The posterior interosseous artery flap: Clinical results with special emphasis on donor site morbidity

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

BACKGROUND

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Reconstruction of Large Soft Tissue Defects in the Distal Lower Extremity: Free Chain-Linked Bilateral Anterolateral Thigh Perforator Flaps versus Extended Latissimus Dorsi Musculocutaneous Flaps

Background: Reconstruction of the large soft-tissue defects in the lower extremity still constitutes a challenge for plastic surgeons. This retrospective study was conducted to compare the surgical and clinical outcomes of the chain-linked bilateral anterolateral thigh perforator flaps and extended latissimus dorsi musculocutaneous flap in the reconstruction of the large soft tissue defects of the lower extremity. Methods: From January 2012 to December 2021, 34 patients aged between 20 and 66 years received chain-linked bilateral anterolateral thigh perforator flaps (15 cases) or extended latissimus dorsi musculocutaneous flaps (19 cases) for the reconstruction of extensive soft-tissue defects in the lower extremity. The two groups were homogeneous in terms of age, etiology, comorbidities, and flap area. In addition, the intraoperative data, outcomes, complications, and long-term follow-up results were collected and analyzed. Results: The extended latissimus dorsi musculocutaneous flap group had a shorter operation time (271.8 ± 59.5 min vs. 429.6 ± 51.9 min), harvest time (58.9 ± 24.8 min vs. 152.7 ± 41.4 min), and anastomosis time (27.2 ± 10.4 min vs. 53.7 ± 8.1 min) than the chain-linked bilateral anterolateral thigh perforator flaps group (p < 0.05). Based on patient self-assessment, the donor site temporary muscle weakness in the extended latissimus dorsi musculocutaneous flap group was significantly more than that in the chain-linked bilateral anterolateral thigh perforator flaps group (p < 0.05). Conclusion: Both methods can repair large defects and restore the function of the injured limbs at a single stage. However, considering the operation time and flap-harvesting time, the authors recommend the extended latissimus dorsi musculocutaneous flap, especially for those who cannot tolerate a prolonged surgery.

The use of the posterior interosseous artery flap and anterolateral thigh flap for post-traumatic soft tissue reconstruction of the hand

The purpose of this study was to examine the differences between the use of a posterior interosseous artery (PIA) flap and an anterolateral thigh (ALT) flap for post-traumatic, medium-sized soft tissue reconstruction of the hand based on flap characteristics, postoperative complications, and aesthetic outcomes.From October, 2010 to March, 2016, 62 patients undergoing soft tissue reconstruction of the hand with 30 PIA flaps and 32 ALT flaps were included in this study. The 62 patients were divided into the PIA flap group and the ALT flap group. The differences between the 2 groups were analyzed.The 62 patients included 52 males and 10 females, and the mean age at the time of surgery was 41 years. The flap failure rate was 13.3% (4/30) in the PIA flap group and 9.4% (3/32) in the ALT flap group. No significant differences in flap failure rate, recipient site complication rate, or donor site complication rate were observed between the 2 groups. However, the operative time (136 min vs 229 min) and aesthetic outcomes (flap bulk swelling, 0 cases vs 31 cases) were statistically significantly different.Both the pedicled PIA flap and the free ALT flap were comparable for the reconstruction of post-traumatic, medium-sized soft tissue defects of the hand according to the evaluated outcomes of postoperative complications. Based on the surgical characteristics of the flap and the evaluation of aesthetic outcomes, the pedicled PIA flap was significantly superior to the free ALT flap.

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

BACKGROUND

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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

The Fascia-Only Reverse Posterior Interosseous Artery Flap

PURPOSE

Fascia flaps are a preferred method to reconstruct the soft tissue envelope of the hand when a thin and pliable flap is required to cover exposed tendons. The aim of this study was to report on our experience with the fascia-only reversed posterior interosseous artery flap. Contrary to commonly used fascia flaps, this flap does not require free tissue transfer.

METHODS

In this retrospective review, 5 patients were identified, each of whom underwent soft tissue reconstruction with a reversed posterior interosseous artery fascia flap. The operative technique is similar to the harvest of a fasciocutaneous flap except that only the fascia is harvested through a straight incision.

RESULTS

No flap loss occurred. In 2 patients a distal wound dehiscence occurred, which healed by secondary intention. No venous congestion or iatrogenic lesion of the motor nerves to the extensor muscles was encountered.

CONCLUSIONS

The fascia-only reverse posterior interosseous artery flap represents a locally available, pedicled option. With regard to the quality of the transferred tissue, this flap is comparable to the temporalis fascia flap. Major advantages are that the donor site is confined to the ipsilateral extremity and microsurgery is not required. Contrary to the fasciocutaneous version, no skin graft has to be applied to the donor site, which improves cosmesis. We consider this flap a worthwhile alternative to other fascia flaps.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic V.

Recurrent branch of anterior interosseous artery perforator-based propeller flap for distal forearm injuries: Report of 2 cases

Despite various options for the reconstruction of soft tissue defects in the distal forearm, perforator-based propeller flap is rarely used. Here, we presented 2 cases of distal forearm injuries that were repaired using the recurrent branch of anterior interosseous artery perforator-based propeller flap. Patients in these cases were 57 and 67 years of age. Wounds resulting from farming machine injury and pyogenic extensor tenosynovitis following cat bite wounds were localized to the distal forearm and dorsum of the hand. Defect dimensions were 5 cm × 10 cm and 5 cm × 8 cm. The 12 cm × 7 cm and 21 cm × 4 cm sized recurrent branch of anterior interosseous artery perforator-based propeller flap was designed adjacent to the wounds. In the latter case, the absence of the posterior interosseous artery in the distal forearm was observed. One perforator from the recurrent branch of the anterior interosseous artery emerged through the septum between the extensor digiti minimi and extensor carpi ulnaris 7.5 cm and 6.0 cm proximal to the ulnar head in cases 1 and 2, respectively. Perforators were identified using multidetector computed tomographic angiography and handheld Doppler. Extending to two-thirds or almost the full length of the forearm, the flaps were raised and rotated by 90° and 120° to cover the defect. The donor sites were closed using free skin graft. Both flaps survived. Except for minor wound dehiscence and hemarthrosis, no other postoperative complications occurred. Patients returned to work or daily activities at 3- and 4-month follow-up after surgery.

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

Current techniques to reconstruct soft tissue of the fingers result in scarring and functional deficits. Perforator flaps raised on the posterior interosseous artery are thin and well vascularised, and cause minimal donor site scarring. Using a flap with sensory nerves was hoped to contribute to the desired postoperative sensory recovery of fingers. We used modified innervated posterior interosseous perforator flaps to repair digital defects in 18 patients. Injuries included digit amputations and palmar soft tissue defects. The posterior antebrachial cutaneous nerve was carried in the flap and bridged with the defect section of the proper digital nerve. The flaps used measured 10 cm × 6 cm to 5 cm × 3 cm. All 18 flaps survived; one necrotic edge eventually healed. During the 10-28 months of follow-up (average, 14 months), two-point discrimination in flaps and injured fingers was 6-15 mm. Good functional and sensory outcomes were obtained in primary operation, and patients were generally satisfied with the aesthetic results. Further work will be needed to assess the branches of the posterior interosseous artery preoperatively to improve surgical planning.

Distally based subcutaneous veins for venous insufficiency of the reverse posterior interosseous artery flap

BACKGROUND

The reverse posterior interosseous artery flap (PIAF) provides soft, thin, and pliable tissue for upper extremity reconstruction without sacrificing any major arteries of the hand. The authors performed a new technique that included one extra distally based subcutaneous vein within the pedicle to diminish venous insufficiency and they aimed to present the results of reconstruction with this technique.

PATIENTS AND METHODS

Twelve patients with a mean age of 30 years (range 5-52 years) underwent reverse PIAF surgery. The defects were located on the hand and wrist, with a mean area of 57.8 cm² (range 20-99 cm²⁾ . After the skin between the distal edge and the pivot point of the flap was elevated, the most reliable subcutaneous vein was chosen, chased, and included within the flap.

RESULTS

The average size of the PIAF was 6 × 5 cm to 12 × 9 cm (mean area: 64.4 cm² ) and the median follow-up time was 13 months (range 4-16 months). The mean quick Disabilities of the Arm, Shoulder and Hand (DASH) score was 21.4, indicating a low degree of disability. Of the 12 patients, ten were very satisfied and two were satisfied with the result of the reconstruction. All but one flap survived completely. One flap was nearly totally lost due to arterial insufficiency after hemodialysis. We observed no venous congestion or insufficiency in the patients.

CONCLUSIONS

Subcutaneous veins may be reliable and useful for overcoming major drawbacks associated with reverse flow posterior interosseous artery flap and for diminishing flap loss due to venous insufficiency. © 2016 Wiley Periodicals, Inc. Microsurgery 36:384-390, 2016.