow-up. Herein, we used the advantage of the protective effect of reconstruction by covering the prosthesis with muscle flap from osteomyelitis and prosthetic infection.
In the study conducted by Richards et al, an open tibia fracture model was performed in dogs, in which blood flow in bone tissue and frequency of union were found be significantly higher in the fracture line of the group covered by the muscle compared to that of the group covered by only skin.  Another study also demonstrated that the muscle flaps increased the cortical porosity, enveloping callus, and intracortical new bone formation.  In the present case, the area where plaque and screw angulated under the scarred and contracted skin in the elbow joint which is the most common location of the wound dehiscence was covered with the biceps brachii muscle and by this way; direct contact of the instruments with the skin was prevented. Thus, the scarred skin tissue with circulatory impairment was healed, and plaque and screw exposition were prevented, and no bone graft loss was observed.
Since the biceps brachii muscle is an active supinator and flexor muscle of forearm, it is not suitable for use as a flap on a functional upper limb. However, in this case, the flexion and supination functions of the elbow joint were irreversibly inactivated with humeroulnar arthrodesis. Thus, the use of biceps brachii muscle in soft-tissue coverage did not cause additional loss of function. Blood supply of Type V muscle flaps is provided by dominant vascular pedicle and secondary segmental vascular pedicles. Muscle flaps can be safely removed through dominant vascular pedicles, also through the secondary vascular pedicles. In this report, the lateral head of the biceps brachii muscle was removed through the distal perforator which was the secondary segmental vascular pedicle, and there was no failure in the flap circulation.
There is only one case in the literature reporting that biceps brachii muscle is sacrificed for flapping.  It is reported that medial head of the biceps brachii muscle was used to cover the axillary defect using proximal perforator in a patient with breast cancer who had lost arm function because of the radiation-induced brachial plexopathy. In our case, the lateral head of the muscle was removed through the distal perforator and turned to the extensor surface of the elbow.
In the literature review, it has been observed that only the latissimus dorsi muscle is used as a muscle flap in elbow arthrodesis. Ozer et al. repaired the bone and skin defects with regional composite rib-latissimus dorsi flap.  Ng et al. used the free latissimus dorsi muscle-skin flap to cover the soft tissue and skin defect after tumor resection.  The most important advantages of biceps brachii muscle flap from these mentioned flaps are the shorter duration of surgery due to the local nature of biceps brachii flap and absence of hematoma and seroma due to excessive dissections, and lack of thoracic complications such as pneumothorax and hemothorax. Furthermore, use of biceps brachii flaps does not have the possible flap complications due to microsurgery methods.
Reconstruction with biceps brachii muscle flap is a simple and an effective method for elbow arthrodesis. With this method, prevention of important complications of elbow arthrodesis such as wound site infection, skin problems, and plate-screw exposition is possible without loss of function. Furthermore, in cases with skin defect, it can be alternative to regional and free muscle flaps combined with skin grafts because of reduced risk of complication in soft-tissue closure.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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Soysal Bas, Sercin Bas (1), Utku Uyan (2), Mustafa Durgun (3)
Departments of Plastic, Reconstructive and Aesthetic Surgery and (2) Orthopedic Surgery, Sanliurfa Mehmet Akif Inan Education and Research Hospital, Sanliurfa, (1) Department of Radiology, Goztepe Education and Research Hospital, Istanbul Medeniyet University, Istanbul, (3) Department of Plastic, Reconstructive and Aesthetic Surgery, Izmir Katip Celebi University, Izmir, Turkey
Address for correspondence: Dr. Soysal Bas, Department of Plastic, Reconstructive and Aesthetic Surgery, Sanliurfa Mehmet Akif Inan Education and Research Hospital, Esentepe Mah. Ertugrul Cad., 63200 Sanliurfa, Turkey.
How to cite this article: Bas S, Bas S, Uyan U, Durgun M. A new method for elbow arthrodesis for soft-tissue coverage: The use of biceps brachii muscle flap. Turk J Plast Surg 2018;26:77-80.
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|Title Annotation:||Case Report|
|Author:||Bas, Soysal; Bas, Sercin; Uyan, Utku; Durgun, Mustafa|
|Publication:||Turkish Journal of Plastic Surgery|
|Date:||Apr 1, 2018|
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