The posterior interosseous flap: a review of 81 clinical cases and 100 anatomical dissections--assessment of its indications in reconstruction of hand defects

Dorsal Carpal Artery Perforator Flaps: An Anatomical and Clinical Study

BACKGROUND

Hand injuries pose challenges due to complexity and aesthetic-functional concerns. Dorsum of hand injuries are difficult to treat due to thin skin cover and increased propensity to exposure of underlying structures. Perforator-based flaps can provide better outcomes with minimal donor site morbidity. This study aims to bridge the gap in anatomical knowledge and explore the potential benefits of dorsal carpal artery perforator flap.

MATERIALS AND METHODS

A prospective study was done from July 2021 to June 2023, focused on study of dorsal carpal artery perforators on 12 fresh frozen cadaveric hands. Anatomical study involved injection of red latex into arteries at the wrist, followed by dissection and measurements. During the clinical phase, we used the inferences gained from the anatomical study to identify and mark perforator of dorsal carpal arteries. We performed V-Y advancement flap based on the DCPs in 5 patients who had dorsum of hand defects due to trauma.

RESULTS

The study was carried out on 6 fresh frozen cadavers (12 hands). Anatomical findings revealed the anatomical location, caliber, and consistent number of dorsal carpal artery perforators supplying the dorsum of the hand arranged in 2 rows. Clinically, we applied this insight to create V-Y flaps in 5 patients with successful outcomes, thus, offering DCP-based flap as an alternative to distant flaps.

CONCLUSION

DCP-based flaps offer an efficient solution for reconstructing proximal hand defects over the dorsum, with minimal complications, enhancing our understanding of hand reconstruction options. The study's comprehensive anatomical insights and clinical outcomes contribute to improving hand defect management and surgical techniques.

Versatility of the Posterior Interosseous Artery Flap: Emphasis on Powering Up the Toe Transfer

BACKGROUND

Reverse-flow posterior interosseous artery (rPIA) flap is an excellent tool for restoration of defects in the hand and upper extremity, sparing the main arteries to the hand. Its reliability has been well established.

MATERIALS AND METHODS

Fifty-one cases of rPIA flap involving 49 patients were retrospectively reviewed. The inclusion criteria were age, sex, etiology, size and location of the defect, flap size, number of perforators included, pedicle length, flap inset, donor site coverage, complications, and ancillary procedures.

RESULTS

This study included 44 men and 5 women, ranging in age between 10 and 73 years. The subjects had soft tissue defects of the hand and upper extremity mainly due to traumatic injuries, including scar contractures of the first web space in 18 cases, thumb amputations in 6 cases, and congenital defects in 1 case. Among the 51 rPIA flap elevations, 3 cases involved flap failure due to the absence of proper pedicle. A fasciocutaneous pattern was observed in 45 cases and a myocutaneous pattern in 3 cases. In 5 cases of unplantable thumb amputations, the rPIA flap was performed for arterial inflow to the secondary toe-to-thumb transfer. Venous congestion of varying degrees was noted in 7 cases involving partial necrosis in 2 cases. During the mean 17 months of follow-up, patients were generally satisfied with the final outcomes.

CONCLUSION

The rPIA flap can be used not only for soft tissue coverage of the hand and upper extremity but also as a recipient arterial pedicle for a secondary toe-to thumb transfer.

Frostbite of the upper extremities: Hot issues in diagnosis and surgical treatment (review)

BACKGROUND

Frostbite is a severe thermal injury, which characterized by tissue necrosis with a high percentage of amputations, disability of patients.

METHODS

According to the databases Web of Science, Google Scholar, PubMed, E-library down to 2001-2021 the search for works related to the problem of diagnosis, treatment of frostbite of the upper extremities was made. Actual possibilities of diagnostics, the questions of classification, treatment of frostbite, including the features of plastic surgery operations used to close hand defects after excision of necrotic tissues have been analyzed.

RESULTS

Frostbite is more common in people with alcohol dependence, mental illness and in socially disadvantaged groups. The most informative instrumental methods of diagnosis: bone scintigraphy, magnetic resonance imaging, single-photon emission computed tomography. Thrombolytic therapy (tPA) and prostacyclin are most effective if used within the first day after tissue rewarming. With deep frostbite and late medical care surgical treatment is fundamental. Amputation and debridement are carried out after the formation of the demarcation line. To replace soft tissue defects that extend beyond the fingers, it is preferable to use fasciocutaneous flaps.

CONCLUSION

The defining moments in the treatment of deep frostbite are timely diagnosis and complex treatment. With late admission surgical treatment, including reconstructive skin plastic surgery, becomes important.

Vascularized ulnar periosteal pedicled flap for forearm nonunion in children

We report our experience with the use of a vascularized ulnar periosteal pedicled flap to treat forearm nonunion in children. Seven children underwent surgical treatment of radial diaphysis nonunion with this technique. The mean duration of nonunion prior to the flap was 9 months. Significant postoperative improvements were observed in pain severity (mean visual analogue scale score of 0.6), Quick Disabilities of the Arm, Shoulder, and Hand (mean score of 7.1) and grip strength (89% higher than preoperative status). Union was achieved in all patients, with a mean time to union of 3 months. One patient developed distal radioulnar synostosis as a postoperative complication. A vascularized ulnar periosteal pedicled flap is a reliable and versatile technique for treating forearm nonunion in children, associated with both good outcomes and low donor morbidity.Level of evidence: IV.

Vascularized Ulnar Periosteal Pedicled Flap for Upper Extremity Reconstruction in Adults: A Prospective Case Series of 11 Patients

PURPOSE

We hypothesized that a vascularized ulnar periosteal pedicled flap (VUPPF) is a versatile graft applicable in adult patients that yields good outcomes and is a reliable alternative to other vascularized bone grafts to reduce both the technical demands and donor site morbidity of other options.

METHODS

We reviewed 11 adult patients who underwent surgical treatment of forearm atrophic nonunion with a VUPPF. Patients' demographics, outcomes (measured by pain on the visual analog scale; Quick Disabilities of the Arm, Shoulder, and Hand score; range of motion; and grip strength), and associated complications were reported.

RESULTS

Of the 11 patients, 5 had previous surgery in an attempt to treat the nonunion with an autologous cancellous bone graft from the iliac crest or olecranon. The average time from nonunion until the VUPPF was 9 months (SD, ±3 months; range, 6-14 months). The mean visual analog scale score improved considerably after surgery (8.7 vs 0.6), and considerable improvement was also noted in the Quick Disabilities of the Arm, Shoulder, and Hand score (50 vs 6). A notable improvement was seen in grip strength after surgery. Pronation/supination also improved considerably between the preoperative assessment and the final postoperative follow-up.

CONCLUSIONS

A vascularized ulnar periosteal pedicled flap seems to be a useful and versatile option for a variety of bone union failures of the upper extremity in adults, either at initial presentation or as a salvage technique.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

An extended distally based reverse posterior interosseous artery flap reconstruction for the thumb and distal defects of the fingers

BACKGROUND

The reverse posterior interosseous artery flap is useful for covering hand defects. However, its major drawback is the short pedicle that limits the reach of the flap up to the metacarpophalangeal level. The authors performed a new modification extending the distal reach of the flap by including the recurrent branch of the posterior interosseous artery and they aimed to present the results of reconstruction with this technique.

PATIENTS AND METHODS

Seven patients with a mean age of 35.2 years (range 17-64 years) underwent extended RPIAF surgery. Six patients were admitted to the emergency department with isolated hand trauma. One patient was present in elective settings with chronic osteomyelitis and skin loss of the thumb related to previous trauma. The defects were located on the distal metacarpophalangeal level (thumb and other fingers). PIA perforators and the recurrent branch were included into the pedicle (Type A) in five cases, whereas the flap was harvested based solely on the recurrent branch (Type B) in two cases. The type B flaps had longer pedicle lengths due to discarding the forearm skin. The donor sites were covered with skin grafts in six patients.

RESULTS

The average size of the extended RPIAF was 3 × 3.5 cm to 10 × 6 cm (mean 8.28 × 4.14 cm). All of the flaps completely survived, and no complications were encountered during the postoperative period. Functional recovery of the operated hands were observed during the follow up period 13.5 months (8-24 months). Both the patient and our satisfactory levels were high and all of the patients returned to their works. Quick DASH score was used in the final functional evaluation retrospectively. Due to the pandemic, the evaluation could be made with a telephone. Two patients could not be reached in the evaluation. The mean quick DASH score of five patients was 28.64.

CONCLUSION

The extended RPIAF is a reliable choice in distally located thumb and finger defects if the recurrent branch of the posterior interosseous artery is included in the pedicle.

Reverse Posterior Interosseous Artery Flap: A Reliable, Comfortable and Versatile Flap for Coverage of Soft Tissue Defects of Hand

Background: Soft tissue defects of the hands require coverage with soft, pliable full-thickness skin. The posterior interosseous artery (PIA) flap fulfils all these requirements and also has significant advantages over other flaps; it is a single-stage procedure that does not sacrifice major vascular axis of the hand. However, the dissection can be challenging and requires meticulous skill. The objective of the study was to evaluate the reverse PIA flap for coverage of hand soft tissue defects in terms of its safety, reliability, comfort, function and aesthetic appearance.Methods: Over a period of 3 years, patients with soft tissue defects over the dorsum of the hand and first web space were observed. A standard PIA flap was raised using loupe magnification under general or brachial anesthesia. The size and location of the defect were noted along with the size and success of the flap.Results: Twelve patients, including nine males and three females, were taken up for this procedure. All the flaps survived completely except one with marginal necrosis not requiring a secondary procedure. All patients were quite satisfied with the procedure and went on to resume their work within a month or two.Conclusion: PIA flap is a safe, reliable option with great versatility for coverage of hand defects, especially over the dorsum. A well-planned flap surgery done under loupe magnification affords excellent results. The entire treatment also requires a shorter hospital stay and allows the patient to return to work quickly.

The use of chimeric musculocutaneous posterior interosseous artery flaps for treatment of osteomyelitis and soft tissue defect in hand

INTRODUCTION

There is growing evidence of the superior ability of muscular tissue to clear bacterial bone infection. Unfortunately, in the hand, there are almost no small local muscular flaps, and muscular transfers to the hand are mainly microsurgical free transfers. In this report, we present the results of the use of a chimeric posterior interosseous flap including part(s) of the forearm muscles to treat osteomyelitis and soft tissue defect of hand from a series of patients.

PATIENTS AND METHODS

Four male patients with an average age of 32 years (range 20-46 years), were affected by acute osteomyelitis in hand. Previous fracture fixation with percutaneous K-wires was the cause of bone infection in three case. In one case, the osteomyelitis was a consequence of an open fracture. The bones affected were four metacarpals and one proximal phalanx, all with a minimal cortical defect (from the K-wire) obscuring a larger medullary infection, which required extensive bone and overlying soft tissue debridement, leaving a soft tissue defect to be reconstructed of size ranging from 2 x 4 cm to 5 x 7 cm. The soft tissue defects were due to concomitant superficial infection and consequent debridement. All patients were treated with bone debridement and a chimeric posterior interosseous flap, which included part of the extensor digiti minimi and/or extensor carpi ulnaris to fill the intramedullary canal of the bones. No fixation of bone was necessary.

RESULTS

The skin paddle of the flaps ranged from 2 x 5 cm to 5 x 6 cm, replicating the defect area, plus a teardrop tail of skin circa 1.5 cm wide and as long as the pedicle of the flap. The muscular components of the flaps used to fill the intramedullary canals ranged from 1 x 1 x 1.5 cm to 1.5 x 1.5 x 4 cm. All flaps survived and osteomyelitis resolved in all cases without major complications. At the final follow-up at 16 months (range 12-26 months), assessment of the hands using TAM, Power Grip and Key Pinch Strength measurements and, where appropriate, Kapandji scores, demonstrated satisfactory hand function.

CONCLUSION

The chimeric posterior interosseous flap including part of the muscles of the forearm may be a robust solution for augmenting the flap bulk and may be used in cases of severe osteomyelitis of the hand.

Posterior interosseous artery flap: our experience and review of modifications done

This is a report on the 14 PIA flaps done in our centre for traumatic hand defects over both volar and dorsal aspects, as well as thumb reconstruction over a six-year period from 2000 to 2007. We were able to achieve reach to the DIPJ with the use of fascia extension and better flap survival with more perforators captured in the flap.

Role of Interosseous Recurrent Artery Perforators in the Posterior Interosseous Artery Flap

The Posterior Interosseous Artery flap is a fasciocutaneous flap based on the Posterior Interosseous artery which lies invested by the fascial septum between the Extensor carpi ulnaris and Extensor Digiti Minimi where it gives off septocutaneous branches that spread out on the deep fascia to form longitudinal fascial arcades as well as supply the deep extensors. The conventional flap based on these perforators is restricted to the middle-thirds of the dorsum of forearm. Preservation of the perforators from the Interosseous Recurrent Artery by proximal ligation of the Interosseous Recurrent Artery and by protecting the index septum prolongation carrying the perforators of IRA can help us to recruit larger tissue in the flap. A total of 20 clinical cases and 10 cadaveric dissections were done to objectively define this technique.

Microsurgical soft tissue and bone transfers in complex hand trauma

Treatment of complex hand trauma includes adequate debridement of nonviable tissue, early reconstruction, and careful selection of various available surgical procedures tailored to patients' needs and requests. Debridement of all necrotic tissue is crucial before any attempt at reconstruction. Surgeons should also consider cosmetic outcomes of the reconstructed hand and donor-site morbidity. For best results reconstruction should be performed early, with proper early postoperative therapy. This article reviews the principles and surgical options in the management of complex hand injuries involving the dorsal and the palmar aspects of the hand, and the different types of tissue in the hand.

Effects of verapamil, nifedipine, and daflon on the viability of reverse-flow island flaps in rats

Reverse-flow flaps are preferable in reconstructive surgery due to their several advantages. However, they may have venous insufficiency and poor blood flow. In this study, effects of various pharmacological agents on the viability of reverse-flow flaps were investigated. Forty Sprague-Dawley rats were used. Superficial epigastric artery- and superficial epigastric vein-based reverse-flow island flaps were preferred. The rats were divided into 4 groups. Group 1 was considered as the control group. Group 2 was given verapamil 0.3 mg/kg per day, group 3 nifedipine 0.5 mg/kg per day, and group 4 Daflon 80 mg/kg per day for 7 days. On day 7, viable flap areas were measured, angiography was performed, serum nitric oxide levels were evaluated, and histopathological examination was done.The mean flap viability rate was 67.59% (±13.12259) in group 1, 77.38% (±4.12506) in group 2, 74.57% (±3.44780) in group 3, and 85.39% (±4.36125) in group 4 (P = 0.001). The mean nitric oxide level was 31.66 μmol/dL (±2.42212) in group 1, 51.00 μmol/dL (±2.96648) in group 2, 34.00 μmol/dL (±2.96648) in group 3, and 47.66 μmol/dL (±2.80476) in group 4 (P = 0.001). On angiography, there were vessel dilations and convolutions in group 2; capillaries became noticeable, and anastomotic vessels extended toward the more distal part of the flaps in group 4. Histological examinations showed severe inflammation in group 3 and minimal inflammation and venous vasodilatation in group 2.Verapamil and Daflon in therapeutic doses significantly increased the viability of reverse-flow island flaps. However, nifedipine did not make a significant contribution to the flap viability. The results of this study will contribute to the literature about the hemodynamics of reverse-flow island flaps and guide further studies on the issue.

Reconstruction of severe contracture of the first web space using the reverse posterior interosseous artery flap

BACKGROUND

To evaluate the outcome and highlight the operative tips of using the reverse posterior interosseous artery (PIA) flap in the treatment of severe contractures of the first web space.

METHODS

From 1985 to 2008, the reverse PIA flaps, which included fasciocutaneous flaps in 25 patients and composite flaps in 2 patients were used to cover skin defects over the first web space after release of severe contractures of the first web space. The severe contracture of the first web space was defined as the distance of less than 2 cm between the interphalangeal joint of the thumb and the metacarpophalangeal joint of the index. The flap dimensions varied between 6 cm and 22 cm (average, 13 cm) in length and 3 cm to 9 cm (average, 6 cm) in width. The largest flap was 22 cm × 6 cm and the smallest 6 cm × 3 cm. The length of the pedicle ranged from 2 cm to 10 cm (average, 8 cm). Skin defects of the donor site were covered by split-thickness skin grafts in 26 patients and direct closure in 1 patient.

RESULTS

Twenty-six of 27 PIA flaps survived completely except venous congestion occurred in 1 patient, which led to necrosis of the distal 1/4 flap. Skin grafts over the donor sites survived completely without complications. The follow-up period ranged from 1 month to 2 years. Lipectomy or revision was performed in two patients because of scar contractures or bulkiness. The postoperative distance of the reconstructed web space was 6 cm on average.

CONCLUSION

The reverse PIA flap is suited for defect cover in the treatment of severe contractures of the first web space. A usual pitfall using the reverse PIA flap is that the skin paddle is inadvertently outlined over the proximal 1 of 3 forearm to increase its distal reach, which usually leads to postoperative venous congestion. However, if the distal flap pole is placed at or distal to the midpoint from the lateral epicondyle to the radial side of the ulnar head, choosing the proximal 1 of 2 forearm as the donor site of the skin paddle to increase its distal reach is reliable.

DEFECTS ON THE DORSUM OF THE HAND — THE POSTERIOR INTEROSSEOUS FLAP AND ITS ALTERNATIVES

There are conditions that preclude the use of the posterior interosseous flap for reconstruction of the dorsum of the hand. Based on a series of 34 cases, these conditions are outlined and alternative solutions discussed.

The posterior interosseous flap was employed for closure in 30 cases. In four cases different methods were used due to severe trauma to the wrist and distal forearm with potential impairment of the pedicle, a complex defect requiring a composite flap and an anatomical variation. Thin free flaps were employed alternatively. All flaps survived but there was marginal flap necrosis in two posterior interosseous flaps.

The posterior interosseous flap proved its usefulness and reliability in reconstruction of the hand in this series. In four cases, free lateral arm and temporoparietal fascial flaps were employed. Flaps based on the main vessels of the forearm were not used due to their significant donor site morbidity.

Three kinds of forearm flaps for hand skin defects: experience of 65 cases

INTRODUCTION

Reverse radial forearm flap has been proven reliable and effective for hand reconstruction. Here we report our experience with the use of reverse forearm flap that does not contain the radial or ulnar artery for reconstruction of hand defects in 65 cases with soft tissue defects of the hand.

METHOD

Sixty-five patients who sought surgical treatment for soft tissue defects of the hand at our hospital between January 2003 and December 2008 were included in the study. 39 cases had soft tissue defect on the dorsal aspect of the hand and 26 cases on the palmar aspect of the hand. 65 flaps were performed with the posterior interosseous artery flap in 26 cases, island flap supplied by the distal cutaneous branch of the ulnar artery in 23 cases, and the flap based on distally perforator of the radial artery in sixteen cases with the size of the flaps ranging from 5 to 12 cm in length and from 4 to 8 cm in width.

RESULTS

The distal cutaneous branch of the ulnar artery flap showed partial necrosis (25-35% of their area) in two cases. Both the donor and the recipient sites healed successfully in other cases. At 8.4 months of follow up, all patients had insensitivity in recipient sites. No patient complained of cold intolerance, pain, numbness and so on in the forearm and hand. According to the TAM criteria (the total active motion of the finger joint) and DASH (Disability of the Arm, Shoulder, and Hand) score showed that postoperative functions were excellent and symptoms were minor, with no significant differences among the groups (P > 0.05).

CONCLUSION

Our results indicated that the reverse forearm flap preserving the radial and ulnar artery is a reliable and effective method to cover skin defects of the hand.

Posterior interosseous artery flap for resurfacing posttraumatic soft tissue defects of the hand

The need for soft tissue coverage of large defects in the hand and the wrist following trauma is a common problem for hand surgeons. Flap coverage of these defects can be either in the form of distant or regional flaps. The posterior interosseous artery flap recently has emerged as a front runner in these situations by its virtue to preserve both the major arteries to the hand. Thirty-two posterior interosseous artery flaps were used in 32 patients with complex soft tissue defects of the hand. All these defects were posttraumatic. There were associated skeletal and soft tissue injuries in 20 patients. The donor site was closed either primarily or by a split skin graft depending on the size of the defect. All flaps healed well, and there were no incidences of flap necrosis. The donor site required a split skin graft in 24 patients. The flap was bulky in one patient and transient extensor carpi ulnaris weakness was seen in three patients. The posterior interosseous artery flap is a versatile flap for coverage of soft tissue defects of the hand. Good aesthetic results can be achieved with minimal donor site morbidity. Harvesting the flap requires a precise surgical technique and as many perforators as possible should be preserved to ensure flap viability.

Close range gun shot injuries of the hand with the "mole gun"

INTRODUCTION

A mole gun is a handmade weapon used as a trap to kill moles by farmers. Their action is based on a simple hammer mechanism: when the moles put their head through the metal ring to get hold of the food, they trigger the mechanism. The hammer strikes the primer, which ignites the gunpowder, propelling the pellets from the barrel. The purpose of this study was to report our experiences in a group of patients who accidentally suffered injuries by mole guns to the hand.

METHOD

Since 2000, 20 patients had attended the clinic with mole gun shot injuries to the hand.

RESULTS

The mean age of patients was 38 years. Thirteen cases involved skin defects over the dorsum of the hand associated with extensor tendon and bone injuries. The skin defect was covered with posterior interosseous artery (PIA) flap in 12 cases. In one case, the PIA pedicle was found to be injured so radial forearm flap was used. The main intervention time for these cases was 6.2 days. All flaps except two PIA flap survived uneventfully. One flap was completely lost while other survived with distal necrosis. In remaining seven cases the thumb was the main injured part; it had complete disruption of its arterial supply and was managed with amputation with or without matarcarpal removal. These cases were managed immediately.

CONCLUSION

The risk of injury to the PIA by pellets is low in such close range shots to the hand and PIA flap could be used to cover the defects. In such cases, initial debridement should be minimal and the soft tissue, tendon, and bone injury can be managed in the same stage during the first week of injury.

Posterior interosseous artery flap, fasciosubcutaneous pedicle technique: a study of 25 cases

This study was undertaken in an attempt to improve the versatility of the posterior interosseous artery flap (PIA flap) and to decrease flap complication rate. The PIA flap was used for resurfacing 25 cases of the hand and distal forearm over a 2-year period. Observations were made on the anatomy of the PIA flap and its distal reach. Doppler analysis was made a mandatory part of the preoperative planning. Flaps were also raised from the zone of injury if Doppler confirmed the presence of good perforators. No attempt was made to identify the anastomosis between the anterior interosseous artery (AIA) and the PIA prior to flap raising since its presence was ascertained preoperatively with a Doppler and flap raising could begin straightway, saving precious tourniquet time. The surgical technique was further modified to include a large amount of fascia and subcutaneous tissue with the flap. This could perhaps be the reason for survival of larger flaps, absence of venous congestion and the low complication rate seen in our series. These flaps were used to resurface defects involving the dorsum of the hand, palm, distal forearm, wrist and fingers (both dorsal and volar surfaces). The distal reach of the flap was improved by exteriorising the pedicle and bowstringing it across the wrist which was kept in extension. The flap could thus easily reach the distal interphalangeal joint. This exteriorised pedicle was covered with a split thickness skin graft and was divided 3 weeks later under local anaesthesia making it a two-stage procedure. Adipofascial and osteocutaneous PIA flaps were also used depending on the requirement. Out of 25 flaps, 23 were of the adipofascial variety and one each of the fascial and osteocutaneous type. The majority of the patients were between 21 and 30 years old. Trauma was the leading cause of tissue deficit in our series (19/25). Within the trauma group occupational mishap (entrapment of hand in roller machine, presser machine, etc.) was the leading cause, road traffic accident being the next most common. The most common site of defect was the dorsum of the hand (14/25). The largest flap measured 12x8cm and the smallest flap measured 3x2cm. Only three minor complications were noted, two cases of partial flap loss (one of them needing a secondary procedure of debridement and grafting) and one partial graft loss in the case of fascial flap which needed regrafting. Importantly no evidence of venous congestion was noted in any of the flaps.

Reverse-flow posterior interosseous flap-a review of 68 cases

We are reporting our 10-year experience with 68 patients. Sixty-six flaps were of fasciocutaneous type and two were of osteofasciocutaneous type. These flaps were used for volar and dorsal traumatic hand defects, first web space reconstruction, thumb reconstruction, and repair of congenital anomalies. Sixty flaps (88.24%) had complete uneventful take-up. Four flaps developed partial necrosis, whereas four flaps suffered complete necrosis. The single most important factor for flap survival in our experience has been inclusion of at least two perforators to supply the skin pedal. The proximal flap dissection has a learning curve and all of our poor results were in the early part of our experience. We believe that posterior interosseous fasciocutaneous flap (PIF) is a versatile and reliable option for the challenging problems of hand soft-tissue coverage.

Distally Based Posterior Interosseous Flap

A series of 15 consecutive patients with various hand defects requiring flap coverage was reviewed in this study. The defects were all covered with the distally based posterior interosseous flap. Its main indications were in complex hand trauma, severe burn injury, or skin cancer ablation, either acute or postprimary. In 12 of the patients, flaps survived completely. In 3 patients, there was partial necrosis of the distal part of the flap, which did not require additional surgical procedure. Radial nerve palsy was noted in one of the cases, with a complete recovery after 3 months. Donor site was closed directly in up to 4-cm-wide flaps, while larger flaps required skin grafting. No major anatomic variation was observed. Distally based posterior interosseous flap is a reliable choice for various types and areas of hand defects, with very low donor-site morbidity, and should be more commonly considered in clinical practice.

Coverage of Skin Defects in Spaghetti Wrist Trauma: Application of the Reverse Posterior Interosseous Flap and its Anatomy

BACKGROUND

To introduce the application of reverse posterior interosseous flap in spaghetti wrist trauma.

METHODS

From 2003 to July 2005, 12 cases of skin defects over the volar wrist in spaghetti wrist trauma were covered by the reverse posterior interosseous flap. The size of the skin defects ranged from 5 cm x 4 cm to approximately 10 cm x 6 cm when the wrist was in the neutral position. The skin defects over donors were covered by split skin graft.

RESULTS

All flaps and skin grafts survived uneventfully. The follow-up period was at least 3 months. The texture, color, and thickness of the skin paddle matched the surrounding skin. The sensation of the flap recovered to S0 to S1 on a five-point scale. The functional recovery of the hand and fingers was dependent on the original injuries to the tendons and nerves.

CONCLUSION

The reverse posterior interosseous flap is a suitable alternative to cover skin defects in spaghetti wrist. The pedicle should include 2 cm of fascia and septum between the extensor carpi ulnaris and extensor digiti quinti proprius, and the subcutaneous tunnel should be wide enough to avoid venous congestion. Temporarily blocking the proximal end of the posterior interosseous artery to observe the blood supply of the flap is helpful to avoid its failure before completing the flap.

The reverse posterior interosseous flap and its composite flap: Experience with 201 flaps

OBJECTIVE

To introduce our experiences of using the reverse posterior interosseous flap and its composite flap.

METHODS

In the series of 201 cases, the fasciocutaneous flap was used to cover skin defects over the distal 1/3rd forearm, wrist and hand in 174 cases. The composite flap with the vascularised ulna bone graft was used to reconstruct the thumbs in 11 cases, and with the vascularised tendon graft was used to repair tendon defects with skin defects in 16 cases. The size of the ulna graft was 3-6cm in length and 1-2cm in width. The 4-7cm tendon graft was obtained from the extensor digiti quinti or extensor carpi ulnaris. The size of the flaps ranged from 5cmx4cm to 16cmx10cm.

RESULTS

One flap failed completely. Of the other 200 flaps which survived 16 cases had venous congestion and had partial necrosis at the distal end. The size of the necrotic area ranged from 1 to 4cm in length. Ninety-three patients were followed up for at least 6 months, and included 10 patients with composite flaps. Generally, the flap matched the surrounding skin. But 10 cases had a lipectomy. The sensibility did not recover or achieved S1 within 6 months. For the extensor tendon defect, the function of finger extension was nearly normal and tenolysis was not required. In contrast, tenolysis was required after the flexor tendon reconstruction. However, these patients refused surgery. The bone grafts were healed in 3 months. The reconstructed thumb looked abnormal and lacked normal sensibility, although the patients used them. The linear scar line was conspicuous over the dorsum of the forearm.

CONCLUSION

The reverse posterior interosseous flap is a reliable method to cover skin defects over the distal 1/3rd of the forearm, the wrist and hand. The composite flap with a vascularised tendon graft is an optimal reconstructive option for any extensor tendon loss (III zone) associated with a skin defect. Using the composite flap with a vascularised bone graft or combined with the digital neurovascular flap is another way to reconstruct the thumb.

The posterior interosseous flap – a prime technique in hand reconstruction. The experience of 100 anatomical dissections and 102 clinical cases

Based on our experience of 102 clinical cases and 100 anatomical dissections, we have assessed the indications for the posterior interosseous flap in reconstruction of the hand. Large fasciocutaneous island flaps can be harvested, even when the radial or ulnar pedicles are damaged. One real advantage is that the posterior interosseous artery is a vessel of secondary importance for hand vascularisation. Fasciocutaneous and osteofasciocutaneous island distally based flaps can be tailored. The major indications are reconstruction of the first web space up to the interphalangeal joint of the thumb, dorsal hand defects up to the metacarpal joints and large defects on the palm-ulnar border of the hand. It is, therefore, a primary weapon amongst hand reconstruction techniques.

Coverage of painful peripheral nerve neuromas with vascularized soft tissue: method and results

OBJECTIVE

Our goals are to describe a method of treating painful peripheral nerve neuromas by means of vascularized tissue coverage, report the results in seven patients, and discuss the indications for this treatment modality. An analysis of pain, functionality of the affected body part, professional activities of the patients, and medications before and after surgery is presented.

METHODS

Seven male patients (mean age, 45.1 yr) with posttraumatic nerve injuries, who had developed painful stump neuromas or neuromas-in-continuity, and who had unsuccessfully undergone several treatment procedures, were selected for the surgery described here. The operation included resection of the stump neuroma (four patients) or neurolysis of the neuroma-in-continuity (three patients) and coverage of the nerve with a vascularized fascial, fasciocutaneous, or perforator flap (three pedicled regional flaps and four free flaps). A modified quadruple visual analog scale was used to quantify pain before and after surgical treatment. The mean follow-up was 16.6 months.

RESULTS

The mean values of the quadruple visual analog scale (pain now/typically/at its best/at its worst) before surgery were 6.5/6.5/4.7/7.9. These values changed to 0.3/0.4/0/0.9 at a mean follow-up of 16.6 months after surgery. Five patients returned to their original profession, one receives a pension, and one began a less demanding job after undergoing surgery. Six of the seven patients received opioids before surgery (one had a spinal cord stimulator). After surgery, all patients stopped taking regular pain killers and the spinal cord stimulator was deactivated in one; two patients still take nonsteroidal anti-inflammatory drugs occasionally, but not on a regular basis.

CONCLUSION

Vascularized soft tissue coverage of painful peripheral nerve neuromas seems to be an effective and attractive, but also complex, method of treatment. This option may be considered and reserved for patients who have already undergone several pain treatment modalities without success.

The reverse posterior interosseous flap: A solution for flap necrosis based on a review of 87 cases

PURPOSE

The relationship of the flap necrosis to the placement of the flaps on the forearm was outlined and a solution in avoiding flap necrosis is discussed.

METHODS

The relationship of the flap necrosis to the placement of the flaps on the forearm was investigated in 87 consecutive posterior interosseous island flaps used for the reconstruction of the hand and wrist. Fifty-eight flaps were taken from the middle and proximal thirds of the forearm, the distal edges being within the middle third of the forearm in 24 and the distal edges being within the distal third of the forearm in 34. Twenty-nine flaps were harvested within the boundaries of the distal two-thirds of the forearm, the distal edge being proximal to the distal third of the forearm in 23 and the distal edge being distal to the third of the forearm in six. The Length of the flaps varied from 6.5 cm to 12 cm. The pedicle length measure 4-13 cm. The number of perforators for each flap was recorded also.

RESULTS

Flaps survived complete in 78 (89.6%) patients. Six patients had superficial necrosis of the distal part of the flap (6.8%). Three flaps were totally lost and alternative coverage was used (3.8%). The flaps that ended up with partial necrosis appeared to be in related to the site it was taken from. One flap with total necrosis and one with partial ncrosis were taken within the boundaries of the proximal third of the forearm while the distal edge was proximal to the level of distal third. One flap with total necrosis and one with partial necrosis were taken from the proximal third of the forearm while their distal edge were at the limits of the distal third of the forearm. The remaining flap ending up with total necrosis was taken from the distal third of the forearm with a short pedicle.

CONCLUSIONS

For the reverse posterior interosseous flap to be reliable the flap should include the septocutaneous perforators in the distal third of the forearm. To cover distant defects reliably by a flap with a long pedicle, the flap should extend up to the distal third of the forearm to include a piece of skin with numerous perforators.

Posterior Interosseous Artery Flap for Hand Defects

BACKGROUND

Reconstruction of soft tissue defects in the hand need an early, single stage and well vascularised cover to achieve the best functional result. Usually a full thickness graft is required since vital structures like tendons, bones and joints are exposed and often there is need for secondary reconstruction.

METHODS

We managed 12 cases of complex defects over the hand in the last 2 years with the posterior interosseous artery flap.

RESULTS

In 5 cases the defect was due to blast injury and in 4 because of crush injury. Males predominated in the ratio of 5:1. The defect was most often in the 1(st) web space and the largest flap was 11×8 cm. In all but one case the donor site was covered by split skin graft, which settled well. 2 patients had superficial flap necrosis needing debridement and skin graft.

CONCLUSION

Flap based on reverse flow in the posterior interosseous artery is a versatile and reliable source for full thickness cover of complex soft tissue defects in the hand.

The posterior interosseous artery in the distal part of the forearm. Is the term ‘recurrent branch of the anterior interosseous artery’ justified?

In 1993 Angrigiani raised the question as to whether the distal part of the posterior interosseous artery (AIP) is a recurrent branch of the anterior interosseous artery (AIA) and forms a "choke"--anastomosis with the AIP in the middle of the forearm. A dissection study was conducted on 66 upper extremities to evaluate the diameters of the dorsal branch of the anterior interosseous artery, the anastomotic branch, the diameter of the posterior interosseous artery at the point of origin of the septocutaneous perforators in the middle of the forearm and the diameter of the posterior interosseous artery at the point of emergence in the dorsal compartment. We further tried to identify different forms and types of the "distal" anastomosis and the connections to the dorsal carpal arch and the ulnar artery. A distal anastomosis between the AIA and AIP was found in 65 of the 66 upper extremities. Three different types of anastomosis could be identified. The smallest diameter was found at the middle of the forearm (mean diameter AIA 1.28 mm; anastomotic branch 0.6 mm; AIP at the middle of the forearm 0.39 mm; AIP prox. 1.35 mm). A branch through the fifth extensor compartment was present in all of our specimens (mean diameter 0.54 mm). A branch through the forth extensor compartment could be found in 16 specimens. Based on our findings and the embryological development, we conclude that the AIP is only present in the proximal half of the forearm. In the distal part, the dorsal branch of the anterior interosseous artery forms a vascular arcade, which gives off branches to the dorsal carpal arch, the ulnar head and the ulnar artery. This arcade anastomoses with the posterior interosseous artery in the middle of the forearm by means of a choke anastomosis. We also conclude that the term "recurrent branch of the anterior interosseous artery" for the distal part of posterior interosseous artery is correct.

Hand and forearm reconstruction after skin cancer ablation

Skin cancer is common on the dorsum of the hand and forearm. The reconstructive challenges in this area are significant, and the options are myriad. Thus, the surgeon who takes on this challenge must know the various options. These options include the entire reconstructive ladder from direct closure all the way through to composite-free tissue transfer. Nail bed reconstruction should be mastered. In addition, the surgeon should be comfortable with all the reliable flaps, including the kite flap, the cross-finger flap, the reverse cross-finger flap, the rotation-advancement flaps, transposition flaps, and the radial forearm flap.

A severe complication of muscle transfer: clostridial myonecrosis

We present a case of gas gangrene as a severe complication of muscle transfer for opponensplasty. After debridement, the extensive palmar wound was covered by a free gracilis muscle transfer. This complication of muscle transfer has to our knowledge never been reported previously.

The retrograde neurocutaneous island flap of the dorsal branch of the ulnar nerve: anatomical basis and clinical application

It is well known that a cutaneous artery is constantly located near a cutaneous peripheral nerve, forming a vascular plexus around it. This vascular axis can be either a true artery or an interlacing network, ensuring the vascularization of the nerve and giving off several neurocutaneous perforators to the skin. The anatomy of the accompanying arteries of the dorsal branch of the ulnar nerve (DBUN) and their relationships with the dorsal branch of the ulnar artery (DBUA) were investigated in 22 fresh upper limbs injected with colored neoprene latex. A constant perineural vascularization of the terminal branch of the DBUN was observed in the fourth web space, connected distally with the corresponding dorsal metacarpal or palmar digital arteries. Our findings therefore provide anatomical bases for a new neurocutaneous island flap. Moreover, they allow us to describe a precise surgical technique in order to raise this flap over the larger branch of the DBUN, in the fourth intermetacarpal space. The flap is harvested on the medial aspect of the dorsum of the hand, and its point of rotation is located in the fourth web space, 1 cm proximal to the metacarpophalangeal joint. It is supplied by a reversed flow originating from distal anastomoses of the perineural vessel with the dorsal metacarpal and digital palmar arteries in the fourth web space. This flap does not involve in its pedicle the distal course of the DBUA. It represents a pure neurocutaneous flap.

Modified posterior interosseous flap in hand reconstruction

Hand reconstruction methods using posterior interosseous flaps have the merits of being thin and pliable, they do not require sacrifice of any major hand arteries, and closure of the donor site is readily performed. Drawbacks include unreliability of blood flow due to the presence of posterior interosseous artery anatomic variants or damage to the venous circulation. We present some modifications to methods for the preparation of posterior interosseous flaps with which we have achieved some favorable results.