Steinberger Zvi, Xu Heng, Kazmers Nikolas H, Thibaudeau Stephanie, Huffman Russel G, Levin L Scott
Department of Orthopedic Surgery, Penn Medicine University City, Philadelphia, PA, USA; Department of Orthopedic Surgery, Sheba Medical Center, Tel Hashomer, Israel.
Department of Orthopedic Surgery, Penn Medicine University City, Philadelphia, PA, USA.
J Shoulder Elbow Surg. 2017 Aug;26(8):1325-1334. doi: 10.1016/j.jse.2017.04.014.
Elbow reconstruction with vascularized composite allotransplantation (VCA) may hold promise in treating end-stage arthritis as no current treatment is both functional and durable. We describe the vascular and gross anatomy of the elbow in the context of VCA procurement and propose a step-by-step surgical technique for human elbow VCA.
We injected latex in the arterial tree of 16 fresh adult cadaveric upper extremities. We identified and measured arteries and nerves and their branch points relative to the medial epicondyle. Based on our determination of the dominant blood supply to osseous and capsular elbow structures, we derived a cadaveric model of elbow VCA by performing donor preparation on 2 fresh cadaveric upper extremities by elevating a lateral arm flap in conjunction with the vascularized elbow joint. We prepared and transplanted 2 size-matched recipient specimens to refine the surgical technique.
The elbow arterial supply was composed of consistent branches contributing to medial, lateral, and posterior arcades. Preservation of the elbow arterial network requires sectioning of the brachial, radial, and ulnar arteries 12 cm proximal, 1 cm distal, and 6 cm distal to the ulnar artery takeoff, respectively. The supinator, anconeus, distal brachialis, proximal aspects of the flexor digitorum profundus, and flexor carpi ulnaris must be preserved to protect osseous perforators. Articular innervation was most commonly derived from ulnar and median nerve branches. We refined our proposed surgical technique after performing 2 cadaveric elbow VCAs.
Elbow VCA may be technically feasible on the basis of its consistent vascular anatomy and our proposed surgical technique.
血管化复合组织异体移植（VCA）重建肘部在治疗终末期关节炎方面可能具有前景，因为目前尚无既有效又持久的治疗方法。我们在VCA获取的背景下描述肘部的血管和大体解剖结构，并提出一种用于人体肘部VCA的分步手术技术。
我们向16具新鲜成年尸体上肢的动脉树中注入乳胶。我们识别并测量了动脉、神经及其相对于内上髁的分支点。基于我们对肘部骨和关节囊结构主要血供的确定，我们通过在2具新鲜尸体上肢上进行供体准备，掀起外侧臂皮瓣并结合血管化肘关节，得出了肘部VCA的尸体模型。我们准备并移植了2个尺寸匹配的受体标本以完善手术技术。
肘部动脉供应由构成内侧、外侧和后弓的一致分支组成。保留肘部动脉网络需要分别在肱动脉、桡动脉和尺动脉距尺动脉起始处近端12厘米、远端1厘米和远端6厘米处切断。必须保留旋后肌、肘肌、肱肌远端、指深屈肌近端和尺侧腕屈肌以保护骨穿支。关节神经支配最常见于尺神经和正中神经分支。在进行2例尸体肘部VCA后，我们完善了我们提出的手术技术。
基于肘部一致的血管解剖结构和我们提出的手术技术，肘部VCA在技术上可能是可行的。
