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 34-year-old male patient was admitted to our center. He had malunion of the distal humerus of his dominant arm (), accompanied with elbow stiffness (), and evident signs of osteoarthritis were seen on radiographs (Figures and ).\nThe study was approved by the hospital's Ethical Review Board, and it was conducted in accordance with the principles of the Declaration of Helsinki and its amendments. We fully informed the subject, and he gave his consent.\nThe patient underwent Grika interposition arthroplasty (see surgical technique paragraph and ) followed by a suitable rehabilitation protocol (see Rehabilitation Protocol and ). The external fixator which was used for initial support was removed 14 weeks after surgery.\nThe injured side (IS) and the noninjured side (NIS) were compared during the clinical follow-up. Function was evaluated with subjective quality of life measured by the Mayo Elbow Performance Score (MEPS) [].\nObjective function was evaluated by range of motion, flexion strength, and supination strength. A calibrated hydraulic dynamometer was used for the strength measurements. During these strength measurements, five measurements were taken by the same evaluator. The mean score of the last four was calculated as the first measurement was disregarded to avoid bias because of a learning curve caused by the patient's awareness.\nAt 1 year after surgery, both the MEPS and muscle strengths showed a difference in favor of the NIS. At 5 years of follow-up, the IS had a flexion strength of 98% of the NIS (28.9 N versus 29.5 N) and supination strength of 98% of that in the NIS (4.6 versus 4.7) and a MEPS of 100. Functional outcomes are shown in .\nThe patient was monitored for any postoperative complications.