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.
Case 1. An 80-year-old female with multiple comorbidities including ischemic heart disease and chronic renal failure developed an ulcerating squamous cell carcinoma of her right elbow measuring 7 × 5 cm. Radiological studies showed no bony or joint involvement. The resultant wide excision included the skin, subcutaneous tissue, and underlying muscle, with a defect size of 75 cm2 exposing the elbow joint capsule and ulnar nerve. To avoid prolonged operative time, the defect was covered with pedicled FCR and FCU muscles (). The postoperative course was uneventful and in 10 months postoperatively the range of motion (ROM) at the elbow was 90°.