VẠT GIAN CỐT SAUPOSTERIOR INTERROSEOUS FLAP

Lê Nghi Thành Nhân

GIẢI PHẪU ĐỘNG MẠCH GIAN CỐT SAU

GIẢI PHẪU: MỘT SỐ ĐIỂM CẦN LƯU Ý

Bó mạch gian cốt sau đi trong vách cân giữa cơ duỗi cổ tay trụ và cơ duỗi ngón năm ở 1/3 dưới cẳng tay.

TK gian cốt sau đi ở bờ quay của ĐM gian cốt sau và nhánh vận động chi phối cơ duỗi cổ tay trụ thường bắt chéo ĐM gian cốt sau ở gần nguyên ủy.

Vùng cấp máu của ĐM gian cốt sau: hầu hết mặt sau cẳng tay từ 2-3cm dưới khuỷu đến cổ tay, giới hạn ngoài bởi xương quay và bên trong bởi bờ sau xương trụ.

5% không có nhánh nối với ĐM gian cốt trước ở đầu xa. Một số trường hợp không có hệ tĩnh mạch đi kèm.

CÁC DẠNG VẠT ĐƯỢC SỬ DỤNG

Vạt da cân (fasciocutaneous flap): cuống đầu gần, cuống đầu xa Vạt cân (fascial flap) Vạt phối hợp da-cơ-xương (the composite ostemyocutaneous flap)

CÁC HÌNH THỨC SỬ DỤNG

Vạt có cuống mạch liền (pedicle flap). Vạt tự do (free flap).

CHỈ ĐỊNH

Vạt có cuống mạch liền:Cuống đầu gần: che phủ khuyết hổng vùng khuỷu.Cuống đầu xa che phủ khuyết hổng vùng:

Mu bàn tay Ngón cái đến mức khớp liên đốt Tạo hình kẻ ngón I, II Mặt mu cổ tay.

MỘT SỐ NGHIÊN CỨU CÓ LIÊN QUAN Dadalt Filho LG, Penteado CV, et al. Absence of the anastomosis between the anterior and

posterior interosseous arteries in a posterior interosseous flap: a case report. J Hand Surg 1994;19:22–25.

33. Hu W, Foucher G, Baudet J, et al. Le lambeau interosseux anterieur. Ann Chir Plast Esthet 1994;39:290–300.

34. Giunta R, Lukas B. Impossible harvest of the posterior interosseous artery flap: a report of an individualized salvage procedure. Br J Plast Surg 1998;51:642–645.

Penteado CV, Cheverel JP, et al. The anatomical basis of the fascia cutaneous flap of the posterior interosseous artery. Surg Radiol Anat 1986;8:209–215.

38. Zancolli EA, Angrigiani C. Posterior interosseous island forearm flap. J Hand Surg 1988;13:130–135.

39. Costa H, Martins A, Rodrigues J, et al. Further experience with the posterior interosseous flap. Br J Plast Surg 1991;44:449–455.

Costa H, Vranchx J, Cunha C, et al. The posterior interosseous flap: a review of 81 clinical cases and 100 anatomical dissections—assessment of its indications in reconstruction of hand defects. Br J Plast Surg 2001;54:28–33.

174. Brunelli F, Dumontier C, Panciera P, et al. The posterior interosseous reverse flap: experience with 113 flaps. Ann Plast Surg 2001;47:25–30.

175. Chen HC, Chuang D, Wei FC, et al. Microvascular free posterior interosseous flap and a comparison with the pedicled posterior interosseous flap. Ann Plast Surg 1996;36:542–550.

176. Mazzer N, Cortez M, et al. The posterior interosseous forearm island flap for skin defects in the hand and elbow. A prospective study of 51 cases. J Hand Surg 1996;21:237–243.

Penteado CV, Masquelet AC, The anatomic basis of the fasciocutaneous flap of the posterior interroseous artery, Surg Radiol Anat (1981), 8, 209-15.

Masquelet AC: 22 flaps Indications: loss of tissue from the elbow or

wrist and constractures of the thumb and dorsal surface of the hand.

All flaps survived complete The largest flaps measured 17-20x7cm. One case of postoperative paralysis of

extensor pollicis longus.

Costa et al. presented a series of 81 clinical cases, finding the flap particularly useful in cases in which there was injury to the radial and ulnar arteries.

Costa et al. used the flap for soft tissue deficits of the dorsal hand up to the metacarpal joints, the first web space up to the IP joint of the thumb, and the ulnar border of the hand.

An island osteo-fasciocutaneous flap, based on the posterior interosseous vessels, is described for thumb reconstruction. The artery supplies the fascial plexus of the posterior forearm as well as the superficial and deep extensor muscles. A vascularised bone segment of the upper third of the ulna can be harvested, including a cuff of the extensor pollicis longus muscle. The flap was used successfully in two clinical cases.

Brunelli et al. reported the use of this flap in 113 cases: Flaps survived completely in 98 patients. Twelve patients had superficial necrosis of the distal part of the flap, which did not require additional surgical procedures. Six patients demonstrated paralysis of the motor branch to the extensor muscles of the wrist or fingers (generally to the ECU, the extensor digiti quinti, or the extensor pollicis longus). All recovered completely within 6 months.

There were major anatomic variations that precluded the use of the flap twice in this series.

MICROVASCULAR FREE POSTERIOR INTEROSSEOUS FLAP AND A COMPARISON WITH THE PEDICLED POSTERIOR INTEROSSEOUS FLAP.

Chen HC, Tang YB, Chuang D, Wei FC, Noordhoff MS.The posterior interosseous flap has been used as a pedicled flap for coverage of

hand wounds. However, the pedicled flap is associated with partial or even complete loss when there is venous congestion. This happens because it depends on retrograde venous drainage. Another pitfall of the pedicled posterior interosseous flap is the undetected damage to the communicating vessels between the anterior and posterior interosseous arteries before surgery. This would result in failure if the flap is used as a distally based flap.

Thirty-four patients had been reconstructed with the microvascular free posterior interosseous flap. The free flap has a large draining vein. Flap survival rate was 97%. There was no venous congestion and no partial loss of the flap. It is thin, sensate, and reliable.

The free posterior interosseous flap is indicated for coverage of the following wounds: (1) first web space and thumb, (2) radial side of the index and ulnar side of the small finger if a cross-finger flap cannot be used, and (3) defects at the dorsum of multiple fingers. It can also be used as a free fascial flap. The free posterior interosseous flap provides a reliable option for coverage of hand wounds.

NHƯỢC ĐIỂM

Khó khăn về mặt kỹ thuật. Động mạch nhỏ. Thần kinh gian cốt sau lại nằm ngay cạnh bó mạch. Tổ chức cân chứa cuống mạch lại rất mỏng manh. Sẹo tại vùng nhận nằm ở vị trí gây mất thẩm mỹ. Không thể chỉ định cho trường hợp cấp cứu nếu có chấn

thương mặt sau cẳng tay.

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