4. 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.
5. 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)
6. CÁC HÌNH THỨC SỬ DỤNG
Vạt có cuống mạch liền (pedicle flap).
Vạt tự do (free flap).
7. 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.
8. 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.
9. 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.
10. 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.
11.
12. 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.
13. 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.
14. 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.
