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.
Case 2. A 29-year-old male sustained an open olecranon fracture of the left elbow. Fixation of the fracture was done resulting in a 60 cm2 soft tissue defect. This was covered with a medial fasciocutaneous transposition flap based on a medial upper arm perforator. The donor site was skin grafted. Recovery was uneventful, and the patient's ROM at the elbow was recorded as 100° 8 months postoperatively ().