Composite Forearm Free Fillet Flaps to Preserve Stump Length Following Traumatic Amputations of the Upper Extremity

Replantation of traumatic upper arm amputations are usually contraindicated due to patient age, comorbid diseases, ischemia time, and/or avulsion of proximal structures. Stable soft tissue coverage preserving proximal stump length and critical joints is required to prevent loss of limb function and aid in prosthetic fitting and comfort. The use of free fillet flaps from the amputated limb is well documented for lower-extremity amputations but has only recently been reported for upper-arm amputations involving distal humeral or elbow wounds or following radical upper-arm tumor resections. Furthermore, these described free fillet flaps were fasciocutaneous rather than composite flaps. Composite free fillet flaps from the amputated upper arm utilizing the flexor muscles adjacent to the vascular pedicles is not well described or documented. Eight upper-extremity, composite, free fillet flaps were performed to cover proximal humeral and shoulder defects secondary to upper-arm traumatic amputation from July 1995 to May 2005 on 7 males and 1 female. A retrospective chart review was completed, and information collected included the age of patient, gender, date of injury and surgery, amputation site, mechanism of injury, ischemia time, type of fillet flap, donor and recipient vessels, flap sensation, flap survival, and number of complications. All upper-arm amputations were trauma related (100%) and secondary to industrial accidents (4), motor vehicle and motorcycle accidents (2), fall (1), and train (1). Patient age ranged from 16 to 62 years and polytrauma was noted in 50%. Procedures included 6 composite free fillet flaps and 2 radial forearm free fillet flaps, with 4 (50%) sensate. Sensory nerves included the medial (3) and lateral (2) antebrachial cutaneous nerves attached to median proximal nerve stumps. Ischemia time ranged from 280 to 630 minutes. All flaps survived and 2 (25%) complications occurred in 1 patient. Subjective and protective sensation was observed in each neurorrhaphy; however, no confirmatory tested was used. Immediate soft tissue coverage using composite free fillet flaps from amputated limbs can be successful, with few complications, and preserves limb length while maximizing available tissue. Furthermore, including flexor muscle belly adjacent to the vascular pedicles provides additional coverage and a well-vascularized composite flap to aid in prosthetic fitting and comfort.