Antebrachial reverse island flap of the posterior interosseus artery pedicle for reconstruction of thumb defects

Fasciocutaneous lobe on AIP ( a. interossea posterior) is characterized by thin skin, good texture and satisfactory pedicle lenght, which enables the repair of numerous hand defects. It can be either loose or reversed on the pedicle. We present here 2 neglected cases of thumb injury in which there was a need to compensate the full thickness of the skin. We believe that thumb defects can be repaired with both functionally and esthetically good effects using AIP lobe.     

前臂骨间后动脉逆行岛状皮瓣及复合组织瓣移植的远期疗效分析

目的：报道应用前臂骨间后动脉逆行岛状皮瓣及复合组织瓣修复手部软组织的远期疗效。方法：对临床应用的90例，就其手术适应证的选择、远期疗效及供区的功能做回顾性分析。结果：90例皮瓣及复合组织瓣术后成活89例，仅1例术后皮瓣坏死。前臂背侧供区外形及功能正常。结论：前臂骨暗后动脉逆行岛状皮瓣是修复手部软组织缺损的较理想方法。     

980例指动脉逆行岛状皮瓣的临床分析

目的 通过对980例指动脉逆行岛状皮瓣修复手指缺损的临床分析，探讨该术式修复手指缺损的远期疗效，以指导临床工作。方法 对980例手指不同部位缺损，采用指动脉逆行岛状皮瓣修复，术后随访5个月～3年，分析随访结果。结果皮瓣全部成活，有89例出现不同程度的并发症。结论 指动脉逆行岛状皮瓣修复手指缺损不失为一种较好方法，但要正确选择适应证，注意并发症的预防。     

前臂骨间背侧动脉逆行岛状皮瓣修复手部创面

目的探讨应用前臂骨间背侧动脉逆行岛状皮瓣修复手部皮肤缺损的临床效果。方法应用前臂骨间背侧岛状皮瓣逆行修复16例手部皮肤缺损。结果16例皮瓣全部存活。随访6-15个月,皮瓣弹性良好,耐摩擦。无皮瓣边缘坏死发生,无前臂骨间背侧神经损伤,患肢功能恢复较满意。结论前臂骨间背侧动脉逆行岛状皮瓣是修复手部皮肤软组织缺损的可靠方法。     

Posterior interosseous artery flap, fasciosubcutaneous pedicle technique: a study of 25 cases.

This study was undertaken in an attempt to improve the versatility of the posterior interosseous artery flap (PIA flap) and to decrease flap complication rate. The PIA flap was used for resurfacing 25 cases of the hand and distal forearm over a 2-year period. Observations were made on the anatomy of the PIA flap and its distal reach. Doppler analysis was made a mandatory part of the preoperative planning. Flaps were also raised from the zone of injury if Doppler confirmed the presence of good perforators. No attempt was made to identify the anastomosis between the anterior interosseous artery (AIA) and the PIA prior to flap raising since its presence was ascertained preoperatively with a Doppler and flap raising could begin straightway, saving precious tourniquet time. The surgical technique was further modified to include a large amount of fascia and subcutaneous tissue with the flap. This could perhaps be the reason for survival of larger flaps, absence of venous congestion and the low complication rate seen in our series. These flaps were used to resurface defects involving the dorsum of the hand, palm, distal forearm, wrist and fingers (both dorsal and volar surfaces). The distal reach of the flap was improved by exteriorising the pedicle and bowstringing it across the wrist which was kept in extension. The flap could thus easily reach the distal interphalangeal joint. This exteriorised pedicle was covered with a split thickness skin graft and was divided 3 weeks later under local anaesthesia making it a two-stage procedure. Adipofascial and osteocutaneous PIA flaps were also used depending on the requirement. Out of 25 flaps, 23 were of the adipofascial variety and one each of the fascial and osteocutaneous type. The majority of the patients were between 21 and 30 years old. Trauma was the leading cause of tissue deficit in our series (19/25). Within the trauma group occupational mishap (entrapment of hand in roller machine, presser machine, etc.) was the leading cause, road traffic accident being the next most common. The most common site of defect was the dorsum of the hand (14/25). The largest flap measured 12x8cm and the smallest flap measured 3x2cm. Only three minor complications were noted, two cases of partial flap loss (one of them needing a secondary procedure of debridement and grafting) and one partial graft loss in the case of fascial flap which needed regrafting. Importantly no evidence of venous congestion was noted in any of the flaps.     

The posterior interosseous reverse flap: experience with 113 flaps.

The authors have used a posterior interosseous flap for resurfacing in 113 cases of hand injury during the past 13 years. Its main indications were complex hand trauma or burn injuries with large skin loss, either acute or postprimary. Flaps survived completely in 98 patients. Twelve patients had superficial necrosis of the distal part of the flap, which did not require additional surgical procedures. Three flaps were lost and alternative coverage was used. Six patients demonstrated paralysis of the motor branch to the extensor muscles of the wrist or fingers (generally to the extensor carpi ulnaris, the extensor digiti quinti, or the extensor pollicis longus). All recovered completely within 6 months. The donor area was closed directly in 3 to 4-cm-wide flaps, leaving an inconspicuous scar. Larger flaps required skin grafting. Donor site morbidity was minimal. Major anatomic variations precluding the use of the flap were encountered twice in this series.     

前臂背侧皮动脉逆行岛状皮瓣的解剖与应用

目的改进切取前臂骨间背侧动脉逆行岛状皮瓣的手术方法。方法新鲜成人上肢标本20侧,对前臂骨间背侧动脉及其皮支进行解剖测量。临床应用前臂骨间背侧皮动脉逆行岛状皮瓣治疗创面26例,男20例,女6例;年龄16～62岁,平均32岁。损伤情况:机器挤压伤14例,皮肤撕脱伤10例,电击伤1例,烧伤1例。损伤部位:手背20例,虎口3例,拇指背侧1例,腕屈侧2例。转位皮瓣最大面积为14cm×9cm,最小面积为6cm×8cm。供区全厚皮片植皮。结果在尺侧腕伸肌和小指伸肌的腱腹交界区域有恒定的前臂背侧皮动脉存在,前臂背侧皮动脉距尺骨茎突(9.24±1.33)cm,直径(0.70±0.15)mm。据此设计了前臂背侧皮动脉的逆行岛状皮瓣,并应用于临床,26例全部成活。术后22例未使用扩血管药物;2例使用扩血管药物6h后皮瓣下出现张力血肿,清理血肿并停用扩血管药物后,皮瓣成活;2例术后4h皮瓣苍白,使用扩血管药物后皮瓣成活。术后随访6周～1年,皮瓣良好。26例均未发生静脉血管危象。皮瓣游离后,供区功能未受到明显影响。结论游离包含前臂背侧皮动脉的皮瓣使切取前臂骨间背侧动脉逆行岛状皮瓣的手术简便、快捷、安全、有效。     

Clinical application of expanded forearm reverse dorsal interosseous artery island flap]

The island flap based distally on the posterior interosseous artery has been proven to be available for the correction of severe cicatricial contracture deformity of the ipsilateral hand. However, the main disadvantages of this flap are the second donor area deformity and muscle or tendon adhesions after skin grafting. Both these complications may be ameliorated by means of tissue expansion to obtain a secure blood supply to the flap. The surgical procedure has been performed in 7 patients with satisfactory result since August 1989.     

The distally based island posterior interosseous flap

The posterior interosseous vessels give a significant contribution to the fascial plexus which supplies the skin of the forearm. This vascular arrangement forms the basis for an island fasciocutaneous flap which can be based either proximally or distally. Twenty-two dissection studies have been carried out to demonstrate the vascular anatomy of the posterior interosseous artery and its contribution to the fascial plexus. Based on this information, the design and usage of an island fasciocutaneous flap is described. A distally based island fasciocutaneous flap appears to have a reliable vascular basis and its role in covering soft tissue defects in the hand is illustrated in three clinical cases.     

The reverse posterior interosseous flap: A solution for flap necrosis based on a review of 87 cases.

PURPOSE: The relationship of the flap necrosis to the placement of the flaps on the forearm was outlined and a solution in avoiding flap necrosis is discussed. METHODS: The relationship of the flap necrosis to the placement of the flaps on the forearm was investigated in 87 consecutive posterior interosseous island flaps used for the reconstruction of the hand and wrist. Fifty-eight flaps were taken from the middle and proximal thirds of the forearm, the distal edges being within the middle third of the forearm in 24 and the distal edges being within the distal third of the forearm in 34. Twenty-nine flaps were harvested within the boundaries of the distal two-thirds of the forearm, the distal edge being proximal to the distal third of the forearm in 23 and the distal edge being distal to the third of the forearm in six. The Length of the flaps varied from 6.5 cm to 12 cm. The pedicle length measure 4-13 cm. The number of perforators for each flap was recorded also. RESULTS: Flaps survived complete in 78 (89.6%) patients. Six patients had superficial necrosis of the distal part of the flap (6.8%). Three flaps were totally lost and alternative coverage was used (3.8%). The flaps that ended up with partial necrosis appeared to be in related to the site it was taken from. One flap with total necrosis and one with partial ncrosis were taken within the boundaries of the proximal third of the forearm while the distal edge was proximal to the level of distal third. One flap with total necrosis and one with partial necrosis were taken from the proximal third of the forearm while their distal edge were at the limits of the distal third of the forearm. The remaining flap ending up with total necrosis was taken from the distal third of the forearm with a short pedicle. CONCLUSIONS: For the reverse posterior interosseous flap to be reliable the flap should include the septocutaneous perforators in the distal third of the forearm. To cover distant defects reliably by a flap with a long pedicle, the flap should extend up to the distal third of the forearm to include a piece of skin with numerous perforators.     

The reverse posterior interosseous flap and its composite flap: experience with 201 flaps.

OBJECTIVE: To introduce our experiences of using the reverse posterior interosseous flap and its composite flap. METHODS: In the series of 201 cases, the fasciocutaneous flap was used to cover skin defects over the distal 1/3rd forearm, wrist and hand in 174 cases. The composite flap with the vascularised ulna bone graft was used to reconstruct the thumbs in 11 cases, and with the vascularised tendon graft was used to repair tendon defects with skin defects in 16 cases. The size of the ulna graft was 3-6cm in length and 1-2cm in width. The 4-7cm tendon graft was obtained from the extensor digiti quinti or extensor carpi ulnaris. The size of the flaps ranged from 5cmx4cm to 16cmx10cm. RESULTS: One flap failed completely. Of the other 200 flaps which survived 16 cases had venous congestion and had partial necrosis at the distal end. The size of the necrotic area ranged from 1 to 4cm in length. Ninety-three patients were followed up for at least 6 months, and included 10 patients with composite flaps. Generally, the flap matched the surrounding skin. But 10 cases had a lipectomy. The sensibility did not recover or achieved S1 within 6 months. For the extensor tendon defect, the function of finger extension was nearly normal and tenolysis was not required. In contrast, tenolysis was required after the flexor tendon reconstruction. However, these patients refused surgery. The bone grafts were healed in 3 months. The reconstructed thumb looked abnormal and lacked normal sensibility, although the patients used them. The linear scar line was conspicuous over the dorsum of the forearm. CONCLUSION: The reverse posterior interosseous flap is a reliable method to cover skin defects over the distal 1/3rd of the forearm, the wrist and hand. The composite flap with a vascularised tendon graft is an optimal reconstructive option for any extensor tendon loss (III zone) associated with a skin defect. Using the composite flap with a vascularised bone graft or combined with the digital neurovascular flap is another way to reconstruct the thumb.     

The posterior interosseous artery flap revisited

There are many ways to replace soft tissues that cover of the hand, from the simplest, eg, split-thickness skin graft to complex, eg, a microvascular free tissue transfer. The multiple, parallel sources of blood supply to the hand, and their arch-like interconnections offer a wide possibility of local reverse-flow or retrograde flaps. The most commonly used, eg, the radial arm flap, typically results in the sacrifice of a major artery. Though somewhat more technically demanding, the posterior interosseous artery flap can be used to cover a wide range of defects of the hand and wrist without potentially compromising circulation to the hand. The anatomy, potential applications and the surgical techniques important to success are discussed.     

前臂逆行骨间背侧皮瓣的临床应用

目的总结前臂逆行骨间背侧皮瓣的临床疗效。方法回顾性分析42例前臂逆行骨间背侧皮瓣，并结合文献阐明其变异程度及变异的处理。结果骨间背侧血管在前臂中1／3缺如1例．皮瓣边缘坏死；皮瓣向近端延伸超过4cm者4例，远端坏死，延迟愈合；其余均一期愈合：结论虽然前臂骨间背侧血管有变异，但前臂逆行骨间背侧皮瓣仍是修复手背中等大小创面较为理想的方法，以近点皮肤穿支向近端延伸皮瓣不要超过4cm。     

指神经血管蒂逆行岛状皮瓣急诊修复指端缺损

目的 报道应用指神经血管蒂逆行岛状皮瓣修复指端缺损的临床效果。方法 应用显微外科技术，采用指神经血管蒂逆行岛状皮瓣修复指端缺损，术后配合适宜的功能训练，共治疗指端缺损32例45指。结果 皮瓣全部成活，术后随访1年以上，皮瓣颜色、质地基本正常，精细感觉恢复（S3＋）及感觉恢复正常（S4）占75．6％，手指活动比较自如。结论 指神经血管蒂逆行岛状皮瓣能确保皮瓣血运，可以恢复手指端感觉，适于指端缺损的修复。     

Impossible harvest of the posterior interosseous artery flap: a report of an individualised salvage procedure.

Although the posterior interosseous artery flap represents a reliable technique to provide vascularised skin cover for the dorsum of the hand, the dissection of the flap is often very difficult because of anatomical variants. The weakest part of the vascularisation is the middle third of the posterior interosseous artery. Whenever it is discovered during the operation that such a flap is impossible to harvest, or likely to be unreliable, there is an immediate need to choose an alternative. Such a case is reported here. The individual anatomical situation allowed the dissection of a flap, the pedicle of which carried its blood supply from a perforating branch of the anterior interosseous artery. The technique described offers an individual solution to the problem of skin coverage when the harvest of the posterior interosseous artery is impossible.     

The reverse flow ulnar artery island flap: 42 clinical cases

Based on anatomical and dye injection observations, since 1984 42 cases of hand tissue defects (due to injury or surgery) have been reconstructed using a reverse flow unlar artery forearm island flap. Of the 42 cases, aetiology has included extensive crushing (25 cases), electric saw injuries (7 cases), burn scars (4 cases) and tissue defects following tumour or chronic ulcer resection (6 cases). Only one flap developed necrosis. The survival rate was 97.6%, including 4 cases of distal marginal necrosis. This procedure, therefore, offers a useful alternative in the repair and reconstruction of extensive tissue defects in the hand, whether caused by accidental injury or by surgery.     

前臂骨间后动脉逆行岛状皮瓣的术式改进方法

目的探讨前臂骨间后动脉逆行岛状皮瓣的临床应用及术式改进的疗效。方法本组对30例手背皮肤缺损,4例虎口皮肤缺损,1例拇指背侧皮肤缺损,2例腕尺侧,1例腕屈侧皮肤缺损的患者行前臂骨间后动脉逆行岛状皮瓣修复术,并利用前臂背侧皮动脉改进手术。结果38例皮瓣全部成活,修复效果满意。结论前臂骨间后动脉逆行岛状皮瓣是修复手背部、虎口、腕尺侧、腕屈侧皮肤缺损的较好选择;对于没有条件行足趾游离移植再造拇指亦是一个可行的选择;改进的手术方法使皮瓣切取更容易,是手部皮肤缺损可供选择的有效术式。