Retrograde posterior interosseous flap A retrospective, continuous clinical series of 36 distally based posterior interosseous island flap procedures is reported. Major anatomic variations precluded the final dissection of the flap on two occasions (690). Thirty-four patients had septocutaneous or septofascial flap coverage for treatment of acute complex injuries (12), subacute soft tissue defects (10), chronic ulcers (5), or contractures (7). The sizes of the flap islands varied from 1.5 by 4 centimeters to 9 by II centimeters. The arc of rotation, centered over the distal radioulnar joint, measured up to 19 centimeters, allowing the flaps to reach the dorsum of the proximal interphalangeal joints. Partial necrosis occurred in seven flaps; four (12%) required additional local or distant flaps. Partial failures were related to bleeding from the pedicle or compression thereof, while other assumed causes of hypoperfusion were not statistically relevant. The flaps remained slightly bulky in about 30% of the patients, but otherwise adapted well to the recipient site and had excellent texture and color match. The donor morbidity was minimal. (J HAl'iD SURG 1991;16A:283-92.)
Ueli BUchler, MD, and Hans-Peter Frey, MD, Bern. Switzerland
Since the first report on the posterior interosseous forearm flap by Zancolli and Angrigiani' and the description of its anatomic basis by Penteado and colleagues? in 1986, the procedure has evoked great interest among upper extremity surgeons. It is now increasingly considered as an alternative to the Chinese forearm flap. the pedicled axial groin flap. the free lateral arm flap. or other regional and distant flaps. The skin, subcutaneous layer, and the fascia along the dorso-ulnar aspect of the forearm are nourished by multiple septocutaneous perforators that originate segmentally from the posterior interosseous vessels and surface between the muscles and tendons of the extensor carpi ulnaris and the extensor digiti quinti ."" The distal termination of the posterior interosseous system connects to the vascular network of the wrist, particularly to the dorsal branches of the anterior interosseous artery 'and vein. Because this collateral sxstem transmits reversed arterial and venous blood flow. septocutaneous posterior interosseous island flaps may be based either
From the Division of Hand Surgery, Inselspital, University of Bern . Switzerland . Received for publication Nov. 28. 1989, accepted in revised form Feb. 28. 1990. . No benefits in any form have been received or will be received from a commerc ial party related directly or indirectly to the subject of this article. Reprint requests: PO Dr. med. Ueli BUchler, Chief of Hand Surgery, Inselspital Bern. Freiburgstrasse, CH-3010 Bern, Switzerland. 3/1/22363
proximally or distally. In the retrograde dissection modality. the flap is taken from the proximal third of the forearm; after division of the trunk of the posterior interosseous vessels. the flap and its elegant vascular pedicle are mobilized distally to a pivot point at the distal radio-ulnar joint, allowing the coverage of defects in the hand. 1.3 ,9.11 • Presently, 32 cases of retrograde posterior interosseous flaps are reported in the literature, I. 3. 9. 10 with only one note on the occurrence of complications (remediable venous congestion). Our own experience with 34 additional cases is of particular interest because (1) the width of the flap was increased, (2) the reach of the flap was extended distally by shifting its territory beyond the point of emergence of the most proximal septocutaneous perforator, and (3) a significant complication rate was encountered. Clinical material From September 1986 to February 1989,36 patients were scheduled for retrograde posterior interosseous flap procedures (PIF). There were 33 males and 3 females in this series . Ages ranged from 5 to 68 years, with an average of37 years. The procedures were done by four full-time hand surgeons in academic practice. The indications are listed in Table I and may be grouped into four categories: (1) acute complex skeletal and soft-tissue lesions with skin defects caused by industrial machinery (12 cases); (2) soft-tissue defects caused by degloving, crushing, or toxic necrosis, addressed postprimarily (11 cases); (3) superinfected ulcerations from animal bites or bums (5 cases); (4) conTHE JOURNAL OF HANDSURGERY
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Table I. Synopsis of data on 36 posterior interosseous flaps
Number
Age! Sl!X
I 2 3
63/M 50/M 381M
Defect, power saw injury Scar , high pressure injection Defect, grinder injury
4 5 6 7 8 9
12 13 14 15 16 17 18 190
42/M 40/F 41/M 171M 381M 42/M 261M 381M 161M 48/M 261M 511M 35/F 40/M 291M 361M
Contracture, posttraumatic Defect, power saw inj ury Defect, power saw injury Infected ulcer, formic acid Defect, explosion injury Defect, printing press Contracture, tetraplegia Defect, power saw injury Defect, explosion injury Infected defect, power saw injury Defect, planer injury Infected defect, firework Infected defect, cat bile Defect, grinder injury Massi ve crushing, press Contracture, after bum
20 21 22 23 24 25 26 270 28 29 30
48/M 511F 301M 381M 281M 201M 58/M 45/M 68/M 63/M 161M
Amputat ion, high volta ge injury Degloving injury Defect, grooving plane injury Infected defect Necrosis after crushing injury Avulsion, car crash Defect, power saw injury Massive crush ing, clay press Infected ulcer Thumb reconstruction Defect , grooving plane
II, III, IV base Midhand, dors al III, dors al Thumb web III, dorsal I II, dorsal Midhand, through Palm I I, dorsal
MP joint Proximal phalanx Middle phalanx Palm MP joint IP joint MP joint MP joint MP joint IP level Finger tip
31 32 33 34 35 36
271M 62/M 171M 231M 5/M 281M
Amputation, grooving plane Defect, grooving plane Contracture, plexus injury Contracture, posttraumatic Contracture, congenital Defect, hot press injury
I-IV I-IV, I dorsal Thumb web Palm Thumb web 1·111, through
MP level IP joint Palm Palm Palm Midhand
10 11
Indicat ion
Location of defect I, ulnar II, III radial IV, V dorsal Thumb web II, III dorsal II, III dorsal Palm I, radial Midhand, dors al Thumb web Wrist, radial Thumb web I, palmar . I, radial Midhand, dorsal Midhand, dorsal III-V, dorsal Forearm , through Thumb web
I, Thumb; II, index etc; a, a~ute; I, elective; -. none; MPP, mostproximal perforator; tunnel; 0, open; S, suture;g, ~raft; PIA, posteriorinterosseousartery. ·Child. t, One patient died of unrelated cause.
tractures of various origin treated electively (8 cases). In 27 patients, the defects lay within the "natural" arc of rotation of the PIF as described by Zan colli and colleagues I and Masquelet and Penteado." Nine patients were seen with defects distal to the interphalangeal (lP) joint of the thumb or the proximal interphalangeal (PIP) joint of the fingers. Major anatomic variations precluding the use of the PIF were encountered twice (deficient anlage of the posterior interosseous vascular system distally, anomalous origin of the relevant most proximal perforator),
0,
Distal border
Timing
IP joint Prox imal phalanx PIP joint
a
Palm Proximal phalanx Proximal phalanx MP jo int IP joint Proximal phalanx Palm Snuffbox Palm IP joint Dist al phalanx MP joint MP joint MP joint Distal one third Palm
Ana tomic pecularities Distal origin of
~IPP
a
a
a a
Nerve crossing of MPP
I
a I I
a I I
MPP origin from cornmon PIA
a Distal origin of MPP Incomplete PIA loop a a
MPP through muscle
I I I
Distal origin of MPP
a
a
posteriorinterosseous flap not raised; DRUJ. distal radioulnar joint, t,
leaving 34 continuous cases in the series. Seven minor, nonprohibitive variations were observed on the relevant, proximal perforator. These included an undesirably distal origin (4), small diameter (1), extensor digiti quinti muscle passage (1), and extensor carpi ulnaris nerve branch embracement (I). The tissue composition of the flaps comprised 30 septocutaneous, 1 fascially extended septocutaneous, and 3 fascio-subcutaneous modalities. The sizes varied from 1.5 by 4 cm to 9 by 11 cm; 20% were larger than 4 by 8 em (Fig. 1). Length measurements were taken
Vol. 16A, No.2 March 1991
Number of septocutaneous perforators
I I
2 2 I I I I I
2 I
2 I
2 I
I
2 I
2 I
1 1 2 I I I I
2 1 2 1
Retrograde posterior interosseous flap
Size width x length (cm)
Flap tip above DRUJ (cm)
3 x 6 3 x 6 3 x 8
17
g
19 16
g
Passage of pedicle
4 3 5.5 4 5 3 5 5 4 4 2 2.5 2 3 3
x x x x x x x x x x x x x x x
7 5 9 6 10 8 7 7 8 6 4 6 6 6 8
9 3 1.5 3 3 3 2
x x x x x x x
II 9 4 9 4 7 6
18 15 18 18 12 17 17
0
3 3 3 3
x x x x
7 6 5 7
17
0
19 19
0
17
0
4 2.5 4 2 3
x x x x x
6 7 8 3 6
17 14 16 9' 15
18
t
17
0
18 15 19 18 18 14 19
0
17
0
19 14 15 14 10
Closure of donor site
Complications
Bleeding, ischemia Bleeding, infection, ischemia Congestion. ischemia
Extent of necrosis
Goalofflap procedure met? (yes/no)
30% loss 30% loss
Yes Yes
30% loss
No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
g
0 0
g
t
S
0
s
t
S
0
g s s s s s
0 0
t
Congestion, bleeding
Ischemia, infection
10% loss
0
0 0
g s s
t Congestion, dehiscence
0 0 0
285
g g s
Ischemia, infection
80% loss
g
Congestion, infection
50% loss
g
PIA cut, repaired, congestion Bleeding, ischemia
50% loss
t
Yes Yes Yes Yes No Yes Yes No Yes Yes No Yes Yes Yes Yes
according to Fig. 2. The total length (distance m) ranged from 10 to 19 em, the length of the vascular pedicle (distance b) from 2 to 15 em (see Table I for details). Donor defects smaller in width than 3 em were always closed by suture, those greater than 5 em all required skin grafts. Operative time required ranged between I and 3 hours.
terventions relating to the flap procedures were recorded. One patient died a few weeks after the initial surgery (repeated suicide attempts); all of the other patients could be observed until the definitive result was established and evaluated. The average follow-up time was 11 months (range, 5 to 24 months).
Methods
Five types of technical mistakes were noted: (1) inadequate debridement of the wound edge before flap application with subsequent minor skin necrosis adja-
Healing of the flaps was assessed clinically at regular intervals. All complications, as well as secondary in-
Results
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width in em 10
8
6 6-
l:::.
t::::,6.
~A
A
6.t::::.6.
6-
l:::.O At A
A 6.
6.l:::.A
66-
t::::,6.
4
l:::.
l:::.
2
t::::,6.
O'------'-------L.----'---------''------'-------L.-------' 12 14 4 6 8 10 o 2
length in em F ig. 1. Dimensions and structure of 34 retrograde posterior interosseous naps . 11. Septocutaneous configuration; D. septo-fascio-subcutanous modali ty; .... cases with partial necrosis . The leng th corresponds to distance a in Fig. 2.
" r.c------- b
_
c ------=':lo.l
,
-----FASCIA
PosrERIOR INr"ROSSEOUS
VASCU£AR PcOICL£
Fig. 2. Geometry of distally based posterior interosseous naps. Important factors: (a ), Length of the nap island; (b) , length of the vascular pedicle; (c), total length; (d). extent of the septocutaneous territory .
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Retrograde posterior interosseous flap
Fig. 3. Anatomic variation prohibiting the use of a retrograde PIF: Absence of septocutaneous perforators in the middle and proximal third of the forearm , except one skin branch originating from the common interosseous artery. Left forearm, dorsal aspect.
Fig. 4. Most proximal relevant perforator originating far distally, requiring a fascial extension of ,h,. "",rli,..1" nf " P IF I "ft fnr""nn nn""l vjr-w.
287
288
BUchler and Frey
cent to the flap (patient 18); (2) inadequate debridement of wound depth leading to scar contracture beneath the flap (patients 12 and 13); (3) inadequate width of the flap causing a benign wound or flap dehiscence (patient 22); (4) inadvertent injury to the posterior interosseus artery requiring microvascular repair, followed by uneventful healing (patient 25); and (5) inadequate hemostasis along the pedicle necessitating revision and drainage (patients 2, 3, 4 and 14). There was no total loss of a flap in this series. However, after a tendency towards venous congestion, 7 (21%) of the 34 flaps developed partial ischemic necrosis. This was localized at the periphery of the perfusion perimeter of the relevant septocutaneous perforator, i.e., distally in the hand and comprised between 10% and 80% of the flap surface. In three of the seven patients, venous engorgement and ischemia were accompanied by compression of the pedicle and in four patients, ischemia was associated to infection. Minor defects resulting from debridement of necrotic PIF areas healed with split-thickness skin grafting on three occasions. Major partial necroses (four cases [12%» required a cross-finger flap and three groin flaps. At the time of final evaluation, all recipient flap sites had healed. Ten (29%) flaps were thicker than desired, 6 (18%) showed some shrinkage and 4 (12%) demonstrated slight circumferential scar contracture. Unsatisfactory color match was noted in 3 (9%) hands. Hirsute forearms produced 4 (12%) conspicuously hairy flaps. The only flap with nerve suture (patient 29, with infection and 15% necrosis) did not become innervated. The donor areas showed broad scar lines in two patients. The majority of the flaps showed excellent adaptation to the recipient site and most donor incisions were linear. There was no instance of vascular disturbance or neurological deficit in the forearm or the hand, nor did we observe cramping, pain, weakness, or limited gliding capacity in theextensor digiti quinti or the extensor carpi ulnaris. All of the patients were pleased with the results, even those who had experienced problems or complications. Discussion The anatomy of the posterior interosseus artery system and its variations are well established in the literature.':" In our material, anomalies precluding the use of a retrograde PIF were encountered on two occasions. In patient 27, the posterior interosseus artery system was seen to "run out" in the distal one third of the forearm, as demonstrated in 5.7% of Penteado's cadaveric dissections." Patient 19 was seen with a hitherto undescribed anomaly (Fig. 3).
The Journal of HAND SURGERY
As one tries to extend the distal arch of rotation of the retrograde PIF by increasing its total length, several problems may be encountered: (I) reduced chance for including two or more septocutaneous perforators in the unit, (2) enhanced risk of having the flap island at some distance proximal to the fascial point of emergence of the most proximal relevant septocutaneous perforator, (3) increased likelihood of aggravating anatomical variations, (4) increased hazard of interference with the nerve branch to the extensor carpi ulnaris. The most proximal relevant perforator (MPRP) is usually a large cutaneous branch located 5 to 11.5 ern from the radiohumeral epicondyle. 2 • 6 • 11 In this series, the majority of the MPRP originated from the descending branch of the posterior interosseus artery within 2 to 3 em of its emergence; an extremely distal origin is shown in Fig. 4. In 23%, the MP~P had its offset from the ascending interosseus recurrent artery as demonstrated in Fig. 5 and recently described by other authors. 10 While septocutaneous perforators are contained within the double sheet of the septum between the extensor carpi ulnaris and the extensor digiti quinti within the middle and distal thirds of the forearm, they tend to vary in more proximal locations. One MPRP passed through the muscle belly of the extensor quinti, another one surfaced at the radial aspect of this muscle unit. The dimension of the fascial territory surviving on a single posterior interosseous artery system perforator has not been determined, nor has the size, shape, and relative position of the skin island that might safely be supported by one defined septo-fascial mediator of blood supply. Masqueler' considered it hazardous to extend the skin island more than 3 ern above the point of emergence of the MPRP. In our series, that distance was often greater than 5 cm with no obvious detriment to flap survival. At the distal end of the posterior interosseus artery, at least two of three communicating branches were always present: (1) the transverse anastomotic artery to the dorsal branch of the anterior interosseus artery (reported to be absent in 1.4% by Penteado? and 2.9% by Bayon and Pho ll ) was consistently present in our series; (2) the branch continuing straight to the rete carpi dorsale was found in about 80% of the preparations; (3) a communicating twig to the dorsal branch of the ulnar artery at the neck of the ulna was observed in roughly half of the patients. Except for patient 18 (defect at the dorsal distal forearm), all of the flaps were pivoted around the fifth dorsal compartment at the distal radioulnar joint; we did not carry the dissection distally to the dorsal branch of the anterior interosseus artery as recently proposed by Bayon and Pho, II who obtained
Vol. 16A, No.2 March 1991
Retrograde posterior interosseous flap
289
Fig. 5. Patient with offset of the relevant perforator from the recurrent branch of the posterior interosseous artery, seen as musculocutaneous perforating branch. Right forearm, dorsal aspect.
additional 1.2 to 3.7 ern of pedicle length in 91% of anatomy laboratory dissections. The venous outflow of the distally based PIF is forced in a retrograde direction through the venae comitantes, the exact anatomy of which is not yet investigated. Drainage may be impeded not only by valves and crisscross flow through the venous network, but also by inadequate passage of the pedicle, insufficient drainage thereof, stretching, rotation and kinking, or tight closure of the donor defect. The branches of the posterior interosseous nerve supplying the epicondylar muscles pass superficial to the ascending branch of the posterior interosseous artery" 10 whereas the nerve branch(es) to the extensor carpi ulnaris relate intimately to the MPRP as seen in Fig. 6. Type A allowed straightforward dissection in 92% of the cases. Type B, with two closely spaced septocutaneous perforators framing the ECU nerve branch, was seen in five patients; four times, the interlacing proximal perforator was ligated, in one case the nerve was divided and sutured. Type C was seen with a short, tightly fixed ECU nerve branch that interlaced with the only available vascular support of the flap in two dissections; we did not raise the flap on one occasion and proceeded with neurotomy and nerve repair in the other case. Both neurorhaphies were followed by prompt reinnervation to the M4 + level within 3 months. The significant complication rate of this series contrasts with the low incidence of postoperative problems reported in the literature; remediable venous congestion
occurred in 1 of 20 retrograde flaps of Zancolli and Angrigianni,? and in none of 12 cases in the series of Masquelet and Penteado" and Costa and Soutar.'? An incidence of 21 % of partial ischemicnecrosis prompted us to investigate several factors possibly influencing the survival of long retrograde posterior interosseous flaps (Table II). Statistical analysis, using Fisher's exact onetailed test, revealed the following: Width, length, or surface area were not shown to influence the likelihood of flap survival (see Fig. 1). All of the wide flaps survived entirely, including an island 9 by 11 em. While circular tightness from closure of donor defects wider than 5 em by direct suture caused some venous congestion in the hand, it did not endanger flap survival. Confirming the favorable reports in the literature on fascial forearm flaps, II all of the three fascial flaps survived entirely and supported the skin grafts used for epidermal coverage. A tendency towards partial necrosis with increasing length of the flap units was not statistically relevant. Success or partial failure were not related to the number of perforators included in the flap design. Anomalies presented no significant risk factor. The experience of the surgeon did not bear on flap survival. Closed passage of the flap, although entailing a risk of tightness, kinking, zig-zag course, or stretching was not significantly related to partial necrosis, nor was an observation of venous congestion. However, a delay in perfusion after release of the tourniquet and bleeding from the pedicle with hematoma formation proved to be significant elements of flap survival. Prein-
290
The Journal of HAND SURGERY
Bachler lind Frey
I'1PRP
J1PRP /1PRP
a
b
c
Fig•.,6. Three types of relation of the extensor carpi ulnaris (ECU) nerve branch (NERVE) to the descending branch of the posterior interosseous artery (PIA) and its most proximal relevant scptocutaneous perforator (MPRP) . Wh ile type a permits simple dissection. type b may require ligation of the MPRP, use of the adj acent perforator and a fascial extension of the pedicle ; in type c, neurotomy and repair of the ECU nerve branch are recommended. Right forearm, dorsal view. EDQ. Extensor digiti quinti muscle.
fected wounds may have a higher incidence of ischemic flap complications than clean ones. How far distally, a posterior interosseous flap wiII safely reach on its pedicle is yet undetermined. The PIP joint area of the long finger was routinely reached. With better understanding of the depth and the predominant direction of the vascular plexus at the superficial fascia and within the subcorial layer, improvements in flap design may be anticipated. By raising and transposing just the fascial and subcutaneous layers of the flap, taking advantage of their lower oxygen demands, further length and/or safety may be gained. The most promising increase in length however, may be provided by carrying the dissection distally along the transverse anastomotic branch as described by Bayon and Pho. II As a result of our experience, the suggested technique for raising a retrograde PIF is as follows: It is helpful to use Doppler mapping to determine the point of emergence of the posterior interosseous artery, especially the presence or absence of the ascending branch, and (by using alternate compression) the competence of the loop system. The operation is done with the patient under axiIIary plexus anasthesia on a moderately exsanguinated arm under tourniquet control. With the elbow flexed to 90 degrees, a line is drawn from the fifth dorsal compartment over the wrist to the radial humeral epicondyle. A point 7.5 to 9.5 ern distal to the latter
landmark is made the center of the flap. If this does not provide sufficient length, the theoretically required position of the island is drawn. The incision is made in the distal half of the forearm I ern radial to' the longitudinal line for safe identification of the septocutanous perforators. The fascia is then incised over the extensor quinti about 5 mm radial to the dense fascial line from which the septocutaneous perforators emerge. At the juncture of the intermuscular septum , the posterior interosseous artery and its venae comitantes are identified. After mobilizing the extensor quinti radially, the continuity of the distal vascular loop is assessed. If this is adequately present, the incision is carried into the proximal forearm along the radial delineation of the flap. One wiII find a firm blending of the forearm fascia to the common tendon of origin of the extensor quinti, extensor ,carpi ulnaris, and extensor digitorum communis. While the extensor quinti is mobilized away from the septum, proceeding in a proximal direction, muscle branches of the posterior interosseous artery system are atraumatically occluded and divided, until the entire course of the vascular loop, its recurrent interosseous branch, and all of the nerve branches are visualized. It is then time to identify the one or two most proximal relevant septocutaneous perforators and decide on the relative position of the flap island with respect to these skin branches . The flap modality (cutaneous, subcutaneous, or purely fascial) is then finally
Vol. 16A, No.2 March 1991
Retrograde posterior interosseous flap
291
Table II. Factors in survival of posterior interosseous flaps and statistical analysis
Width of nap territory Length of nap territory Type of nap
3 em or less Larger than 3 em 6 ern or longer Less than 6 em Fascial
Fasciocutaneous Distance from nap tip to DRUJt Number of perforators Anatomic anomalies Experience of surgeon Passage of pedicle Age of the patient Infection Venous congestion of nap Delay in perfusion after release of tourniquet Bleeding and/or compression of pedicle
17 cm or shorter Longer than 17 ern 2 or more 1 or not specified Regular anatomy Significant anomaly 4th case or more First three cases Open Closed 40 or under More than 40 No Yes No Yes No Yes No Yes
Statistical relevance (yes/no)
Survived
Partial
n=
n=
p value'
15 12 13 14 3 24 10 17 9 18 24 3 21 6 17 10 18 9 22 5 24 3 25 2 26 I
5 2 3 4 0 7 3 4 I 6 4 3 3 4 2 5 3 5 3 4 5 2 4 3 4 3
0.38
No
0.57
No
0.48
No
0.76
No
0.31
No
0.09
No
0.09
No
0.11
No
0.14
No
0.061
No
0.95
No
0.048
Yes
0.021
Yes
'Stat Graphics by STSC. Version 2.6 (1987) contingency tables. Fisher's exact test (one-tail), tdruj. Distal radioulnar joint.
selected. If perforators with an origin from the recurrent interosseous branch are used, anatomic variants must be recognized before the posterior interosseous artery and veins are ligated and nerve branches completely freed. Next, the ulnar side of the flap is delineated and the fascia over the extensor carpi ulnaris incised longitudinally, taking care to stay away from the juncture of the intermuscular septum. The muscle belly of the extensor carpi ulnaris is drawn ulnarly and muscle branches are ligated as outlined. Finally, the intermuscular septum is divided at a reasonable distance from the PMRP, through the site of division of the posterior interosseus vessels, and deep to its descending branch to the level of the distal radioulnar joint. On release of the tourniquet, flushing of the flap is awaited, and meticulous hemostasis obtained. If a closed passage is chosen, it should be straight, wide, and adequately drained. The features of the distally based, retrograde posterior interosseous flap as compared to those of other commonly used alternate methods of coverage, the Chinese forearm flap, the internal cubital flap, the axial
pedicled groin flap and any free flap, are summarized in Table III. The main advantages include its fineness, its excellent texture and color match, its easy accessability, and its minimal donor morbidity. Disadvantages are limitation of distal reach, technical difficulty, and susceptibility to partial necrosis. REFERENCES I. Zancolli EA, Angrigianni C. Colgajo dorsal de antebrazo (en "isla" con pediculo de vasos interoseos posteriores). Rev Asoc Arg Ortop Traumatol 1986;51:161-8. 2. Penteado CV, Masquelet AC, Chevrel JP. The anatomic basis of the fascio-cutaneous flap of the posterior interosseus artery. Surg Radiol Anat 1986;8:209-15. 3. Masquelet AC, Pcnteado CV. Le lambeau interosseux posterieur, Ann Chir Main 1987;6:131-9. 4. Testut L. Traite d'anatomie humaine. Tome 2. Paris: Doin, 1890. 5. Manchot C. Die Hautarterien des menschlichen Korpers (1898). The cutaneous arteries of the human body. New York: Springer, 1983. 6. Salmon M. Arteres de la peau. Paris: Masson, 1936. 7. Valdecasas-Huelin JMG, Barreiro FJJ, Barcia EC. Etude
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Table III. Features of the posterior interosseous flap and comparison with other commonly utilized flaps
I
Flap Size: length width Texture conformity Color match Fineness Absence of hair Sensibility Dissection Same field Consistency of anatomy Technical simplicity OR time Reach Proximally Distally Complications, resistance against infection Donor deficit functional Vascularity of hand Vascularity of forearm Safety for maintenance of nerve supply Esthetic Conspicuousness Aspect Other Elevation of ann Mobilization of wrist, thumb, digits
PIF
I
++ + + ++ ++
Chinese
I
++ ++ + +
+ +
Groin
++ ++
+
I
Free dorsalis pedis
+ ++ + + + + +
?
+ ++ + +
++ +
++
+ +
++ ++ +
++ ++ ++
++ ++
++ ++ +
+
++
+ +
++
++ ++ ++
+
++
+ +
+
++ ++ ++
++
+
++ ++
+ + ++ ++
Flaps., PIF. Posterior interosseous flap; Chinese. radial forearm flap: groin. axial pedicled groin flap. - - From maximum disadvantage to + + maximum advantage.
radio-anatomique des artercs interosseuses. Acta Anat 1978;102:147-56. 8. Lamberty BGH, Cormack GC. The forearm angiotomes . Br J Plast Surg 1982;35:420-9. 9. Zancolli EA,. Angrigianni C. Posterior interosseous island forearm flap. J HAND SURG 1988;138 :130-5. 10. Costa H, Soutar OS. The distally based island posterior interosseus flap. Dr J Plast Surg 1988;41:221-7.
11. 8ayon P, Pho RWH. Anatomical basis of dorsal forearm flap. J HAND SURG 1988;13B:435-9 . 12. Schoofs M, Bienfait 8, Calteux N, Dachy C, Van Dermaeren CA, De Coninck A. Le lambeau aponevrotique de l'avant-bras. Ann Chir Main 1983;3:197-201.
Ueli BUchler, MD, and Hans-Peter Frey, MD, Bern. Switzerland
Since the first report on the posterior interosseous forearm flap by Zancolli and Angrigiani' and the description of its anatomic basis by Penteado and colleagues? in 1986, the procedure has evoked great interest among upper extremity surgeons. It is now increasingly considered as an alternative to the Chinese forearm flap. the pedicled axial groin flap. the free lateral arm flap. or other regional and distant flaps. The skin, subcutaneous layer, and the fascia along the dorso-ulnar aspect of the forearm are nourished by multiple septocutaneous perforators that originate segmentally from the posterior interosseous vessels and surface between the muscles and tendons of the extensor carpi ulnaris and the extensor digiti quinti ."" The distal termination of the posterior interosseous system connects to the vascular network of the wrist, particularly to the dorsal branches of the anterior interosseous artery 'and vein. Because this collateral sxstem transmits reversed arterial and venous blood flow. septocutaneous posterior interosseous island flaps may be based either
From the Division of Hand Surgery, Inselspital, University of Bern . Switzerland . Received for publication Nov. 28. 1989, accepted in revised form Feb. 28. 1990. . No benefits in any form have been received or will be received from a commerc ial party related directly or indirectly to the subject of this article. Reprint requests: PO Dr. med. Ueli BUchler, Chief of Hand Surgery, Inselspital Bern. Freiburgstrasse, CH-3010 Bern, Switzerland. 3/1/22363
proximally or distally. In the retrograde dissection modality. the flap is taken from the proximal third of the forearm; after division of the trunk of the posterior interosseous vessels. the flap and its elegant vascular pedicle are mobilized distally to a pivot point at the distal radio-ulnar joint, allowing the coverage of defects in the hand. 1.3 ,9.11 • Presently, 32 cases of retrograde posterior interosseous flaps are reported in the literature, I. 3. 9. 10 with only one note on the occurrence of complications (remediable venous congestion). Our own experience with 34 additional cases is of particular interest because (1) the width of the flap was increased, (2) the reach of the flap was extended distally by shifting its territory beyond the point of emergence of the most proximal septocutaneous perforator, and (3) a significant complication rate was encountered. Clinical material From September 1986 to February 1989,36 patients were scheduled for retrograde posterior interosseous flap procedures (PIF). There were 33 males and 3 females in this series . Ages ranged from 5 to 68 years, with an average of37 years. The procedures were done by four full-time hand surgeons in academic practice. The indications are listed in Table I and may be grouped into four categories: (1) acute complex skeletal and soft-tissue lesions with skin defects caused by industrial machinery (12 cases); (2) soft-tissue defects caused by degloving, crushing, or toxic necrosis, addressed postprimarily (11 cases); (3) superinfected ulcerations from animal bites or bums (5 cases); (4) conTHE JOURNAL OF HANDSURGERY
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Table I. Synopsis of data on 36 posterior interosseous flaps
Number
Age! Sl!X
I 2 3
63/M 50/M 381M
Defect, power saw injury Scar , high pressure injection Defect, grinder injury
4 5 6 7 8 9
12 13 14 15 16 17 18 190
42/M 40/F 41/M 171M 381M 42/M 261M 381M 161M 48/M 261M 511M 35/F 40/M 291M 361M
Contracture, posttraumatic Defect, power saw inj ury Defect, power saw injury Infected ulcer, formic acid Defect, explosion injury Defect, printing press Contracture, tetraplegia Defect, power saw injury Defect, explosion injury Infected defect, power saw injury Defect, planer injury Infected defect, firework Infected defect, cat bile Defect, grinder injury Massi ve crushing, press Contracture, after bum
20 21 22 23 24 25 26 270 28 29 30
48/M 511F 301M 381M 281M 201M 58/M 45/M 68/M 63/M 161M
Amputat ion, high volta ge injury Degloving injury Defect, grooving plane injury Infected defect Necrosis after crushing injury Avulsion, car crash Defect, power saw injury Massive crush ing, clay press Infected ulcer Thumb reconstruction Defect , grooving plane
II, III, IV base Midhand, dors al III, dors al Thumb web III, dorsal I II, dorsal Midhand, through Palm I I, dorsal
MP joint Proximal phalanx Middle phalanx Palm MP joint IP joint MP joint MP joint MP joint IP level Finger tip
31 32 33 34 35 36
271M 62/M 171M 231M 5/M 281M
Amputation, grooving plane Defect, grooving plane Contracture, plexus injury Contracture, posttraumatic Contracture, congenital Defect, hot press injury
I-IV I-IV, I dorsal Thumb web Palm Thumb web 1·111, through
MP level IP joint Palm Palm Palm Midhand
10 11
Indicat ion
Location of defect I, ulnar II, III radial IV, V dorsal Thumb web II, III dorsal II, III dorsal Palm I, radial Midhand, dors al Thumb web Wrist, radial Thumb web I, palmar . I, radial Midhand, dorsal Midhand, dorsal III-V, dorsal Forearm , through Thumb web
I, Thumb; II, index etc; a, a~ute; I, elective; -. none; MPP, mostproximal perforator; tunnel; 0, open; S, suture;g, ~raft; PIA, posteriorinterosseousartery. ·Child. t, One patient died of unrelated cause.
tractures of various origin treated electively (8 cases). In 27 patients, the defects lay within the "natural" arc of rotation of the PIF as described by Zan colli and colleagues I and Masquelet and Penteado." Nine patients were seen with defects distal to the interphalangeal (lP) joint of the thumb or the proximal interphalangeal (PIP) joint of the fingers. Major anatomic variations precluding the use of the PIF were encountered twice (deficient anlage of the posterior interosseous vascular system distally, anomalous origin of the relevant most proximal perforator),
0,
Distal border
Timing
IP joint Prox imal phalanx PIP joint
a
Palm Proximal phalanx Proximal phalanx MP jo int IP joint Proximal phalanx Palm Snuffbox Palm IP joint Dist al phalanx MP joint MP joint MP joint Distal one third Palm
Ana tomic pecularities Distal origin of
~IPP
a
a
a a
Nerve crossing of MPP
I
a I I
a I I
MPP origin from cornmon PIA
a Distal origin of MPP Incomplete PIA loop a a
MPP through muscle
I I I
Distal origin of MPP
a
a
posteriorinterosseous flap not raised; DRUJ. distal radioulnar joint, t,
leaving 34 continuous cases in the series. Seven minor, nonprohibitive variations were observed on the relevant, proximal perforator. These included an undesirably distal origin (4), small diameter (1), extensor digiti quinti muscle passage (1), and extensor carpi ulnaris nerve branch embracement (I). The tissue composition of the flaps comprised 30 septocutaneous, 1 fascially extended septocutaneous, and 3 fascio-subcutaneous modalities. The sizes varied from 1.5 by 4 cm to 9 by 11 cm; 20% were larger than 4 by 8 em (Fig. 1). Length measurements were taken
Vol. 16A, No.2 March 1991
Number of septocutaneous perforators
I I
2 2 I I I I I
2 I
2 I
2 I
I
2 I
2 I
1 1 2 I I I I
2 1 2 1
Retrograde posterior interosseous flap
Size width x length (cm)
Flap tip above DRUJ (cm)
3 x 6 3 x 6 3 x 8
17
g
19 16
g
Passage of pedicle
4 3 5.5 4 5 3 5 5 4 4 2 2.5 2 3 3
x x x x x x x x x x x x x x x
7 5 9 6 10 8 7 7 8 6 4 6 6 6 8
9 3 1.5 3 3 3 2
x x x x x x x
II 9 4 9 4 7 6
18 15 18 18 12 17 17
0
3 3 3 3
x x x x
7 6 5 7
17
0
19 19
0
17
0
4 2.5 4 2 3
x x x x x
6 7 8 3 6
17 14 16 9' 15
18
t
17
0
18 15 19 18 18 14 19
0
17
0
19 14 15 14 10
Closure of donor site
Complications
Bleeding, ischemia Bleeding, infection, ischemia Congestion. ischemia
Extent of necrosis
Goalofflap procedure met? (yes/no)
30% loss 30% loss
Yes Yes
30% loss
No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
g
0 0
g
t
S
0
s
t
S
0
g s s s s s
0 0
t
Congestion, bleeding
Ischemia, infection
10% loss
0
0 0
g s s
t Congestion, dehiscence
0 0 0
285
g g s
Ischemia, infection
80% loss
g
Congestion, infection
50% loss
g
PIA cut, repaired, congestion Bleeding, ischemia
50% loss
t
Yes Yes Yes Yes No Yes Yes No Yes Yes No Yes Yes Yes Yes
according to Fig. 2. The total length (distance m) ranged from 10 to 19 em, the length of the vascular pedicle (distance b) from 2 to 15 em (see Table I for details). Donor defects smaller in width than 3 em were always closed by suture, those greater than 5 em all required skin grafts. Operative time required ranged between I and 3 hours.
terventions relating to the flap procedures were recorded. One patient died a few weeks after the initial surgery (repeated suicide attempts); all of the other patients could be observed until the definitive result was established and evaluated. The average follow-up time was 11 months (range, 5 to 24 months).
Methods
Five types of technical mistakes were noted: (1) inadequate debridement of the wound edge before flap application with subsequent minor skin necrosis adja-
Healing of the flaps was assessed clinically at regular intervals. All complications, as well as secondary in-
Results
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width in em 10
8
6 6-
l:::.
t::::,6.
~A
A
6.t::::.6.
6-
l:::.O At A
A 6.
6.l:::.A
66-
t::::,6.
4
l:::.
l:::.
2
t::::,6.
O'------'-------L.----'---------''------'-------L.-------' 12 14 4 6 8 10 o 2
length in em F ig. 1. Dimensions and structure of 34 retrograde posterior interosseous naps . 11. Septocutaneous configuration; D. septo-fascio-subcutanous modali ty; .... cases with partial necrosis . The leng th corresponds to distance a in Fig. 2.
" r.c------- b
_
c ------=':lo.l
,
-----FASCIA
PosrERIOR INr"ROSSEOUS
VASCU£AR PcOICL£
Fig. 2. Geometry of distally based posterior interosseous naps. Important factors: (a ), Length of the nap island; (b) , length of the vascular pedicle; (c), total length; (d). extent of the septocutaneous territory .
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Retrograde posterior interosseous flap
Fig. 3. Anatomic variation prohibiting the use of a retrograde PIF: Absence of septocutaneous perforators in the middle and proximal third of the forearm , except one skin branch originating from the common interosseous artery. Left forearm, dorsal aspect.
Fig. 4. Most proximal relevant perforator originating far distally, requiring a fascial extension of ,h,. "",rli,..1" nf " P IF I "ft fnr""nn nn""l vjr-w.
287
288
BUchler and Frey
cent to the flap (patient 18); (2) inadequate debridement of wound depth leading to scar contracture beneath the flap (patients 12 and 13); (3) inadequate width of the flap causing a benign wound or flap dehiscence (patient 22); (4) inadvertent injury to the posterior interosseus artery requiring microvascular repair, followed by uneventful healing (patient 25); and (5) inadequate hemostasis along the pedicle necessitating revision and drainage (patients 2, 3, 4 and 14). There was no total loss of a flap in this series. However, after a tendency towards venous congestion, 7 (21%) of the 34 flaps developed partial ischemic necrosis. This was localized at the periphery of the perfusion perimeter of the relevant septocutaneous perforator, i.e., distally in the hand and comprised between 10% and 80% of the flap surface. In three of the seven patients, venous engorgement and ischemia were accompanied by compression of the pedicle and in four patients, ischemia was associated to infection. Minor defects resulting from debridement of necrotic PIF areas healed with split-thickness skin grafting on three occasions. Major partial necroses (four cases [12%» required a cross-finger flap and three groin flaps. At the time of final evaluation, all recipient flap sites had healed. Ten (29%) flaps were thicker than desired, 6 (18%) showed some shrinkage and 4 (12%) demonstrated slight circumferential scar contracture. Unsatisfactory color match was noted in 3 (9%) hands. Hirsute forearms produced 4 (12%) conspicuously hairy flaps. The only flap with nerve suture (patient 29, with infection and 15% necrosis) did not become innervated. The donor areas showed broad scar lines in two patients. The majority of the flaps showed excellent adaptation to the recipient site and most donor incisions were linear. There was no instance of vascular disturbance or neurological deficit in the forearm or the hand, nor did we observe cramping, pain, weakness, or limited gliding capacity in theextensor digiti quinti or the extensor carpi ulnaris. All of the patients were pleased with the results, even those who had experienced problems or complications. Discussion The anatomy of the posterior interosseus artery system and its variations are well established in the literature.':" In our material, anomalies precluding the use of a retrograde PIF were encountered on two occasions. In patient 27, the posterior interosseus artery system was seen to "run out" in the distal one third of the forearm, as demonstrated in 5.7% of Penteado's cadaveric dissections." Patient 19 was seen with a hitherto undescribed anomaly (Fig. 3).
The Journal of HAND SURGERY
As one tries to extend the distal arch of rotation of the retrograde PIF by increasing its total length, several problems may be encountered: (I) reduced chance for including two or more septocutaneous perforators in the unit, (2) enhanced risk of having the flap island at some distance proximal to the fascial point of emergence of the most proximal relevant septocutaneous perforator, (3) increased likelihood of aggravating anatomical variations, (4) increased hazard of interference with the nerve branch to the extensor carpi ulnaris. The most proximal relevant perforator (MPRP) is usually a large cutaneous branch located 5 to 11.5 ern from the radiohumeral epicondyle. 2 • 6 • 11 In this series, the majority of the MPRP originated from the descending branch of the posterior interosseus artery within 2 to 3 em of its emergence; an extremely distal origin is shown in Fig. 4. In 23%, the MP~P had its offset from the ascending interosseus recurrent artery as demonstrated in Fig. 5 and recently described by other authors. 10 While septocutaneous perforators are contained within the double sheet of the septum between the extensor carpi ulnaris and the extensor digiti quinti within the middle and distal thirds of the forearm, they tend to vary in more proximal locations. One MPRP passed through the muscle belly of the extensor quinti, another one surfaced at the radial aspect of this muscle unit. The dimension of the fascial territory surviving on a single posterior interosseous artery system perforator has not been determined, nor has the size, shape, and relative position of the skin island that might safely be supported by one defined septo-fascial mediator of blood supply. Masqueler' considered it hazardous to extend the skin island more than 3 ern above the point of emergence of the MPRP. In our series, that distance was often greater than 5 cm with no obvious detriment to flap survival. At the distal end of the posterior interosseus artery, at least two of three communicating branches were always present: (1) the transverse anastomotic artery to the dorsal branch of the anterior interosseus artery (reported to be absent in 1.4% by Penteado? and 2.9% by Bayon and Pho ll ) was consistently present in our series; (2) the branch continuing straight to the rete carpi dorsale was found in about 80% of the preparations; (3) a communicating twig to the dorsal branch of the ulnar artery at the neck of the ulna was observed in roughly half of the patients. Except for patient 18 (defect at the dorsal distal forearm), all of the flaps were pivoted around the fifth dorsal compartment at the distal radioulnar joint; we did not carry the dissection distally to the dorsal branch of the anterior interosseus artery as recently proposed by Bayon and Pho, II who obtained
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Retrograde posterior interosseous flap
289
Fig. 5. Patient with offset of the relevant perforator from the recurrent branch of the posterior interosseous artery, seen as musculocutaneous perforating branch. Right forearm, dorsal aspect.
additional 1.2 to 3.7 ern of pedicle length in 91% of anatomy laboratory dissections. The venous outflow of the distally based PIF is forced in a retrograde direction through the venae comitantes, the exact anatomy of which is not yet investigated. Drainage may be impeded not only by valves and crisscross flow through the venous network, but also by inadequate passage of the pedicle, insufficient drainage thereof, stretching, rotation and kinking, or tight closure of the donor defect. The branches of the posterior interosseous nerve supplying the epicondylar muscles pass superficial to the ascending branch of the posterior interosseous artery" 10 whereas the nerve branch(es) to the extensor carpi ulnaris relate intimately to the MPRP as seen in Fig. 6. Type A allowed straightforward dissection in 92% of the cases. Type B, with two closely spaced septocutaneous perforators framing the ECU nerve branch, was seen in five patients; four times, the interlacing proximal perforator was ligated, in one case the nerve was divided and sutured. Type C was seen with a short, tightly fixed ECU nerve branch that interlaced with the only available vascular support of the flap in two dissections; we did not raise the flap on one occasion and proceeded with neurotomy and nerve repair in the other case. Both neurorhaphies were followed by prompt reinnervation to the M4 + level within 3 months. The significant complication rate of this series contrasts with the low incidence of postoperative problems reported in the literature; remediable venous congestion
occurred in 1 of 20 retrograde flaps of Zancolli and Angrigianni,? and in none of 12 cases in the series of Masquelet and Penteado" and Costa and Soutar.'? An incidence of 21 % of partial ischemicnecrosis prompted us to investigate several factors possibly influencing the survival of long retrograde posterior interosseous flaps (Table II). Statistical analysis, using Fisher's exact onetailed test, revealed the following: Width, length, or surface area were not shown to influence the likelihood of flap survival (see Fig. 1). All of the wide flaps survived entirely, including an island 9 by 11 em. While circular tightness from closure of donor defects wider than 5 em by direct suture caused some venous congestion in the hand, it did not endanger flap survival. Confirming the favorable reports in the literature on fascial forearm flaps, II all of the three fascial flaps survived entirely and supported the skin grafts used for epidermal coverage. A tendency towards partial necrosis with increasing length of the flap units was not statistically relevant. Success or partial failure were not related to the number of perforators included in the flap design. Anomalies presented no significant risk factor. The experience of the surgeon did not bear on flap survival. Closed passage of the flap, although entailing a risk of tightness, kinking, zig-zag course, or stretching was not significantly related to partial necrosis, nor was an observation of venous congestion. However, a delay in perfusion after release of the tourniquet and bleeding from the pedicle with hematoma formation proved to be significant elements of flap survival. Prein-
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The Journal of HAND SURGERY
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I'1PRP
J1PRP /1PRP
a
b
c
Fig•.,6. Three types of relation of the extensor carpi ulnaris (ECU) nerve branch (NERVE) to the descending branch of the posterior interosseous artery (PIA) and its most proximal relevant scptocutaneous perforator (MPRP) . Wh ile type a permits simple dissection. type b may require ligation of the MPRP, use of the adj acent perforator and a fascial extension of the pedicle ; in type c, neurotomy and repair of the ECU nerve branch are recommended. Right forearm, dorsal view. EDQ. Extensor digiti quinti muscle.
fected wounds may have a higher incidence of ischemic flap complications than clean ones. How far distally, a posterior interosseous flap wiII safely reach on its pedicle is yet undetermined. The PIP joint area of the long finger was routinely reached. With better understanding of the depth and the predominant direction of the vascular plexus at the superficial fascia and within the subcorial layer, improvements in flap design may be anticipated. By raising and transposing just the fascial and subcutaneous layers of the flap, taking advantage of their lower oxygen demands, further length and/or safety may be gained. The most promising increase in length however, may be provided by carrying the dissection distally along the transverse anastomotic branch as described by Bayon and Pho. II As a result of our experience, the suggested technique for raising a retrograde PIF is as follows: It is helpful to use Doppler mapping to determine the point of emergence of the posterior interosseous artery, especially the presence or absence of the ascending branch, and (by using alternate compression) the competence of the loop system. The operation is done with the patient under axiIIary plexus anasthesia on a moderately exsanguinated arm under tourniquet control. With the elbow flexed to 90 degrees, a line is drawn from the fifth dorsal compartment over the wrist to the radial humeral epicondyle. A point 7.5 to 9.5 ern distal to the latter
landmark is made the center of the flap. If this does not provide sufficient length, the theoretically required position of the island is drawn. The incision is made in the distal half of the forearm I ern radial to' the longitudinal line for safe identification of the septocutanous perforators. The fascia is then incised over the extensor quinti about 5 mm radial to the dense fascial line from which the septocutaneous perforators emerge. At the juncture of the intermuscular septum , the posterior interosseous artery and its venae comitantes are identified. After mobilizing the extensor quinti radially, the continuity of the distal vascular loop is assessed. If this is adequately present, the incision is carried into the proximal forearm along the radial delineation of the flap. One wiII find a firm blending of the forearm fascia to the common tendon of origin of the extensor quinti, extensor ,carpi ulnaris, and extensor digitorum communis. While the extensor quinti is mobilized away from the septum, proceeding in a proximal direction, muscle branches of the posterior interosseous artery system are atraumatically occluded and divided, until the entire course of the vascular loop, its recurrent interosseous branch, and all of the nerve branches are visualized. It is then time to identify the one or two most proximal relevant septocutaneous perforators and decide on the relative position of the flap island with respect to these skin branches . The flap modality (cutaneous, subcutaneous, or purely fascial) is then finally
Vol. 16A, No.2 March 1991
Retrograde posterior interosseous flap
291
Table II. Factors in survival of posterior interosseous flaps and statistical analysis
Width of nap territory Length of nap territory Type of nap
3 em or less Larger than 3 em 6 ern or longer Less than 6 em Fascial
Fasciocutaneous Distance from nap tip to DRUJt Number of perforators Anatomic anomalies Experience of surgeon Passage of pedicle Age of the patient Infection Venous congestion of nap Delay in perfusion after release of tourniquet Bleeding and/or compression of pedicle
17 cm or shorter Longer than 17 ern 2 or more 1 or not specified Regular anatomy Significant anomaly 4th case or more First three cases Open Closed 40 or under More than 40 No Yes No Yes No Yes No Yes
Statistical relevance (yes/no)
Survived
Partial
n=
n=
p value'
15 12 13 14 3 24 10 17 9 18 24 3 21 6 17 10 18 9 22 5 24 3 25 2 26 I
5 2 3 4 0 7 3 4 I 6 4 3 3 4 2 5 3 5 3 4 5 2 4 3 4 3
0.38
No
0.57
No
0.48
No
0.76
No
0.31
No
0.09
No
0.09
No
0.11
No
0.14
No
0.061
No
0.95
No
0.048
Yes
0.021
Yes
'Stat Graphics by STSC. Version 2.6 (1987) contingency tables. Fisher's exact test (one-tail), tdruj. Distal radioulnar joint.
selected. If perforators with an origin from the recurrent interosseous branch are used, anatomic variants must be recognized before the posterior interosseous artery and veins are ligated and nerve branches completely freed. Next, the ulnar side of the flap is delineated and the fascia over the extensor carpi ulnaris incised longitudinally, taking care to stay away from the juncture of the intermuscular septum. The muscle belly of the extensor carpi ulnaris is drawn ulnarly and muscle branches are ligated as outlined. Finally, the intermuscular septum is divided at a reasonable distance from the PMRP, through the site of division of the posterior interosseus vessels, and deep to its descending branch to the level of the distal radioulnar joint. On release of the tourniquet, flushing of the flap is awaited, and meticulous hemostasis obtained. If a closed passage is chosen, it should be straight, wide, and adequately drained. The features of the distally based, retrograde posterior interosseous flap as compared to those of other commonly used alternate methods of coverage, the Chinese forearm flap, the internal cubital flap, the axial
pedicled groin flap and any free flap, are summarized in Table III. The main advantages include its fineness, its excellent texture and color match, its easy accessability, and its minimal donor morbidity. Disadvantages are limitation of distal reach, technical difficulty, and susceptibility to partial necrosis. REFERENCES I. Zancolli EA, Angrigianni C. Colgajo dorsal de antebrazo (en "isla" con pediculo de vasos interoseos posteriores). Rev Asoc Arg Ortop Traumatol 1986;51:161-8. 2. Penteado CV, Masquelet AC, Chevrel JP. The anatomic basis of the fascio-cutaneous flap of the posterior interosseus artery. Surg Radiol Anat 1986;8:209-15. 3. Masquelet AC, Pcnteado CV. Le lambeau interosseux posterieur, Ann Chir Main 1987;6:131-9. 4. Testut L. Traite d'anatomie humaine. Tome 2. Paris: Doin, 1890. 5. Manchot C. Die Hautarterien des menschlichen Korpers (1898). The cutaneous arteries of the human body. New York: Springer, 1983. 6. Salmon M. Arteres de la peau. Paris: Masson, 1936. 7. Valdecasas-Huelin JMG, Barreiro FJJ, Barcia EC. Etude
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Table III. Features of the posterior interosseous flap and comparison with other commonly utilized flaps
I
Flap Size: length width Texture conformity Color match Fineness Absence of hair Sensibility Dissection Same field Consistency of anatomy Technical simplicity OR time Reach Proximally Distally Complications, resistance against infection Donor deficit functional Vascularity of hand Vascularity of forearm Safety for maintenance of nerve supply Esthetic Conspicuousness Aspect Other Elevation of ann Mobilization of wrist, thumb, digits
PIF
I
++ + + ++ ++
Chinese
I
++ ++ + +
+ +
Groin
++ ++
+
I
Free dorsalis pedis
+ ++ + + + + +
?
+ ++ + +
++ +
++
+ +
++ ++ +
++ ++ ++
++ ++
++ ++ +
+
++
+ +
++
++ ++ ++
+
++
+ +
+
++ ++ ++
++
+
++ ++
+ + ++ ++
Flaps., PIF. Posterior interosseous flap; Chinese. radial forearm flap: groin. axial pedicled groin flap. - - From maximum disadvantage to + + maximum advantage.
radio-anatomique des artercs interosseuses. Acta Anat 1978;102:147-56. 8. Lamberty BGH, Cormack GC. The forearm angiotomes . Br J Plast Surg 1982;35:420-9. 9. Zancolli EA,. Angrigianni C. Posterior interosseous island forearm flap. J HAND SURG 1988;138 :130-5. 10. Costa H, Soutar OS. The distally based island posterior interosseus flap. Dr J Plast Surg 1988;41:221-7.
11. 8ayon P, Pho RWH. Anatomical basis of dorsal forearm flap. J HAND SURG 1988;13B:435-9 . 12. Schoofs M, Bienfait 8, Calteux N, Dachy C, Van Dermaeren CA, De Coninck A. Le lambeau aponevrotique de l'avant-bras. Ann Chir Main 1983;3:197-201.
