Oncologic resection around the shoulder often results in ...



Introduction

Tumor extirpation around the shoulder can result in large composite tissue defects. Reconstruction of these defects often requires durable and stable coverage of allograft and or alloprosthetic constructs and vital neurovascular structures. Additionally, reconstructive techniques should strive to preserve both the wide range of motion around the shoulder and anatomical contour of the shoulder girdle.

In the upper extremity, the LD has been used for defects of the forearm, elbow, arm and shoulder. (Rogachefsky, 2002; Pierce, 2000) The LD has a relatively large surface area that can cover most large defects of the shoulder. As a regional flap for the shoulder, the LD and its vascular pedicle are often unadultered outside the oncologic field. In this setting, this flap is pedicled and thus eliminates the small but risk associated with microsurgical free tissue transfer.

The purpose of this study was to review our experience with the pedicled latissimus dorsi (LD) flap in reconstruction of large shoulder defects after oncologic resection.

Methods

This was a retrospective review of all patients in whom a pedicled LD flap was used to reconstruct complex shoulder defects resulting from oncologic resection between 1994 and 2004. Patients were identified using our prospectively maintained database; chart review and patient examinations were performed. Patient demographics, comorbid conditions, pathology, adjuvant treatment, defect characteristics, skin paddle dimensions and operative records were reviewed. Major and minor complications, patient survival, and limb viability were evaluated as outcome variables.

Thirty-three patients were identified during the study period (age range 6-74 years, mean age 36.5 years; 15 males and 18 females). Wide excision or radical en-bloc resection of the shoulder tissues were performed in all patients with defects often extending intra-articularly and to the level of the mid-arm. Defects averaged approximately 287.7 cm2, as recorded in eleven cases.

Thirteen patients underwent allograft and alloprosthetic composite shoulder reconstruction. Six patients were reconstructed solely with a metallic prosthesis while three patients underwent bony reconstruction with allograft alone.

Two patients required secondary flaps in addition to the primary LD flap, including a multiple slip serratus flap and a local deltoid flap.

Adjuvant therapy included: radiation therapy in twelve patients and chemotherapy in eighteen patients. Brachytherapy was utilized twice.

Results

All thirty-three patients in our patient series went on to heal their shoulder reconstructions. In twenty eight cases myocutaneous flap transfer was performed. The dimensions of the skin paddles ranged from 3.0 to 10 cm in width (mean 5.8 cm) and 7.0 to 35 cm in length (mean 18.8 cm); mean surface area was 118.9 cm2.

Five of the twenty-eight myocutaneous flaps required additional split-thickness skin grafting. In five cases a latissimus muscle flap alone was utilized; split thickness grafts were used in three of these patients. Two patients experienced partial skin flap necrosis treated successfully with conservative management. All other patients went on to heal without additional complications.

All thirteen patients who underwent bony and or prosthetic reconstruction of the shoulder went on to heal their constructs. One patient did require a revision of his humeral allograft-prosthetic nonunion with iliac crest bone graft.

The patient that required a multiple serratus slip flap required debridement and eventually an STSG. His LD flap however proved entirely viable. The deltoid flap healed without complication.

As of their last documented follow up visits, only one patient went on to amputation before her later demise. One patient later demonstrated local recurrence that necessitated further resection and reconstruction utilizing pectoralis major, external oblique and local fasciocutaneous flaps on separate occasions. Twenty-six patients are documented alive and without evidence of local tumor recurrence.

Discussion

In this series, all thirty-three patients obtained stable and reliable coverage of their shoulder defects after oncologic extirpation. No matter the size of the defect (average of 287.7 cm2), the LD flap provided ample tissue in reconstruction. All twenty-eight myocutaenous flaps healed successfully with only two flaps demonstrating partial skin necrosis that required nonoperative intervention.

In our patient series, thirteen patients underwent allograft and alloprosthetic composite shoulder reconstruction. All thirteen patients who underwent bony and or prosthetic reconstruction of the shoulder went on to heal their constructs without evidence of infection. Only one patient required a revision of his humeral allograft-prosthetic nonunion with iliac crest bone graft. This patient also went on to heal without further complication. To date, only one patients has undergone amputation secondary to recurrent disease and not infection.

Conclusion

The pedicled LD flap is our first choice for reconstruction of defects around the shoulder after tumor extirpation. Use of the pedicled LD flap in complex shoulder reconstructions provides ample well-vascularized soft tissue, minimizes the risk of infection, and thus maximizes limb salvage.

Jutte DL, Rees R, Nanney L, Bueno R, Lynch JB. Latissimus dorsi flap: a valuable resource in lower arm reconstruction. South Med J. 1987 Jan;80(1):37-40.

Pierce TD, Tomaino MM. Use of the pedicled latissimus muscle flap for upper-extremity reconstruction. J Am Acad Orthop Surg. 2000 Sep-Oct;8(5):324-31.

Quinn RH, Mankin HJ, Springfield DS, Gebhardt Mc. Management of infected bulk allografts with antibiotic impregnated polymethylmethacrylate spacers. Orthopaedics. 2001 Oct; 24 (10): 971-5.

Rogachefsky RA, Aly A, Brearley W. Latissimus dorsi pedicled flap for upper extremity soft-tissue reconstruction. Orthopedics. 2002 Apr;25(4):403-8.

Strauch B, Yu HL. Atlas of Microvascular Surgery. Thieme Medical Publishers. New York, NY. 1993; pp482.

Tansini I, Sopra IL. Mio Nuovo Processo Di Amputazione Della Mamella. Riforma Med 12: 757, 1906.

Vasconez HC, Oishi S. Soft-tissue coverage of the shoulder and brachium.

Orthop Clin North Am. 1993 Jul;24(3):435-48.

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