The composite extensor retinaculum cutaneous flap: an anatomical cadaveric study
Main Article Content
tendons, tendon injuries, surgical flaps
Background: Complex digital extensor tendon injuries are difficult to manage when adhesion formation and stiffness prevail. Vascularised tissue to reconstruct the skin and extensor defect would be the ideal reconstruction in both the acute and delayed settings. This anatomical study evaluates vascular supply to a suitable composite flap comprising skin, subcutaneous tissue and extensor retinaculum.
Methods: An anatomical study of 18 cadaveric upper limbs was conducted to investigate the technical feasibility of a composite flap prior to its clinical application. The anterior (n = 9) or posterior (n = 9) interosseous artery was exposed and selectively injected with a coloured dye. Specimens were then dissected to raise the proposed composite flap of extensor retinaculum and the overlying integument. Specimens were subsequently assessed by digital subtraction angiography to evaluate the corresponding microvascular supply to the composite flap.
Results: The anterior and posterior interosseous arteries supplied the extensor retinaculum through a dense network of vessels with choke anastomoses. The skin overlying the extensor retinaculum was predictably supplied by either artery through the perforator vessels between the fourth and fifth extensor tendon compartments.
Conclusion: A composite unit of skin and extensor retinaculum can be harvested on either the anterior or posterior interosseous arteries. It can be employed for simultaneous vascularised tendon and skin reconstruction.
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2. Wavreille G, Cassio J, Chantelot C, Mares O, Guinand R, Fontaine C. Anatomical bases of the second toe composite dorsal flap for simultaneous skin defect coverage and tendinous reconstruction of the dorsal aspect of the fingers. J Plast Reconstr Aesthet Surg. 2007;60:710–19. https://doi.org/10.1016/j.bjps.2007.03.016 PMid:17449342
3. Turner A, Ragowannsi R, Hanna J, Teo T, Blair J, Pickford M. Microvascular soft tissue reconstruction of the digits. J Plast Reconstr Aesthet Surg. 2006;59:441–50. https://doi.org/10.1016/j.bjps.2005.10.009 PMid:16631554
4. Guimberteau J, Delage J, McGrouther D, Wong J. The microvacuolar system: how connective tissue sliding works. J Hand Surg Eur. 2010;35:614–22. https://doi.org/10.1177/1753193410374412 PMid:20571142
5. Shibata M, Ogishyo N. Free flaps based on the anterior interosseous artery. Plast Reconstr Surg. 1996;97:746–55. https://doi.org/10.1097/00006534-199604000-00010 PMid:8628769
6. Ross RJ, Baillieu CE, Shayan R, Leung M, Ashton MW. The anatomical basis for improving the reliability of the supraclavicular flap. J Plast Reconstr Aesthet Surg. 2014;67:198–204. https://doi.org/10.1016/j.bjps.2013.10.006 PMid:24189308
7. Saint-Cyr M, Schaverien M, Arbique G, Hatef D, Brown SA, Rohrich RJ. Three-and four-dimensional computed tomographic angiography and venography for the investigation of the vascular anatomy and perfusion of perforator flaps. Plast Reconstr Surg. 2008;121:772–80. https://doi.org/10.1097/01.prs.0000299338.97612.90 PMid:18317127
8. Barr JS, Schneider L, Sharma S. Reconstruction of a functional gliding surface with extensor retinaculum in extensor tendon reconstruction in the digits. Ann Plast Surg. 2014;72:155–58. https://doi.org/10.1097/SAP.0b013e318260555b PMid:23241777
9. Singer DI, Morrison WA, Gumley GJ, O’Brien BM, Mitchell GM, Barton RM, Frykman GK. Comparative study of vascularized and non-vascularized tendon grafts for reconstruction of flexor tendons in zone 2: an experimental study in primates. J Hand Surg. 1989;14:55–63. https://doi.org/10.1016/0363-5023(89)90059-2
10. Fenwick SA, Hazleman BL, Riley GP. The vasculature and its role in the damaged and healing tendon. Arthritis Res. 2002;4:252–60. https://doi.org/10.1186/ar416 PMid:12106496 PMCid:PMC128932
11. Morrison W, Cleland H. Vascularised flexor tendon grafts. Ann Acad Med Singapore. 1995;24:26–31.
12. Taylor GI, Townsend P. Composite free flap and tendon transfer: an anatomical study and a clinical technique. Br J Plast Surg. 1979;32:170–83. https://doi.org/10.1016/0007-1226(79)90030-4
13. Sundine M, Scheker L. A comparison of immediate and staged reconstruction of the dorsum of the hand. J Hand Surg [Eur]. 1996;21:216–21. https://doi.org/10.1016/S0266-7681(96)80102-1
14. Adani R, Marcoccio I, Tarallo L. Flap coverage of dorsum of hand associated with extensor tendons injuries: a completely vascularized single-stage reconstruction. Microsurgery. 2003;23:32–39. https://doi.org/10.1002/micr.10086 PMid:12616517
15. Brody MJ, Merrell GA. The effect of progressive extensor retinaculum excision on wrist biomechanics and bowstringing. J Hand Surg. 2015;40:2388–92. https://doi.org/10.1016/j.jhsa.2015.07.033 PMid:26432768
16. Kitamura T, Moritomo H, Arimitsu S, Berglund LJ, Zhao KD, An K-N, Rizzo M. The biomechanical effect of the distal interosseous membrane on distal radioulnar joint stability: a preliminary anatomic study. J Hand Surg. 2011;36:1626–30. https://doi.org/10.1016/j.jhsa.2011.07.016 PMid:21872404
17. Salva-Coll G, Garcia-Elias M, Hagert E. Scapholunate instability: proprioception and neuromuscular control. J Wrist Surg. 2013;2:136–40. https://doi.org/10.1055/s-0033-1341960 PMid:24436806 PMCid:PMC3699267
18. Patterson RW, Van Niel M, Shimko P, Pace C, Seitz WH. Proprioception of the wrist following posterior interosseous sensory neurectomy. J Hand Surg. 2010;35:52–56. https://doi.org/10.1016/j.jhsa.2009.10.014 PMid:20117308
19. Hagert E, Persson JK. Desensitizing the posterior interosseous nerve alters wrist proprioceptive reflexes. J Hand Surg. 2010;35:1059–66. https://doi.org/10.1016/j.jhsa.2010.03.031 PMid:20610049