Anatomical study. H. Costa, M. L. Gracia*, J. Vranchx?, C. Cunha, A. Conde and D. Soutar:~

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1 British Journal of Plastic Surgery (2001), 54, The British Association of Plastic Surgeons doi: /bjps PLASTIC SURGERY The posterior interosseous flap: a review of 81 clinical cases and 100 anatomical dissections - assessment of its indications in reconstruction of hand defects H. Costa, M. L. Gracia*, J. Vranchx?, C. Cunha, A. Conde and D. Soutar:~ Plastic Surgery Unit, Centro Hospitalar Vila Nova de Gaia, Portugal; *Hospital Fremap Sevilla, Spain;?Plastic Surgery Unit, Hospital Sao Jodo, Porto, Portugal; and ~Canniesburn Hospital, Glasgow, UK SUMMARY. Based on our experience of 100 cadaveric dissections and a series of 81 clinical cases, we have assessed the indications for the posterior interosseous flap in reconstruction of the hand. Large fasciocutaneous island flaps can be harvested, even when the radial or ulnar pedicles are damaged, sacrificing only vessels of secondary importance to the perfusion of the hand. Compound flaps can be dissected based on muscular, musculoperiosteal and fascioperiosteal branches. The primary indications for using this flap are dorsal hand defects up to the metacarpal joints, reconstruction of the first web space up to the interphalangeal joint of the thumb and extensive lesions on the ulnar border of the hand The British Association of Plastic Surgeons Keywords: posterior interosseous flap, anatomical dissection, hand defects. Reconstruction of large soft tissue defects in the hand should consider possible compromise of the remaining hand vascularisation and future reconstructive options. The posterior interosseous flap offers some advantages over other available reconstructive methods, since it sacrifices vessels that are not essential in maintaining hand viability. Based on our experience of 100 cadaveric dissections and 81 clinical cases, we present an assessment of the indications for using this flap in hand reconstruction. Materials and methods Anatomical study The posterior interosseous flap is a fasciocutaneous flap based on the posterior interosseous artery, which lies invested by the fascial septum between the extensor carpi ulnaris and the extensor digiti minimi. The artery gives off septocutaneous branches that spread out on the deep fascia to form longitudinal fascial arcades, as well as further branches that pass through the deep fascia to supply the underlying deep extensor muscles. In the lower third of the posterior forearm, direct septoperiosteal branches to the ulna are also present. In 100 fresh cadaveric limbs the posterior interosseous artery at the upper third of the anterior forearm was dissected, catheterised and injected with coloured latex. A selective injection of the posterior interosseous artery with methylene blue was performed in 20 cases, after the whole skin of the forearm had been raised subfascially, via circumferential incisions at the level of the inter-epicondylar line and at the wrist joined by a longitudinal incision in the middle of the volar surface of the forearm. In this way, the fasciocutaneous unit was left attached only by the fascial septum between the extensor carpi ulnaris and the extensor digiti minimi, where the posterior interosseous artery and its septocutaneous branches lie. Results. Our results confirmed previous accounts. 1-6 In 82 cases the artery originated from the common interosseous artery and in 18 cases it originated from the ulnar artery. After passing between the chorda obliqua and the interosseous membrane, the artery emerged in the deep extensor compartment of the forearm, underneath the supinator at an average distance of 7.9cm (range: cm) from the lateral epicondyle of the humerus and 14.5 cm (range: cm) from the ulnar styloid. The interosseous recurrent artery originated at this level, ran proximally and was present in 91 dissections. The posterior interosseous artery passed distally in the intermuscular septum and, in all of the 100 cadaveric dissections, was found to reach as far as the wrist, lateral to the ulnar head. Here, the anastomosis between the posterior and anterior interosseous arteries, underneath the extensor tendons, was present in all the dissections. In 97 cases, the anastomosis was formed by a single branch and in three cases by a dual network, just proximal and lateral to the ulnar head, the largest anastomotic branch always being the distal one. After its emergence in the deep posterior forearm, the posterior interosseous artery had an average external diameter of 1.7 mm (range: mm), while the anastomotic branch had a diameter of 0.95mm (range: ram). Two venae comitantes accompanying the artery in the fascial septum, as well as the anastomotic branch, were always identified. The artery gave off fasciocutaneous perforators along its length through the septum between the extensor carpi ulnaris and the extensor digiti minimi. Three distinct patterns of septocutaneous vessels were identified: 3 in 28

2 i The posterior interosseous flap 29 pattern 1 the septocutaneous branches were distributed in two sub-groups, one proximal and the other distal, each containing three or four vessels (27 cases); in pattern 2 multiple small branches arose at 1-2 cm intervals along the total length of the posterior interosseous artery (59 cases); and in pattern III there was a large proximal perforator in the proximal group sharing the same origin as the interosseous recurrent artery, with a larger diameter than the remaining septocutaneous vessels and fanned out into several branches (14 cases). Being a deep vessel, the posterior interosseous artery gave origin to between nine and 20 branches to the muscles of the posterior compartment of the forearm. Branches to the deep extensor muscles, namely, abductor pollicis longus, extensor pollicis longus and extensor indicis, were a constant finding. A few variable periosteal branches were found but only in the distal third of the ulna (neck and head). The cadaveric injection studies showed staining across the whole width of the posterior skin of the forearm extending from 2-4 cm below the inter-epicondylar line to the wrist. Clinical study Between 1988 and 1998, 81 patients with large hand defects, as the result of crush-degloving injuries, bum contractures, or skin necrosis subsequent to chemotherapy, burns or trauma, underwent reconstruction using the posterior interosseous flap as either a fasciocutaneous island flap or an osteocutaneous flap. Of the 81 patients, 76 were male, between 7 and 84 years old, and five were female, between 1 and 64 years old. Forty patients (49.5%) were younger than 30 years of age. In all, 46 patients (56.8%) had sustained a crushdegloving injury to the hand, ten patients (12.3%) had post-traumatic sequelae, mainly contractures of the first web space, and 20 patients (24.7%) had contractures due to burns. The remaining five cases included chemotherapy extravasation causing dorsal skin necrosis of the hand and wrist, a large malignant melanoma resection, ischaemic skin loss after a revascularisation procedure, an extensive squamous cell carcinoma resection and an extensive recurrent Dupuytren's contracture necessitating extensive skin excision. Six osteocutaneous flaps were used to reconstruct the second metacarpal bone (three cases) or the thumb (three cases). The skin flap varied in size from 4 5 cm to 14 9 cm. Direct closure was achieved in donor sites smaller than 7 x 6 cm; larger defects required a skin graft. Operative technique The surface marking of the posterior interosseous artery is drawn in a line between the lateral epicondyle and the ulnar head with the forearm in full pronation. A point 9 cm (range: cm) distal to the lateral epicondyle marks the centre of the fasciocutaneous element of the flap. The important anatomical consideration is that the fascial septum between the extensor carpi ulnaris and the extensor digiti minimi, in which the vessels lie, is orientated E.RL. l~ ~ Ulna.&.EL. A ~E.D,M ED.C. E.P.L. A.P.L. -?..%~ ~m~r~ r ~ ~L]~, ".:~'..i::'.j DM Figure 1---Cross-section through the upper third of the forearm demonstrating the plane of dissection of (A) the fasciocutaneous flap and (B) the osteocutaneous flap. EPL: extensor pollicis longus; APL: abductor pollicis longus; ECU: extensor carpi ulnaris; EDM: extensor digiti minimi; EDC: extensor digitorum cominis. sagittally. In the distal half the artery is relatively superficial but in the proximal half the septum lies underneath the extensor digiti minimi and so the vessel is more deeply situated. This is the main reason why the dissection must be performed from distal to proximal (Fig. 1A,B). 3-6 Results In this series of 81 clinical cases the technique had to be abandoned and an alternative method of reconstruction used in three cases. In each case the posterior interosseous artery appeared to terminate in the middle third of the forearm and the usual anastomosis between the posterior and anterior interosseous arteries lateral to the ulnar head could not be identified. The flap he~lled uneventfully in 73 out of the remaining 78 cases (93.6%). Three cases suffered delayed wound healing because of marginal rim necrosis of the flap, but subsequently healed with conservative management. One case sustained necrosis of the distal third of the flap, requiring secondary skin grafting, and there was one complete flap loss, which necessitated secondary C

3 30 reconstruction; in both these cases the flap was used to reconstruct defects arising f r o m c r u s h - d e g l o v i n g injuries. Case reports Case 1 A 27-year-old man sustained a severe crush-degloving injury to his fight dominant hand when it was caught in a roller machine 2 weeks prior to presentation. On examination he was found to have extensive loss of skin over the dorsum, ulnar border and palm of the hand and amputation of the little finger through the metacarpophalangeal joint (Fig. 2A). Further debridement was British Journal of Plastic Surgery carried out, including revision of the fifth metacarpal amputation stump (Fig. 2B). The defect was reconstructed using a 12.5 x 7.5cm distally based posterior interosseous island fasciocutaneous flap (Fig. 2C,D). The donor area was skin grafted. Healing was uneventful and a good functional result was achieved (Fig. 2E,F). Case 2 A 55-year-old man sustained a crush-degloving injury with devascularisation of his fight hand. Although revascularisation was achieved, subsequent skin necrosis over the dorsum of the hand with tendon exposure gradually occurred (Fig. 3A-C). Figure 2--Case 1. (A) Crush degloving injury involving the dorsum, ulnar border and palm, with amputation of the little finger through the metacarpophalangeai joint. (B) Debridement carried out, including the fifth metacarpal amputation stump. (C) Marking of the large posterior interosseous flap. (D) The fascioeutaneous flap was raised and immediately transposed. (E,F) Postoperative result at 6 months. The donor area was split-skin grafted.

4 The posterior interosseous flap 31 Figure 3--Case 2. (A) Skin necrosis over the dorsum of the hand with tendon exposure after revascularisation of the right hand. Marking of a large fasciocutaneous posterior interosseous flap. (B) Radiograph showing multiple fractures of the first, second, fourth and fifth metacarpal bones. (C) Radiograph showing the bone fixation with K-wires. (D) Appearance 3 months after surgery. After debridement, the defect was reconstructed using a distally based posterior interosseous island flap (fasciocutaneous paddle 14x9cm). The donor area was skin grafted. Healing was uneventful and a good functional result was achieved (Fig. 3D). Case 3 A 35-year-old man sustained a severe crush-degloving injury to his dominant left hand. There was extensive soft tissue loss on the dorsum of the hand, with extensor tendon exposure and bone loss of the second and third metacarpal bones (Fig. 4A,B). Iliac bone grafts to the metacarpal bones (Fig. 4C) and tendon grafts to the extensor tendons of the index and middle fingers were performed. Skin cover was achieved using a 10 x 7 cm distally based posterior interosseous island fasciocutaneous flap (Fig. 4D,E). Healing was uneventful and a good functional result was achieved (Fig. 4F). Discussion In reconstruction of soft tissue defects of the hand, single-stage procedures that can offer well-vascularised wound closure are essential to help prevent infection, enable early mobilisation and physiotherapy, and shorten hospital stay. If local flaps are insufficient to meet these requirements, distant flaps or free flaps can be used. The forearm is a versatile local donor site for reconstruction of the hand by retrograde perfusion. There are five axes possible. The distally based radial forearm flap is often considered the workhorse for covering large hand defects. Its advantages are a large skin paddle with reliable reversed perfusion, and available tendons and bone if required. 7-1~ Dissection is simple, but this flap should not be used in heavily mutilated hands where the additional loss of the radial artery could compromise hand viability The ulnar flap is based on the major arterial supply to the hand and sacrificing the ulnar artery is the major disadvantage of this flap. Vascularised tendon grafts and bone can be included, and the flap can reach the tips of the fingers as a distally based pedicled island flap The dorsoulnar flap, based on the ascending branch of the dorsoulnar artery, is a distally based flap that is easily dissected but has a short pedicle and limited rotation. Only defects on the ulnar-dorsal side of the hand and the proximal palm can be reached. 17 The anterior interosseous flap, with its skin paddle on the dorso-radial side, can provide skin, tendon, nerve, muscle and bone of the distal radius. The dissection, however, is very demanding, involving fragile and anatomically variable vessels, l s-z1 The last remaining axis is the posterior interosseous artery, giving off septocutaneous branches that spread out on the deep fascia to form longitudinal fascial arcades and muscular branches that pass through the deep fascia. In the lower third of the posterior forearm, direct septoperiosteal branches to the ulna are present. 1-6'22-29 There are two main anatomical variants of the posterior interosseous artery: one involves absence of the distal dorsal carpal anastomosis with the anterior interosseous artery and the other is hypoplasia or aplasia of the middle third of the posterior interosseous artery. Penteado et al found variations in five out of 70 dissections involving either the disappearance of the artery in the middle third of the forearm (four cases) or absence of the anastomosis at the wrist (one case). 2 Costa and Soutar found in 22 dissections and three clinical cases that the posterior interosseous artery was always in the fascial septum

5 32 British Journal of Plastic Surgery Figure 4--Case 3. (A) Crush degloving injury of the left hand, involvingthe dorsum, with extensor tendon exposure and loss. (B) Radiograph showing fractures with bone loss of the second and third metacarpal bones and fracture of the first phalange of the index finger. (C) Radiograph showing bone fixation with K-wires, screws and plates with iliac bone grafts. (D) Marking of the posterior interosseous flap. (E) Immediate postoperative result. The donor area was split-skin grafted. (F) Appearance4 months after surgery. between the extensor carpi ulnaris and the extensor digiti minimi until it reached the level of the ulnar head, where it anastomosed with the anterior interosseous artery. 3 In a series of 40 fresh cadaver specimens and 80 clinical cases of posterior interosseous reverse forearm flaps, Angrigiani et al noted absence of the continuity of the posterior interosseous artery at the level of the mid-forearm in one anatomic specimen and one clinical case; these authors also observed narrowing of the posterior interosseous artery in the mid-forearm in 74 out of 80 clinical cases (80%). 28 Buchler and Frey found the posterior interosseous artery to be missing in the mid-forearm in two cases in a series of 36 patients 3~ and Giunta and Lukas reported a clinical case of absence of continuity of the posterior interosseous artery in the middle third of the forearm. 31 To negate these anatomical variations around its distal pedicle, Chen et al designed three auxiliary procedures to make the flap more reliable: first, an additional venous anastomosis when there is congestion after inset of the distally based flap; second, converting to a free flap when it proves impossible to harvest the flap; and third, raising the flap with a wide base, incorporating the branches of both the anterior and the posterior interosseous arteries when the patient is elderly or has possible peripheral arterial disease. 32 The main advantage of the posterior interosseous flap is the location of its vascular root at the anastomosis between the posterior and the anterior interosseous arteries, making

6 The posterior interosseous flap 33 it possible to use this flap in situations where the main vascular radial or ulnar axes are damaged, and even in reconstruction of the replanted hand. In our series, we have found the flap particularly useful for the reconstruction of first web space contractures and large dorsal hand defects with tendon and bone exposure. The posterior interosseous osteocutaneous flap is useful in metacarpal reconstruction and thumb reconstruction, leaving open possibilities for secondary microsurgical procedures. 3-6'33 The major vascular advantages of this flap are the location of the dorsal carpal anastomosis, which allows it to be used even in the presence of extensive vascular damage to the hand, and the preservation of the radial and ulnar arteries, which are the major arterial supply to the hand. Acknowledgements The authors would like to thank Secundina Lopes and Paula Rocha for typing the manuscript, References 1. Zancolli EA, Angrigiani C. Colgajo dorsal de antebrazo (en isla) (pediculo de vasos interoseos posteriores). Rev Assoc Arg Ortop Traumatol 1986; 51: Penteado CV, Masquelet AC, Chevrel JP. The anatomic basis of the fascio-cutaneous flap of the posterior interosseous artery. Surg Radiol Anat 1986; 8: Costa H, Soutar DS. The distally based island posterior interosseous flap. Br J Plast Surg 1988; 41: Costa H, Smith R, McGrouther DA. Thumb reconstruction by the posterior interosseous osteocutaneous flap. Br J Plast Surg 1988; 41: Costa H, Comba S, Martins A, Rodrigues J, Reis J, Amarante J. Further experience with the posterior interosseous flap. Br J Plast Surg 1991; 44: Costa H, Cunha C, Silva A, et at. One real advantage of the distally based posterior interosseous island flap. Eur J Plast Surg 1996; 19: Stock W, Muhlhauer W, Biemer E. Der neurovasculare Unterarm- Insel-Lappen. Z Plast Chir 1981; 5: Biemer E, Stock W. Total thumb reconstruction: a one-stage reconstruction using an osteo-cutaneous forearm flap. Br J Plast Surg 1983; 36: Soutar DS, Tanner NSB. The radial forearm flap in the management of soft tissue injuries of the hand. Br J Plast Surg 1984; 37: Foucher G, Van Genechten F, Merle N, Michon J. A compound radial artery forearm flap in hand surgery: an original modification of the Chinese forearm flap. Br J Plast Surg 1984; 37: Jones BM, O'Brien CJ. Acute ischaemia of the hand resulting from elevation of a radial forearm flap. Br J Plast Surg 1985; 38: Suominen S, Asko-Seljavaara S, Attovuo J. Thermography and color doppler ultrasonography of hands after radial forearm flap elevation. Presented at the Fifth Annual Meeting of the European Association of Plastic Surgeons, Geneva, 1994: Kleinert JM, Fleming SG, Abel CS, Firrell J. Radial and ulnar artery dominance in normal digits. J Hand Surg 1989; 14A: Glasson DW, Lovie MJ. The ulnar island flap in hand and forearm reconstruction. Br J Plast Surg 1988; 41: Guimberteau JC, Goin JL, Panconi B, Schuhmacher B. The reverse ulnar artery forearm island flap in hand surgery: 54 cases. Plast Reconstr Surg 1988; 81: Li Z, Liu K, Cao Y. The reverse flow ulnar artery island flap: 42 clinical cases. Br J Plast Surg 1989; 43: Becker C, Gilbert A. Le Lambeau Cubito dorsal. Ann Chir Main 1988; 7: Hu W, Martin D, Foucher G, Baudet J. The anterior interosseous retrograde island flap: a new flap in hand surgery. Book Of Abstracts For The Fifth Congress of International Federation of Surgery of The Hand. Paris 1992: Hu W, Martin D, Baudet J. Thumb reconstruction by the anterior interosseous osteocutaneous retrograde island flap. Eur J Plast Surg 1994; 17: Hu W, Baudet J. The anterior interosseous retrograde island flap. Anatomic study and clinical application. Transactions of Fifth Annual Meeting of EURAPS, Geneva 1996: Martin D, Bakhach J. Anterior interosseous flap. In Clinics In Plastic Surgery, Hand Surgery Update II, 1997: Zancolli EA, Angrigiani C. Colgajo inter6sseo posterior. Presented at the Argentinian Congress of Hand Surgery, Zancolli EA. Presentation at the International Federation of Societies for Surgery of the Hand, Tokyo, Zancolli EA, Angrigiani C. Posterior interosseous island forearm flap. J Hand Surg 1988; 13B: Masquelet AC, Penteado CV. Le lambeau interosseux posttrieur. Ann Chit Main 1987; 6: Costa H, Guimar~es A, Rodrigues J. Experience with the posterior interosseous flap: 38 clinical cases. Transactions of 5th Annual Meeting of EURAPS, Geneva, 1996: Costa H. The distally based island posterior interosseous flap. Br J Plast Surg 1998; 51: Angrigiani C, Grilli D, Dominikow D, Zancolli EA. Posterior interosseous reverse forearm flap: experience with 80 consecutive cases. Plast Reconstr Surg 1993; 92: Teo TC, Richard BM. The distally based posterior interosseous fasciocutaneous island flap in reconstruction of the hand in leprosy. Indian J Lepr 1997; 69: Buchler U, Prey HE Retrograde posterior interosseous flap. J Hand Surg 1991; 16A: Giunta R, Lukas B. Impossible harvest of the posterior interosseous artery flap: a report of an individualised salvage procedure. Br J Plast Surg 1998; 51: Chen H, Cheng M, Schneeberger AG, Cheng T, Wei E Tang Y. Posterior interosseous flap and its variations for coverage of hand wounds. J Trauma 1998; 45: Costa H, Mesquita A, Cunha C, et al. Retalho inter6sseo posterior na cirurgia da m~o. Rev Port Ortop Traum 1997; 5: The Authors Hor~icio Costa PhD, Professor in Plastic Surgery, Clinical Director Cristina Cunha MD, Consultant Plastic Surgeon Ant6nio Conde MD, Consultant Plastic Surgeon Centro Hospitalar Vila Nova de Gaia, R. Conceiq~o Femandes, 4430 Vila Nova de Gaia, Portugal. Manoel Luanco Gracia PhD, Professor in Plastic Surgeon Hospital Fremap, Seville, Spain. Jan Vranchx MD, Fellow in Plastic Surgery Plastic Surgery Unit, Hospital Sao Jofio, Porto, Portugal. David Soutar MD, Consultant Plastic Surgeon, Clinical Director Canniesburn Hospital, Switchback Road, Bearsden, Glasgow G61 1QL, UK. Correspondence to Professor Hor~icio Costa MD PhD, Rua Corvo n ~ 323, 4405~039 Arcozelo, Vila Nova de Gaia, Portugal. Paper received 28 January Accepted 22 August 2000, after revision.