PMC6300093_01
Pre-operative clinical photograph of the 41-year old man with a synovial sarcoma in the right medial elbow region.
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Physical examination confirmed a 75 x 51 x 15 cm mass localized on the medial aspect of the right elbow (Figure 1).
Pre-operative magnetic resonance image, showing the axial T2WI (a), and coronal Gd-DTPA-enhanced T1WI (b).
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On T2-weighted MR imaging (T2WI) (Figure 2a), the lesion presented as a high intensity. On gadolinium-diethylenetriamine penta-acetic acid (Gd-DTPA)-enhanced T1WI, the lesion presented an inhomogeneous contrast enhancement (Figure 2b).
Intraoperative photographs showing the frozen autograft technique. The tumor was excised en bloc with a wide (2 cm) margin (a). All soft tissue and the tumor were dissected from the bone, with exception of the articular capsule and the tendon of triceps brachii with its insertion (b). The bone specimen was treated in liquid nitrogen (c). The frozen autograft was fixed in situ with plates (d).
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The tumor was excised en bloc (Figure 3a), with the level of resection determined based on preoperative MR images. With the exception of the articular capsule attached to the humerus and the tendon of the triceps brachii with its insertion, all other soft tissues and the tumor were dissected from the bone sections (Figure 3b). The resected bone was then frozen in liquid nitrogen for 20 min, thawed in air at room temperature for 15 min and thawed in distilled water for 10 min, according to a previously published protocol (Figure 3c). The tendon of the triceps brachii was repaired using a triclosan-coated polidioxanone suture (PDS  PLUS: Ethicon Inc., Somerville, NJ) (Figure 3d).
Follow-up radiograph and photograph obtained 2 years after the surgery. Anterior-posterior (a) and lateral (b) radiographs showing bony union of the osteotomy site, with no evidence of osteoarthritic changes at the elbow joint. Clinical photograph showing functional results in extension (c) and flexion (d).
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At the 2-year follow-up, elbow ROM was -35  of extension and 130  flexion, and bone union was achieved (Figure 4a,b), with complete and stable coverage of the defect (Figure 4c,d).
PMC6300093_02
Pre-operative clinical photograph of the 73-year old woman, with a fibrosarcoma on the left lateral aspect of her elbow.
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On physical examination, two masses (2 x 2 cm in size) were identified on the lateral aspect of the right elbow (Figure 5), with the scar of a previous surgery between the two masses.
Pre-operative magnetic resonance image, showing the coronal Gd-DTPA-enhanced T1WI.
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T1WI, contrast enhancement was observed in the tumors and the fascia and subcutaneous tissue surrounding the lesions, which was considered as residual tumor tissue (Figure 6).
Intraoperative photographs showing the reconstruction, combining the frozen autograft technique with a free anterolateral thigh (ALT) flap. The tumor was excised en bloc with a wide (2 cm) margin (a). The resected specimen was treated in liquid nitrogen (b). The frozen autograft was fixed in situ with plates and a headless compression screw. Repair of the tendon of the triceps brachii and the radial articular capsule were repaired (c). The appropriately sized ALT (27 x 18 cm) flap was harvested and the soft tissue defect reconstructed (d).
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The location of the skin incision and the level of resection were defined in the same manner as in Case 1. The tumor was excised en bloc (Figure 7a). The excised bone portion was frozen in liquid nitrogen in the same manner as in Case 1 (Figure 7b) and then reconstructed in situ using a locking plate (LCP Distal Humerus Plate: DePuy Synthes) and headless compression screw (3.5 mm HCS: DePuy Synthes). The wrist and finger extensor were repaired by using a polyethylene terephthalate suture (ETHIBOND : Ethicon Inc.) (Figure 7c). ALT flap (Figure 7d). Arterial revascularization was performed end-to-end to the deep brachial artery.
Follow-up radiograph and photograph obtained 12 months after surgery. Anterior-posterior (a) and lateral (b) radiographs showing bony union of the osteotomy site, with no evidence of osteoarthritic changes at the elbow joint. Clinical photograph showing functional results in extension (c) and flexion (d).
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Bone union was achieved (Figure 8a,b), and a complete and stable coverage of the defect was obtained (Figure 8c,d).