{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,4,3]],"date-time":"2026-04-03T17:45:59Z","timestamp":1775238359195,"version":"3.50.1"},"reference-count":52,"publisher":"MDPI AG","issue":"2","license":[{"start":{"date-parts":[[2025,2,8]],"date-time":"2025-02-08T00:00:00Z","timestamp":1738972800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Medicina"],"abstract":"<jats:p>Background and Objectives: The elbow joint, essential for daily activities, often requires soft tissue reconstruction following trauma, infection, or tumor excision. Free flap surgery using the brachial artery (BA) as the recipient vessel offers stable vascular support, but preserving distal blood flow is crucial. Due to vessel diameter differences, end-to-side (ETS) anastomosis is usually necessary, as flow-through anastomosis can be challenging. Although reports exist on soft tissue reconstruction using the BA as the recipient vessel, complications and outcomes related to using the sole main artery as the recipient remain unclear. We developed the microscopic parachute end-to-side (MPETS) technique, adapted from ETS, to more easily address vessel size discrepancies. This study evaluates the effectiveness and safety of MPETS in BA-based elbow reconstruction, alongside a review of outcomes in other cases. Materials and Methods: We retrospectively analyzed seven cases of elbow reconstruction from April 2018 to September 2023, focusing on patients with BA recipient vessels and a minimum 12-month follow-up. Variables included patient demographics, etiologies, flap types, and postoperative outcomes measured by Jupiter\u2019s Criteria. Following PRISMA 2020 guidelines, a systematic literature review identified similar cases using the BA in free flap reconstruction for comparison. Results: In all our cases, flap survival was 100%, with no distal ischemia observed, and the average range of motion was 119\u00b0. Complications were limited, with one reoperation due to venous thrombosis. The MPETS technique minimized blood flow issues and accommodated the BA\u2019s diameter. The literature review included 77 cases, confirming the BA\u2019s viability and stability as a recipient vessel. Conclusions: Using the BA as a recipient vessel with MPETS demonstrates high effectiveness and safety in elbow soft tissue reconstruction. Our results support the BA\u2019s suitability for complex reconstructions, with MPETS enhancing vessel compatibility and reducing complications.<\/jats:p>","DOI":"10.3390\/medicina61020295","type":"journal-article","created":{"date-parts":[[2025,2,10]],"date-time":"2025-02-10T06:43:07Z","timestamp":1739169787000},"page":"295","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":1,"title":["Free Flap Surgery for Elbow Soft Tissue Reconstruction Using the Brachial Artery as Recipient Vessel: Evaluation of MPETS Cases and Comparative Literature Review"],"prefix":"10.3390","volume":"61","author":[{"given":"Mitsutoshi","family":"Ota","sequence":"first","affiliation":[{"name":"Department of Orthopaedic Surgery, Obihiro Kosei Hospital Hand Center, Obihiro 080-0024, Japan"},{"name":"Department of Orthopaedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo 060-0808, Japan"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6204-6229","authenticated-orcid":false,"given":"Makoto","family":"Motomiya","sequence":"additional","affiliation":[{"name":"Department of Orthopaedic Surgery, Obihiro Kosei Hospital Hand Center, Obihiro 080-0024, Japan"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Naoya","family":"Watanabe","sequence":"additional","affiliation":[{"name":"Department of Orthopaedic Surgery, Obihiro Kosei Hospital Hand Center, Obihiro 080-0024, Japan"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Kazuya","family":"Kitaguchi","sequence":"additional","affiliation":[{"name":"Department of Radiological Technology, Obihiro Kosei Hospital, Obihiro 080-0024, Japan"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5496-4046","authenticated-orcid":false,"given":"Norimasa","family":"Iwasaki","sequence":"additional","affiliation":[{"name":"Department of Orthopaedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo 060-0808, Japan"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1968","published-online":{"date-parts":[[2025,2,8]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"141","DOI":"10.1016\/j.ocl.2007.12.001","article-title":"Anatomy and biomechanics of the elbow","volume":"39","author":"Bryce","year":"2008","journal-title":"Orthop. Clin. N. Am."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"387e","DOI":"10.1097\/PRS.0b013e31829ae29f","article-title":"Soft-tissue coverage of the elbow","volume":"132","author":"Stevanovic","year":"2013","journal-title":"Plast. Reconstr. Surg."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"528","DOI":"10.1016\/j.jhsa.2020.01.016","article-title":"Elbow Biomechanics: Bony and Dynamic Stabilizers","volume":"45","author":"Wilps","year":"2020","journal-title":"J. Hand Surg. Am."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"943","DOI":"10.1007\/s00276-018-2066-5","article-title":"Focus on anatomical aspects of soft tissue coverage options in elbow reconstruction: An updating review","volume":"40","author":"Gandolfi","year":"2018","journal-title":"Surg. Radiol. Anat."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"251","DOI":"10.1016\/j.ocl.2007.12.009","article-title":"Soft tissue coverage of the elbow: A reconstructive algorithm","volume":"39","author":"Jensen","year":"2008","journal-title":"Orthop. Clin. N. Am."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"693","DOI":"10.1016\/j.hcl.2015.06.013","article-title":"Soft-Tissue Coverage for Elbow Trauma","volume":"31","author":"Kelley","year":"2015","journal-title":"Hand Clin."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"586","DOI":"10.1177\/1558944717725381","article-title":"The Pedicled Latissimus Dorsi Flap Provides Effective Coverage for Large and Complex Soft Tissue Injuries Around the Elbow","volume":"13","author":"Hacquebord","year":"2018","journal-title":"Hand"},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"1852","DOI":"10.1097\/01.prs.0000259182.53294.67","article-title":"Soft-tissue coverage of the elbow: An outcome analysis and reconstructive algorithm","volume":"119","author":"Choudry","year":"2007","journal-title":"Plast. Reconstr. Surg."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"130","DOI":"10.5999\/aps.2012.39.2.130","article-title":"Use of the fix and flap approach to complex open elbow injury: The role of the free anterolateral thigh flap","volume":"39","author":"Chui","year":"2012","journal-title":"Arch. Plast. Surg."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"991","DOI":"10.1016\/j.bjps.2021.11.091","article-title":"Flap survival and functional outcomes in elbow soft tissue reconstruction: A 25-year systematic review","volume":"75","author":"Kahramangil","year":"2022","journal-title":"J. Plast. Reconstr. Aesthet. Surg."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"314","DOI":"10.1055\/s-0039-3401470","article-title":"Anterolateral Thigh Flap\u2014The Optimal Flap in Coverage of Severe Elbow Injuries","volume":"52","author":"Prakash","year":"2019","journal-title":"Indian J. Plast. Surg."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"S19","DOI":"10.1097\/SAP.0000000000000487","article-title":"Treatment of elbow osteomyelitis with an interposition arthroplasty using a rectus abdominis free flap","volume":"74","author":"Jaiswal","year":"2015","journal-title":"Ann. Plast. Surg."},{"key":"ref_13","first-page":"2841816","article-title":"Maximizing Outcomes While Minimizing Morbidity: An Illustrated Case Review of Elbow Soft Tissue Reconstruction","volume":"2016","author":"Ooi","year":"2016","journal-title":"Plast. Surg. Int."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"773","DOI":"10.1016\/S0094-1298(20)30795-1","article-title":"Avoiding free flap failure","volume":"19","author":"Khouri","year":"1992","journal-title":"Clin. Plast. Surg."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"673","DOI":"10.1097\/00006534-197964050-00013","article-title":"Preferential use of end-to-side arterial anastomoses in free flap transfers","volume":"64","author":"Godina","year":"1979","journal-title":"Plast. Reconstr. Surg."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"285","DOI":"10.1097\/00006534-198609000-00001","article-title":"Early microsurgical reconstruction of complex trauma of the extremities","volume":"78","author":"Godina","year":"1986","journal-title":"Plast. Reconstr. Surg."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"e1228","DOI":"10.1097\/GOX.0000000000001228","article-title":"A Comprehensive Approach to Lower Extremity Free-tissue Transfer","volume":"5","author":"Pu","year":"2017","journal-title":"Plast. Reconstr. Surg. Glob. Open"},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"e31163","DOI":"10.1002\/micr.31163","article-title":"Free flap reconstruction of elbow soft tissue defects: Lessons learned from 15 years of experience","volume":"44","author":"McGraw","year":"2024","journal-title":"Microsurgery"},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"2169","DOI":"10.1007\/s43465-022-00760-y","article-title":"Anterolateral Thigh Flap Coverage for Large Posterior Defects of the Elbow","volume":"56","author":"Bezirgan","year":"2022","journal-title":"Indian J. Orthop."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"e2644","DOI":"10.1097\/GOX.0000000000002644","article-title":"Boomerang-shaped Lateral-to-back Flap Utilizing Multiple Thoracodorsal Artery Perforators around the Lateral Border of Latissimus Dorsi Muscle for Reconstruction of Large Circular Defect","volume":"8","author":"Kagaya","year":"2020","journal-title":"Plast. Reconstr. Surg. Glob. Open"},{"key":"ref_21","first-page":"8295736","article-title":"Use of Osteofasciocutaneous Fibular Free Flap and Radial Head Arthroplasty in Trauma for Limb Salvage and Continued Elbow Function","volume":"2018","author":"Kilmartin","year":"2018","journal-title":"Case Rep. Orthop."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"2239","DOI":"10.1016\/j.bjps.2020.05.022","article-title":"Reliable free flaps using the microscopic parachute end-to-side technique in severe extremity injuries","volume":"73","author":"Motomiya","year":"2020","journal-title":"J. Plast. Reconstr. Aesthet. Surg."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"2495","DOI":"10.1016\/j.bjps.2021.03.022","article-title":"Blood flow distribution after end-to-side anastomosis with wide arteriotomy in extremity free flap surgery","volume":"74","author":"Motomiya","year":"2021","journal-title":"J. Plast. Reconstr. Aesthet. Surg."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"189","DOI":"10.1016\/j.jpra.2022.10.003","article-title":"Efficacy of the microscopic parachute end-to-side technique for creating large-to-small venous anastomoses in free flaps in the extremities","volume":"34","author":"Motomiya","year":"2022","journal-title":"JPRAS Open"},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"48","DOI":"10.1016\/j.jpra.2023.08.003","article-title":"A simple free flap strategy using end-to-side anastomosis to the main vessels in injured extremity","volume":"38","author":"Motomiya","year":"2023","journal-title":"JPRAS Open"},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"131","DOI":"10.1093\/bmb\/ldn023","article-title":"Rating systems for evaluation of the elbow","volume":"87","author":"Longo","year":"2008","journal-title":"Br. Med. Bull."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"226","DOI":"10.2106\/00004623-198567020-00008","article-title":"Intercondylar fractures of the humerus. An operative approach","volume":"67","author":"Jupiter","year":"1985","journal-title":"J. Bone Jt. Surg. Am."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"183","DOI":"10.1177\/1358863x06070516","article-title":"Guidelines for noninvasive vascular laboratory testing: A report from the American Society of Echocardiography and the Society for Vascular Medicine and Biology","volume":"11","author":"Gardin","year":"2006","journal-title":"Vasc. Med."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"1006","DOI":"10.1016\/j.jclinepi.2009.06.005","article-title":"Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement","volume":"62","author":"Moher","year":"2009","journal-title":"J. Clin. Epidemiol."},{"key":"ref_30","unstructured":"NIH (2024, August 06). Study Quality Assessment Tools, Available online: https:\/\/www.nhlbi.nih.gov\/health-topics\/study-quality-assessment-tools."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"1175","DOI":"10.1097\/01.PRS.0000110332.74289.2B","article-title":"A clinical experience with perforator flaps in the coverage of extensive defects of the upper extremity","volume":"113","author":"Hamdi","year":"2004","journal-title":"Plast. Reconstr. Surg."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"97","DOI":"10.1177\/1558944715614854","article-title":"Elbow Reconstruction With Compression Plate Arthrodesis and Circumferential Muscle-Sparing Latissimus Dorsi Flap After Tumor Resection: A Case Report","volume":"11","author":"Ng","year":"2016","journal-title":"Hand"},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"405","DOI":"10.1002\/micr.30431","article-title":"Reconstruction of complex soft tissue defects including tendons with anterolateral thigh flap extended to fascia lata: Long term recovery and functional outcomes","volume":"39","author":"Sapino","year":"2019","journal-title":"Microsurgery"},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"100463","DOI":"10.1016\/j.tcr.2021.100463","article-title":"The use of the anterolateral thigh vascular free flap in complex open elbow fractures after major trauma\u2014An illustrated report of an interesting case","volume":"34","author":"Gerakopoulos","year":"2021","journal-title":"Trauma Case Rep."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"785","DOI":"10.1016\/j.otsr.2011.07.012","article-title":"Free Gracilis muscle transfer to restore elbow flexion in brachial plexus injuries","volume":"97","author":"Coulet","year":"2011","journal-title":"Orthop. Traumatol. Surg. Res."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"e1","DOI":"10.1016\/j.bjps.2008.06.082","article-title":"Restoration of elbow flexion after brachial plexus injury by free functional rectus femoris muscle transfer","volume":"62","author":"Wechselberger","year":"2009","journal-title":"J. Plast. Reconstr. Aesthet. Surg."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"26","DOI":"10.1097\/BTH.0000000000000258","article-title":"The Inverted Free Functioning Gracilis Muscle Transfer For Restoration of Elbow Flexion Following Delayed Presentation or Failed Primary Nerve Reconstruction of Upper Trunk Injuries","volume":"24","author":"Wade","year":"2020","journal-title":"Tech. Hand Up. Extrem. Surg."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"461","DOI":"10.1055\/s-0030-1254230","article-title":"Perforator vessel recipient options in the lower extremity: An anatomically based approach to safer limb salvage","volume":"26","author":"Haddock","year":"2010","journal-title":"J. Reconstr. Microsurg."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"559","DOI":"10.1053\/jhsu.2000.6926","article-title":"The use of simultaneous free latissimus dorsi tissue transfers for reconstruction of bilateral upper extremities in a case of purpura fulminans","volume":"25","author":"Redett","year":"2000","journal-title":"J. Hand Surg. Am."},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"1519","DOI":"10.1016\/j.bjps.2008.05.016","article-title":"Use of the slit arteriotomy for end-to-side arterial anastomosis in free-tissue transfers to the extremities","volume":"62","author":"Tan","year":"2009","journal-title":"J. Plast. Reconstr. Aesthet. Surg."},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"1302","DOI":"10.1097\/PRS.0000000000006791","article-title":"Limb Salvage Rates and Functional Outcomes Using a Longitudinal Slit Arteriotomy End-to-Side Anastomosis for Limb-Threatening Defects in a High-Risk Patient Population","volume":"145","author":"Black","year":"2020","journal-title":"Plast. Reconstr. Surg."},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"69","DOI":"10.4103\/0028-3886.198207","article-title":"The \u201c11 O\u2019clock Heel First\u201d technique for microvascular end-to-side anastomosis","volume":"65","author":"Hegazy","year":"2017","journal-title":"Neurol. India"},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"73","DOI":"10.1016\/j.wneu.2021.07.091","article-title":"Toe-First Technique for End to Side Microvascular Anastomosis","volume":"154","author":"Tyagi","year":"2021","journal-title":"World Neurosurg."},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"37","DOI":"10.1097\/00007611-198701000-00009","article-title":"Latissimus dorsi flap: A valuable resource in lower arm reconstruction","volume":"80","author":"Jutte","year":"1987","journal-title":"South. Med. J."},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"634","DOI":"10.1016\/S1058-2746(99)90104-0","article-title":"Latissimus dorsi pedicle flap for coverage of soft tissue defects about the elbow","volume":"8","author":"Stevanovic","year":"1999","journal-title":"J. Shoulder Elb. Surg."},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"872","DOI":"10.2106\/00004623-198163060-00002","article-title":"A biomechanical study of normal functional elbow motion","volume":"63","author":"Morrey","year":"1981","journal-title":"J. Bone Jt. Surg. Am."},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"511","DOI":"10.1002\/micr.30020","article-title":"Free flaps for reconstruction of soft tissue defects in lower extremity: A meta-analysis on microsurgical outcome and safety","volume":"36","author":"Xiong","year":"2016","journal-title":"Microsurgery"},{"key":"ref_48","doi-asserted-by":"crossref","first-page":"1184","DOI":"10.1016\/j.bjps.2015.05.009","article-title":"Free tissue transfer to the traumatized upper extremity: Risk factors for postoperative complications in 282 cases","volume":"68","author":"Gupta","year":"2015","journal-title":"J. Plast. Reconstr. Aesthet. Surg."},{"key":"ref_49","doi-asserted-by":"crossref","first-page":"463","DOI":"10.1002\/micr.30460","article-title":"Soft tissue free flap for reconstruction of upper extremities: A meta-analysis on outcome and safety","volume":"39","author":"Zhang","year":"2019","journal-title":"Microsurgery"},{"key":"ref_50","doi-asserted-by":"crossref","first-page":"351","DOI":"10.29252\/wjps.7.3.351","article-title":"Anastomosis of Free Flap Pedicle to Great Vessels","volume":"7","author":"Khoshnevis","year":"2018","journal-title":"World J. Plast. Surg."},{"key":"ref_51","doi-asserted-by":"crossref","first-page":"587","DOI":"10.1055\/s-0039-1688718","article-title":"Vein Size Mismatch Increases Flap Failure in Lower Extremity Trauma Free Flap Reconstruction","volume":"35","author":"Lee","year":"2019","journal-title":"J. Reconstr. Microsurg."},{"key":"ref_52","first-page":"e20978","article-title":"Analysis of Anastomotic Venous Factors in Traumatic Lower Extremity Injuries Reconstructed by Free Flap","volume":"14","author":"Shimbo","year":"2022","journal-title":"Cureus"}],"container-title":["Medicina"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/1648-9144\/61\/2\/295\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,9]],"date-time":"2025-10-09T16:29:35Z","timestamp":1760027375000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/1648-9144\/61\/2\/295"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,2,8]]},"references-count":52,"journal-issue":{"issue":"2","published-online":{"date-parts":[[2025,2]]}},"alternative-id":["medicina61020295"],"URL":"https:\/\/doi.org\/10.3390\/medicina61020295","relation":{},"ISSN":["1648-9144"],"issn-type":[{"value":"1648-9144","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,2,8]]}}}