TECHNIQUE
Deepithelized Posterior Interosseous Artery Flap for 3-Dimensional Defect Coverage in the Hand Tolga Tu¨rker, MD,* Jorge P. Gonzalez,w and Nicole Capdarest-Arest, MAz
Abstract: The posterior interosseous artery (PIA) flap is a pedicle flap that can be harvested at the posterior forearm based on blood supply from the PIA and its concomitant veins. The flap can be used for posttrauma coverage of exposed bones, tendons, and defects; for treatment of a surgical wound; or as a spacer in congenital or burnrelated contracture releases. The surgical technique has been reported with limited donor morbidity and few complications to cover exposed structures. In this article, we present our methods and experience using a modification of the posterior interosseous flap that was deepithelized to fill a 3-dimensional cavity in the hand. This method has been successfully used, and the example of the patient shows good outcome, function, and range of motion with no significant complications. The deepithelized PIA flap is a technique that surgeons may add to their toolbox for 3-dimensional defect coverage in the hand. It offers the following advantages: (a) technically uncomplicated; (b) does not create significant donor site morbidity; (c) does not sacrifice any major vessels; and (d) provides good cosmetic appearance, especially in the dorsum of the hand. Key Words: defects, hand, posterior interosseous artery flap, reconstruction, technique (Tech Hand Surg 2015;19: 51–54)
T
he posterior interosseous artery (PIA) flap is a pedicle flap that can be harvested at the posterior forearm based on blood supply from the PIA and its concomitant veins. The flap can be used for posttrauma coverage of exposed bones, tendons, and defects; for treatment of a surgical wound; or as a spacer in congenital or burn-related contracture releases.1 The PIA flap can be designed as either (a) a proximal-based flap that may be used to treat proximal forearm defects including defects in the elbow area; or (b) a distal-based flap that may be used to cover defects in the wrist or in the hand.1,2 Harvesting the flap does not require using an operative microscope; only 2.5 loop magnification is sufficient to perform dissection. The surgical technique has been reported with limited donor morbidity and few complications.3,4 The flap is mostly used to cover exposed structures, however, a modification of the flap is also used to reconstruct 3-dimensional (3D) defects such as in the thumb.5 In this study, we present a new modification of the flap to fill a 3D cavity in the hand. From the *Department of Orthopaedic Surgery; wUniversity of Arizona, Tucson, AZ; and zLane Medical Library, Stanford University, Stanford, CA. J.P.G. was supported by R25 HL108837/HL/NHLBI NIH HHS/United States. For the remaining authors none were declared. Address correspondence and reprint requests to Tolga Tu¨rker, MD, Department of Orthopaedic Surgery, The University of Arizona, 1609N Warren Ave, Bldg 220, Room 108, Tucson, AZ 85719. E-mail: [email protected] Supplemental Digital Content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Website, www. techhandsurg.com. Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
Techniques in Hand & Upper Extremity Surgery
ANATOMY AND SURGICAL TECHNIQUE Flap Design, Dissection, and Harvesting An appropriate size tourniquet cuff is applied to the upper arm; sterile preparation up to the tourniquet level is performed; and the tourniquet is exsanguinated. The dorsal forearm skin incision is designed on the axis of ulnar head and the lateral epicondyle according to the previously published technique described by Penteado and colleagues.6–8 Reports of the vascular anatomy of the area are largely consistent.8–10 Given this consistency, a 2-cm incision at the dorsal aspect of the distal radio ulnar joint (DRUJ) area and identifying the PIA in the intermuscular septum between the extensor digiti quinti (EDQ) and extensor carpi ulnaris (ECU) tendons should be sufficient to provide reassurance to the surgeon before progressing with the dissection. Once the vascular structures are identified, the dissection is carried over the ECU tendon sheath until the first skin perforator is identified. Once the perforator is identified, the incision at ulnar side of the flap can be carried on the ECU tendon until the most proximal portion of the desired flap is reached. The incision is then rounded at the most proximal portion of the flap and turns to head distally as a radial side incision, until both incisions are connected at the distal forearm. After the skin incisions are complete, the skin island/flap dissection is deepened. The small muscle branches to the ECU and EDQ are either cauterized or metal ligaclips are applied to disconnect them from the PIA. Once the dissection is deepened to the level of the radial nerve, the proximal portion of the PIA is clipped and disconnected from the distal portion at the level of the radial nerve. The pedicle dissection is performed proximally to distally over the ulna until the PIA and anterior interosseous artery (AIA) connection is reached. Attention is given to take as wide a pedicle as possible for adequate venous return and in order not to disrupt the connection between AIA and PIA. The flap is then rotated distally using the pivot point at the connection of AIA and PIA, approximately 2 to 3 cm proximal of the DRUJ.
Deepithelization Process This process can be performed in 2 ways: (1) Flap harvesting followed by deepithelization of the flap. This method may be used if the wound is small enough and the forearm provides enough skin coverage. After the PIA flap is harvested according the above-mentioned technique, the desired deepithelization is performed by deepithelizing the perimeter of the flap from approximately 30 to 330 degrees, leaving a peninsula with skin attached (Fig. 1). The width of the deepithelization around the peninsula is approximately 2 cm and is removed with scissors (Fig. 1). Then the island portion is sutured to the skin at the recipient area and the deepithelized parts can be folded into the defect (Fig. 2). (2) Flap harvesting with simultaneous deepithelization of the flap. If the defect to be filled is large and closure of the forearm
Volume 19, Number 2, June 2015
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51
Techniques in Hand & Upper Extremity Surgery
Tu¨rker et al
FIGURE 1. Deepithelization procedure of the harvested posterior interosseous arterys flap.
might be compromised after flap harvest, the skin layer of the flap can be designed and cut first. Subsequently, the skin surrounding this area of the flap can be dissected from the subcutaneous tissue, which will become part of the flap. The flap is then harvested and the skin remaining on the perimeter of the flap, now with the subcutaneous tissue removed, is returned to its original place as a full-thickness skin graft.
INDICATIONS/CONTRAINDICATIONS Indications Filling 3D soft-tissue defects in the hand. As asphalt is filled and then leveled to repair a pothole in a road, a 3D defect can be repaired using this technique (ie, the defect is filled with the flap and leveled with the surrounding skin).
Volume 19, Number 2, June 2015
FIGURE 2. Deepithelized portions are folded into the defect in the left fourth metacarpal bone. defect (Fig. 2). Despite some venous congestion that occurred after performing the flap procedure, it healed with slight serous discharge, which resolved itself with a 20.3 mm scab formation on the ulnar side without infection in 3 weeks. The patient began active range-ofmotion exercises 2 weeks after surgery. Patient showed full range of motion in 4 weeks, the scab healed in the following 5 weeks and the hand and fifth metacarpal bone were stable by 12 weeks postsurgery (Fig. 6, and see Video 1, Supplementary Digital Content 1, http:// links.lww.com/BTH/A48, which demonstrates hand function).
EXPECTED OUTCOMES The deepithelized PIA flap is a technique that surgeons may add to their toolbox for 3D defect coverage in the hand. It offers the following advantages: (a) technically uncomplicated; (b) does not create significant donor site morbidity; (c) does
Contraindications Contraindications are active infection in the recipient area, possible injury to the PIA, incomplete arch between PIA and AIA, significant scar tissue at the dorsal portion of DRUJ, previous soft-tissue injury of the dorsal forearm, and projected poor patient compliance.
CASE EXAMPLE A 57-year-old male presented to the emergency room with a severe infection of the left ring finger (Fig. 3). His medical history is significant for insulin-dependent type 2 diabetes, hepatitis C, gastroesophageal reflux, and diabetic foot ulcer, and he is a 30-pack/year smoker. Even though the first irrigation and debridement was performed adequately, methicillin-resistant Staphylococcus aureus and bhemolytic streptococcus infection was detected and ceftaroline 400 mg Q12H was started. The finger infection continued to progress despite medical management with infection progressing to the hand, and an open ray amputation was performed. Wound care and dressing changes were performed after amputation, but the wound did not have any sign of granulation in 3 weeks and it was decided to cover the wound and fill the defect, which was 4 2 2 cm (Fig. 4). A modified PIA flap was considered to not only cover the defect but also to fill the defect in the fourth metacarpal area. The flap was designed (64.5 cm) in a teardrop shape and a skin island, which was used to cover the dorsal aspect of the defect, was designed in the middle of the flap (Fig. 5). At the proximal end of the designed island skin part of the flap (which will become distal after rotation), about 2 cm was removed and deepithelized, and 1.5 to 2 cm was removed and deepithelized on the lateral and medial sides of the of the designed island part of the flap (Fig. 1). The incision at the distal position of flap was extended to the dorsal aspect of the hand and the flap was flipped over distally. The skin portion of the flap was sutured to the dorsal skin of the hand and the deepithelized area of the flap was folded in to the
52 | www.techhandsurg.com
FIGURE 3. Presentation of infected left ring finger and metacarpal. Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Techniques in Hand & Upper Extremity Surgery
Volume 19, Number 2, June 2015
Deepithelized Posterior Interosseous Artery Flap
FIGURE 6. Twelve-week postoperative follow-up image of deepithelized posterior interosseous artery flap procedure.
DISCUSSION FIGURE 4. After ring finger ray amputation, a large wound defect remained.
not sacrifice any major vessels; and (d) provides good cosmetic appearance, especially in the dorsum of the hand.
COMPLICATIONS Complications include partial or total flap necrosis; paralysis of ECU, extensor pollicis longus, or EDQ; venous congestion; infection.
FIGURE 5. Flap design on the left forearm.
We herein present a modification of the PIA flap for 3D defect coverage for the hand. This technique uses the deepithelization process in PIA flap technique that was described by Penteado and colleagues6,7 and modifies it to fill a 3D defect. The deepithelization process for the PIA flap was also previously reported by Lim et al11 during a reconstruction and coverage of a finger after a trauma with a PIA flap. Because they needed to cover a finger, a more proximal portion of the flap is needed to reach the finger. However, because most perforators are at the middle portion of the flap, they kept the subcutaneous tissue intact with deepithelization of the distal portion of the flap, and then when they flipped the flap distally, the deepithelized part was put through a subcutaneous tunnel. They used the flap to pass it through a tunnel without complications, whereas we have modified the flap technique to use it to fill a gap. Even though we utilized a new modification of the PIA flap in this case, there may be other techniques that could have also been used to address care for this patient. We could have applied a small wound vacuum closure to stimulate granulation tissue or could have managed the wound with serial dressing changes until the tissue filled itself in the hand. Such approaches, however, not only require a longer period of time for wound healing but also could be more fatiguing and expensive for the patient. Other flaps such as groin flap could also be considered. Another approach would be to osteomize the fifth metacarpal bone proximally and transfer the fifth metacarpal bone to the base of the fourth one. However, this approach might also have drawbacks such as introducing a osteotomy which may require approximately 6 weeks of immobilization, risk of possible nonunion, and a change to the course of the extensor and flexor tendon vectors12 that could lead to decreased grip strength and a narrower hand that may also cause patient discomfort with hand function. Moreover, performing an osteotomy could be risky in a previously infected area. Finally, we could have used the PIA flap as an osteofasciocutenous flap as Costa et al5 described. They harvested the flap with a piece of bone from the ulna to reconstruct a thumb. However, this could also have been a valid approach in our case as we did not need stability, and considering that fracture risk in the ulna is high, a soft-tissue procedure such as that chosen would be less invasive and cause less morbidity. However, if a thumb reconstruction is needed, we believe that taking the fracture risk in ulna after harvesting an osteofascicutenous flap should be considered. In our experience with the PIA flap procedure, it seems that the flap has more reliable skin perforators at the junction of the middle and distal third of the flap. Therefore, harvesting the flap in a teardrop shape as Balakrishnan et al2 described or tennis racquet shape as Acharya et al1 recommended would increase the chance of catching the vascular perforators. We designed our flap in a teardrop shape and, once we saw the distal first perforator to the skin, the incision was modified so that the maximum size of skin and subcutaneous tissue was harvested. We also believe that starting the dissection at the
Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
www.techhandsurg.com |
53
Techniques in Hand & Upper Extremity Surgery
Tu¨rker et al
distal ulnar border and then finding and securing the perforators is a good approach to harvest the flap.2 Puri et al’s4 review found that partial and total flap necrosis, paralysis of ECU, extensor pollicis longus and EDQ, and venous congestion are the most commonly reported complications, however, we agree with others that the PIA flap is a reliable flap.1,2,4,6,7,9,10 Technically, it is not complicated, does not create a significant morbidity and does not sacrifice any major vessels. In the dorsum of the hand, especially, it has the added benefit of providing good cosmetic appearance.1 Even though ultrasound has been stated to be an recommended step in the technique of the reverse flow PIA flap,13 we did not use ultrasound in this case or our other PIA flap cases, however, we agree with Puri et al4 that especially for trauma cases, and if the trauma is close to the dorsal DRUJ, it might be a good idea to use the ultrasound to make sure that the vascular network is reliable. In conclusion, PIA flap with modification of the deepithelization process provided not only a good coverage of the wound but also provided good vascular tissue to fill the defect. In the case reported, because the patient did not have enough subcutaneous tissue, it was necessary to take as big a flap as possible from the forearm. However, if a patient had more subcutaneous tissue available in the forearm, a smaller flap would be enough to fill the defect. In this case, there was only a slight venous congestion and serous drainage, which resolved in 3 weeks with a scab formation that healed in 5 weeks without any intervention. We believe that, in addition to the other techniques mentioned above, the PIA flap could be a good alternative technique to reconstruct 3D defects in the hand.
Volume 19, Number 2, June 2015
2. Balakrishnan G, Kumar BS, Hussain SA. Reverse-flow posterior interosseous artery flap revisited. Plast Reconstruct Surg. 2003;111:2364–2369. 3. Gong X, Lu LJ. Reconstruction of severe contracture of the first web space using the reverse posterior interosseous artery flap. J Trauma. 2011;71:1745–1749. 4. Puri V, Mahendru S, Rana R. Posterior interosseous artery flap, fasciosubcutaneous pedicle technique: a study of 25 cases. J Plast Reconstruct Aesth Surg. 2007;60:1331–1337. 5. Costa H, Smith R, McGrouther DA. Thumb reconstruction by the posterior interosseous osteocutaneous flap. Br J Plast Surg. 1988;41:228–233. 6. Penteado CV, Masquelet AC, Chevrel JP. The anatomic basis of the fascio-cutaneous flap of the posterior interosseous artery. Surg Radiol Anat. 1986;8:209–215. 7. Zancolli EA, Angrigiani C. Posterior interosseous island forearm flap. J Hand Surg (Edinburgh, Scotland). 1988;13:130–135. 8. Cheema TA, Lakshman S, Cheema MA, et al. Reverse-flow posterior interosseous flap-a review of 68 cases. Hand (N Y). 2007;2:112–116. 9. Costa H, Pinto A, Zenha H. The posterior interosseous flap—a prime technique in hand reconstruction. The experience of 100 anatomical dissections and 102 clinical cases. J Plast Reconstruct Aesth Surg. 2007;60:740–747. 10. Angrigiani C, Grilli D, Dominikow D, et al. Posterior interosseous reverse forearm flap: experience with 80 consecutive cases. Plast Reconstr Surg. 1993;92:285–293. 11. Lim YJ, Sebastin SJ, Fong PL, et al. Extending the reverse posterior interosseous artery flap using a de-epithelised bridge segment. J Plast Reconstruct Aesth Surg. 2010;63:e111–e113.
REFERENCES
12. Mountney J, Blundell CM, McArthur P, et al. Free tendon interposition grafting for the repair of ruptured extensor tendons in the rheumatoid hand. A clinical and biomechanical assessment. J Hand Surg Br. 1998;23:662–665.
1. 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. 2012;37:575–582.
13. El-Sabbagh AH, Zeina AA, El-Hadidy AM, et al. Reversed posterior interosseous flap: safe and easy method for hand reconstruction. J Hand Microsurg. 2011;3:66–72.
54 | www.techhandsurg.com
Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Deepithelized Posterior Interosseous Artery Flap for 3-Dimensional Defect Coverage in the Hand Tolga Tu¨rker, MD,* Jorge P. Gonzalez,w and Nicole Capdarest-Arest, MAz
Abstract: The posterior interosseous artery (PIA) flap is a pedicle flap that can be harvested at the posterior forearm based on blood supply from the PIA and its concomitant veins. The flap can be used for posttrauma coverage of exposed bones, tendons, and defects; for treatment of a surgical wound; or as a spacer in congenital or burnrelated contracture releases. The surgical technique has been reported with limited donor morbidity and few complications to cover exposed structures. In this article, we present our methods and experience using a modification of the posterior interosseous flap that was deepithelized to fill a 3-dimensional cavity in the hand. This method has been successfully used, and the example of the patient shows good outcome, function, and range of motion with no significant complications. The deepithelized PIA flap is a technique that surgeons may add to their toolbox for 3-dimensional defect coverage in the hand. It offers the following advantages: (a) technically uncomplicated; (b) does not create significant donor site morbidity; (c) does not sacrifice any major vessels; and (d) provides good cosmetic appearance, especially in the dorsum of the hand. Key Words: defects, hand, posterior interosseous artery flap, reconstruction, technique (Tech Hand Surg 2015;19: 51–54)
T
he posterior interosseous artery (PIA) flap is a pedicle flap that can be harvested at the posterior forearm based on blood supply from the PIA and its concomitant veins. The flap can be used for posttrauma coverage of exposed bones, tendons, and defects; for treatment of a surgical wound; or as a spacer in congenital or burn-related contracture releases.1 The PIA flap can be designed as either (a) a proximal-based flap that may be used to treat proximal forearm defects including defects in the elbow area; or (b) a distal-based flap that may be used to cover defects in the wrist or in the hand.1,2 Harvesting the flap does not require using an operative microscope; only 2.5 loop magnification is sufficient to perform dissection. The surgical technique has been reported with limited donor morbidity and few complications.3,4 The flap is mostly used to cover exposed structures, however, a modification of the flap is also used to reconstruct 3-dimensional (3D) defects such as in the thumb.5 In this study, we present a new modification of the flap to fill a 3D cavity in the hand. From the *Department of Orthopaedic Surgery; wUniversity of Arizona, Tucson, AZ; and zLane Medical Library, Stanford University, Stanford, CA. J.P.G. was supported by R25 HL108837/HL/NHLBI NIH HHS/United States. For the remaining authors none were declared. Address correspondence and reprint requests to Tolga Tu¨rker, MD, Department of Orthopaedic Surgery, The University of Arizona, 1609N Warren Ave, Bldg 220, Room 108, Tucson, AZ 85719. E-mail: [email protected] Supplemental Digital Content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Website, www. techhandsurg.com. Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
Techniques in Hand & Upper Extremity Surgery
ANATOMY AND SURGICAL TECHNIQUE Flap Design, Dissection, and Harvesting An appropriate size tourniquet cuff is applied to the upper arm; sterile preparation up to the tourniquet level is performed; and the tourniquet is exsanguinated. The dorsal forearm skin incision is designed on the axis of ulnar head and the lateral epicondyle according to the previously published technique described by Penteado and colleagues.6–8 Reports of the vascular anatomy of the area are largely consistent.8–10 Given this consistency, a 2-cm incision at the dorsal aspect of the distal radio ulnar joint (DRUJ) area and identifying the PIA in the intermuscular septum between the extensor digiti quinti (EDQ) and extensor carpi ulnaris (ECU) tendons should be sufficient to provide reassurance to the surgeon before progressing with the dissection. Once the vascular structures are identified, the dissection is carried over the ECU tendon sheath until the first skin perforator is identified. Once the perforator is identified, the incision at ulnar side of the flap can be carried on the ECU tendon until the most proximal portion of the desired flap is reached. The incision is then rounded at the most proximal portion of the flap and turns to head distally as a radial side incision, until both incisions are connected at the distal forearm. After the skin incisions are complete, the skin island/flap dissection is deepened. The small muscle branches to the ECU and EDQ are either cauterized or metal ligaclips are applied to disconnect them from the PIA. Once the dissection is deepened to the level of the radial nerve, the proximal portion of the PIA is clipped and disconnected from the distal portion at the level of the radial nerve. The pedicle dissection is performed proximally to distally over the ulna until the PIA and anterior interosseous artery (AIA) connection is reached. Attention is given to take as wide a pedicle as possible for adequate venous return and in order not to disrupt the connection between AIA and PIA. The flap is then rotated distally using the pivot point at the connection of AIA and PIA, approximately 2 to 3 cm proximal of the DRUJ.
Deepithelization Process This process can be performed in 2 ways: (1) Flap harvesting followed by deepithelization of the flap. This method may be used if the wound is small enough and the forearm provides enough skin coverage. After the PIA flap is harvested according the above-mentioned technique, the desired deepithelization is performed by deepithelizing the perimeter of the flap from approximately 30 to 330 degrees, leaving a peninsula with skin attached (Fig. 1). The width of the deepithelization around the peninsula is approximately 2 cm and is removed with scissors (Fig. 1). Then the island portion is sutured to the skin at the recipient area and the deepithelized parts can be folded into the defect (Fig. 2). (2) Flap harvesting with simultaneous deepithelization of the flap. If the defect to be filled is large and closure of the forearm
Volume 19, Number 2, June 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
www.techhandsurg.com |
51
Techniques in Hand & Upper Extremity Surgery
Tu¨rker et al
FIGURE 1. Deepithelization procedure of the harvested posterior interosseous arterys flap.
might be compromised after flap harvest, the skin layer of the flap can be designed and cut first. Subsequently, the skin surrounding this area of the flap can be dissected from the subcutaneous tissue, which will become part of the flap. The flap is then harvested and the skin remaining on the perimeter of the flap, now with the subcutaneous tissue removed, is returned to its original place as a full-thickness skin graft.
INDICATIONS/CONTRAINDICATIONS Indications Filling 3D soft-tissue defects in the hand. As asphalt is filled and then leveled to repair a pothole in a road, a 3D defect can be repaired using this technique (ie, the defect is filled with the flap and leveled with the surrounding skin).
Volume 19, Number 2, June 2015
FIGURE 2. Deepithelized portions are folded into the defect in the left fourth metacarpal bone. defect (Fig. 2). Despite some venous congestion that occurred after performing the flap procedure, it healed with slight serous discharge, which resolved itself with a 20.3 mm scab formation on the ulnar side without infection in 3 weeks. The patient began active range-ofmotion exercises 2 weeks after surgery. Patient showed full range of motion in 4 weeks, the scab healed in the following 5 weeks and the hand and fifth metacarpal bone were stable by 12 weeks postsurgery (Fig. 6, and see Video 1, Supplementary Digital Content 1, http:// links.lww.com/BTH/A48, which demonstrates hand function).
EXPECTED OUTCOMES The deepithelized PIA flap is a technique that surgeons may add to their toolbox for 3D defect coverage in the hand. It offers the following advantages: (a) technically uncomplicated; (b) does not create significant donor site morbidity; (c) does
Contraindications Contraindications are active infection in the recipient area, possible injury to the PIA, incomplete arch between PIA and AIA, significant scar tissue at the dorsal portion of DRUJ, previous soft-tissue injury of the dorsal forearm, and projected poor patient compliance.
CASE EXAMPLE A 57-year-old male presented to the emergency room with a severe infection of the left ring finger (Fig. 3). His medical history is significant for insulin-dependent type 2 diabetes, hepatitis C, gastroesophageal reflux, and diabetic foot ulcer, and he is a 30-pack/year smoker. Even though the first irrigation and debridement was performed adequately, methicillin-resistant Staphylococcus aureus and bhemolytic streptococcus infection was detected and ceftaroline 400 mg Q12H was started. The finger infection continued to progress despite medical management with infection progressing to the hand, and an open ray amputation was performed. Wound care and dressing changes were performed after amputation, but the wound did not have any sign of granulation in 3 weeks and it was decided to cover the wound and fill the defect, which was 4 2 2 cm (Fig. 4). A modified PIA flap was considered to not only cover the defect but also to fill the defect in the fourth metacarpal area. The flap was designed (64.5 cm) in a teardrop shape and a skin island, which was used to cover the dorsal aspect of the defect, was designed in the middle of the flap (Fig. 5). At the proximal end of the designed island skin part of the flap (which will become distal after rotation), about 2 cm was removed and deepithelized, and 1.5 to 2 cm was removed and deepithelized on the lateral and medial sides of the of the designed island part of the flap (Fig. 1). The incision at the distal position of flap was extended to the dorsal aspect of the hand and the flap was flipped over distally. The skin portion of the flap was sutured to the dorsal skin of the hand and the deepithelized area of the flap was folded in to the
52 | www.techhandsurg.com
FIGURE 3. Presentation of infected left ring finger and metacarpal. Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Techniques in Hand & Upper Extremity Surgery
Volume 19, Number 2, June 2015
Deepithelized Posterior Interosseous Artery Flap
FIGURE 6. Twelve-week postoperative follow-up image of deepithelized posterior interosseous artery flap procedure.
DISCUSSION FIGURE 4. After ring finger ray amputation, a large wound defect remained.
not sacrifice any major vessels; and (d) provides good cosmetic appearance, especially in the dorsum of the hand.
COMPLICATIONS Complications include partial or total flap necrosis; paralysis of ECU, extensor pollicis longus, or EDQ; venous congestion; infection.
FIGURE 5. Flap design on the left forearm.
We herein present a modification of the PIA flap for 3D defect coverage for the hand. This technique uses the deepithelization process in PIA flap technique that was described by Penteado and colleagues6,7 and modifies it to fill a 3D defect. The deepithelization process for the PIA flap was also previously reported by Lim et al11 during a reconstruction and coverage of a finger after a trauma with a PIA flap. Because they needed to cover a finger, a more proximal portion of the flap is needed to reach the finger. However, because most perforators are at the middle portion of the flap, they kept the subcutaneous tissue intact with deepithelization of the distal portion of the flap, and then when they flipped the flap distally, the deepithelized part was put through a subcutaneous tunnel. They used the flap to pass it through a tunnel without complications, whereas we have modified the flap technique to use it to fill a gap. Even though we utilized a new modification of the PIA flap in this case, there may be other techniques that could have also been used to address care for this patient. We could have applied a small wound vacuum closure to stimulate granulation tissue or could have managed the wound with serial dressing changes until the tissue filled itself in the hand. Such approaches, however, not only require a longer period of time for wound healing but also could be more fatiguing and expensive for the patient. Other flaps such as groin flap could also be considered. Another approach would be to osteomize the fifth metacarpal bone proximally and transfer the fifth metacarpal bone to the base of the fourth one. However, this approach might also have drawbacks such as introducing a osteotomy which may require approximately 6 weeks of immobilization, risk of possible nonunion, and a change to the course of the extensor and flexor tendon vectors12 that could lead to decreased grip strength and a narrower hand that may also cause patient discomfort with hand function. Moreover, performing an osteotomy could be risky in a previously infected area. Finally, we could have used the PIA flap as an osteofasciocutenous flap as Costa et al5 described. They harvested the flap with a piece of bone from the ulna to reconstruct a thumb. However, this could also have been a valid approach in our case as we did not need stability, and considering that fracture risk in the ulna is high, a soft-tissue procedure such as that chosen would be less invasive and cause less morbidity. However, if a thumb reconstruction is needed, we believe that taking the fracture risk in ulna after harvesting an osteofascicutenous flap should be considered. In our experience with the PIA flap procedure, it seems that the flap has more reliable skin perforators at the junction of the middle and distal third of the flap. Therefore, harvesting the flap in a teardrop shape as Balakrishnan et al2 described or tennis racquet shape as Acharya et al1 recommended would increase the chance of catching the vascular perforators. We designed our flap in a teardrop shape and, once we saw the distal first perforator to the skin, the incision was modified so that the maximum size of skin and subcutaneous tissue was harvested. We also believe that starting the dissection at the
Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
www.techhandsurg.com |
53
Techniques in Hand & Upper Extremity Surgery
Tu¨rker et al
distal ulnar border and then finding and securing the perforators is a good approach to harvest the flap.2 Puri et al’s4 review found that partial and total flap necrosis, paralysis of ECU, extensor pollicis longus and EDQ, and venous congestion are the most commonly reported complications, however, we agree with others that the PIA flap is a reliable flap.1,2,4,6,7,9,10 Technically, it is not complicated, does not create a significant morbidity and does not sacrifice any major vessels. In the dorsum of the hand, especially, it has the added benefit of providing good cosmetic appearance.1 Even though ultrasound has been stated to be an recommended step in the technique of the reverse flow PIA flap,13 we did not use ultrasound in this case or our other PIA flap cases, however, we agree with Puri et al4 that especially for trauma cases, and if the trauma is close to the dorsal DRUJ, it might be a good idea to use the ultrasound to make sure that the vascular network is reliable. In conclusion, PIA flap with modification of the deepithelization process provided not only a good coverage of the wound but also provided good vascular tissue to fill the defect. In the case reported, because the patient did not have enough subcutaneous tissue, it was necessary to take as big a flap as possible from the forearm. However, if a patient had more subcutaneous tissue available in the forearm, a smaller flap would be enough to fill the defect. In this case, there was only a slight venous congestion and serous drainage, which resolved in 3 weeks with a scab formation that healed in 5 weeks without any intervention. We believe that, in addition to the other techniques mentioned above, the PIA flap could be a good alternative technique to reconstruct 3D defects in the hand.
Volume 19, Number 2, June 2015
2. Balakrishnan G, Kumar BS, Hussain SA. Reverse-flow posterior interosseous artery flap revisited. Plast Reconstruct Surg. 2003;111:2364–2369. 3. Gong X, Lu LJ. Reconstruction of severe contracture of the first web space using the reverse posterior interosseous artery flap. J Trauma. 2011;71:1745–1749. 4. Puri V, Mahendru S, Rana R. Posterior interosseous artery flap, fasciosubcutaneous pedicle technique: a study of 25 cases. J Plast Reconstruct Aesth Surg. 2007;60:1331–1337. 5. Costa H, Smith R, McGrouther DA. Thumb reconstruction by the posterior interosseous osteocutaneous flap. Br J Plast Surg. 1988;41:228–233. 6. Penteado CV, Masquelet AC, Chevrel JP. The anatomic basis of the fascio-cutaneous flap of the posterior interosseous artery. Surg Radiol Anat. 1986;8:209–215. 7. Zancolli EA, Angrigiani C. Posterior interosseous island forearm flap. J Hand Surg (Edinburgh, Scotland). 1988;13:130–135. 8. Cheema TA, Lakshman S, Cheema MA, et al. Reverse-flow posterior interosseous flap-a review of 68 cases. Hand (N Y). 2007;2:112–116. 9. Costa H, Pinto A, Zenha H. The posterior interosseous flap—a prime technique in hand reconstruction. The experience of 100 anatomical dissections and 102 clinical cases. J Plast Reconstruct Aesth Surg. 2007;60:740–747. 10. Angrigiani C, Grilli D, Dominikow D, et al. Posterior interosseous reverse forearm flap: experience with 80 consecutive cases. Plast Reconstr Surg. 1993;92:285–293. 11. Lim YJ, Sebastin SJ, Fong PL, et al. Extending the reverse posterior interosseous artery flap using a de-epithelised bridge segment. J Plast Reconstruct Aesth Surg. 2010;63:e111–e113.
REFERENCES
12. Mountney J, Blundell CM, McArthur P, et al. Free tendon interposition grafting for the repair of ruptured extensor tendons in the rheumatoid hand. A clinical and biomechanical assessment. J Hand Surg Br. 1998;23:662–665.
1. 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. 2012;37:575–582.
13. El-Sabbagh AH, Zeina AA, El-Hadidy AM, et al. Reversed posterior interosseous flap: safe and easy method for hand reconstruction. J Hand Microsurg. 2011;3:66–72.
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Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
