Axial Pattern Flap Reconstruction of a Chronic Non-Healing Elbow Wound in a Golden Retriever

Ginger is a 7-year-old female spayed golden retriever who presented to MedVet Toledo with a chronic non-healing open skin wound over the right elbow. (Fig. 1) 

Fig. 1: Ginger

The owner adopted Ginger 1.5 years prior to presentation and the wound was present at that time. Ginger was otherwise healthy with no major medical issues. Serous fluid drained from the wound occasionally. Antibiotic therapy previously prescribed did not result in significant improvement of the wound.

Physical examination of Ginger was normal except for a large (8cm diameter) open wound over the right elbow that appeared to be a decubital ulcer. (Fig. 2) 

Fig. 2: The non-healing chronic open wound over the right elbow on Ginger

Extensive fibrotic scar tissue was present around the periphery of the circular wound, and unhealthy granulation tissue was seen in the wound center. Little to no discharge was present on the wound surface.

A fine needle aspirate of the peripheral scar tissue was performed to rule out neoplasia and the cytology results indicated chronic inflammation. Routine preoperative CBC and serum chemistry profile were normal. The plan was to anesthetize Ginger, perform an extensive surgical debridement of the fibrotic peripheral tissues, and reconstruct the skin using an axial pattern skin flap. 

Ginger was anesthetized and the right elbow and surrounding skin clipped and prepared for aseptic surgery. The donut shaped abnormal scar tissue was removed using blunt and sharp dissection. (Fig. 3) 

Fig. 3: The right elbow of Ginger immediately after surgical debridement of the chronic wound. 

During this dissection it became clear that the tissue was highly vascularized. Hemostasis was difficult and bleeding became brisk throughout the dissected area. The hemorrhage was controlled with electrocautery and direct pressure. We elected to delay the skin flap reconstruction so that open wound management with tie-over bandages could be used on the elbow to allow the debrided area to be in more optimal condition for the definitive reconstruction procedure. (for more information see: tie-over bandages)

One week after the surgical debridement Ginger was re-admitted to the hospital for the skin flap procedure. Ginger was placed under general anesthesia and a thoracodorsal axial pattern skin flap was performed to reconstruct the elbow decubitalulcer. (Fig. 4)
(for more information see: axial pattern skin flaps) 

Fig. 4: Completed thoracodorsal axial pattern flap reconstruction of the elbow on Ginger.
White arrow indicates direction of transfer of the rectangular skin flap harvested from skin over the scapula.

Complete coverage of the wound was achieved with the skin flap. A spica bandage was placed over the leg and thorax to protect the incisions and Ginger was recovered from anesthesia. 

The following day Ginger’s bandage was changed and she was discharged from the hospital. Bandage changes occurred every 2-3 days until the incisions were healed and staples removed. (Fig. 5) 

Fig. 5: Appearance of the surgical incisions on Ginger 10 days postoperatively.

Ginger finally was discharged with no rechecks necessary unless problems arose. However 5 months later she represented to MedVet Toledo for problems unrelated to her elbow. The owner reported that since the skin flap reconstruction Ginger had been much more comfortable and mobile. Ginger’s skin flap had grown a thick, bushy amount of hair. There was redundant skin at the elbow but the overall cosmetic appearance was quite satisfactory. (Fig. 6) In general the owner was very pleased with the end result of the reconstruction.

Fig. 6: Appearance of Ginger's right elbow area 5 months after reconstruction.

Chronic wounds of the elbow in dogs are one of the most difficult to manage. Skin tension, excessive motion, and trauma to the area combine to interfere with healing in this part of the body. Debridement and local advancement of skin over the defect is generally unrewarding for reconstruction, particularly if it results in a suture line directly over the olecranon. Skin flap techniques that bring healthy, robust tissue into the site without creating a suture line over the olecranon, such as an axial pattern flap, is more likely to be successful.

Several aspects of the postoperative care are key to the success of this procedure. A well-padded bandage to protect and cushion the skin flap is mandatory for at least 10-14 days postoperatively. Exercise restriction is also important along with frequent postoperative rechecks to monitor for flap survival and healing. 

One clinical study of 10 dogs having thoracodorsal axial pattern flaps found complications to be common but good functional and cosmetic outcome resulted in 6 of 7 dogs long term follow up. (1)

References

1. Aper R, Smeak, D:  Complications and Outcome After Thoracodorsal Axial Pattern Flap Reconstruction of Forelimb Skin Defects in 10 Dogs, 1989–2001 32:4, 2003, Pages 378-384.