The posterior interosseous flap 

- a
prime technique in hand
reconstruction. The experience of 100
anatomical dissections and 102 clinical
cases
Hora´cio Costa*, Armindo Pinto, Hora´cio Zenha
• Journal:              Journal of Plastic, Reconstructive & Aesthetic Surgery

• Impact Factor:  2.7

• Year:                   2007

• Place:                 Plastic, Reconstructive, Maxillofacial & Microsurgery Unit,

Centro Hospitalar Vila Nova Gaia, Portugal
Introduction
• The posterior interosseous flap is a fasciocutaneous flap – described
in literature for use in hand reconstruction 
• Costa et al. (1991) - reinforced the advantage of the retrogade flow of
this flap from the dorsal carpal arch:
• Anastomoses between the posterior and anterior interosseous arteries
• Allows the flap to be used even with damage of the radial or ulnar arteries or
palmar arches.
• The posterior interosseous flap - based on the posterior
interosseous artery
• Branches:
• Septocutaneous branches that spread out on the deep fascia  
• Deep branchces - Underlying deep extensor muscles.
Objective
• In this paper, the authors present an assessment of
indications for using this flap in hand reconstruction, based on the
experience of 100 fresh cadaveric dissections and 102 clinical cases
Methodology
• 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

• Clinical Study – Analysis of 102 cases

Results
Anatomy
• Origin: 
• Common interosseous artery – 82 cases
• Ulnar artery – 18 cases
• PIA - passed distally in the intermuscular septum and was found to reach as
far as the wrist, lateral to the ulnar head. 
• Anastomosis – between PIA and AIA 
• Underneath the extensor tendons – all cases
• Single branch – 97 cases
• Dual network – 3 cases
• The artery gave off fasciocutaneous perforators along its length through the
septum between the extensor carpi ulnaris and the  extensor digiti minimi. 
• Patterns of septocutaneous vessels
• Pattern 1: 
• 27 cases - two sub-groups, one proximal and the other distal each containing three or four vessels 
• Pattern 2:
• 59 cases - Multiple small branches arose at 1-2 cm intervals along the total length
• Pattern 3: 
• 14 cases - Large proximal perforator in the proximal group: fanned out into several branches

• Branches to posterior compartment:

• Deep extensor muscles: APL, EPL, EI – all cases
• Few variable periosteal branches -only in the distal third of the ulna (neck and head).
• Cutaneous Supply:
• Cadaveric methylene blue injection studies
• 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
• Duration: 1988 and 2006
• No of patients: 102
• Large hand defects:
• Crush-degloving injuries
• Burn contractures
• Skin necrosis
• Reconstruction – PIA flap either a fasciocutaneous island flap or an
osteocutaneous flap
• Demographics:
• Age: 1-84 years
• Male:Female - 90:12

• Osteocutaneous flaps – 7:
• Second metacarpal bone - 4 cases
• Thumb - 3 cases

• The skin flap varied in size from 4x5 cm to 14x9 cm 

• Direct closure was achieved in donor sites smaller than 7x6 cm
• larger defects required a skin graft
• Results:
• 94 cases - flap healed uneventfully (95%)
• In 4 clinical cases the flap was used in the presence of a positive Allen test, inferring the presence of
damage to the radial or palmar arches, 
• 1 case - replanted hand 
• 3cases - extensive crush-degloving hand injuries

• 3 cases: delayed wound healing

• marginal rim necrosis 
• subsequently healed with conservative management.
• 1 case: necrosis of the distal third of the flap
•  secondary skin grafting
• 1 case: complete flap loss
• necessitated secondary reconstruction
Clinical case 1: male, 24 years old,
victim of industrial machine
accident; crush-degloving injury of
the thumb (A); flap design (B); flap
elevated (C); immediate post-
operative view (D); 3 months post-
operative view (E) with donor area
skin-grafted (F)
Clinical case 2: male, 55 years
old with crush injury of right
hand; revascularisation of right
thumb; soft tissue defect of the
palm, thenar eminence and
dorsum of the hand (A); flap
design (B); flap dissection (C);
one-week post-operative view
(D); 3 months post-operative
view with writing skills
recovered (E)
Clinical case 6: male, 38 years
old, victim of rolling machine
accident with crush-degloving
injury 3 months previously
with resulting unstable scar of
the dorsum of the left hand
and EDC loss (index and
middle finger) and EP loss of
the index finger (A); flap
planning (B); extensor
tendons reconstruction with
palmaris longus tendon grafts
(C); transposition of the
distally based flap (D); the
thick fascial septal origin of
EDM was used to reconstruct
EIP (E); 3 months post-
operative view with good
functional result (F,G) and
donor area skin grafted (H).
Discussion
• Distally based island fasciocutaneous flaps in the forearm:
• Simple, versatile and reliable;
• Can be used to reconstruct variety of soft tissue defects of the hand

• The radial and the ulnar forearm flaps

• Both flaps are based on the integrity of the palmar arches and a major artery
for the vascular supply of the hand is sacrificed by flap harvesting. 
• Another controversial point is which artery carries the main blood supply to
the hand: the radial or the ulnar artery. 
Anatomic Variability in Literature
Study Year Cases Findings
Penteado et al. 1986 70 5 dissections - either the disappearance of the artery in the
dissections middle third of the forearm (4 cases) or the absence altogether of
the anastomosis at the wrist (1 case). 
Costa and Soutar 1988 22 always found the posterior interosseous artery in the fascial
dissections septum between the extensor carpi ulnaris and extensor digit
+ 3 cases minimi
Buchler and Frey 1991 36cases posterior interosseous artery to be missing in the mid-forearm in
two cases
Giunta and Lukas 1998 Case absence of continuity of the posterior interosseous artery in the
Report middle third of the forearm
Current Study 2007 100 posterior interosseous artery and its anastomosis to the anterior
dissection interosseous artery was a constant finding, except in one clinical
+ 102 case where bilateral disappearance of the posterior interosseous
cases artery in the middle third of the forearm was found
• Recommend Doppler testing during preoperative planning to identify
the anastomosis between PIA and AIA 
• Procedures can be designed to overcome these anatomical variations
- enhancing flap reliability:
• An additional venous anastomosis when there is congestion after inset of a
distally based flap. 
• Converting to a free flap when it proves impossible to harvest the distally
pedicled flap.
• Raising the flap with a wide base, incorporating perforating branches from:
AIA or both AIA and PIA
• Maximisation of the distal reach of the flap: 
• Hyperextension of the wrist for a tension-free pedicle in thumb
reconstruction.
• Exteriorizing the pedicle and keeping the wrist in extension.
• Distal dissection along the transverse anastomotic branch.
• Could make the flap reach up to PIP joint
• Although - higher incidence of flap necrosis
• Tunelling the pedicle and flap through a hole in the interosseous membrane
to cover a volar wrist defect
• PIA flap
• First choice for soft tissue reconstruction of the hand
• The major vascular advantage - location of the dorsal carpal anastomosis,
which allows it to be used even in the presence of extensive vascular damage
of the hand. 
• Moderate to large-sized fasciocutaneous and osteofasciocutaneous flaps can
be harvested - reconstruction of the majority of large defects of the hand. 
• Leaves the radial artery unaffected - available for later free tissue transfers
THANK YOU