Microsurgery. 2026 Oct;46(7):e70307. doi: 10.1002/micr.70307.
ABSTRACT
BACKGROUND: The pedicled reverse-flow posterior interosseous artery (PIA) flap is a reliable option for soft-tissue reconstruction of the hand and wrist. However, the predictors of complications and the impact of early revision surgery have not been adequately evaluated using multivariable analysis. This study aimed to investigate the factors affecting flap survival, complication rates, and outcomes of salvage surgery.
PATIENTS AND METHODS: A retrospective analysis was conducted on 110 patients who underwent reconstruction with a pedicled reverse PIA flap between 2010 and 2025. Univariable and multivariable logistic regression analyses were performed to identify predictors of venous congestion, flap loss, and donor site grafting. Receiver operating characteristic (ROC) analysis was used to determine the dimensional thresholds.
RESULTS: The mean patient age was 34.2 years, and the majority of defects were traumatic in etiology (80.9%). Venous congestion occurred in 30 patients (27.3%), whereas total and partial flap loss occurred in five (4.5%) and 15 (13.6%) patients, respectively. On multivariable analysis, flap length was independently associated with venous congestion (OR = 1.45, 95% CI 1.17-1.79; p < 0.001) and flap loss (OR = 1.47, 95% CI 1.17-1.85; p < 0.001). ROC analysis identified a flap length of 9 cm as a practical reference threshold (high specificity, modest sensitivity) for these complications. In a separate donor-site grafting model, flap width > 4 cm was associated with grafting on univariable analysis but became only borderline significant after multivariable adjustment (OR 1.60, 95% CI 0.98-2.60; p = 0.059), while traumatic etiology was independently associated with donor site grafting (OR = 8.00, 95% CI 2.20-29.03). Among patients with venous congestion, early revision was associated with a lower flap loss rate than conservative management (43.75% vs. 92.86%, p = 0.007).
CONCLUSIONS: In reverse-flow PIA flap reconstruction, greater flap length was independently associated with venous congestion and flap loss. Traumatic etiology emerged as an independent predictor of donor-site grafting, an association that has received little prior attention. In patients with venous compromise, early revision was associated with a lower overall flap loss rate, although this observational finding requires confirmation in prospective studies.
PMID:42885255 | DOI:10.1002/micr.70307