In reverse-flow posterior interosseous artery flap reconstruction, greater flap length was independently associated with venous congestion and flap loss, and early revision was associated with a lower flap loss rate than conservative management in patients with venous compromise.
Key Findings
Results
Venous congestion occurred in 27.3% of reverse-flow PIA flap reconstructions, with total and partial flap loss rates of 4.5% and 13.6% respectively.
Study included 110 patients who underwent reconstruction with a pedicled reverse PIA flap between 2010 and 2025
Mean patient age was 34.2 years
Majority of defects were traumatic in etiology (80.9%)
Venous congestion occurred in 30 patients (27.3%)
Total flap loss occurred in 5 patients (4.5%) and partial flap loss in 15 patients (13.6%)
Results
Flap length was independently associated with venous congestion on multivariable logistic regression analysis.
OR = 1.45, 95% CI 1.17–1.79; p < 0.001
Both univariable and multivariable logistic regression analyses were performed
ROC analysis identified a flap length of 9 cm as a practical reference threshold with high specificity and modest sensitivity
The 9 cm threshold serves as a practical reference point for anticipating venous congestion risk
Results
Flap length was independently associated with flap loss on multivariable logistic regression analysis.
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 for both venous congestion and flap loss complications
The threshold was characterized by high specificity and modest sensitivity
Results
Traumatic etiology was independently associated with donor site grafting requirements.
OR = 8.00, 95% CI 2.20–29.03
This association has received little prior attention in the literature
Flap width > 4 cm was associated with donor site grafting on univariable analysis but became only borderline significant after multivariable adjustment (OR 1.60, 95% CI 0.98–2.60; p = 0.059)
Traumatic etiology remained independently significant after multivariable adjustment while flap width did not
Results
Early revision surgery was associated with a significantly lower flap loss rate compared to conservative management in patients who developed venous congestion.
Flap loss rate with early revision: 43.75% versus 92.86% with conservative management (p = 0.007)
Analysis was conducted among the subgroup of 30 patients who experienced venous congestion
Authors note this is an observational finding that requires confirmation in prospective studies
The finding suggests a clinically meaningful benefit of early surgical intervention for venous compromise
What This Means
This research studied 110 patients who had a specific type of reconstructive surgery called a reverse-flow posterior interosseous artery (PIA) flap, which uses tissue from the forearm to repair wounds on the hand and wrist. The researchers tracked complications over a 15-year period and used statistical methods to identify which factors predicted problems. They found that about one in four patients developed venous congestion (a condition where blood cannot drain properly from the flap), and overall flap failure—either partial or complete—was also a notable concern.
The most important predictor of both venous congestion and flap failure was the length of the flap: longer flaps carried a meaningfully higher risk of these complications, with a flap length of 9 cm identified as a practical threshold above which surgeons should exercise extra caution. The researchers also found that patients with traumatic wounds were much more likely to need a skin graft at the donor site on the forearm compared to patients with non-traumatic wounds—a finding that had not been well-documented before. When patients did develop venous congestion, those who underwent early revision surgery had a substantially lower rate of flap loss (about 44%) compared to those managed conservatively (about 93%), suggesting that prompt surgical intervention may help save compromised flaps.
This research suggests that surgeons planning this type of reconstructive procedure should be especially cautious when flap dimensions exceed approximately 9 cm in length, and that patients with traumatic injuries should be counseled about the higher likelihood of needing a skin graft at the forearm donor site. The finding that early revision surgery appears to rescue more flaps from failure is clinically relevant, though the authors appropriately caution that this was an observational study and the results should be confirmed through prospective research before being adopted as a firm treatment guideline.
Erol K, Yener C, Kerekulov B, Er E, Güntürk &. (2026). Predictors of Complications and the Role of Early Revision in Reverse-Flow Posterior Interosseous Artery Flaps: A Multivariable Analysis of 110 Cases.. Microsurgery. https://doi.org/10.1002/micr.70307