[Distally pedicled posterior interosseous artery flap for the coverage of defects on the wrist and hand]

Matthias Rab, Karl-Josef Prommersberger
Operative Orthopädie und Traumatologie 2008, 20 (2): 111-8

OBJECTIVE: Coverage of defects on the upper limb with the distally pedicled, fasciocutaneous posterior interosseous artery flap.

INDICATIONS: Defects with exposed tendon and/or bony tissue on the palmar and dorsal side of the wrist, the hand upon the proximal interphalangeal joint level and the whole thumb. Coverage of defects on the palmar side of wrist and palm of the hand with exposed median and/or ulnar nerve. Enlargement of the 1st interdigital web space in cases of thumb adduction contracture.

CONTRAINDICATIONS: Surgery at the flap harvesting site on the proximal third of the forearm. Surgery at the site of the flap pedicle on the middle and distal third of the forearm upon the distal radioulnar joint. Absence of the distal anastomosis between the anterior and posterior interosseous arteries at the level of the distal radioulnar joint (5% of the cases).

SURGICAL TECHNIQUE: Skin markings of the planned island flap and subsequent S-curved skin incision along the flap pedicle upon the level of the distal radioulnar joint; blunt dissection onto the forearm fascia. Incision of the forearm fascia between the extensor digitorum communis and extensor digiti minimi muscles. Dissection of the flap pedicle between the extensor digiti minimi and extensor carpi ulnaris muscles with subsequent identification of the posterior interosseous artery (no dissection!). Skin incision around the flap island. Dissection and ligation of the proximal anastomosis between the anterior and posterior interosseous arteries; mobilization of the flap island and pedicle from the ulnar shaft. Mobilization can be performed until the distal anastomosis of the anterior and posterior interosseous arteries is reached (flap pivot point).

POSTOPERATIVE MANAGEMENT: Plaster immobilization of the wrist and/or fingers for 7 days. Start of occupational therapy from the 7th postoperative day. Removal of sutures on the 12th-14th postoperative day. Wearing of compression garments.

RESULTS: From November 2005 until June 2007, 25 distally pedicled posterior interosseous artery flaps were performed. With this type of flap, it was possible to successfully enlarge the 1st interdigital web space in two patients and to cover the whole thumb in two cases of degloving injury. In nine patients, the flap was used to cover the median and/or ulnar nerve at the level of the wrist and/or palm of the hand, and in four cases, to cover defects after tumor resection on the palm of the hand. Exposed extensor tendons and/or bony structures were covered with this flap in another eight patients. In two of the 25 flaps, distinct necroses of the most distal edge of the skin island were seen. After surgical debridement and split-skin transplantation, all of these small superficial defects healed well. Absence of the distal anastomosis as well as complete flap failure could not be observed in this series.

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