A 41-year-old man was referred to our hospital with a two-year history of a tumor in his right elbow. Physical examination confirmed a 75 × 51 × 15 cm mass localized on the medial aspect of the right elbow (). The range of motion (ROM) of the elbow was within normal limits. Plain radiographs revealed the shadow of a soft tissue mass, with no abnormal findings in the humerus, radius, and ulna. On T1-weighted magnetic resonance (MR) imaging (T1WI), the lesion showed mainly as an iso intensity. On T2-weighted MR imaging (T2WI) (), the lesion presented as a high intensity. On gadolinium-diethylenetriamine penta-acetic acid (Gd-DTPA)-enhanced T1WI, the lesion presented an inhomogeneous contrast enhancement (). Subsequent pathological examination of biopsy tissue confirmed a diagnosis of synovial sarcoma. After three courses of neoadjuvant chemotherapy, a wide tumor excision, with a 2-cm safety margin, defined on the basis of a brightness change of Gd-DTPA-enhanced T1WI, was performed, followed by reconstruction using an autograft treated with liquid nitrogen and a free ALT flap. The tumor was excised en bloc (), with the level of resection determined based on preoperative MR images. The following muscles were included in the resection: pronator teres, wrist and finger flexors, brachialis, anconeus, and part of the triceps brachii. The ulnar nerve was sacrificed out of necessity, but the median nerve was preserved by using ethanol as an adjuvant []. One third of the medial humerus and ulna were also resected using a bone saw. With the exception of the articular capsule attached to the humerus and the tendon of the triceps brachii with its insertion, all other soft tissues and the tumor were dissected from the bone sections (). The resected bone was then frozen in liquid nitrogen for 20 min, thawed in air at room temperature for 15 min and thawed in distilled water for 10 min, according to a previously published protocol (). The bones were then reconstructed in situ using locking plates (LCP Distal Humerus Plate, LCP Metaphyseal Plate 3.5: DePuy Synthes, Zuchwil, Switzerland), a headless compression screw (4.5 mm HCS: DePuy Synthes) and a cannulated cancellous screw (3.0 mm CCS: MEIRA, Japan). The tendon of the triceps brachii was repaired using a triclosan-coated polidioxanone suture (PDS® PLUS: Ethicon Inc., Somerville, NJ) (). An ALT musculocutaneous flap with a vastus lateralis muscle of appropriate size was harvested and the soft tissue defect at the elbow reconstructed. Arterial revascularization was performed end-to-end to the transected ulnar artery. Venous anastomosis was done end-to-end to the cephalic vein. The affected limb was elevated postoperatively and the elbow was immobilized for 14 days to obtain wound healing and to avoid the risk of flap failure. Subsequently, range of motion (ROM) exercise was initiated. Bone union was defined as trabecular bone continuity, which can be seen as filling of the host-graft junction gap []. Filling of the host-graft junction gap was observed 12 months after the operation.\nAt the 2-year follow-up, elbow ROM was −35° of extension and 130° flexion, and bone union was achieved (), with complete and stable coverage of the defect (). No local recurrence of the tumor was observed.
A 76-year-old woman visited her previous doctor with a six-month history of two tumors in her elbow. An excision biopsy was performed, with a diagnosis of fibrosarcoma confirmed through pathological examination. The patient was referred to our hospital for further assessment and treatment. On physical examination, two masses (2 × 2 cm in size) were identified on the lateral aspect of the right elbow (), with the scar of a previous surgery between the two masses. The ROM of the elbow was within normal limits. No abnormal findings were identified on plain radiographs. On Gd-DTPA-enhanced T1WI, contrast enhancement was observed in the tumors and the fascia and subcutaneous tissue surrounding the lesions, which was considered as residual tumor tissue (). The location of the skin incision and the level of resection were defined in the same manner as in Case 1. The tumor was excised en bloc (). Briefly, the wrist and finger extensor, supinator, anconeus, and triceps brachii were resected. One third of the lateral portion of the distal humerus and radial head were also resected using a bone saw. With the exception of the radial articular capsule attached to the humerus, the fascia of the wrist and finger extensor with its insertion and the tendon of the triceps brachii with its insertion, all other soft tissues and the tumor were dissected from the bone sections. The excised bone portion was frozen in liquid nitrogen in the same manner as in Case 1 () and then reconstructed in situ using a locking plate (LCP Distal Humerus Plate: DePuy Synthes) and headless compression screw (3.5 mm HCS: DePuy Synthes). The triceps brachii, augmented with the Leeds-Keio ligament, was reattached to the olecranon and the radial articular capsule was reattached to the radial notch using a suture anchor (Corkscrew, Mini Corkscrew: Arthrex, Naples, FL). The wrist and finger extensor were repaired by using a polyethylene terephthalate suture (ETHIBOND®: Ethicon Inc.) (). The soft tissue defect was reconstructed with a free, 27 × 18 cm, ALT flap (). Arterial revascularization was performed end-to-end to the deep brachial artery. Venous anastomosis was done end-to-end to the vena comitans of the deep brachial artery and the basilic vein. The affected limb was elevated postoperatively and the elbow was immobilized for 14 days. Subsequently, ROM exercise was initiated in the same manner as in Case 1. Filling of the host-graft junction gap was observed 7 months after the operation. At the 1-year follow-up, elbow ROM was −35° extension and 130° flexion. Bone union was achieved (), and a complete and stable coverage of the defect was obtained (). Local recurrence of the tumor was not detected.