Reconstruction of Severe Contracture of the First Web Space Using the Reverse Posterior Interosseous Artery Flap

Background: To evaluate the outcome and highlight the operative tips of using the reverse posterior interosseous artery (PIA) flap in the treatment of severe contractures of the first web space. Methods: From 1985 to 2008, the reverse PIA flaps, which included fasciocutaneous flaps in 25 patients and composite flaps in 2 patients were used to cover skin defects over the first web space after release of severe contractures of the first web space. The severe contracture of the first web space was defined as the distance of less than 2 cm between the interphalangeal joint of the thumb and the metacarpophalangeal joint of the index. The flap dimensions varied between 6 cm and 22 cm (average, 13 cm) in length and 3 cm to 9 cm (average, 6 cm) in width. The largest flap was 22 cm x 6 cm and the smallest 6 cm x 3 cm. The length of the pedicle ranged from 2 cm to 10 cm (average, 8 cm). Skin defects of the donor site were covered by split-thickness skin grafts in 26 patients and direct closure in 1 patient. Results: Twenty-six of 27 PIA flaps survived completely except venous congestion occurred in 1 patient, which led to necrosis of the distal 1/4 flap. Skin grafts over the donor sites survived completely without complications. The follow-up period ranged from 1 month to 2 years. Lipectomy or revision was performed in two patients because of scar contractures or bulkiness. The postoperative distance of the reconstructed web space was 6 cm on average. Conclusion: The reverse PIA flap is suited for defect cover in the treatment of severe contractures of the first web space. A usual pitfall using the reverse PIA flap is that the skin paddle is inadvertently outlined over the proximal 1 of 3 forearm to increase its distal reach, which usually leads to postoperative venous congestion. However, if the distal flap pole is placed at or distal to the midpoint from the lateral epicondyle to the radial side of the ulnar head, choosing the proximal 1 of 2 forearm as the donor site of the skin paddle to increase its distal reach is reliable.