2510: Elbow vascularized composite allotransplantation - Surgical anatomy and technique

Abstract

2510: Elbow vascularized composite allotransplantation Surgical anatomy and technique Zvi Steinberger, MD, Heng Xu, Nikolas H. Kazmers, Stephanie Thibaudeau, Russel G. Huffman, and L. Scott Levin University of Pennsylvania, Philadelphia, PA, USA Background 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 elbow VCA. Methods Sixteen fresh adult cadaveric upper extremities underwent arterial tree latex injection. Arteries, nerves, and their branch points were identified and measured relative to the medial epicondyle. Based upon our determination of the dominant blood supply to elbow osseous and capsular structures, a cadaveric model of elbow VCA was derived by performing donor preparation on two fresh cadaveric upper extremities, with elevation of a lateral arm flap in conjunction with the vascularized elbow joint. Two size-matched specimens underwent recipient preparation, followed by transplantation. The surgical technique was refined with each successive transplant. Results The arterial supply to the elbow was comprised of consistent branches contributing to medial, lateral, and posterior arcades (Table 1). Preservation of the elbow arterial network requires sectioning of brachial, radial and ulnar arteries 12 cm proximal, 1 cm distal, and 6 cm distal to the ulnar artery take-off, respectively. Preservation of the supinator, anconeus, distal brachialis, proximal aspects of the flexor digitorum profundus, and flexor carpi ulnaris is required to protect osseous perforators. Nerves branches to the joint most commonly were derived from ulnar and median nerves (Table 1). Following two cadaveric elbow VCA procedures, our proposed surgical technique has been refined (Table 2).