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REVERSE POSTERIOR INTEROSSEOUS FLAP BASED ON AN EXTERIORIZED PEDICLE TO COVER DIGITAL SKIN DEFECTS
REVERSE POSTERIOR INTEROSSEOUS FLAP BASED ON AN EXTERIORIZED PEDICLE TO COVER DIGITAL SKIN DEFECTS F. BRUNELLI, H. GIELE and R. PERROTTA From the Institut de la Main, Paris and the Laboratoire d'Anatomie Biomedicale des Saints Peres, UniversiteÁ Rene Descartes, Paris, France
The posterior interosseous arterial ¯ap is limited by its short vascular pedicle and proximal axis of rotation to the coverage of defects on the dorsal aspect of the hand and the ®rst web space. The authors present the results of three cases in which these limits were surpassed by extending the wrist and exteriorizing the vascular pedicle, thus causing it to bowstring across the angle created by the extended wrist. When ¯ap inset is complete the vascular pedicle is excised under local anaesthesia. This technique is an amalgamation of an island ¯ap and a traditional pedicle ¯ap and, as such, it is a two-stage procedure. Journal of Hand Surgery (British and European Volume, 2000) 25B: 3: 296±299 INTRODUCTION
pedicle transfer. This intervention allows an increase of approximately 5 cm in the distal range of the ¯ap.
The posterior interosseous arterial ¯ap (Penteado et al., 1986; Zancolli and Angrigiani, 1986) has proved to be excellent for reconstruction of defects of the hand, wrist and elbow (Angrigiani et al., 1993; Bayon and Pho, 1988; Buchler and Frey, 1991; Costa et al., 1991; Dap et al., 1993; Mazzer et al., 1996). It has progressively replaced the radial forearm ¯ap (which was extremely popular in the 1980s) because it does not prejudice the main vascular axes of the hand. The posterior interosseous ¯ap is an island fasciocutaneous ¯ap vascularized by branches of the posterior interosseous artery. The posterior interosseous artery measures about 1 mm in diameter at its origin and progressively reduces in calibre as it courses distally and gives o several muscular and cutaneous branches. It forms an anastomosis with the anterior interosseous artery at the wrist, through the interosseous septum at the level of the distal radioulnar joint. This anastomosis represents the point of rotation of the vascular pedicle of the posterior interosseous ¯ap. To gain additional length and to shift the axis distally, several authors have suggested sacri®cing this anastomosis and basing the ¯ap on the ®ne arterioles of the dorsal carpus. However, these branches are extremely small, poorly de®ned and inconstant, and we believe that conserving the distal anastomosis between the two interosseous arteries is essential for reliable ¯ap survival. Preserving this anastomosis, whilst maximizing ¯ap viability and robustness, does limit the distal arc of rotation of the ¯ap to coverage of the ®rst web space and the back of the hand as far distally as the metacarpophalangeal joints of the ®ngers. We present the results of three cases in which these limits were surpassed by extending the wrist and exteriorizing the vascular pedicle, thus allowing it to bowstring across the angle created by the extended wrist. When the ¯ap inset is complete, usually at 3 weeks, the vascular pedicle is excised under local anaesthesia. This is, therefore, an amalgamation of the modern technique of island ¯ap coverage and the traditional technique of two-stage
OPERATIVE TECHNIQUE The operation starts with careful debridement of the defect. The precise dimensions of the defect and the required pedicle length can then be measured to assist in ¯ap design. Raising of the ¯ap is no dierent from the usual technique, though one should base the ¯ap as far proximal as possible whilst still including the main cutaneous branch of the posterior interosseous artery which is found at the junction of the proximal third and the distal two thirds of the line joining the lateral epicondyle with the distal radioulnar joint. When the ¯ap is raised the donor site is closed. The wrist is then placed in 408 of extension and maintained in that position by a palmar metallic splint held with a carefully applied elastic bandage. The posterior interosseous ¯ap is then inset into the defect, allowing the pedicle to exit along its proximal edge. Once the ¯ap is inset into the defect, the pedicle bowstrings across the extended wrist. Instead of covering the pedicle with a split skin graft (Govila, 1989) it is wrapped in tulle gras and laid upon a bed of moist gauze applied to the back of the hand. The forearm, wrist and hand are all bandaged lightly, leaving a window to allow ¯ap monitoring. The postoperative period is one of the most critical in the procedure, and continual monitoring should be performed diligently by specialist nurses. In the case of vascular insuciency (no complications were noted in this short series), local action and anti-thrombotic therapy should be instituted, as for the usual venous or arterial problems encountered with island ¯aps. During the ®rst 8 days an irrigation system is used to irrigate the pedicle with normal saline and avoid desiccation, which would result in vascular thrombosis. Early mobilization is begun to avoid digital stiness, and the dressings are changed every 4 days with the exception of the tulle gras surrounding the pedicle and 296
EXTERIORIZATION OF POSTERIOR INTEROSSEOUS FLAP PEDICLE
the bandage which supports the splint. At 3 weeks a clamping test is performed and the inset and viability of the ¯ap are assessed. If the ¯ap demonstrates sucient inset and vascularity then the pedicle is excised in theatre under local anaesthesia. The resulting defects are closed appropriately. The postoperative period is as usual after this stage.
297
CASE REPORTS Case 1 (Fig 1) A women of 42 years presented following a work-related hot press accident in which she sustained deep burns to the dorsum of the left hand. The full thickness burn
Fig 1 Case 1. (a) Excisional debridement of the dead tissue exposing the extensor apparatus of the index, middle and ring ®ngers following hot press accident. (b) Intraoperative view of the ¯ap elevation (the arrow indicates the anastomosis between the posterior interosseous artery and the anterior interosseous artery). (c) Clamping test on the day 25 revealed that the ¯ap had adequately inset. (d) Staged separation of the ®ngers. (e, f) Final result.
298
involved the dorsum of the index, middle and ring ®ngers. Excisional debridement of the dead tissue exposed the extensor apparatus and the proximal interphalangeal joints. A posterior interosseous ¯ap was designed and raised using our usual techniques. It was centered on the main cutaneous branch of the posterior interosseous artery and inset into the defect as described. On day 25 the pedicle was clamped, revealing that it had adequately inset. Under local anaesthesia the pedicle was resected and the remaining wounds were closed. The wrist splint was removed and physiotherapy
THE JOURNAL OF HAND SURGERY VOL. 25B No. 3 JUNE 2000
was commenced immediately. The digits were separated and the ¯aps were defatted in the subsequent month. Case 2 (Fig 2) A female cook of 58 years sustained a full thickness burn of the dorsal aspect of the right index and long ®ngers when her hand fell into a pot of boiling oil during an epileptic ®t. After surgical debridement, the extensor tendons and the proximal interphalangeal joints were
Fig 2 Case 2. (a) Preoperative view. (b) Excisional debridement of the dead tissue. (c) Intraoperative view of the exteriorized pedicle. (d, e) Final result.
EXTERIORIZATION OF POSTERIOR INTEROSSEOUS FLAP PEDICLE
299
observed to be exposed and devascularized. Soft tissue coverage with a posterior interosseous ¯ap was carried out in a similar manner to case 1, leaving the pedicle exteriorized. On day 24 the pedicle was divided; the adequate skin cover allowed for a satisfactory active motion of the ®ngers.
tissue has formed to protect the pedicle from desiccation and thrombosis. In our three cases there were no vascular complications, ¯ap survival was complete and wrist mobility 6 months following surgery was normal. The indications for this technique are uncommon but it is useful in cases in which there are contraindications to microvascular procedures or to the sacri®ce of the radial artery.
Case 3 A man of 32 years presented following a work accident in which a bullet wound caused an avulsion amputation of the left ring ®nger. The amputated ®nger was replanted but a thrombosed artery necessitated terminalization on the third day. The remaining proximal and middle phalanges were completely denuded of skin and the tendons and bone were widely exposed. As he refused amputation for cosmetic reasons the ®nger was covered by a posterior interosseous ¯ap with an exteriorized pedicle in the same way as the other cases. Resection of the pedicle was done after a clamping test at the end of the third week. Physiotherapy was commenced immediately and there were no postoperative complications. The coverage of the denuded digit allowed preservation of length. DISCUSSION Other extracorporeal tissue transfers have been reported in experimental models (Duy et al., 1993), for reconstruction of facial defects (Govila, 1989) and, for coverage of soft tissue loss in the hand (Olding, 1991) and for use with free ¯aps from the toe (Brunelli et al., 1992; 1994). The main disadvantage of the posterior interosseous ¯ap is its relatively short pedicle which limits its use to defects along an arc from the ®rst web space to the metacarpophalangeal joints of the ®ngers. By exteriorizing the pedicle and extending the wrist, the relative length of the pedicle is increased so that it can cover the most distal regions of the hand and digits. The risk of desiccation is avoided by continuous irrigation during the ®rst 8 days, following which sucient granulation
References Angrigiani C, Grilli D, Dominikow D (1993). Posterior interosseous reverse forearm ¯ap: experience with 80 consecutive cases. Plastic and Reconstructive Surgery, 92: 285±293. Bayon P, Pho RW (1988). Anatomical basis of the dorsal forearm ¯ap. Journal of Hand Surgery, 13B: 435±439. Brunelli F, Capucci M, Magnano D (1994). Transfer libre du pulpe d'orteil avec pedicule exteriorise. Un compromis entre la microchirurgie et la chirurgie traditionelle. Annales de Chirurgie de la Main, 13: 373±377. Brunelli F, Brunelli GR, Perrotta R (1992). Combined second toe and partial nail transfer from the big toe by means of an exteriorised pedicle. Annals of Hand Surgery, 11: 411±415. Buchler U, Frey HP (1991). Retrograde posterior interosseous ¯ap. Journal of Hand Surgery, 16A: 283±292. Costa H, Comba S, Martins J, Rodriguez G, Reis J, Amarante J (1991). Further experience with the posterior interosseous ¯ap. British Journal of Plastic Surgery, 44: 449±455. Dap F, Dautel G, Voche P, Thomas C, Merle M (1993). The posterior interosseous ¯ap in primary repair of hand injuries. A review of 23 cases. Journal of Hand Surgery, 18B: 437±445. Duy FJ, Pribaz JJ, Hergrueter CA, Maitz PK (1993). Flap prefabrication using an exteriorised vascular pedicle in a rabbit ear model. British Journal of Plastic Surgery, 46: 279±284. Govila A (1989). Extracorporeal tissue transfer for extensive facial defects. British Journal of Plastic Surgery, 42: 521±525. Mazzer N, Barbieri CH, Cortez M (1996). The posterior interosseous forearm island ¯ap for skin defects in the hand and elbow. A prospective study of 51 cases. Journal of Hand Surgery, 21B: 237±243. Olding M (1991). Reverse forearm ¯ap based on an `exteriorised' pedicle. Journal of Hand Surgery, 16A: 157±160. Penteado CV, Masquelet AC, Chevrel JP (1986). The anatomic basis of the fascio-cutaneous ¯ap of the posterior interosseus artery. Surgical and Radiological Anatomy, 8: 209±215. Zancolli EA, Angrigiani C (1986). Colgajo dorsal de antebraze: Pediculo de vasos interoseos posteriors. Revista de la Associacion Argentina de Ortopedia y Traumatologia, 51: 161±168. Received: 31 May 1999 Accepted after revision: 3 March 2000 Dr Francesco Brunelli, Institute de la Main, 6 Square Jouvenet, 75016 Paris, France # 2000 The British Society for Surgery of the Hand DOI: 10.1054/jhsb.2000.0392, available online at http://www.idealibrary.com on
The posterior interosseous arterial ¯ap is limited by its short vascular pedicle and proximal axis of rotation to the coverage of defects on the dorsal aspect of the hand and the ®rst web space. The authors present the results of three cases in which these limits were surpassed by extending the wrist and exteriorizing the vascular pedicle, thus causing it to bowstring across the angle created by the extended wrist. When ¯ap inset is complete the vascular pedicle is excised under local anaesthesia. This technique is an amalgamation of an island ¯ap and a traditional pedicle ¯ap and, as such, it is a two-stage procedure. Journal of Hand Surgery (British and European Volume, 2000) 25B: 3: 296±299 INTRODUCTION
pedicle transfer. This intervention allows an increase of approximately 5 cm in the distal range of the ¯ap.
The posterior interosseous arterial ¯ap (Penteado et al., 1986; Zancolli and Angrigiani, 1986) has proved to be excellent for reconstruction of defects of the hand, wrist and elbow (Angrigiani et al., 1993; Bayon and Pho, 1988; Buchler and Frey, 1991; Costa et al., 1991; Dap et al., 1993; Mazzer et al., 1996). It has progressively replaced the radial forearm ¯ap (which was extremely popular in the 1980s) because it does not prejudice the main vascular axes of the hand. The posterior interosseous ¯ap is an island fasciocutaneous ¯ap vascularized by branches of the posterior interosseous artery. The posterior interosseous artery measures about 1 mm in diameter at its origin and progressively reduces in calibre as it courses distally and gives o several muscular and cutaneous branches. It forms an anastomosis with the anterior interosseous artery at the wrist, through the interosseous septum at the level of the distal radioulnar joint. This anastomosis represents the point of rotation of the vascular pedicle of the posterior interosseous ¯ap. To gain additional length and to shift the axis distally, several authors have suggested sacri®cing this anastomosis and basing the ¯ap on the ®ne arterioles of the dorsal carpus. However, these branches are extremely small, poorly de®ned and inconstant, and we believe that conserving the distal anastomosis between the two interosseous arteries is essential for reliable ¯ap survival. Preserving this anastomosis, whilst maximizing ¯ap viability and robustness, does limit the distal arc of rotation of the ¯ap to coverage of the ®rst web space and the back of the hand as far distally as the metacarpophalangeal joints of the ®ngers. We present the results of three cases in which these limits were surpassed by extending the wrist and exteriorizing the vascular pedicle, thus allowing it to bowstring across the angle created by the extended wrist. When the ¯ap inset is complete, usually at 3 weeks, the vascular pedicle is excised under local anaesthesia. This is, therefore, an amalgamation of the modern technique of island ¯ap coverage and the traditional technique of two-stage
OPERATIVE TECHNIQUE The operation starts with careful debridement of the defect. The precise dimensions of the defect and the required pedicle length can then be measured to assist in ¯ap design. Raising of the ¯ap is no dierent from the usual technique, though one should base the ¯ap as far proximal as possible whilst still including the main cutaneous branch of the posterior interosseous artery which is found at the junction of the proximal third and the distal two thirds of the line joining the lateral epicondyle with the distal radioulnar joint. When the ¯ap is raised the donor site is closed. The wrist is then placed in 408 of extension and maintained in that position by a palmar metallic splint held with a carefully applied elastic bandage. The posterior interosseous ¯ap is then inset into the defect, allowing the pedicle to exit along its proximal edge. Once the ¯ap is inset into the defect, the pedicle bowstrings across the extended wrist. Instead of covering the pedicle with a split skin graft (Govila, 1989) it is wrapped in tulle gras and laid upon a bed of moist gauze applied to the back of the hand. The forearm, wrist and hand are all bandaged lightly, leaving a window to allow ¯ap monitoring. The postoperative period is one of the most critical in the procedure, and continual monitoring should be performed diligently by specialist nurses. In the case of vascular insuciency (no complications were noted in this short series), local action and anti-thrombotic therapy should be instituted, as for the usual venous or arterial problems encountered with island ¯aps. During the ®rst 8 days an irrigation system is used to irrigate the pedicle with normal saline and avoid desiccation, which would result in vascular thrombosis. Early mobilization is begun to avoid digital stiness, and the dressings are changed every 4 days with the exception of the tulle gras surrounding the pedicle and 296
EXTERIORIZATION OF POSTERIOR INTEROSSEOUS FLAP PEDICLE
the bandage which supports the splint. At 3 weeks a clamping test is performed and the inset and viability of the ¯ap are assessed. If the ¯ap demonstrates sucient inset and vascularity then the pedicle is excised in theatre under local anaesthesia. The resulting defects are closed appropriately. The postoperative period is as usual after this stage.
297
CASE REPORTS Case 1 (Fig 1) A women of 42 years presented following a work-related hot press accident in which she sustained deep burns to the dorsum of the left hand. The full thickness burn
Fig 1 Case 1. (a) Excisional debridement of the dead tissue exposing the extensor apparatus of the index, middle and ring ®ngers following hot press accident. (b) Intraoperative view of the ¯ap elevation (the arrow indicates the anastomosis between the posterior interosseous artery and the anterior interosseous artery). (c) Clamping test on the day 25 revealed that the ¯ap had adequately inset. (d) Staged separation of the ®ngers. (e, f) Final result.
298
involved the dorsum of the index, middle and ring ®ngers. Excisional debridement of the dead tissue exposed the extensor apparatus and the proximal interphalangeal joints. A posterior interosseous ¯ap was designed and raised using our usual techniques. It was centered on the main cutaneous branch of the posterior interosseous artery and inset into the defect as described. On day 25 the pedicle was clamped, revealing that it had adequately inset. Under local anaesthesia the pedicle was resected and the remaining wounds were closed. The wrist splint was removed and physiotherapy
THE JOURNAL OF HAND SURGERY VOL. 25B No. 3 JUNE 2000
was commenced immediately. The digits were separated and the ¯aps were defatted in the subsequent month. Case 2 (Fig 2) A female cook of 58 years sustained a full thickness burn of the dorsal aspect of the right index and long ®ngers when her hand fell into a pot of boiling oil during an epileptic ®t. After surgical debridement, the extensor tendons and the proximal interphalangeal joints were
Fig 2 Case 2. (a) Preoperative view. (b) Excisional debridement of the dead tissue. (c) Intraoperative view of the exteriorized pedicle. (d, e) Final result.
EXTERIORIZATION OF POSTERIOR INTEROSSEOUS FLAP PEDICLE
299
observed to be exposed and devascularized. Soft tissue coverage with a posterior interosseous ¯ap was carried out in a similar manner to case 1, leaving the pedicle exteriorized. On day 24 the pedicle was divided; the adequate skin cover allowed for a satisfactory active motion of the ®ngers.
tissue has formed to protect the pedicle from desiccation and thrombosis. In our three cases there were no vascular complications, ¯ap survival was complete and wrist mobility 6 months following surgery was normal. The indications for this technique are uncommon but it is useful in cases in which there are contraindications to microvascular procedures or to the sacri®ce of the radial artery.
Case 3 A man of 32 years presented following a work accident in which a bullet wound caused an avulsion amputation of the left ring ®nger. The amputated ®nger was replanted but a thrombosed artery necessitated terminalization on the third day. The remaining proximal and middle phalanges were completely denuded of skin and the tendons and bone were widely exposed. As he refused amputation for cosmetic reasons the ®nger was covered by a posterior interosseous ¯ap with an exteriorized pedicle in the same way as the other cases. Resection of the pedicle was done after a clamping test at the end of the third week. Physiotherapy was commenced immediately and there were no postoperative complications. The coverage of the denuded digit allowed preservation of length. DISCUSSION Other extracorporeal tissue transfers have been reported in experimental models (Duy et al., 1993), for reconstruction of facial defects (Govila, 1989) and, for coverage of soft tissue loss in the hand (Olding, 1991) and for use with free ¯aps from the toe (Brunelli et al., 1992; 1994). The main disadvantage of the posterior interosseous ¯ap is its relatively short pedicle which limits its use to defects along an arc from the ®rst web space to the metacarpophalangeal joints of the ®ngers. By exteriorizing the pedicle and extending the wrist, the relative length of the pedicle is increased so that it can cover the most distal regions of the hand and digits. The risk of desiccation is avoided by continuous irrigation during the ®rst 8 days, following which sucient granulation
References Angrigiani C, Grilli D, Dominikow D (1993). Posterior interosseous reverse forearm ¯ap: experience with 80 consecutive cases. Plastic and Reconstructive Surgery, 92: 285±293. Bayon P, Pho RW (1988). Anatomical basis of the dorsal forearm ¯ap. Journal of Hand Surgery, 13B: 435±439. Brunelli F, Capucci M, Magnano D (1994). Transfer libre du pulpe d'orteil avec pedicule exteriorise. Un compromis entre la microchirurgie et la chirurgie traditionelle. Annales de Chirurgie de la Main, 13: 373±377. Brunelli F, Brunelli GR, Perrotta R (1992). Combined second toe and partial nail transfer from the big toe by means of an exteriorised pedicle. Annals of Hand Surgery, 11: 411±415. Buchler U, Frey HP (1991). Retrograde posterior interosseous ¯ap. Journal of Hand Surgery, 16A: 283±292. Costa H, Comba S, Martins J, Rodriguez G, Reis J, Amarante J (1991). Further experience with the posterior interosseous ¯ap. British Journal of Plastic Surgery, 44: 449±455. Dap F, Dautel G, Voche P, Thomas C, Merle M (1993). The posterior interosseous ¯ap in primary repair of hand injuries. A review of 23 cases. Journal of Hand Surgery, 18B: 437±445. Duy FJ, Pribaz JJ, Hergrueter CA, Maitz PK (1993). Flap prefabrication using an exteriorised vascular pedicle in a rabbit ear model. British Journal of Plastic Surgery, 46: 279±284. Govila A (1989). Extracorporeal tissue transfer for extensive facial defects. British Journal of Plastic Surgery, 42: 521±525. Mazzer N, Barbieri CH, Cortez M (1996). The posterior interosseous forearm island ¯ap for skin defects in the hand and elbow. A prospective study of 51 cases. Journal of Hand Surgery, 21B: 237±243. Olding M (1991). Reverse forearm ¯ap based on an `exteriorised' pedicle. Journal of Hand Surgery, 16A: 157±160. Penteado CV, Masquelet AC, Chevrel JP (1986). The anatomic basis of the fascio-cutaneous ¯ap of the posterior interosseus artery. Surgical and Radiological Anatomy, 8: 209±215. Zancolli EA, Angrigiani C (1986). Colgajo dorsal de antebraze: Pediculo de vasos interoseos posteriors. Revista de la Associacion Argentina de Ortopedia y Traumatologia, 51: 161±168. Received: 31 May 1999 Accepted after revision: 3 March 2000 Dr Francesco Brunelli, Institute de la Main, 6 Square Jouvenet, 75016 Paris, France # 2000 The British Society for Surgery of the Hand DOI: 10.1054/jhsb.2000.0392, available online at http://www.idealibrary.com on