Versatility of the Posterior Interosseous Artery Flap: Emphasis on Powering Up the Toe Transfer

Abstract

Background:

Reverse-flow posterior interosseous artery (rPIA) flap is an excellent tool for restoration of defects in the hand and upper extremity, sparing the main arteries to the hand. Its reliability has been well established.

Materials and Methods:

Fifty-one cases of rPIA flap involving 49 patients were retrospectively reviewed. The inclusion criteria were age, sex, etiology, size and location of the defect, flap size, number of perforators included, pedicle length, flap inset, donor site coverage, complications, and ancillary procedures.

Results:

This study included 44 men and 5 women, ranging in age between 10 and 73 years. The subjects had soft tissue defects of the hand and upper extremity mainly due to traumatic injuries, including scar contractures of the first web space in 18 cases, thumb amputations in 6 cases, and congenital defects in 1 case. Among the 51 rPIA flap elevations, 3 cases involved flap failure due to the absence of proper pedicle. A fasciocutaneous pattern was observed in 45 cases and a myocutaneous pattern in 3 cases. In 5 cases of unplantable thumb amputations, the rPIA flap was performed for arterial inflow to the secondary toe-to-thumb transfer. Venous congestion of varying degrees was noted in 7 cases involving partial necrosis in 2 cases. During the mean 17 months of follow-up, patients were generally satisfied with the final outcomes.

Conclusion:

The rPIA flap can be used not only for soft tissue coverage of the hand and upper extremity but also as a recipient arterial pedicle for a secondary toe-to thumb transfer.

Keywords

reverse posterior interosseous artery flap toe transfer toe-to-thumb transfer forearm flap amputation trauma diagnosis soft tissue reconstruction

Introduction

Posterior interosseous artery (PIA) flap has gained widespread acceptance and popularity as a pedicled or free flap for reconstruction of the hand and upper extremity.^1-5 It could be used as a proximal island flap for elbow coverage and as a distal one for hand and wrist reconstruction. Because PIA flap does not sacrifice the main arteries of the hand, it could be an alternative option when either radial or ulnar artery was damaged, or when palmar arches were absent.

Although anatomical variations of the PIA are very common, many surgeons suggest the reliability of PIA flap^2-6 since its original report as a cutaneous flap for adduction contracture of the thumb and extensive defects of the hand dorsum.¹ Reverse PIA (rPIA) flap is also available because of the anastomosis between the PIA and the anterior interosseous artery (AIA) at the level of the distal forearm proximal to the carpus, even in the presence of extensive vascular damage of the hand.⁷ The rPIA flap provides successful resurfacing of the composite defects in the wrist and distal forearm, palm,⁸ fingers including thumb,^1,9 and even the fingertip¹⁰ with fully extended pedicle. It can also be performed as a free flap with higher success rate when the pedicled flap is not connected with AIA or when the distal forearm is injured.¹¹

The indications for rPIA flap can be extended to a wide range of hand and upper extremity reconstructions, such as distal radius graft,¹² revision surgery of carpal tunnel release,¹³ and synostosis of the elbow joint and forearm.¹⁴ Although reverse radial forearm flap has been used to provide arterial inflow during a toe-transfer surgery,^15,16 the role of rPIA has yet to be reported in such cases. In addition to the well-established indications of the rPIA flap, we present the varying applications of the rPIA flap based on our clinical experience.

Materials and Methods

A retrospective review of patients who underwent rPIA flap at MS JaeGeon Hospital by a single surgeon between March 2003 and December 2019 was performed. For each patient, data including age, sex, cause, indications, the size and location of the defect, pedicle length, number of perforators included, flap inset technique, donor coverage, complications, and ancillary procedures and operation results were collected individually. This study was approved by the ethics committee of the institution. Preoperatively, handheld Doppler tracing of the PIA was performed in all cases to locate the cutaneous perforators of the PIA. The connection of the PIA with the AIA was also confirmed intraoperatively; otherwise, we did not perform the rPIA flap.

Results

A total of 51 cases involving 49 patients were included (Table 1). The subjects included 44 men and 5 women, and the mean age of the patients was 43.2 years (range, 10-73 years). The victims had soft tissue defects of the hand and upper extremity due to crushing, press-degloving injuries including traumatic amputations in 30 cases, posttraumatic scar contractures of the first web space including burn injuries in 18 cases, acute burn injury in 1 case, human bites in 1 case, and congenital contracture in 1 case. The left side was affected in 23 cases, the right side in 24 cases, and both sides in 2 hands. The defect areas involved first web space in 18 cases (Figure 1; Supplemental Figure S1), hand dorsum in 12 cases, thumb amputation in 6 cases, palmar and hypothenar in 4 cases, wrist and distal forearm in 4 cases, finger defects in 2 cases, and amputated hand stump in 2 cases (Supplemental Table S1). Twenty-seven patients carried associated fractures of the hand and wrist. Varying degrees of amputations of the hand and bone loss, even including the metacarpal hand, were observed in 11 patients.

Table 1.

Patients’ Clinical Demographics.

Cases	Age	Sex	Cause	Site	Defect area	Associated injury	Flap size (length × width), cm	Number of perforators included	Pedicle length, cm	Flap inset	Cover of donor site	Complications	Ancillary procedures	Comments	Follow-up, mo
1	66	Male	Tractor crushing	Right	Hand dorsum	MC 1-5th open fxs	9 × 3	2	9	Skin paddle between skin bridges	P-closure	Infection, drainage	Arterial anastomosis, tenorrhaphy		17
2	38	Male	Press crushing	Right	Hand dorsum	Open MC 3-4th fxs	10 × 6		7	Tunneling	STSG		EDC tendon graft, MCP joint transfer (2nd toe)		12
3	38	Male	Electrical saw	Left	Thumb avulsion defect	Avulsion fx., proximal phalanx	7 × 4		13	Skin paddle between skin bridges + tunneling	P-closure	Venous congestion	EPL reconstruction using 2 folds of palmaris longus		4
4	58	Male	crushing	Left	Hand dorsum	2-3rd amputation, MC 2-5th fxs	11.5 × 6.5		11	Tunneling	STSG	Osteomyelitis, drainage	Multiple curettage		11
5	54	Female	Grinding, crushing	Left	Hand dorsum	MC 2-4th open fxs, ALT free flap failure	11 × 8	1	8	Skin paddle between skin bridges	FTSG	Venous congestion	Silicone 3 rods for 2-4th EDC, bone graft		15
6	40	Male	Crushing	Right	Hand dorsum	MC 2-4th open fxs	6 × 3		6.5	Tunneling	P-closure		Silicone 4 rods for 2-5th EDC, additional radial forearm flap		12
7	48	Male	Degloving	Right	Metacarpal hand dorsum	Multiple phalangeal amputations, previous ALT free flap	9 × 4.5	2	7	Tunneling	FTSG		defatting, separation of syndactyly, thumb lengthening syndactyly separation		18
8	56	Male	Roller	Right	Hand dorsum	EDC tendon defects, MC 3-4th head level	8 × 6	1	8	Tunneling	FTSG		2 tendon grafts for 3-4th EDC, defatting		9
9	53	Male	Mechanical	Right	Metacarpal mitten glove hand, 1st web	Amputation, previous ALT free flap	8 × 2	2	8	Tunneling	P-closure		Bone cement on 2-3rd proximal phalanges, 1st web contracture release, implant removal, defatting		23
10	65	Male	Press crushing	Left	Hand dorsum	MC 2-4th open fxs	11 × 6		8	Tunneling	FTSG				9
11	40	Male	Press crushing	Left	Thumb		5 × 7		10	Tunneling	P-closure	Venous congestion	1st web space deepening	Author’s first clinical case	12
12	39	Male	Mechanical	Right	Hand dorsum, hypothenar, wrist	MC 4-5th fxs	12 × 4		11	Skin paddle between skin bridges	P-closure	Venous congestion (30% partial necrosis)	Arterial anastomosis	Too thin pedicle	21
13	27	Male	Grinding, crushing	Left	Hypothenar, palm	Amputation 4-5th and palm, 1st MC fx., ALT free flap	12 × 7	2	5	Tunneling	FTSG	Osteomyelitis (OM), hematoma, drainage	Replantation, bone graft		41
14	67	Male	Falling down	Right	Hand dorsum	Distal radius fx.	6 × 3.5	1	9	Tunneling	P-closure		Carpal tunnel release, ORIF, wrist fusion		12
15	40	Female	Press	Left	Thumb	Incomplete amputation, MC, PP, 1-2nd open fxs	12 × 6	1	8	Tunneling	FTSG		Revasularization, thumb MCP joint fusion		70
16	32	Male	Press	Right	Amputation 1-4th fingers, palm, stump cover	Proximally 1-4th CMC joint level injury	8 × 8	2	5	Tunneling	FTSG		Amputation	5th ray intact only	5
17	65	Female	Crushing	Left	Amputated wrist	STSG using Pelnac	8 × 3	1	7.5	Skin paddle between skin bridges	P-closure		Stump plasty		5
18	26	Male	Contact burn	Left	Distal forearm, dorsum		10 × 11		5	Skin paddle between skin bridges	FTSG			Injury at the AIA-PIA connecting area	6
19	33	Male	Human bite	Right	hand dorsum—middle finger	Rt MF, proximal phalanx fx.	7 × 2.5		8	Tunneling	P-closure		Curettage, bone resection, bone cement insertion, MCP joint transfer (2nd toe)		20
20	73	Male	Mechanical	Right	Distal forearm, volar	Incomplete amputation, distal radius open fx.	8 × 8	2	6	Skin paddle + open up + resuture	FTSG	Venous congestion, OM-infection drainage	Including EDM within the flap, flexor tenorrhaphy, distal radius ORIF	Myocutaneous flap, injury at the AIA-PIA connecting area	1
21	44	Male	Mechanical	Right	Hand dorsum	MC 1-2nd, 4-5th open fxs	6 × 5		8	Tunneling	STSG		Rt thumb replantation, bone graft, EDC reconstruction using 2 silicone rods		32
22	23	Male	Rolling machine	Right	Hypothenar, hand dorsum		8 × 5		6	Tunneling	FTSG		Neurorrhaphy, defatting		3
23	39	Male	Mechanical	Right	2nd finger wrapping to the PIP joint level	2.3.5th open fxs	8 × 5	2	6	Skin paddle between skin bridges + tunneling	FTSG		Defatting		15
24	38	Male	Rolling, crushing	Left	Hand dorsum	1-4th MC open fxs	8 × 6		8	Tunneling	STSG		Radial and ulnar a. anastomosis c vein graft, 1st CMC j. and 2, 3, 4th metacarpal fixation, bone graft, 2, 3, 4th FDP tenorrhaphy, 5th extensor tenorrhaphy, tenolysis, bone graft		11
25	40	Male	Press	Right	Traumatic cleft hand	Crushing amputation, 2-4th fingers	7 × 6					Flap failure	Reverse radial forearm free flap	Too thin pedicle
26	54	Male	Press	Right	MC stump plasty	Amputation, 2-5th MC level	8.5 × 5.5					Flap failure	Reverse radial forearm free flap	Absence of pedicle
27	54	Male	Grinding machine	Left	1st web space contracture	Multiple 1-5th finger amputation state	9 × 5					Flap failure	ALT free flap	Absence of pedicle
28	31	Male	Press	Left	Wrist dorsum, hypothenar	1st, MC, PP, DP fxs	7 × 10. 5		6	Open up and resuture	FTSG		Thumb fx.—ORIF, IP joint fusion FCU reconstruction with PL, neuroma excision		31
29	49	Male	Press, crushing	Right	Thumb	Amputation	8 × 6	1	8	Tunneling	FTSG		Rt great toe transfer (venous congestion → reexploration)		14
30	24	Male	Rolling belt	Right	Thumb	Amputation	7 × 8.5		10	Tunneling	STSG		Rt great toe transfer		13
31	35Male		Press	Left	Thumb	Amputation	Lt 6 × 8		10	Tunneling	P-closure		Rt 2nd toe transfer		22
32	35Male		Press	Right	Thumb	Amputation	Rt 9 × 11	2	12	Tunneling	FTSG		Lt great toe transfer		22
33	47Male		Press	Left	Thumb	Amputation	8 × 11		8	Tunneling	FTSG		Rt 2nd toe transfer		15
	47Male		Press	Right	Thumb	Amputation							Lt great toe partial transfer (cross toe flap for donor site cover)
34	59	Male	Press	Left	1st web space	Lt radioulnar fxs	3 × 10	2	9	Skin paddle between skin bridges	P-closure		Opponensplasty, including EDM within the flap, bone graft, defatting	Myocutaneous flap	22
35	36	Male	Degloving	Left	1st web space	Lt ALT flap mitten glove state	5 × 7	3	16	Skin paddle between skin bridges	FTSG		Both hands—mitten gloves with both ALT free flaps, syndactyly division		15
36	61	Male	Crushing	Right	1st web space	Rt palm (2, 3, 4, 5th) amputation—replantation	3 × 10		8	Skin paddle between skin bridges	P-closure		MCP joint arthrolysis, opponensplasty		30
37	28	Male	Degloving	Right	1st web space	All finger amputation	8 × 3	2	10	Tunneling	P-closure		Replantation of all fingers, FTSG, defatting		21
38	39	Male	Degloving	Left	1st web space	Degloving thumb and palm, 1, 4, 5th MC, and 1st, 4th PP fxs	8 × 3	3	9	Skin paddle between skin bridges	P-closure		Replantation, FTSG, nerve graft, tenolysis, defatting		8
39	53Male		Contact burn	Right	1st web space—palm		5 × 9	2	11	Skin paddle between skin bridges	FTSG		Nerve graft, opponensplasty using hypothenar muscle		24
40	53Male		Contact burn	Left	Wrist dorsum		6 × 11	2	3	Skin paddle between skin bridges	FTSG			Injury at the AIA-PIA connecting area
41	44	Male	Electrical burn	Right	1st web space		5 × 9		12	Tunneling	P-closure		UCL reconstruction, tendon transfer (EIP for EPL), opponensplasty with PL transfer		14
42	41	Male	Press	Left	1st web space	1-5th, palm, multiple MC, PP fxs	12 × 4		10	Skin paddle between skin bridges	FTSG	Venous congestion, hematoma	vein graft, intrinsic muscle release, Lt great toe transfer to Lt thumb		35
43	19	Male	Press, crushing	Left	1st web space	Palm degloving, carpal fxs. Lt ALT flap stump plasty	9 × 3	2	11	Tunneling	P-closure		Revascularization on 3-5th fingers, neurorrhaphy, multiple flexor tenorrhaphy, amputation, ALT free flap		11
44	12	Male	Congenital	Left	1st web space	Congenital adduction contracture	9 × 3.5		8	Tunneling	P-closure				2
45	50	Male	Crushing	Left	1st web space	Contracture on palm	9 × 3		9	Tunneling	P-closure		2-5th flexor tenorrhaphy, 3rd EDC reconstruction, tenolysis, tendon transfer, corrective ostectomy		8
46	28	Male	degloving	Right	1st web space	Contracture on wrist, thumb, 5th, palm degloving	5 × 9	1	7	Tunneling	FTSG		Arterial anastomosis (thumb, 5th), contracture release, thumb amputation → Rt great toe transfer using remnant radial artery		23
47	54	Male	Degloving	Right	1st web space	Contracture on metacarpal hand, crushing amputations, 2-5th, 2nd MC, 1st PP, DP fxs	4 × 8		10	Skin paddle between skin bridges	P-closure		2nd MC bone transfer to 3rd MC (widening the 1st web space)		3
48	58	Male	Belt, crushing	Left	1st web space	Palm incomplete amputation, contracture after replantation	3 × 9		10	Skin paddle between skin bridges	P-closure	Venous congestion, partial necrosis	Replantation		8
49	30	Male	Press, contact burn	Left	1st web space, hand dorsum	Burn scar contracture	12 × 5	2	4	Tunneling	P-closure		Lt 3-4th EDC reconstruction with silicone rods, Lt 2nd toe joint transfer for MF MCP joint		37
50	10	Female	Press, crushing, degloving	Left	Thumb, 1st web space	1-5th MC fxs, thumb amputation, palm contracture after pollicization	10 × 3		6	Tunneling	P-closure		including EDM within the flap, FPL reconstruction with silicone rod, pollicization, opponensplasty with 2nd FDP transfer	Myocutaneous flap	32
51	57	Female	Contact burn	Right	hand dorsum, 1st web space	Burn scar contracture	11 × 6	2	5	Open up and resuture	FTSG		Adductor tenotomy, hand ulnar side dermofat graft, EPL silicone rod reconstruction, defatting		12

Note. AIA = anterior interosseous artery; PIA = posterior interosseous artery; EDM = extensor digiti minimi; fxs = fractures; Rt = right; Lt = left; ORIF = open reduction and internal fixation; STSG = split-thickness skin graft; EDC = extensor digitorum communis; MCP = metacarpophalangeal; EPL = extensor pollicis longus; ALT = anterolateral thigh; FTSG = full-thickness skin graft; MC = metacarpal; PP = proximal phalanx; PIP = proximal interphalangeal; FDP = flexor digitorum profundus; UCL = ulnar collateral ligament; FCU = flexor carpi ulnaris; EIP = extensor indicis proprius; FPL = flexor pollicis longus; DP = distal phalanx; CMC = carpometacarpal joint; IP = interphalangeal; P-closure = primary closure.

In the 51 cases of rPIA flap elevation, the anastomosis of the PIA with the AIA was found consistently above the wrist joint in all except 3 cases (5.9%) in which flap failure occurred due to the absence of proper pedicle of rPIA. They were changed to the radial forearm and anterolateral thigh flaps (Table 1; Supplemental Table S1). The 48 successful cases of rPIA flap included fasciocutaneous pattern in 45 cases (93.8%) and myocutaneous pattern involving the extensor digiti minimi (EDM) muscle in 3 cases (6.2%) (Supplemental Figure S2 and Table S2). The number of perforators in the rPIA flap was 1.85, ranging from 1 to 3. The average length of the vascular pedicle was 8.3 cm, ranging from 3 to 16 cm.

The pedicle was tunneled in 29 cases (60.4%), and the tunnel was opened up and resutured loosely without tension in 2 cases (4.2%). The racket-shaped skin paddle was inset between the intervening skin bridges in 17 cases (35.4%) (Supplemental Figure S2 and Table S3). The pedicle was not exteriorized at all. The donor defect was covered with full-thickness and split-thickness skin graft after minimizing the raw surface with tense, purse-string sutures of the donor site in 26 cases (54.2%) and closed primarily in 22 cases (45.8%) (Supplemental Table S4). The defects healed well without any complications.

All the flaps survived completely except in 2 cases (4.2%) of partial necrosis, which resulted from venous congestion (Supplemental Table S5). Venous congestion of varying degrees was noted in 7 cases (14.6%) and among 5 of them was salvaged successfully using medical leech and heparin dripping successfully (Supplemental Figure S2). In 3 cases, the rPIA flap was performed successfully despite a probable injury to the distal forearm zone in which PIA was supposed to connect with the AIA (Supplemental Figure S2). Other minor complications included 2 cases (4.2%) of hematoma and 4 cases (8.3%) of infection. Two patients (4.2%) showed a temporary drop of little finger, which recovered spontaneously without any intervention (Supplemental Table S5). Forty-four cases (91.7%) needed ancillary procedures such as replantation, neurorrhaphy, tenorrhaphy, second-stage tendon reconstruction, tendon graft, tenolysis, bone graft, carpal tunnel release, distal radius open reduction and internal fixation, arthrodesis, joint fusion, toe joint transfer, scar revision, and defatting procedures. During the mean 17 months of follow-up, ranging from 1 to 3 years, the flaps in all patients showed adequate match with the recipients in terms of skin color, texture, elasticity, and thickness.

Specifically, in 5 cases (10.4%) of thumb amputation in which replantation was impossible, the rPIA flap was transferred for coverage of the thumb base and provided arterial inflow for the secondary toe-to-thumb transfer (Figures 2 and 3; Supplemental Figures S3 and S4, and Table S6). We performed 3 great toe and 2 second toe transfers for thumb reconstruction. In all cases, the first dorsal metatarsal artery was anastomosed with the proximal stump of the PIA within the transposed rPIA flap, which provided the arterial inflow for the toe transfer. They survived completely except for 1 case of venous congestion, which was resolved after immediate exploration and reanastomosis of the vessels. All the patients in this series were satisfied with the final functional and aesthetic outcomes.

Arterial Inflow to the Secondary Toe-to-Thumb Transfer

A 52-year-old patient sustained a crushing amputation of the left thumb while working with a drilling machine. The stump was unreplantable and needed an additional soft tissue coverage around the remnant metacarpal head (Supplemental Figure S3). With the aid of handheld Doppler, the 11 × 8 cm rPIA flap was elevated and transferred to cover the defect through the subcutaneous tunnel. Postoperatively, the rPIA flap showed no congestion and survived completely (Figure 2). There was neither pain nor cold intolerance of the hand.

Three months later, we performed a contralateral second toe transfer to the thumb. The transposed proximal PIA was dissected carefully and anastomosed end-to-end with the first dorsal metatarsal artery (Figure 2). The dorsal vein of the great toe was anastomosed end-to-end with a dorsal wrist vein. Most of the donor site was closed primarily, and the small residual defect was covered with a full-thickness skin graft from the left groin. The appearance of the thumb and the functional motion were satisfactory at 1-year postoperative follow-up.

Discussion

Various forearm flaps using the radial or ulnar artery may disrupt the main circulation to the hand, which results in hand stiffness and cold intolerance.¹⁷ Under such conditions, the PIA flap is an attractive option as an island fasciocutaneous flap.¹ Compared with the radial forearm flap, it is safer, thinner, softer, and pliable with excellent skin color and texture matching the hand. Above all, it does not sacrifice the main arteries in the hand.

Many reports have constantly supported the reliability and versatility of the PIA flap. The antegrade PIA adipofascial flap shows a proximal pattern and was used to prevent the recurrence of synostosis of the elbow joint and forearm.¹⁸ However, the PIA flap has been more widely used distally for the repair of various soft tissue defects in the wrist, palm, hand dorsum, first web space, and even distal to the fingers.^1,9,19 Because the rPIA flap depends on retrograde flow from the dorsal recurrent branch of the AIA,^7,20-24 its anastomosis with PIA in the distal forearm and narrowing or abrupt termination of the PIA in the middle third of forearm^1,19 are the 2 major concerns in the elevation of the rPIA flap. Venous congestion due to the narrow width of the pedicle and the subcutaneous tunnel is another drawback and accounts for an estimated 3% to 37%,^1,3,20,25 which was similar to the prevalence in our case series, at 14.6%. Therefore, many authors suggested detaching the pedicle with the septum included, splitting the skin bridge between the rotation point and the recipient,²⁵ including the subcutaneous vein as a salvage pathway, instead of a fascial strip,⁸ including additional perforators in the flap,²⁶ or decreasing the inflow in the flap by decreasing the number of perforators included.²⁷ We usually recommend leaving at least 0.5 cm of fibro-fatty sleeve on the pedicle. Other options to increase the survival of the rPIA flap include avoidance of the dissection of the anastomotic arc between the AIA and PIA,²⁸ additional venous anastomosis,¹² and changing into a free flap. We usually design a racquet-shaped flap to avoid tunneling and incorporate additional superficial veins as reported by Reyad et al²⁶ (Supplemental Figure S2). Regarding donor site morbidity, the primary closure of the donor site is possible up to a width of 6 cm, resulting in aesthetically unappealing result in 45.8% in our series.^5,29

In addition to simple resurfacing of the soft tissue defects triggered by complex trauma or scar contracture release, the indications for rPIA flap have expanded to include specific cases and provided secondary reconstructive options for the hand and upper extremities, such as the toe-to-thumb transfer in our series (Figures 2 and 3; Supplemental Figures S3 and S4). A few studies reported a reverse radial forearm flap to provide a recipient arterial pedicle for a toe-toe thumb procedure, as well as soft tissue coverage of the unreplantable amputated thumb.^15,16 Costa et al¹¹ used the rPIA flap in one such case of their series. However, to our knowledge, powering up both the toe-to-thumb procedures using rPIA flaps for both thumbs has yet to be reported (Figure 3; Supplemental Figure S4). We believe that the rPIA flap is a very reliable procedure without sacrificing the major arteries in the hand as a “Sister” or “Siamese” flap, in which the vascular pedicle of a single free flap provides perfusion to a second free flap.³⁰ In our 5 case series of secondary toe-to-thumb transfers (Figures 2 and 3; Supplemental Figures S3 and S4; Table 1), the rPIA flap provided not only a recipient arterial inflow for a secondary toe transfer but also primary soft tissue coverage around the thumb and first web space defect.

Although the proximal axis of rotation of the rPIA flap limits the distal reach to the metacarpophalangeal (MCP) joint level, various modifications to extend the maximal reach of the rPIA flap even to distal interphalangeal joint level have been reported. They include the skin over the supinator,^3,5,22 more distal dissection along the transverse anastomotic branch,¹⁹ splitting of the skin bridge between the pivot point and the defect,²⁸ using an exteriorized pedicle³¹ and the extended fascia or skin flap,^5,21 and bowstringing it across to maintain an extended wrist.²⁵ Zaidenberg et al³² used a dorsal intercarpal arch through the fifth extensor compartment artery as a pivot point of the PIA flap and extended the distal reach of the PIA flap to the fingertips. Furthermore, due to the reliability of the PIA flap, its applications have been extended to various modifications such as PIA-pedicled flap based on a septal perforator for distal forearm³³ and free PIA perforator flap for fingertip.²¹

In a severely mutilated hand, the rPIA flap provides additional soft tissue coverage around any part of the hand and wrist even when the radial or ulnar artery is injured. Shibata et al³ combined the rPIA flap with the lateral arm flap to cover a large defect. Considering the limited flap size with a width of 4 to 6 cm and a length of 8 to 10 cm,² we successfully used the rPIA flap as a subsidiary and a backup option for the remaining soft tissue defect involving a large degloving hand injury (Supplemental Figure S5).

The rPIA flap may be performed as an adipofascial,^14,25 osteofasciocutaneous flap.³⁴ It can be used as 3 types of fascia-only, fasciocutaneous, and fasciocutaneous-fascia free flaps²² or as a free vascularized tendon or bone graft.²⁵ We performed rPIA flaps involving the musculocutaneous type using the EDM muscle in 3 cases (6.2%) to fill up the dead space (Supplemental Figure S2 and Table S1). In addition, the role of rPIA flap has been reported in revision surgery after carpal tunnel release to sheath the neurolyzed median nerve.^13,35,36 The rPIA-pedicled ulnar segment has been used for thumb reconstruction³⁵ and infected forearm nonunion.¹⁴ The rPIA-pedicled radius segment has been used for ulnar nonunion treatment.^12,37 To reconstruct multiple hand subunits, multi-paddled PIA flap has been reported.^4,13 Yoon et al³⁸ introduced a new flap based on the longitudinal fascial branches of the PIA, which reduced the risk of surgical failure due to irregular perforator distributions. As a neurocutaneous flap, the posterior cutaneous nerve of the forearm was included within the rPIA flap.³⁵ This perineural arterial network may have contributed to its viability in the absence of the distal artery. The terminal part of the posterior interosseous nerve (PIN) was also used as a vascularized nerve graft, when harvested with the accompanying PIA.²² Based on recent technical advances in microsurgical reconstruction, free PIA perforator flap represents a minimally invasive procedure for donor and recipient sites despite the technical demand.^23,39 Because the venous drainage is also a problem with a free PIA flap along with the pedicle length, the drawback of the short pedicle may be overcome by perforator-to-perforator super-microsurgery.

Due to frequent anatomical variations and technically demanding procedures, hand surgeons hesitate to choose the rPIA flap as a first-line surgical option. However, according to Vögelin et al,⁶ no statistical correlation exists between anatomical variations and complications, such as injury to the PIN, venous congestion, and PIA flap loss. The rPIA flap is generally avoided in patients with deep scar tissue in the distal forearm, associated with traumatic history or electrical burns. However, Baylan et al⁴⁰ reported the successful use of rPIA flap in cases of previous burn injury to the skin and also reported favorable results in 3 cases of distal forearm open injuries (Supplemental Figure S2). The wide knowledge of anatomical variations, a meticulous surgical technique for flap dissection, and an adequate learning curve are the key criteria for successful rPIA flap elevation and survival.

Conclusion

Although variations and the absence of the PIA generally occur during flap elevation, the rPIA flap appears to be relatively reliable and versatile in hand and upper extremity reconstructions. Without sacrificing the main arteries to the hand, the rPIA flap provides a thin, pliable coverage of similar quality in cases of traumatic thumb loss, significant soft tissue defect, and contracture of the first web space. Furthermore, in this series, we extended the range of applications of the rPIA flap to power up the toe-to-thumb transfer. The use of the proximal PIA pedicle in the rPIA flap is a safe and reliable procedure in case of insufficient recipient artery for the toe-to-thumb transfer.

Supplemental Material

sj-pdf-1-han-10.1177_15589447211028925 – Supplemental material for Versatility of the Posterior Interosseous Artery Flap: Emphasis on Powering Up the Toe Transfer

Supplemental material, sj-pdf-1-han-10.1177_15589447211028925 for Versatility of the Posterior Interosseous Artery Flap: Emphasis on Powering Up the Toe Transfer by GiJun Lee, BumSik Kim, Neunghan Jeon, JungSoo Yoon, Ki Yong Hong, SooA Lim and SuRak Eo in HAND

Supplemental Material

sj-pdf-10-han-10.1177_15589447211028925 – Supplemental material for Versatility of the Posterior Interosseous Artery Flap: Emphasis on Powering Up the Toe Transfer

Supplemental material, sj-pdf-10-han-10.1177_15589447211028925 for Versatility of the Posterior Interosseous Artery Flap: Emphasis on Powering Up the Toe Transfer by GiJun Lee, BumSik Kim, Neunghan Jeon, JungSoo Yoon, Ki Yong Hong, SooA Lim and SuRak Eo in HAND

Supplemental Material

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Supplemental Material

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Supplemental material, sj-pdf-9-han-10.1177_15589447211028925 for Versatility of the Posterior Interosseous Artery Flap: Emphasis on Powering Up the Toe Transfer by GiJun Lee, BumSik Kim, Neunghan Jeon, JungSoo Yoon, Ki Yong Hong, SooA Lim and SuRak Eo in HAND

Footnotes

Ethical Approval

The study protocol was approved by the hospital ethical committee before research initiation.

Statement of Human and Animal Rights

This article does not contain any studies with human or animal subjects.

Statement of Informed Consent

Informed consent was obtained when necessary.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

SuRak Eo

Supplemental material is available in the online version of the article.

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