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Category: Volume 09 Issue 07 July 2021
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Title: Technical Refinements in Posterior Interosseous Artery flap

Authors: Dr Dharanipriya Arikrishnan, Dr Jaganmohan Janardhanam, Dr Ashok Kumar Ranganathan

 DOI: https://dx.doi.org/10.18535/jmscr/v9i7.28

Abstract

Introduction: Hand injuries continue to be a major occupational hazard and a frequently associated injury in road traffic accidents requiring flap cover for soft tissue defects. Various local flaps, regional flaps, distant flaps, and free flaps are used for covering hand defects. Posterior Interosseous Artery (PIA) Flap is a reliable regional flap for such defects. It is a reverse pedicled fasciocutaneous flap, based on the anastomosis between Posterior and Anterior Interosseous arteries near distal Radio Ulnar Joint. In our present study, we have documented a consistent branch from the ulnar artery, running around the neck of the ulna and anastomosing with the PIA which enhances flap vascularity when carefully retained. We have designed the flap based on mid-forearm perforator from PIA which avoids encountering PIN branches present proximally. The perforator is eccentrically placed in the flap design, thus allowing the proximal forearm skin to be raised in the flap without compromising the reach of the flap

Aim: To study the technical refinements in PIA flap and to recapitulate the versatility of PIA flap for various defects of distal forearm and hand.

Methodology: A prospective study was conducted over a period of 15 months to include 15 cases of distal forearm and hand defects that could be covered with PIA flap. The patients were observed for outcomes.

Results: Fifteen cases were included in this study over a span of 15 months. The average age was 41.9 years. Post-traumatic defects in the dorsum of hand, fingers, thumb, and volar aspect of the distal forearm; Post burn contractures in the palm (camphor burns), 1st web space, and thumb; and post excisional defect of tumor in hand were included. None of the flaps had any partial or total necrosis. One patient had flap edema (6.67%) and another patient had venous congestion (6.67%) of the flap which subsided by conservative management.

Conclusion: PIA is a versatile and reliable flap for the defects in the distal forearm and hand. Mid-forearm perforator can be chosen whenever feasible with appropriate flap design to avoid encountering PIN branches. Vascularity can be enhanced by maintaining the communicating vessels from the ulnar artery around the neck of the ulna.

Keywords:  dorsal interosseous artery flap, distally based island flap, distally based fasciocutaneous flap, hand reconstruction, distal forearm reconstruction, post-burns reconstruction of hand.

References

  1. Gavaskar AS. Posterior Interosseous Artery Flap for Resurfacing Posttraumatic Soft Tissue Defects of the Hand. HAND. 2010 Dec;5(4):397–402.
  2. Dogra B, Singh M, Chakravarty B, Basu S. Posterior Interosseous Artery Flap for Hand Defects. Med J Armed Forces India. 2006 Jan;62(1):33–5.
  3. Zancolli EA, Angrigiani C. Colgajo dorsal de antebrazo (en isla) (pediculo de vasos interoseos posteriores). Rev Assoc Arg Ortop Traumatol 1986;54:161e8.
  4. Angrigiani C, Grilli D, Dominikow D, Zancolli EA. Posterior interosseous reverse forearm flap: experience with 80 consecutive cases. Plast Reconstr Surg 1993; 92: 285-93.\
  5. Penteado C, Masquelet A, Chevrel J. The anatomic basis of the fascio-cutaneous flap of the posterior interosseous artery. Surg Radiol Anat. 1986 Dec;8(4):209–15.
  6. Acharya AM, Bhat AK, Bhaskaran K, The Reverse Posterior Interosseous Flap (2012) Technical considerations in raising an easier and more reliable flap. JHS 37(3):575–582.
  7. Zaidenberg EE, Farias-Cisneros E, Pastrana MJ, Zaidenberg CR. Extended Posterior Interosseous Artery Flap: Anatomical and Clinical Study. J Hand Surg. 2017 Mar;42(3):182–9.
  8. Büchler U, Frey H-P. Retrograde posterior interosseous flap. J Hand Surg. 1991 Mar;16(2):283–92.
  9. Zaidenberg EE, Zancolli P, Farias Cisneros E, Miller AG, Moreno R. Antegrade Posterior Interosseous Flap for Nonhealing Wounds of the Elbow: Anatomical and Clinical Study. Plast Reconstr Surg Glob Open [Internet]. 2018 Nov 7 [cited 2020 Aug 16];6(11). Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6414117/
  10. Jones ME, Rider MA, Hughes J, Tonkin MA. The use of a proximally based posterior interosseous adipofascial flap to prevent recurrence of synostosis of the elbow joint and forearm. The Journal of Hand Surgery, European Volume. 2007 Apr;32(2):143-147. DOI: 10.1016/j.jhsb.2006.09.004.
  11. Wang J-Q, Cai Q-Q, Yao W-T, Gao S-T, Wang X, Zhang P. Reverse Posterior Interosseous Artery Flap for Reconstruction of the Wrist and Hand after Sarcoma Resection: Pia Flaps for Sarcoma. Orthop Surg. 2013 Nov;5(4):250–4.
  12. Chen HC, Tang YB, Chuang D, Wei FC, Noordhoff MS. Microvascular free posterior interosseous flap and a comparison with the pedicled posterior interosseous flap. Ann Plast Surg. 1996;36:542-50.
  13. Eo SR, Hwang SH, Hong KY, Lim SA, Lee GJ. Revisiting the Posterior Interosseous Artery Flap. Arch Hand Microsurg. 2018;23(3):195.
  14. H C, A P, H Z. The posterior interosseous flap - a prime technique in hand reconstruction. The experience of 100 anatomical dissections and 102 clinical cases. J Plast Reconstr Aesthetic Surg JPRAS. 2007 May 16;60(7):740–7.
  15. Prasad R, Balakrishnan TM. Role of Interosseous Recurrent Artery Perforators in the Posterior Interosseous Artery Flap. J Hand Microsurg. 2016 Sep 13;07(01):36–41.
  16. Sotereanos DG, Darlis NA, Dailiana ZH, Sarris IK, Malizos KN. A capsular-based vascularized distal radius graft for proximal pole scaphoid pseudarthrosis. J Hand Surg 2006;31A:580 –587
  17. Sheetz KK, Bishop AT, Berger RA. The arterial blood supply of the distal radius and ulna and its potential use in vascularized pedicled bone grafts. J Hand Surg. 1995 Nov;20(6):902–14.
  18. Xarchas KC, Chatzipapas C, Koukou O, Kazakos K. Upper limb flaps for hand reconstruction. 2004;70:9.
  19. Kelly S, Pertierra G, Orbay JL, Vernon LL, Shah A. Versatility of the Posterior Interosseous Artery Flap in Outpatient. Advances in Plastic & Reconstructive Surgery2018 March; 164.
  20. Reyad KA, Shaker AA, Elbarbary AS, Sayed MA, Elghareeb MA. The Number of Perforators Included in Reversed Flow Posterior Interosseous Artery Flap: Does It Affect the Incidence of Venous Congestion? Plast Reconstr Surg Glob Open [Internet]. 2016 Dec 22 [cited 2020 Aug 16];4(12). Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5222658/
  21. Ghareeb Fouad M, Megahed Mohamed A, El Kashty Sherif M, LabebAlaa A, Abd El Kader Hesham K. H. Functional and cosmetic outcomes of posterior interosseous artery flap in reconstructing hand defects. Menoufia Medical Journal. 2018; 31(4):1375-1379
  22. Naalla R, Chauhan S, Dave A, Singhal M. Reconstruction of post-traumatic upper extremity soft tissue defects with pedicled flaps: An algorithmic approach to clinical decision making. Chin J Traumatol. 2018 Dec 1;21(6):338–51.
  23. Shibata M, Iwabuchi Y, Kubota S, Matsuzaki H. Comparison of free and reversed pedicled posterior interosseous cutaneous flaps. Plast Reconstr Surg. 1997 Mar;99(3):791–802.

Corresponding Author

Dr Jaganmohan Janardhanam

Rajiv Gandhi Government General Hospital & Madras Medical College, Chennai