Retrograde posterior interosseous flap

A retrospective, continuous clinical series of 36 distally based posterior interosseous island flap
procedures is reported. Major anatomic variations precluded the final dissection of the flap on
two occasions (690). Thirty-four patients had septocutaneous or septofascial flap coverage for
treatment of acute complex injuries (12), subacute soft tissue defects (10), chronic ulcers (5), or
contractures (7). The sizes of the flap islands varied from 1.5 by 4 centimeters to 9 by II
centimeters. The arc of rotation, centered over the distal radioulnar joint, measured up to 19
centimeters, allowing the flaps to reach the dorsum of the proximal interphalangeal joints. Partial
necrosis occurred in seven flaps; four (12%) required additional local or distant flaps. Partial
failures were related to bleeding from the pedicle or compression thereof, while other assumed
causes of hypoperfusion were not statistically relevant. The flaps remained slightly bulky in about
30% of the patients, but otherwise adapted well to the recipient site and had excellent texture
and color match. The donor morbidity was minimal. (J HAl'iD SURG 1991;16A:283-92.)

Ueli BUchler, MD, and Hans-Peter Frey, MD, Bern. Switzerland

Since the first report on the posterior in-
terosseous forearm flap by Zancolli and Angrigiani' and
the description of its anatomic basis by Penteado and
colleagues? in 1986, the procedure has evoked great
interest among upper extremity surgeons. It is now in-
creasingly considered as an alternative to the Chinese
forearm flap. the pedicled axial groin flap. the free
lateral arm flap. or other regional and distant flaps.
The skin, subcutaneous layer, and the fascia along
the dorso-ulnar aspect of the forearm are nourished by
multiple septocutaneous perforators that originate seg-
mentally from the posterior interosseous vessels and
surface between the muscles and tendons of the extensor
carpi ulnaris and the extensor digiti quinti ."" The distal
termination of the posterior interosseous system con-
nects to the vascular network of the wrist, particularly
to the dorsal branches of the anterior interosseous artery
'and vein. Because this collateral sxstem transmits re-
versed arterial and venous blood flow. septocutaneous
posterior interosseous island flaps may be based either
From the Division of Hand Surgery, Inselspital, University of Bern .
Switzerland .
Received for publication Nov. 28. 1989, accepted in revised form
Feb. 28. 1990. .
No benefits in any form have been received or will be received from
a commerc ial party related directly or indirectly to the subject of
this article.
Reprint requests: PO Dr. med. Ueli BUchler, Chief of Hand Surgery,
Inselspital Bern. Freiburgstrasse, CH-3010 Bern, Switzerland.
3/1/22363
proximally or distally. In the retrograde dissection mo-
dality. the flap is taken from the proximal third of the
forearm; after division of the trunk of the posterior
interosseous vessels. the flap and its elegant vascular
pedicle are mobilized distally to a pivot point at the
distal radio-ulnar joint, allowing the coverage of defects
in the hand. 1.3 ,9.11 •
Presently, 32 cases of retrograde posterior interos-
seous flaps are reported in the literature, I. 3. 9. 10 with
only one note on the occurrence of complications (re-
mediable venous congestion).
Our own experience with 34 additional cases is of
particular interest because (1) the width of the flap was
increased, (2) the reach of the flap was extended distally
by shifting its territory beyond the point of emergence
of the most proximal septocutaneous perforator, and (3)
a significant complication rate was encountered.
Clinical material
From September 1986 to February 1989,36 patients
were scheduled for retrograde posterior interosseous
flap procedures (PIF). There were 33 males and 3 fe-
males in this series . Ages ranged from 5 to 68 years,
with an average of37 years. The procedures were done
by four full-time hand surgeons in academic practice.
The indications are listed in Table I and may be
grouped into four categories: (1) acute complex skeletal
and soft-tissue lesions with skin defects caused by in-
dustrial machinery (12 cases); (2) soft-tissue defects
caused by degloving, crushing, or toxic necrosis, ad-
dressed postprimarily (11 cases); (3) superinfected ul-
cerations from animal bites or bums (5 cases); (4) con-

THE JOURNAL OF HANDSURGERY 283

 The Journal of
284 Biichler and Frey HAND SURGERY

Table I. Synopsis of data on 36 posterior interosseous flaps

Number Age! Sl!X Indicat ion Location of defect Distal border Timing Ana tomic pecularities

I 63/M Defect, power saw injury I, ulnar IP joint a Distal origin of ~IPP
2 50/M Scar , high pressure injection II, III radial Prox imal phalanx
3 381M Defect, grinder injury IV, V dorsal PIP joint a

4 42/M Contracture, posttraumatic Thumb web Palm

5 40/F Defect, power saw inj ury II, III dorsal Proximal phalanx
6 41/M Defect, power saw injury II, III dorsal Proximal phalanx a
7 171M Infected ulcer, formic acid Palm MP jo int
8 381M Defect, explosion injury I, radial IP joint
9 42/M Defect, printing press Midhand, dors al Proximal phalanx
10 261M Contracture, tetraplegia Thumb web Palm
11 381M Defect, power saw injury Wrist, radial Snuffbox a
12 161M Defect, explosion injury Thumb web Palm a Nerve crossing of MPP
13 48/M Infected defect, power saw injury I, palmar IP joint I
14 261M Defect, planer injury . I, radial Dist al phalanx a
15 511M Infected defect, firework Midhand, dorsal MP joint I
16 35/F Infected defect, cat bile Midhand, dorsal MP joint I
17 40/M Defect, grinder injury III-V, dorsal MP joint a
18 291M Massi ve crushing, press Forearm , through Distal one third I
190 361M Contracture, after bum Thumb web Palm I MPP origin from corn-
mon PIA
20 48/M Amputat ion, high volta ge injury II, III, IV base MP joint a
21 511F Degloving injury Midhand, dors al Proximal phalanx
22 301M Defect, grooving plane injury III, dors al Middle phalanx Distal origin of MPP
23 381M Infected defect Thumb web Palm
24 281M Necrosis after crushing injury III, dorsal MP joint Incomplete PIA loop
25 201M Avulsion, car crash I IP joint a
26 58/M Defect, power saw injury II, dorsal MP joint a MPP through muscle
270 45/M Massive crush ing, clay press Midhand, through MP joint I
28 68/M Infected ulcer Palm MP joint I
29 63/M Thumb reconstruction I IP level I Distal origin of MPP
30 161M Defect , grooving plane I, dorsal Finger tip a

31 271M Amputation, grooving plane I-IV MP level

32 62/M Defect, grooving plane I-IV, I dorsal IP joint a
33 171M Contracture, plexus injury Thumb web Palm
34 231M Contracture, posttraumatic Palm Palm
35 5/M Contracture, congenital Thumb web Palm
36 281M Defect, hot press injury 1·111, through Midhand
I, Thumb; II, index etc; a, a~ute; I, elective; -. none; MPP, mostproximal perforator; 0, posteriorinterosseous flap not raised; DRUJ. distal radioulnar joint, t,
tunnel; 0, open; S, suture;g, ~raft; PIA, posteriorinterosseousartery.
·Child.
t, One patient died of unrelated cause.

tractures of various origin treated electively (8 cases).
In 27 patients, the defects lay within the "natural" arc
of rotation of the PIF as described by Zan colli and
colleagues I and Masquelet and Penteado." Nine patients
were seen with defects distal to the interphalangeal (lP)
joint of the thumb or the proximal interphalangeal (PIP)
joint of the fingers.
Major anatomic variations precluding the use of the
PIF were encountered twice (deficient anlage of the
posterior interosseous vascular system distally, anom-
alous origin of the relevant most proximal perforator),
leaving 34 continuous cases in the series. Seven minor,
nonprohibitive variations were observed on the rele-
vant, proximal perforator. These included an undesir-
ably distal origin (4), small diameter (1), extensor digiti
quinti muscle passage (1), and extensor carpi ulnaris
nerve branch embracement (I).
The tissue composition of the flaps comprised 30
septocutaneous, 1 fascially extended septocutaneous,
and 3 fascio-subcutaneous modalities. The sizes varied
from 1.5 by 4 cm to 9 by 11 cm; 20% were larger than
4 by 8 em (Fig. 1). Length measurements were taken
Vol. 16A, No.2
March 1991 Retrograde posterior interosseous flap 285

Number of Size Flap tip Goalofflap

septocutaneous width x length above DRUJ Passage of Closure of Extent of procedure met?
perforators (cm) (cm) pedicle donor site Complications necrosis (yes/no)

3 x 6 17 g
3 x 6 19 Bleeding, ischemia 30% loss Yes
3 x 8 16 g Bleeding, infection, 30% loss Yes
ischemia
I 4 x 7 18 t Congestion. ischemia 30% loss No
I 3 x 5 17 0 Yes
2 5.5 x 9 18 0 g Yes
2 4 x 6 15 0 Yes
I 5 x 10 19 0 g Yes
I 3 x 8 18 t S Yes
I 5 x 7 18 0 s Yes
I 5 x 7 14 t S Yes
I 4 x 8 19 0 g Yes
2 4 x 6 17 0 s Yes
I 2 x 4 19 s Congestion, bleeding Yes
2 2.5 x 6 14 0 s Yes
I 2 x 6 15 0 s Yes
2 3 x 6 14 t s Ischemia, infection 10% loss Yes
I 3 x 8 10 0 Yes

I 9 x II 18 0 g t
2 3 x 9 15 0 s Yes
I 1.5 x 4 18 0 s Congestion, dehiscence Yes
2 3 x 9 18 0 Yes
I 3 x 4 12 0 g Yes
1 3 x 7 17 0 g Ischemia, infection 80% loss No
1 2 x 6 17 s Yes

2 3 x 7 17 0 Yes
I 3 x 6 19 0 g Congestion, infection 50% loss No
I 3 x 5 19 t Yes
I 3 x 7 17 0 g PIA cut, repaired, Yes
congestion
I 4 x 6 17 Bleeding, ischemia 50% loss No
2 2.5 x 7 14 Yes
1 4 x 8 16 Yes
2 2 x 3 9' Yes
1 3 x 6 15 Yes

according to Fig. 2. The total length (distance m) ranged
from 10 to 19 em, the length of the vascular pedicle
(distance b) from 2 to 15 em (see Table I for details).
Donor defects smaller in width than 3 em were always
closed by suture, those greater than 5 em all required
skin grafts. Operative time required ranged between
I and 3 hours.
Methods
Healing of the flaps was assessed clinically at regular
intervals. All complications, as well as secondary in-
terventions relating to the flap procedures were re-
corded. One patient died a few weeks after the initial
surgery (repeated suicide attempts); all of the other pa-
tients could be observed until the definitive result was
established and evaluated. The average follow-up time
was 11 months (range, 5 to 24 months).
Results
Five types of technical mistakes were noted: (1) in-
adequate debridement of the wound edge before flap
application with subsequent minor skin necrosis adja-
 The Journal of
286 Bilchler and Frey HAND SURGERY

width in em

10

6
6-
t::::,6. l:::.

4 l:::. ~A A 6.t::::.6.

6- l:::.O At A A 6.l:::.A t::::,6.

6.
2 l:::. 6- t::::,6.
6-

O'------'-------L.----'---------''------'-------L.-------'
o 2 4 6 8 10 12 14
length in em
F ig. 1. Dimensions and structure of 34 retrograde posterior interosseous naps . 11. Septocutaneous
configuration; D. septo-fascio-subcutanous modali ty; .... cases with partial necrosis . The leng th
corresponds to distance a in Fig. 2.

" c
r.c------- b ------=':lo.l
,

_
------ FASCIA

PosrERIOR INr"ROSSEOUS
VASCU£AR PcOICL£

Fig. 2. Geometry of distally based posterior interosseous naps. Important factors: (a ), Length of
the nap island; (b) , length of the vascular pedicle; (c), total length; (d). extent of the septocutaneous
territory .
Vol. 16A, No.2
March 1991 Retrograde posterior interosseous flap 287

Fig. 3. Anatomic variation prohibiting the use of a retrograde PIF: Absence of septocutaneous
perforators in the middle and proximal third of the forearm , except one skin branch originating
from the common interosseous artery. Left forearm, dorsal aspect.

Fig. 4. Most proximal relevant perforator originating far distally, requiring a fascial extension of
,h,. "",rli,..1" nf " P IF I "ft fnr""nn nn""l vjr-w.

288 BUchler and Frey
cent to the flap (patient 18); (2) inadequate debridement
of wound depth leading to scar contracture beneath the
flap (patients 12 and 13); (3) inadequate width of the
flap causing a benign wound or flap dehiscence (patient
22); (4) inadvertent injury to the posterior interosseus
artery requiring microvascular repair, followed by un-
eventful healing (patient 25); and (5) inadequate he-
mostasis along the pedicle necessitating revision and
drainage (patients 2, 3, 4 and 14).
There was no total loss of a flap in this series. How-
ever, after a tendency towards venous congestion,
7 (21%) of the 34 flaps developed partial ischemic ne-
crosis. This was localized at the periphery of the per-
fusion perimeter of the relevant septocutaneous perfor-
ator, i.e., distally in the hand and comprised between
10% and 80% of the flap surface. In three of the seven
patients, venous engorgement and ischemia were ac-
companied by compression of the pedicle and in four
patients, ischemia was associated to infection. Minor
defects resulting from debridement of necrotic PIF areas
healed with split-thickness skin grafting on three oc-
casions. Major partial necroses (four cases [12%» re-
quired a cross-finger flap and three groin flaps.
At the time of final evaluation, all recipient flap sites
had healed. Ten (29%) flaps were thicker than desired,
6 (18%) showed some shrinkage and 4 (12%) dem-
onstrated slight circumferential scar contracture. Un-
satisfactory color match was noted in 3 (9%) hands.
Hirsute forearms produced 4 (12%) conspicuously hairy
flaps. The only flap with nerve suture (patient 29, with
infection and 15% necrosis) did not become innervated.
The donor areas showed broad scar lines in two patients.
The majority of the flaps showed excellent adaptation
to the recipient site and most donor incisions were lin-
ear. There was no instance of vascular disturbance or
neurological deficit in the forearm or the hand, nor did
we observe cramping, pain, weakness, or limited glid-
ing capacity in theextensor digiti quinti or the extensor
carpi ulnaris. All of the patients were pleased with the
results, even those who had experienced problems or
complications.
Discussion
The anatomy of the posterior interosseus artery sys-
tem and its variations are well established in the liter-
ature.':" In our material, anomalies precluding the use
of a retrograde PIF were encountered on two occasions.
In patient 27, the posterior interosseus artery system
was seen to "run out" in the distal one third of the
forearm, as demonstrated in 5.7% of Penteado's ca-
daveric dissections." Patient 19 was seen with a hitherto
undescribed anomaly (Fig. 3).
The Journal of
HAND SURGERY
As one tries to extend the distal arch of rotation of
the retrograde PIF by increasing its total length, several
problems may be encountered: (I) reduced chance for
including two or more septocutaneous perforators in the
unit, (2) enhanced risk of having the flap island at some
distance proximal to the fascial point of emergence of
the most proximal relevant septocutaneous perforator,
(3) increased likelihood of aggravating anatomical vari-
ations, (4) increased hazard of interference with the
nerve branch to the extensor carpi ulnaris. The most
proximal relevant perforator (MPRP) is usually a large
cutaneous branch located 5 to 11.5 ern from the radio-
humeral epicondyle. 2 • 6 • 11 In this series, the majority of
the MPRP originated from the descending branch of
the posterior interosseus artery within 2 to 3 em of its
emergence; an extremely distal origin is shown in Fig.
4. In 23%, the MP~P had its offset from the ascending
interosseus recurrent artery as demonstrated in Fig. 5
and recently described by other authors. 10 While septo-
cutaneous perforators are contained within the double
sheet of the septum between the extensor carpi ulnaris
and the extensor digiti quinti within the middle and
distal thirds of the forearm, they tend to vary in more
proximal locations. One MPRP passed through the mus-
cle belly of the extensor quinti, another one surfaced
at the radial aspect of this muscle unit.
The dimension of the fascial territory surviving on
a single posterior interosseous artery system perforator
has not been determined, nor has the size, shape, and
relative position of the skin island that might safely be
supported by one defined septo-fascial mediator of
blood supply. Masqueler' considered it hazardous to
extend the skin island more than 3 ern above the point
of emergence of the MPRP. In our series, that distance
was often greater than 5 cm with no obvious detriment
to flap survival.
At the distal end of the posterior interosseus artery,
at least two of three communicating branches were al-
ways present: (1) the transverse anastomotic artery to
the dorsal branch of the anterior interosseus artery (re-
ported to be absent in 1.4% by Penteado? and 2.9% by
Bayon and Pho ll ) was consistently present in our series;
(2) the branch continuing straight to the rete carpi dor-
sale was found in about 80% of the preparations; (3) a
communicating twig to the dorsal branch of the ulnar
artery at the neck of the ulna was observed in roughly
half of the patients. Except for patient 18 (defect at the
dorsal distal forearm), all of the flaps were pivoted
around the fifth dorsal compartment at the distal ra-
dioulnar joint; we did not carry the dissection distally
to the dorsal branch of the anterior interosseus artery
as recently proposed by Bayon and Pho, II who obtained
Vol. 16A, No.2
March 1991
Fig. 5. Patient with offset of the relevant perforator from the recurrent branch of the posterior
interosseous artery, seen as musculocutaneous perforating branch. Right forearm, dorsal aspect.
additional 1.2 to 3.7 ern of pedicle length in 91% of
anatomy laboratory dissections.
The venous outflow of the distally based PIF is forced
in a retrograde direction through the venae comitantes,
the exact anatomy of which is not yet investigated.
Drainage may be impeded not only by valves and criss-
cross flow through the venous network, but also by
inadequate passage of the pedicle, insufficient drainage
thereof, stretching, rotation and kinking, or tight clo-
sure of the donor defect.
The branches of the posterior interosseous nerve sup-
plying the epicondylar muscles pass superficial to the
ascending branch of the posterior interosseous ar-
tery" 10 whereas the nerve branch(es) to the extensor
carpi ulnaris relate intimately to the MPRP as seen in
Fig. 6. Type A allowed straightforward dissection in
92% of the cases. Type B, with two closely spaced sep-
tocutaneous perforators framing the ECU nerve branch,
was seen in five patients; four times, the interlacing
proximal perforator was ligated, in one case the nerve
was divided and sutured. Type C was seen with a short,
tightly fixed ECU nerve branch that interlaced with the
only available vascular support of the flap in two dis-
sections; we did not raise the flap on one occasion and
proceeded with neurotomy and nerve repair in the other
case. Both neurorhaphies were followed by prompt re-
innervation to the M4 + level within 3 months.
The significant complication rate of this series con-
trasts with the low incidence of postoperative problems
reported in the literature; remediable venous congestion
Retrograde posterior interosseous flap 289
occurred in 1 of 20 retrograde flaps of Zancolli and
Angrigianni,? and in none of 12 cases in the series of
Masquelet and Penteado" and Costa and Soutar.'? An
incidence of 21 % of partial ischemicnecrosis prompted
us to investigate several factors possibly influencing the
survival of long retrograde posterior interosseous flaps
(Table II). Statistical analysis, using Fisher's exact one-
tailed test, revealed the following: Width, length, or
surface area were not shown to influence the likelihood
of flap survival (see Fig. 1). All of the wide flaps
survived entirely, including an island 9 by 11 em.
While circular tightness from closure of donor defects
wider than 5 em by direct suture caused some venous
congestion in the hand, it did not endanger flap survival.
Confirming the favorable reports in the literature on
fascial forearm flaps, II all of the three fascial flaps sur-
vived entirely and supported the skin grafts used for
epidermal coverage. A tendency towards partial necro-
sis with increasing length of the flap units was not
statistically relevant. Success or partial failure were not
related to the number of perforators included in the flap
design. Anomalies presented no significant risk factor.
The experience of the surgeon did not bear on flap
survival. Closed passage of the flap, although entailing
a risk of tightness, kinking, zig-zag course, or stretch-
ing was not significantly related to partial necrosis, nor
was an observation of venous congestion. However, a
delay in perfusion after release of the tourniquet and
bleeding from the pedicle with hematoma formation
proved to be significant elements of flap survival. Prein-
 The Journal of
290 Bachler lind Frey HAND SURGERY

J1PRP I'1PRP
/1PRP

a b c
Fig•.,6. Three types of relation of the extensor carpi ulnaris (ECU) nerve branch (NERVE) to the
descending branch of the posterior interosseous artery (PIA) and its most proximal relevant scp-
tocutaneous perforator (MPRP) . Wh ile type a permits simple dissection. type b may require ligation
of the MPRP, use of the adj acent perforator and a fascial extension of the pedicle ; in type c,
neurotomy and repair of the ECU nerve branch are recommended. Right forearm, dorsal view.
EDQ. Extensor digiti quinti muscle.

fected wounds may have a higher incidence of ischemic
flap complications than clean ones.
How far distally, a posterior interosseous flap wiII
safely reach on its pedicle is yet undetermined. The
PIP joint area of the long finger was routinely reached.
With better understanding of the depth and the pre-
dominant direction of the vascular plexus at the super-
ficial fascia and within the subcorial layer, improve-
ments in flap design may be anticipated. By raising and
transposing just the fascial and subcutaneous layers of
the flap, taking advantage of their lower oxygen de-
mands, further length and/or safety may be gained.
The most promising increase in length however, may
be provided by carrying the dissection distally along
the transverse anastomotic branch as described by
Bayon and Pho. II
As a result of our experience, the suggested technique
for raising a retrograde PIF is as follows: It is helpful
to use Doppler mapping to determine the point of emer-
gence of the posterior interosseous artery, especially
the presence or absence of the ascending branch, and
(by using alternate compression) the competence of the
loop system. The operation is done with the patient
under axiIIary plexus anasthesia on a moderately exsan-
guinated arm under tourniquet control. With the elbow
flexed to 90 degrees, a line is drawn from the fifth
dorsal compartment over the wrist to the radial humeral
epicondyle. A point 7.5 to 9.5 ern distal to the latter
landmark is made the center of the flap. If this does
not provide sufficient length, the theoretically required
position of the island is drawn. The incision is made
in the distal half of the forearm I ern radial to' the
longitudinal line for safe identification of the septocu-
tanous perforators. The fascia is then incised over the
extensor quinti about 5 mm radial to the dense fascial
line from which the septocutaneous perforators emerge.
At the juncture of the intermuscular septum , the pos-
terior interosseous artery and its venae comitantes are
identified. After mobilizing the extensor quinti radially,
the continuity of the distal vascular loop is assessed. If
this is adequately present, the incision is carried into
the proximal forearm along the radial delineation of the
flap. One wiII find a firm blending of the forearm fascia
to the common tendon of origin of the extensor quinti,
extensor ,carpi ulnaris, and extensor digitorum com-
munis. While the extensor quinti is mobilized away
from the septum, proceeding in a proximal direction,
muscle branches of the posterior interosseous artery
system are atraumatically occluded and divided, until
the entire course of the vascular loop, its recurrent in-
terosseous branch, and all of the nerve branches are
visualized. It is then time to identify the one or two
most proximal relevant septocutaneous perforators and
decide on the relative position of the flap island with
respect to these skin branches . The flap modality (cu-
taneous, subcutaneous, or purely fascial) is then finally
Vol. 16A, No.2
March 1991 Retrograde posterior interosseous flap 291

Table II. Factors in survival of posterior interosseous flaps and statistical analysis
Statistical
Survived Partial relevance
n= n= p value' (yes/no)

Width of nap territory 3 em or less 15 5 0.38 No

Larger than 3 em 12 2
Length of nap territory 6 ern or longer 13 3 0.57 No
Less than 6 em 14 4
Type of nap Fascial 3 0 0.48 No
Fasciocutaneous 24 7
Distance from nap tip to 17 cm or shorter 10 3 0.76 No
DRUJt Longer than 17 ern 17 4
Number of perforators 2 or more 9 I 0.31 No
1 or not specified 18 6
Anatomic anomalies Regular anatomy 24 4 0.09 No
Significant anomaly 3 3
Experience of surgeon 4th case or more 21 3 0.09 No
First three cases 6 4
Passage of pedicle Open 17 2 0.11 No
Closed 10 5
Age of the patient 40 or under 18 3 0.14 No
More than 40 9 5
Infection No 22 3 0.061 No
Yes 5 4
Venous congestion of nap No 24 5 0.95 No
Yes 3 2
Delay in perfusion after No 25 4 0.048 Yes
release of tourniquet Yes 2 3
Bleeding and/or compres- No 26 4 0.021 Yes
sion of pedicle Yes I 3
'Stat Graphics by STSC. Version 2.6 (1987) contingency tables. Fisher's exact test (one-tail),
tdruj. Distal radioulnar joint.

selected. If perforators with an origin from the recurrent
interosseous branch are used, anatomic variants must
be recognized before the posterior interosseous artery
and veins are ligated and nerve branches completely
freed. Next, the ulnar side of the flap is delineated and
the fascia over the extensor carpi ulnaris incised lon-
gitudinally, taking care to stay away from the juncture
of the intermuscular septum. The muscle belly of the
extensor carpi ulnaris is drawn ulnarly and muscle
branches are ligated as outlined. Finally, the intermus-
cular septum is divided at a reasonable distance from
the PMRP, through the site of division of the posterior
interosseus vessels, and deep to its descending branch
to the level of the distal radioulnar joint. On release of
the tourniquet, flushing of the flap is awaited, and me-
ticulous hemostasis obtained. If a closed passage is
chosen, it should be straight, wide, and adequately
drained.
The features of the distally based, retrograde poste-
rior interosseous flap as compared to those of other
commonly used alternate methods of coverage, the
Chinese forearm flap, the internal cubital flap, the axial
pedicled groin flap and any free flap, are summarized
in Table III. The main advantages include its fineness,
its excellent texture and color match, its easy access-
ability, and its minimal donor morbidity. Disadvantages
are limitation of distal reach, technical difficulty, and
susceptibility to partial necrosis.
REFERENCES
I. Zancolli EA, Angrigianni C. Colgajo dorsal de antebrazo
(en "isla" con pediculo de vasos interoseos posteriores).
Rev Asoc Arg Ortop Traumatol 1986;51:161-8.
2. Penteado CV, Masquelet AC, Chevrel JP. The anatomic
basis of the fascio-cutaneous flap of the posterior inter-
osseus artery. Surg Radiol Anat 1986;8:209-15.
3. Masquelet AC, Pcnteado CV. Le lambeau interosseux
posterieur, Ann Chir Main 1987;6:131-9.
4. Testut L. Traite d'anatomie humaine. Tome 2. Paris:
Doin, 1890.
5. Manchot C. Die Hautarterien des menschlichen Korpers
(1898). The cutaneous arteries of the human body.
New York: Springer, 1983.
6. Salmon M. Arteres de la peau. Paris: Masson, 1936.
7. Valdecasas-Huelin JMG, Barreiro FJJ, Barcia EC. Etude
 The Journal oi
292 Buchler and Frey HAND SURGERY

Table III. Features of the posterior interosseous flap and comparison with other commonly utilized flaps
I PIF I Chinese I Groin I Free dorsalis pedis

Flap
Size: length ++ ++ ++ +
width + ++ ++ ++
Texture conformity + + +
Color match ++ + +
Fineness ++ + +
Absence of hair + + +
Sensibility ? +
Dissection
Same field + +
Consistency of anatomy + ++ ++ ++
Technical simplicity + +
OR time + +
Reach
Proximally + ++ ++ ++
Distally + ++ ++ ++
Complications, resistance + ++
against infection
Donor deficit functional
Vascularity of hand ++ + ++ ++
Vascularity of forearm ++ + ++ ++
Safety for maintenance + + ++ ++
of nerve supply
Esthetic
Conspicuousness + ++ +
Aspect ++ + +
Other
Elevation of ann ++ ++ ++
Mobilization of wrist, ++ ++ ++
thumb, digits
Flaps., PIF. Posterior interosseous flap; Chinese. radial forearm flap: groin. axial pedicled groin flap.
- - From maximum disadvantage to + + maximum advantage.

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