Elbow vascularized composite allotransplantation—surgical anatomy and technique

Elbow reconstruction with vascularized composite allotransplantation (VCA) may hold promise in treating end-stage arthritis as no current treatment is both functional and durable. We describe the vascular and gross anatomy of the elbow in the context of VCA procurement and propose a step-by-step sur...

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Bibliographic Details
Published in:Journal of shoulder and elbow surgery 2017-08, Vol.26 (8), p.1325-1334
Main Authors: Steinberger, Zvi, Xu, Heng, Kazmers, Nikolas H., Thibaudeau, Stephanie, Huffman, Russel G., Levin, L. Scott
Format: Article
Language:English
Subjects:
Adult
Cadaver
Elbow - anatomy & histology
Elbow - blood supply
Elbow - innervation
Elbow - surgery
Elbow Joint - blood supply
Elbow Joint - innervation
elbow reconstruction
End-stage elbow arthritis
Forearm - blood supply
Forearm - innervation
Forearm - surgery
Humans
Muscle, Skeletal - surgery
Peripheral Nerves - anatomy & histology
Radius - blood supply
Radius - surgery
surgical anatomy
Surgical Flaps
surgical steps
Ulna - blood supply
Ulna - surgery
vascularized composite allotransplantation
Vascularized Composite Allotransplantation - methods
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Summary:Elbow reconstruction with vascularized composite allotransplantation (VCA) may hold promise in treating end-stage arthritis as no current treatment is both functional and durable. We describe the vascular and gross anatomy of the elbow in the context of VCA procurement and propose a step-by-step surgical technique for human elbow VCA. We injected latex in the arterial tree of 16 fresh adult cadaveric upper extremities. We identified and measured arteries and nerves and their branch points relative to the medial epicondyle. Based on our determination of the dominant blood supply to osseous and capsular elbow structures, we derived a cadaveric model of elbow VCA by performing donor preparation on 2 fresh cadaveric upper extremities by elevating a lateral arm flap in conjunction with the vascularized elbow joint. We prepared and transplanted 2 size-matched recipient specimens to refine the surgical technique. The elbow arterial supply was composed of consistent branches contributing to medial, lateral, and posterior arcades. Preservation of the elbow arterial network requires sectioning of the brachial, radial, and ulnar arteries 12 cm proximal, 1 cm distal, and 6 cm distal to the ulnar artery takeoff, respectively. The supinator, anconeus, distal brachialis, proximal aspects of the flexor digitorum profundus, and flexor carpi ulnaris must be preserved to protect osseous perforators. Articular innervation was most commonly derived from ulnar and median nerve branches. We refined our proposed surgical technique after performing 2 cadaveric elbow VCAs. Elbow VCA may be technically feasible on the basis of its consistent vascular anatomy and our proposed surgical technique.
ISSN:1058-2746
1532-6500
DOI:10.1016/j.jse.2017.04.014