Anatomical basis of a proximal fasciocutaneous extension of the distal-based posterior interosseous flap that allows exclusion of the proximal posterior interosseous artery.

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Journal of Plastic, Reconstructive & Aesthetic Surgery (2014) xx, 1e9

Anatomical basis of a proximal fasciocutaneous extension of the distal-based posterior interosseous flap that allows exclusion of the proximal posterior interosseous artery Chao Sun a, Yu-long Wang b, Zi-hai Ding b,e, Peng Liu b, Xiang-zheng Qin c, Hong-liang Lee d, An-min Jin a,*,e a Department of Orthopaedics, Zhu Jiang Hospital, Southern Medical University, Guangzhou, Guangdong Province 510282, PR China b Anatomical Institute of Minimally Invasive Surgery, Southern Medical University, Guangzhou, Guangdong Province 510515, PR China c Department of Anatomy, Yanbian University Medical College, Yanbian 133002, PR China d Department of Orthopedics, General Hospital of Chinese PLA, Beijing 100853, PR China

Received 22 September 2013; accepted 15 September 2014

KEYWORDS Posterior interosseous artery; Chain-link perforator flaps; Anatomy; Forearm; Hand

Summary Objective: The objective of this study was to provide anatomical information for the repair of small tissue defects in the hand with posterior interosseous artery chain-link perforator flaps, a proximal fasciocutaneous extension of the distal-based posterior interosseous flap, which allows the exclusion of the proximal posterior interosseous artery. Methods: Fourteen posterior interosseous artery chain-link perforator flaps taken from human cadavers were studied by the following three methods: latex perfusion for microanatomy analysis, denture material and vinyl chloride mixed packing for cast analysis, and latex perfusion for the production of clearance specimens. Statistical analysis was performed on cutaneous perforators coming from the intermuscular septum of the extensor carpi ulnaris and the extensor digitorum communis. A cluster analysis was conducted to determine the overall distribution of perforators. Results: There are two main clusters of perforators at a relative distance of 21% and 48% along the ulnar head-to-lateral epicondyle interval. On average, the posterior interosseous artery extends six cutaneous perforators through the intermuscular septum of the extensor carpi ulnaris and the extensor digitorum communis. Of these six arteries, two are clinically significant

* Corresponding author. E-mail addresses: [email protected] (C. Sun), [email protected] (Z.-h. Ding), [email protected] (A.-m. Jin). e An-Min Jin and Zi-hai Ding contributed equally to the manuscript. http://dx.doi.org/10.1016/j.bjps.2014.09.042 1748-6815/ª 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: Sun C, et al., Anatomical basis of a proximal fasciocutaneous extension of the distal-based posterior interosseous flap that allows exclusion of the proximal posterior interosseous artery, Journal of Plastic, Reconstructive & Aesthetic Surgery (2014), http://dx.doi.org/10.1016/j.bjps.2014.09.042

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C. Sun et al. perforators (0.5 mm or more in diameter) and are located 6 2 cm proximal to the head of the ulna and 10 1 cm distal to the lateral epicondyle of the humerus. Their mean diameters are 0.5 0.1 and 0.6 0.1 mm, with pedicle lengths of 16.8 5.1 and 21.2 12.3 mm, respectively. At the two main clusters of perforator-intensive sites, the vessel chains formed by adjacent perforators are parallel to the intermuscular septum of the extensor carpi ulnaris and the extensor digitorum communis. Conclusions: This study demonstrates that the posterior interosseous artery has two main clusters of perforators in the middle and distal one-fifth of the forearm, which can be used for repairing hand defects with posterior interosseous artery chain-link perforator flaps. ª 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

Since Lu et al.,1 Penteado et al.,2 and Zan-colli and Angrigiani3 independently described the original technique, the reverse posterior interosseous artery (PIA) flap has been largely applied to covering skin defects over the distal forearm, wrist, and hand due to its advantages, including versatility, good texture, large area, simple operation, ease of survival, and no need for sacrificing the main vessels.4e19 The disadvantages of this technique include unreliable vascular anatomy as a result of damage to the small vessels or anatomical variations3,5,15,20 and tedious pedicle dissection.13 Additionally, because the PIA is proximally accompanied by the posterior interosseous nerve (PIN) in the form of neurovascular bundles, the hazard of cutting the PIN branches increases during pedicle dissection.8,19,20 Sporadic reports have demonstrated that PIA21e23 or PIA perforator24,25 free flaps are clinically useful. However, technical difficulties have limited their widespread use. In recent years, the authors found complete vessel chains between adjacent cutaneous perforators of stem blood vessels in an anatomic study.26 Hypothetically, flaps with cutaneous perforators of the PIA pedicle, linking vessels to the feeding artery, could be an alternative approach to the traditional reverse PIA flap for the repair of small-scale tissue defects and could avoid the disadvantages mentioned above. Although several anatomical studies of PIA flaps have been published previously,4,20,27,28 the locations of the perforator clusters along the ulnar head-tolateral epicondyle interval axis have not been defined. Therefore, the present study systematically studied the cutaneous perforators of the PIA using modern anatomical microscopy techniques, such as vascular perfusion, molding, and specimen clearance to provide anatomical information for clinical practice. To facilitate the identification of the cutaneous vascular chain of the PIA in clinical practice, the authors targeted the cutaneous perforators extending from the intermuscular septum of the extensor carpi ulnaris and the extensor digitorum communis, which contains an abundance of cutaneous perforators.

Materials and methods Fourteen fresh upper-extremity specimens from men without vascular disease and a history of surgery or trauma were provided by the Invasive Surgical Anatomy Department of the Southern Medical University. The instruments used in the analysis included a surgical microscope (M520 F40; Leica

Microsystems, Wetzlar, Germany), micro-instruments, general surgical instruments, a vernier calliper (digital callipers, Har-bin Measuring & Cutting Tool Group Co., Ltd., Harbin, People’s Republic of China), and a digital camera (Canon 50D; Canon, Inc., Tokyo, Japan). The 14 upper extremities were amputated at the elbow and studied using the following methods: latex perfusion microdissection (10 specimens), specimen molding (two specimens), and latex perfusion for making clearance specimens (two specimens).

Microscopic dissection after latex perfusion The brachial artery was cannulated and perfused with red latex under manual pressure until incisions within the pulp of the fingers stained red. The arm was stored in a refrigerator at 0 C. Dissection was postponed until 24 h after preparation, and an incision was made on the ulnar and dorsal side of the forearm. The skin over the deep fascia was reflected to the radialis margin of the extensor carpi ulnaris to reveal the intermuscular septum between the extensor carpi ulnaris and the extensor digiti minimi. The fat tissue was removed carefully from the superficial fascia under a surgical microscope (16) to observe the linking vessels. The intermuscular septum was cut to expose the PIA. Subsequently, the course of the PIA was observed, and the parameters of the septocutaneous perforators were recorded, including their location, distance from the center of the ulnar head for distal perforators, distance from the lateral epicondyle for proximal perforators, external diameter, number, cluster patterns, and pedicle length. These parameters were measured at the level of the septocutaneous perforators through the deep fascia, with the exception of pedicle length, which was measured from the point of the cutaneous branches through the deep fascia to the first branch point that traveled to the superficial fascia. The diameter of the septocutaneous perforator (artery only) was measured using calipers under the surgical microscope without stretching the cutaneous perforators. The location and diameter of the anastomosis of the dorsal branch of the anterior interosseous artery (AIA) and the PIA were also measured (Figures 1e4).

Cast specimens The brachial artery was filled with 10 ml ethyl acetate to expand the small blood vessels, and two cast specimens were made by filling the brachial artery with denture


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Anatomical basis of a proximal fasciocutaneous extension of the distal-based posterior interosseous flap

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Figure 1 (Figures 1e4 show the same specimen to explain the process of microscopic dissection). Lift the flap over the deep fascia from the ulnar and dorsal side of the forearm to the radialis margin of the extensor carpi ulnaris muscle to reveal the intermuscular septum between the extensor carpi ulnaris muscle and extensor digiti minimi. : indicates the point where the PIA courses superficially between the intermuscular septum located 8 cm proximal to the head of the ulna, in approximately the distal one-third of the forearm. + indicates the septocutaneous perforators of the PIA. 1 indicates the center of the ulnar head. ECU Z extensor carpi ulnaris.

Figure 2 (Figures 1e4 show the same specimen to explain the process of microscopic dissection). Open the intermuscular septum to expose the distal part of the PIA. The distal large blue arrow indicates the distal, dominant perforator located approximately 6 cm proximal to the center of the ulnar head, with a diameter of 0.5 mm, which forms vessel chains with adjacent perforators. This perforator can be used for hand coverage. The proximal large blue arrow indicates the proximal cluster of the most proximal perforator arising from the PIA approximately 10 cm distal to the lateral epicondyle with a diameter of 0.6 mm. 1. extensor carpi ulnaris, 2. extensor digiti minimi, 3. extensor indicis. :, +, and 1 have the same meaning as in Figure 1. indicates anastomoses with the dorsal branches of the AIA located approximately 2 cm proximal to the head of the ulna with a diameter of 0.7 mm.

Figure 3 (Figures 1e4 show the same specimen to explain the process of microscopic dissection). Carefully remove the fat tissue from the superficial fascia to observe the linking vessels between the adjacent perforators, and expose the proximal indicate the same things as Figures 1 and 2. * indicates medial septocutaneous covered part of the PIA. :, +, 1, , and perforators of PIA.


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C. Sun et al.

Figure 4 (Figures 1e4 show the same specimen to explain the process of microscopic dissection). Posterior interosseous nerve have the same meaning as Figures 1e3. 1. extensor carpi ulnaris, 2. (PIN) and proximal covered part of the PIA. :, +, and extensor digitorum, 3. the PIA, 4. interosseous recurrent, 5. posterior interosseous nerve (PIN), 6. muscular branches of the PIN.

material and a perchloroethylene mixture. One specimen preserved the bone, and the other did not. The connection patterns of the cutaneous perforators of the PIA were observed carefully (Figures 5 and 6).

Clearance specimens For the clearance specimens, red latex was perfused into the brachial artery. An upper palmar incision was made, and the tissue covering the deep fascia was removed. Then, the skin was fixed with alcohol solutions for approximately 24 h. When the vessels were visible in the skin, the skin was placed in a methyl salicylate solution. Finally, the skin was dried in the sun. The connection patterns of the cutaneous perforators were observed carefully. Finally, photographs were taken with a digital camera (Figure 7).

Statistical analysis Statistical analysis was performed on the 10 microscopic dissection specimens. The distance percentages were calculated for every septocutaneous perforator extending through the intermuscular septum of the extensor carpi ulnaris and extensor digitorum communis from the PIA. A

Figure 5

cluster analysis was performed using a two-step clustering procedure based on the SchwarzeBayesian criterion to determine the overall distribution of the septocutaneous perforators. Comparisons between the distal and proximal clusters concerning the number, diameter, and pedicle length of the septocutaneous perforators were carried out with Student’s t-tests, and P < 0.05 was considered statistically significant in the calculations performed using the SPSS 13.0 statistical package (SPSS, Inc., Chicago, IL, USA) with the formula x s.

Results In the 10 microscopically dissected specimens, there were nine cases in which the PIA originated from the common interosseous artery, and one case originated from the ulnar artery. After penetrating the interosseous membrane, the artery emerged in the deep extensor compartment of the forearm, underneath the supinator at an average distance of 9 1 cm from the lateral epicondyle. The interosseous recurrent artery originated at this level and went proximally. The PIA first coursed under the extensor digitorum and extensor digiti minimi. It then traveled inward and downward and was accompanied by two venae comitantes

Cast specimen of forearm artery without bone.


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Figure 6

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Cast specimen of forearm artery with bone.

Figure 7 Pellucid specimen of forearm artery, the linking vessels formed by adjacent perforators. 1. The perforators of the PIA; 2. The perforators of the radial artery; 3. The perforators of the ulnar artery.

and the PIN in the form of a neurovascular bundle. It coursed superficially, approximately 8 1 cm proximal to the center of the ulnar head. At this level, the artery could be divided into the proximal covered part and the distal exposed part (Figures 1e3). Finally, it ran underneath the

Figure 8

intermuscular septum of the extensor digiti minimi and extensor carpi ulnaris. Along its course, the PIA gave off osseous, muscular, tendineus, and septocutaneous branches. Approximately four to eight cutaneous perforators were dissected, and they extended from the PIA and

Illustration of proximal and distal clusters of PIA septocutaneous perforators.


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C. Sun et al. Table 1 Cluster analysis demonstrating the relative distance proximal to the center of the ulnar heada(n Z 10). Cluster

Relative distance (%)

Distal Proximal

21 7 48 9

Mean SD expressed as a percentage of the distance between the center of the ulnar head and lateral epicondyle, for clusters of septocutaneous perforators. a

penetrated through the intermuscular septum of the extensor carpi ulnaris and extensor digitorum communis (Figures 1e4 and Table 2). In the 10 microscopically dissected specimens, a total of 62 septocutaneous perforators penetrating through the

Table 2

intermuscular septum of the extensor carpi ulnaris and extensor digitorum communis were dissected (average diameter 0.4 0.1 mm). Defining the line from the center of the ulnar head to the lateral epicondyle as the standard unit length (100%, 24 1 cm), two main clusters were identified at a distance of 21% and 48% along the ulnar head-to-lateral epicondyle interval (Figure 8). The distal cluster included 33 branches with an average diameter of 0.4 0.1 mm and a pedicle length of 15.9 3.9 mm. The proximal cluster included 29 branches with an average diameter of 0.5 0.1 mm and a pedicle length of 19.5 8.1 mm. The diameters of the distal and proximal clusters of septocutaneous perforators were statistically significant (P < 0.01), but there were no significant differences with regard to pedicle lengths (t Z 1.243, P Z 0.230) or number (t Z 0.871, P Z 0.395) (Tables 1 and 2).

Numbers and index analysis of clusters of proximal and distal perforators of PIA for 10 specimens.

Specimen Forearm 1 2 3 4 5 6 7 8 9 10 Mean value SD Distal cluster 1 2 3 4 5 6 7 8 9 10 Mean value SD Proximal cluster 1 2 3 4 5 6 7 8 9 10 Mean value SD

Septocutaneous perforator number

Mean diameter (mm)

Mean pedicle length (mm)

8 6 6 8 7 6 4 7 4 6 6.20 1.39

0.3 0.4 0.4 0.4 0.5 0.5 0.5 0.4 0.5 0.5 0.44 0.07

14.6 19.7 20.9 15.9 28.3 16.3 14.5 18.8 13.2 13.3 17.55 4.62

4 3 4 5 4 3 3 2 2 3 3.30 0.95

0.3 0.4 0.3 0.4 0.5 0.4 0.4 0.3 0.4 0.4 0.38 0.06a

14.8 23.4 18.1 15.2 20.3 10.6 15.3 16.8 11.9 12.8 15.92 3.90

4 3 2 3 3 3 1 5 2 3 2.90 1.10

0.3 0.5 0.6 0.5 0.7 0.5 0.6 0.5 0.6 0.5 0.53 0.11a

14.5 16.1 26.3 17.1 39.0 22.0 11.8 19.6 14.4 13.8 19.46 8.12

Indicates statistically significant difference (Student’s t-test, t Z clusters. a

3.845, P < 0.01) in comparison between distal and proximal


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Figure 9 origin.

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Illustration of the technique used to raise the traditional reverse PIA flap. Ligate the PIA in the proximal third near its

Figure 10 Illustration of the technique used to raise the reverse PIA pedicle cutaneous branches-chain perforator flap. Ligate the PIA in the distal one-third of the forearm where the PIA courses superficially.

In the distal cluster, a clinically significant perforator (0.5 mm in diameter) extended from the PIA 6 2 cm proximal to the center of the ulnar head with a diameter of 0.5 0.1 mm and a pedicle length of 16.8 5.1 mm. In the proximal cluster, a clinically significant perforator extended from the PIA (eight cases) or interosseous recurrent artery (two cases) 10 1 cm distal to the lateral epicondyle of the humerus with a diameter of 0.6 0.1 mm and a pedicle length of 21.2 12.3 mm (Figures 1e3). The anastomosis of the dorsal branch of the AIA and the PIA was located 2.5 0.2 cm proximal to the center of the

ulnar head with a diameter of 0.8 0.1 mm. This location was identified in all specimens. There were two primary linking vessel configurations between the adjacent septocutaneous perforators after the perforators exited the deep fascia. The first configuration was direct linking: composed of two or three first-class ascending and descending branches that extended 0.5e2 cm at the superficial fascia level with few, relatively large-diameter anastomoses. The second configuration was subdermal vascular plexus: anastomoses between dendritic branches with smaller diameters sent from first-class

Figure 11 Illustration of the technique used to raise the reverse bipaddle PIA perforator flap. Ligate the PIA in the proximal third near its origin.


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8 vessels into the dermis after leaving the superficial fascia. The connecting vessel chains of the two configurations ran along the long axis of the PIA (Figures 1e3, 5 and 6). In addition, the cast and clearance specimens showed that the cutaneous perforators of the PIA had connections with the cutaneous perforators of the radial artery and ulnar artery (Figures 5e7).

Discussion The PIA flap is considered to be an ideal choice to cover any skin defect over the distal forearm, wrist, hand, and fingers8,15,29 (Figure 9). However, the technical demands of the pedicle dissection, along with the risks of ischemic necrosis and venous congestion, are considered to be major drawbacks of the flap.4,8,13 Furthermore, dissecting the neurovascular bundle formed by the PIA, venae comitantes, and PIN could injure the PIN,8,19,20 and dissecting the neurovascular bundle takes precious tourniquet time. A more simple and convenient approach is required for flap harvest when practicable. In the previous study, the authors studied the characteristics of the cutaneous branches-chain perforator flap with the ulnar artery pedicle26 and demonstrated the repairing potential of the cutaneous branches-chain perforator flap. Based on this potential, we further explored the PIA pedicle chain-link perforator flap for the repair of small hand defects. Therefore, we performed a cadaveric study of the PIA and septocutaneous perforators to provide the anatomical evidence for clinical use. This study demonstrates that the PIA has two main clusters of perforators in the proximal middle and distal one-fifth of the forearm. In the two clusters, adjacent septocutaneous perforators formed linking vessels parallel to the long axis of the PIA. These two clusters have clinically significant perforators extending through the intermuscular septum of the extensor carpi ulnaris and extensor digiti minimi. We also found that the PIA courses superficially at approximately the distal one-third of the forearm. These findings support the possibility that the PIA chain-link perforator flap can be dissected for clinical use. Based on our findings, we can design the reverse PIA chain-link perforator flap. The pivoting point of the flap is the anastomosis of the dorsal branches of the AIA and the PIA. The axis is the body surface projection of the PIA. The feeding vessels for the flap are the linking vessels formed by the adjacent septocutaneous perforators, which are rooted at a dominant perforator approximately 6 cm proximal to the radial margin of the ulnar head. The main artery could be ligated at the location where the PIA travels superficially within the distal one-third of the forearm (Figure 10). This ligation placement prevents unnecessary separation and dissection of the PIN and muscular branches arising from the PIA at the proximal covered part. Over the years, the technique of harvesting PIA flaps has improved to prevent venous congestion and flap necrosis.13,30 The operative technique was modified by Vinita Puri et al.13 in 2007. They preoperatively ascertained with Doppler ultrasonography that the anastomosis between the AIA and PIA was raised straightway, which saved precious tourniquet time. In addition, they raised the flap as a septofasciosubcutaneous pedicle flap and included a large

C. Sun et al. amount of fascia and subcutaneous tissue with the flap. To raise an easier and more reliable PIA flap, Acharya et al.30 concluded that technical details should be considered, including performing a proximo-distal flap dissection with the deep fascia, creating a broad pedicle with a cutaneous handle, and avoiding its tunneling for inset. Therefore, to improve the survival of a reverse PIA pedicle chain-link perforator flap, we suggest that the flap could be raised with the deep fascia by dissecting from the proximal to the distal end, followed by the pedicle dissection in the distal third of the forearm. The pedicle is fashioned from an inchwide section of adipofascial tissue, including the main vessels, deep fascia, plexus of veins surrounded by the adipofascial tissue, and a 1-cm width of skin as the handle. Recently, Yi Xin Zhang et al.19 modified the PIA flap and designed the reverse bipaddle PIA perforator flap. The skin paddle could be separated into two independent flaps based on two separate PIA perforators for covering large defects of the hand that required multiple subunits to be reconstructed at the same time. In addition, we found a constantly dominant septocutaneous perforator at approximately 10 cm distal to the lateral epicondyle in the proximal cluster. This proximal perforator can be associated with the distal perforator in the distal cluster to design a reverse bipaddle PIA perforator flap for hand repair (Figure 11), just as reported by Yi Xin Zhang et al.19 A common problem associated with the traditional approach is kinking of the vessels, with an increased risk of venous congestion and partial flap necrosis, which has been reported to be as high as 30%.6 Another problem is inadvertent injury to the PIN when dissecting and ligating the PIA near its origin (Figure 9).8,19,20 The PIA chain-link perforator flap (Figure 10) has some advantages in common with the traditional reverse PIA flap (Figure 9), such as good texture, simple operation, ease of survival, and no need for sacrificing the main vessels,5,8,9,15,16,29 but it also has some unique features. First, it reduces operation time. We use only a small part of the distal PIA stem as a pedicle. The stem is ligated at the location where the PIA courses superficially (Figures 1, 2 and 10). Second, the linking vessels are parallel to the PIA axis, which form anastomoses with perforators of the radial and ulnar artery (Figures 5e7), guaranteeing the width of the flap. Third, fewer muscular branches need to be ligated because the distal PIA stem is superficial, and the muscular branches of the PIA are mainly located at the proximal covered area. Moreover, there is less risk of injuring the PIN because the flap dissection is performed in the distal third of the forearm, where the vascular pedicle is more superficial and the terminal branches of the PIN have already penetrated the extensor muscles (Figures 1, 2 and 10). Therefore, our approach to harvesting the flap is easier and safer than the traditional method of harvesting a reverse PIA flap. However, the shorter pedicle of the chain-link perforator flap of the PIA limits its distal reach to the metacarpophalangeal joint on the dorsum of the hand. In this case, the bipaddle PIA perforator flap (Figure 11) can be used to cover large defects of the hand involving multiple subunits.19 Moreover, the anastomosis of the AIA and PIA may be absent, and the location and diameter of the septocutaneous perforators can also vary.2,5,15,20,31 Doppler may be needed for preoperative exploration. Because


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Anatomical basis of a proximal fasciocutaneous extension of the distal-based posterior interosseous flap vasospasm can often occur in small blood vessels when stretched or distorted, traction-applied stress should be avoided when proceeding with vessel anatomy techniques.

Conflict of interest None.

Funding None.

Acknowledgment The authors thank Ms. Zhou Xin, postdoctorate in the Hematology Department of Zhujiang Hospital, Southern Medical University, and Ms. Wang Bing, doctor in the Dermatology Department of 404 Hospital of Chinese PLA, Weihai, P.R. China, for their corrections and revision.

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13. Puri V, Mahendru S, Rana R. Posterior interosseous artery flap, fasciosubcutaneous pedicle technique: a study of 25 cases. J Plast Reconstr Aesthet Surg 2007;60(12):1331e7. 2007-01-20. 14. Xu G, Lai-jin L. Coverage of skin defects in spaghetti wrist trauma: application of the reverse posterior interosseous flap and its anatomy. J Trauma 2007;63(2):402e4. 2007-08-01. 15. Costa H, Pinto A, Zenha H. The posterior interosseous flap e a prime technique in hand reconstruction. The experience of 100 anatomical dissections and 102 clinical cases. J Plast Reconstr Aesthet Surg 2007;60(7):740e7. 2007-01-20. 16. Lu LJ, Gong X, Lu XM, Wang KL. The reverse posterior interosseous flap and its composite flap: experience with 201 flaps. J Plast Reconstr Aesthet Surg 2007;60(8):876e82. 2007-01-20. 17. Liu DX, Wang H, Li XD, Du SX. Three kinds of forearm flaps for hand skin defects: experience of 65 cases. Arch Orthop Trauma Surg 2011;131(5):675e80. 2011-05-01. 18. Suzuki S, Iwamoto T, Koshima I. Adipofascial turnover perforator flap for dorsal hand reconstruction based on both the posterior interosseous artery and radial artery. J Hand Surg Eur Vol 2012;37(2):178e80. 2012-02-01. 19. Zhang YX, Qian Y, Pu Z, et al. Reverse bipaddle posterior interosseous artery perforator flap. Plast Reconstr Surg 2013; 131(4):552ee62e. 2013-04-01. 20. Buchler U, Frey HP. Retrograde posterior interosseous flap. J Hand Surg Am 1991;16(2):283e92. 1991-03-01. 21. Park JJ, Kim JS, Chung JI. Posterior interosseous free flap: various types. Plast Reconstr Surg 1997;100(5):1186e97. 199710-01, 1198-1199. 22. Cavadas PC. Posterior interosseous free flap with extended pedicle for hand reconstruction. Plast Reconstr Surg 2001; 108(4):897e901. 2001-09-15. 23. Pauchot J, Lepage D, Leclerc G, Flamans B, Obert L, Tropet Y. Posterior interosseous free flap because of absence of posterior interosseous pedicle. A report of an individualised salvage procedure and of an exceptional anatomical variation. Review of the literature. Ann Chir Plast Esthet 2010;55(1):56e60. 2010-02-01. 24. Ishiko T, Nakaima N, Suzuki S. Free posterior interosseous artery perforator flap for finger reconstruction. J Plast Reconstr Aesthet Surg 2009;62(7):e211e5. 2009-07-01. 25. Pan ZH, Jiang PP, Wang JL. Posterior interosseous free flap for finger re-surfacing. J Plast Reconstr Aesthet Surg 2010;63(5): 832e7. 2010-05-01. 26. Sun C, Hou ZD, Wang B, Ding ZH. An anatomical study on the characteristics of cutaneous branches-chain perforator flap with ulnar artery pedicle. Plast Reconstr Surg 2013;131(2): 329e36. 2013-02-01. 27. Bayon P, Pho RW. Anatomical basis of dorsal forearm flap. Based on posterior interosseous vessels. J Hand Surg Br 1988; 13(4):435e9. 1988-11-01. 28. Ding YC, Sun GC, Lu Y, Ly SY. The vascular microanatomy of skin territory of posterior forearm and its clinical application. Ann Plast Surg 1989;22(2):126e34. 1989-02-01. 29. Neuwirth M, Hubmer M, Koch H. The posterior interosseous artery flap: clinical results with special emphasis on donor site morbidity. J Plast Reconstr Aesthet Surg 2013;66(5):623e8. 2013-05-01. 30. Acharya AM, Bhat AK, Bhaskaranand K. The reverse posterior interosseous artery flap: technical considerations in raising an easier and more reliable flap. J Hand Surg Am 2012;37(3): 575e82. 2012-03-01. 31. Giunta R, Lukas B. Impossible harvest of the posterior interosseous artery flap: a report of an individualised salvage procedure. Br J Plast Surg 1998;51(8):642e5. 1998-12-01.


Retrograde posterior interosseous flap.

Posterior interosseous flap.

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

Posterior Interosseous Artery Flap for Hand Defects.

Improvement of the Rotation Arch of the Posterior Interosseous Pedicle Flap Preserving Both Reverse Posterior and Anterior Interosseous Vascular Sources.

Intraosseous Lipoma of the Proximal Radius with Extra Osseous Extension leading to Posterior Interosseous Nerve Compression: HRUS Diagnosis.

Posterior interosseous nerve compression.

Intraneural lipoma of the posterior interosseous nerve.

Reverse posterior interosseous artery flap for reconstruction of the wrist and hand after sarcoma resection.

Deepithelized posterior interosseous artery flap for 3-dimensional defect coverage in the hand.

Ultrasonographic findings of posterior interosseous nerve syndrome.

Posterior interosseous artery perforator-free flap: treating intermediate-size hand and foot defects.

Cross-sectional sonographic assessment of the posterior interosseous nerve.

Posterior interosseous nerve syndrome from thermal injury.

Reconstruction of the axilla with a posterior arm fasciocutaneous flap.

Sonographic Diagnosis Of Posterior Interosseous Nerve Entrapment Syndrome.

Posterior interosseous nerve incarceration with endobutton repair of distal biceps.

DIAGNOSIS AND TREATMENT OF POSTERIOR INTEROSSEOUS NERVE ENTRAPMENT: SYSTEMATIC REVIEW.

Use of Free Modified Innervated Posterior Interosseous Artery Perforator Flap to Repair Digital Skin and Soft Tissue Defects.

In reply: fascicular constrictions in spontaneous anterior interosseous nerve palsy and spontaneous posterior interosseous nerve palsy.

Fascicular constrictions in spontaneous anterior interosseous nerve palsy and spontaneous posterior interosseous nerve palsy.

Treatment of Distal Radius Fracture Nonunion With Posterior Interosseous Bone Flap.

Important anatomical relationships of the posterior interosseous nerve in the distal forearm for surgical planning: a cadaveric study.

Posterior interosseous nerve axonotmesis from compression by a ganglion.