Inferior Cubital Artery Perforator Flap for Soft-Tissue Coverage of the Elbow by Olivier Camuzard, Rémi Foissac, Cyril Clerico, Jonathan Fernandez, Thierry Balaguer, Tarik Ihrai, Fernand de Peretti, Patrick Baqué, Pascal Boileau, Charalambos Georgiou, and Nicolas Bronsard J Bone Joint Surg Am Volume 98(6):457-465 March 16, 2016 ©2016 by The Journal of Bone and Joint Surgery, Inc.

Illustrations depicting the anatomical variations of the inferior cubital artery (ICA) according to the site of origin as described by Magden et al.11. Illustrations depicting the anatomical variations of the inferior cubital artery (ICA) according to the site of origin as described by Magden et al.11. The ICA (indicated by an asterisk [*]) originated from the radial artery in 62.5% of specimens (Fig. 1-A), from the radial recurrent artery in 17.5% (Fig. 1-B), from the radial recurrent artery originating from the brachial artery in 7.5% (Fig. 1-C), from the brachial artery in 7.5% (Fig. 1-D), from the radial recurrent artery arising from the brachial artery bifurcation in 2.5% (Fig. 1-E), and from a radial recurrent artery that has an aberrant proximal origin in 2.5% (Fig. 1-F). Olivier Camuzard et al. J Bone Joint Surg Am 2016;98:457-465 ©2016 by The Journal of Bone and Joint Surgery, Inc.

Illustration depicting the cutaneous capillary perforators as described by Yousif et al.14. Illustration depicting the cutaneous capillary perforators as described by Yousif et al.14. S = source artery, M = muscle, MC-cp = musculocutaneous capillary perforator; D-cp = direct capillary perforator; IT-cp = in-transit capillary perforator, and T-cp = terminal capillary perforator. Olivier Camuzard et al. J Bone Joint Surg Am 2016;98:457-465 ©2016 by The Journal of Bone and Joint Surgery, Inc.

Figs. 3-A, 3-B, and 3-C Illustration and photographs depicting the general anatomy of the inferior cubital artery. Figs. 3-A, 3-B, and 3-C Illustration and photographs depicting the general anatomy of the inferior cubital artery. BB = biceps brachialis, CV = cephalic vein, ICA = inferior cubital artery, BR = brachioradialis, BRA = brachioradialis artery, SBRN = superficial branch of the radial nerve, RRA = radial recurrent artery, UA = ulnar artery, RA = radial artery, PT = pronator teres, FCR = flexor carpi radialis, BA = brachial artery, and BV = brachial vein. The ICA cutaneous capillary perforator is indicated by asterisks (*). Fig. 3-A Schematic drawing of the right forearm, showing the ICA. Fig. 3-B Photograph of a cadaveric forearm, made after the injection of red latex, showing a Type-A ICA (originating from the radial artery) and cutaneous capillary perforators. Fig. 3-C Photograph showing a Type-A ICA after removal of the venous network. Note the ICA perforator and the voluminous branch to the brachioradialis derived from the ICA. Olivier Camuzard et al. J Bone Joint Surg Am 2016;98:457-465 ©2016 by The Journal of Bone and Joint Surgery, Inc.

Photographs of a fresh cadaveric forearm that was injected with red latex, showing the ICA cutaneous capillary perforators. Photographs of a fresh cadaveric forearm that was injected with red latex, showing the ICA cutaneous capillary perforators. The left image shows the in-transit and terminal cutaneous perforators (black arrowheads). The lateral antebrachial cutaneous nerve is indicated by an asterisk (*). The right image shows the musculocutaneous perforators (white arrowheads). It should be noted that the artery accompanying the lateral antebrachial cutaneous nerve arises from the ICA. The black arrowhead in the right image indicates a terminal cutaneous perforator. Olivier Camuzard et al. J Bone Joint Surg Am 2016;98:457-465 ©2016 by The Journal of Bone and Joint Surgery, Inc.

Top: Photographs of a fresh cadaveric forearm that was injected with red latex, showing the ICA perforator pedicled propeller flap. Top: Photographs of a fresh cadaveric forearm that was injected with red latex, showing the ICA perforator pedicled propeller flap. The ICA perforator flap has been elevated (left). Note the arc of rotation of the flap to resurface the anterior, medial, and lateral aspects of the cubital fossa (right). Bottom: Schematic drawing of the ICA perforator flap. The black arrowhead indicates the ICA. Olivier Camuzard et al. J Bone Joint Surg Am 2016;98:457-465 ©2016 by The Journal of Bone and Joint Surgery, Inc.

Photograph showing the vascular territory of the ICA following the injection of red ink. Photograph showing the vascular territory of the ICA following the injection of red ink. Ten ICA perforators were selectively injected. Our image analysis showed that the mean surface of all injected skin areas was 30.9 ± 11.9 cm2. Olivier Camuzard et al. J Bone Joint Surg Am 2016;98:457-465 ©2016 by The Journal of Bone and Joint Surgery, Inc.

Left image: Photograph showing a degloving injury in the anteromedial side of the left elbow pit area. Left image: Photograph showing a degloving injury in the anteromedial side of the left elbow pit area. An ICA perforator pedicled flap procedure was performed after marking of the perforator at 4 cm from the middle of the interepicondylar line. The use of bidirectional Doppler acoustics allowed us to confirm the presence of this perforator. Middle images: Photograph showing the perforator artery (white arrow). The flap was turned 100° in a counterclockwise direction to place it over the site of tissue loss. Right image: Postoperative photograph. Olivier Camuzard et al. J Bone Joint Surg Am 2016;98:457-465 ©2016 by The Journal of Bone and Joint Surgery, Inc.

Two months postoperatively, the flap was healing well. Olivier Camuzard et al. J Bone Joint Surg Am 2016;98:457-465 ©2016 by The Journal of Bone and Joint Surgery, Inc.