Reconstruction of Hand Dorsum Defect Using Double Perforators-Based Anterior Interosseous Artery Island Flap: A Case Report and Description of a New Anterior Interosseous Artery Perforator.

The anterior interosseous artery (AIA) perforator flap is not commonly used in hand dorsum reconstruction compared with alternatives. However, it is a versatile flap with several advantages. Literature on the AIA perforator flap is based on the dorsal septocutaneous branch (DSB), which branches from the AIA and passes through fascia between the extensor pollicis longus (EPL) and extensor pollicis brevis muscles. In the described case, the authors reconstructed a hand dorsum defect in a 78-year-old man using an AIA perforator flap with double perforators supplied by the DSB and a new perforator branching from the distal than DSB. No complication was encountered, and the flap survived completely. A retrospective computed tomography review revealed the presence of the new perforator in 14 of 21 patients. Two types of new perforator were observed. One passed through the ulnar side of the extensor indicis proprius (EIP) muscle and penetrated fascia between the extensor digitorum minimi and extensor digitorum communis tendons, whereas the other passed between the EPL and EIP muscles. This report describes the anatomical location and clinical application of the new AIA perforators. The double perforators-based AIA flap provides a straightforward, reliable means of reconstructing hand dorsum defects.

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.

Cobertura de tejidos blandos en una lesión por aplastamiento de la mano en paciente con anemia de células falciformes

Se presenta el caso de una lesión por aplastamiento de la mano derecha en un paciente con historia clínica de anemia de células falciformes. Se realizó la reconstrucción con un colgajo de ingle, seguido de un colgajo de arteria interósea posterior y un colgajo anterolateral de muslo. El tratamiento de estas lesiones es complejo debido a la necesidad de tejidos blandos especializados, difíciles de reproducir para grandes defectos de la palma de la mano; además el grado de desarrollo de tejido cicatricial conduce a contracturas y dificultades en el uso funcional de la mano y los dedos. Este caso se agravó por el historial de anemia de células falciformes del paciente.

We report the case of a crush injury to the right hand in a patient with a clinical history of sickle cell anemia. Reconstruction was performed with a groin flap, followed by a posterior interosseous artery flap and an anterolateral thigh flap. The treatment of these injuries was complex due to the need for specialized soft tissues, which are difficult to reproduce for large defects in the palm of the hand. In addition, the degree of development of scar tissue leads to contractures and difficulties in the functional use of the hand and fingers. This case was aggravated by the patient's history of sickle cell anemia.

Malignant transformation of a phalangeal enchondroma into a recurrent grade II chondrosarcoma requiring successive transcarpal amputations: a case report.

We report a case of malignant transformation of a phalangeal enchondroma into a grade II chondrosarcoma requiring two successive transcarpal amputations owing to recurrence. Soft tissue defects were repaired using single-stage reconstruction with a posterior interosseous artery flap. The 2-year follow-up assessment was satisfactory and no recurrence was observed.

ALTERING THE MARKING OF THE REVERSE POSTERIOR INTEROSSEOUS ARTERY FLAP.

Background: Full-thickness defects on the dorsum of the hand requires thin, soft, and pliable skin for which there are limited locoregional flaps. The reverse posterior interosseous artery (PIA) flap based on the communicating artery fulfills all above requirements and can reach upto the fingers. However, there has been discrepancy in the surface marking of the flap and the anatomical position of the vessel pedicle. We share our alteration with the marking and ease of harvesting this flap. Method and material: This is a prospective study conducted at a private teaching hospital in Karachi, over a period of 2 years from November 2017 to December 2019. After taking consent and ensuring confidentiality of all patients who had PIA flap reconstruction, we collected patient's demographic details, mode of injury, and flap surface area. We altered the described skin marking and took measures to prevent venous congestion and noted the outcomes in term of flap congestion and flap loss. Results: Twenty-eight patients with a mode age of 32 years were operated during this period. The majority (64.2%) had a motor vehicle accident and machine injuries. The mean surface area of flaps was 6 × 10 cm2, and 11 (39.2%) flaps had venous supercharging. All patients had a 10-20° wrist extension splint for 2 weeks. The mean follow-up of the patients was 14 ± 5 days, and 6 (21.4%) flaps developed a minimal marginal flap loss, which was managed conservatively. Conclusion: By minimally altering our surface marking, we experienced a easy and quick harvesting of this flap. However, one has to be vigilant and take all described precautions for venous congestion.

Free quadruple paddled posterior interosseous artery flaps combined with free hallux nail flap in repair of defects of 5 digits in one hand: A case report / 中华显微外科杂志

A patient who suffered soft tissue defects of all 5 digits of left hand was referred to the Department of Hand and Foot Surgery, Affiliated Nanhua Hospital, University of South China in January 2020. A quadruple paddled posterior interosseous artery flaps was used to cover the defect in index, middle, ring and little fingers and a free hallux nail flap was used to repair the defect in thumb. Two years after operation, the appearance and texture of the flaps of all digits in the left hand were good. The function of the digits was good as well. There were slightly noticeable scars left in both the donor sites of left forearm and right foot.

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.

Reverse posterior interosseous flap for defects of the dorsal ulnar wrist using previously burned and recently grafted skin.

BACKGROUND: In the severely burned patient, coverage of exposed bone in the dorsal ulnar wrist can be a difficult problem. This is especially challenging in patients with a high percentage total body surface area (TBSA) where donor flaps can be scarce. The use of previously burned and/or recently grafted skin as flaps is an option. It has been postulated that use of previously burned skin can result in higher rates of local or distant flap failures. The reverse posterior interosseous flap (PIF) is an axial flap, based on the retrograde posterior interosseous artery, to provide coverage of the hand. Here we describe utilization of the PIF, using previously burned and/or recently grafted skin for coverage of dorsal ulnar wrist defects. METHODS: This is a case series of three patients, with extensive burns (range 35-83%TBSA), where defects of the dorsal ulnar wrist necessitated coverage. Each patient underwent PIF(s) utilizing previously burned and/or grafted skin, all within three months after their initial burn event. RESULTS: Case 1: 28 year old male who suffered 35% TBSA via blast mechanism developed a chronic open wound over the dorsal ulnar wrist with exposed tendon. The patient successfully underwent a left PIF using previously grafted skin. Case 2: 23 year old male with 83% TBSA. Bilateral ulnar styloids were exposed. PIFs were performed bilaterally, using previously burned and recently grafted skin. Coverage was successful but received leech therapy post-operatively for venous congestion. Case 3: 37 year old male with 52% TBSA, with the most severe burns isolated to his bilateral upper extremities; the ulnar head was exposed. The posterior interroseous artery was explored and PIF was attempted, but there was no retrograde flow in the distal artery due to a deeper injury than previously recognized. The patient ultimately underwent a pedicled abdominal flap for coverage. CONCLUSIONS: Defects of the distal ulnar wrist after deep and extensive burns can be problematic. Use of the reverse PIF using previously burned skin, even those that has just been recently grafted is a viable option for this difficult patient population. However, it may not be possible in all patients. Vigilance and early intervention for post-operative venous congestion are important.

Anatomy and physiology of perforator flaps of the upper limb.

Perforator flaps are an excellent reconstructive option for a functional upper limb reconstruction. This article explores the physiology and general principles of perforator flaps and their indications for use in reconstruction of the upper extremity. Workhorse perforator flaps of the upper extremity, such as the radial artery perforator, ulnar artery perforator, lateral arm perforator, posterior interosseous artery, first dorsal metacarpal artery perforator and perforator-based propeller flaps, are discussed in greater detail.

Release of severe post-burn contracture of the first web space using the reverse posterior interosseous flap: Our experience with 12 cases.

We retrospectively assessed outcomes after treating severe contractures of the first web space from burns with the reverse posterior interosseous flaps (RPIF). Twelve consecutive patients (ages 18-58 years) with burns from 10% to 70% (mean, 30.1%) total body surface area and severe contractures of the first web space of the hand (initial thumb to index angles from 10° to 35° [mean, 23°]) underwent contracture release using the RPIF. Seventeen RPIFs were used, with sizes from 9cm×6cm to 14cm×10cm (mean area, 83.6cm(2)). The patients were followed for 5-26 months. All flaps survived completely, rapidly adapted to the recipient beds, and achieved good color and texture harmony. No early complications occurred. Fifteen donor sites were closed with skin grafts. Two donor sites were closed by direct suture. No paralysis of the posterior interosseous nerve was observed in these cases. At last follow-up the mean thumb to index angle was 78°, increasing the web length 260%. All patients regained fundamental hand functions. The RPIF is reliable and safe for releasing severe contractures of the first web space of the hand after burn, with distinct advantages over currently used alternative methods.

Posterior Interosseous Artery Flap for Hand Defects.

BACKGROUND: Reconstruction of soft tissue defects in the hand need an early, single stage and well vascularised cover to achieve the best functional result. Usually a full thickness graft is required since vital structures like tendons, bones and joints are exposed and often there is need for secondary reconstruction. METHODS: We managed 12 cases of complex defects over the hand in the last 2 years with the posterior interosseous artery flap. RESULTS: In 5 cases the defect was due to blast injury and in 4 because of crush injury. Males predominated in the ratio of 5:1. The defect was most often in the 1(st) web space and the largest flap was 11×8 cm. In all but one case the donor site was covered by split skin graft, which settled well. 2 patients had superficial flap necrosis needing debridement and skin graft. CONCLUSION: Flap based on reverse flow in the posterior interosseous artery is a versatile and reliable source for full thickness cover of complex soft tissue defects in the hand.