Long-term steroid therapy has long been used to treat a variety of autoimmune and inflammatory diseases. However, it is associated with an increased perioperative risk of developing complications related to inhibition of the hypothalamic-pituitary-adrenal axis in surgical patients.1 This inhibition causes an insufficient stress response, an impairment of healing, and various endocrine and metabolic adverse effects, including increased susceptibility to infection. Supraphysiologic “stress-dose” glucocorticoids (GCs) have routinely been considered the perioperative standard of care over the past 6 decades for these patients.2–4 Recently these years, however, developing evidence is beginning to suggest that such a practice may not be necessary.4,5
In the field of reconstructive surgery, it is hard to evaluate the amount of disturbance various procedures would cause to the internal environment of the patients, thus making consensus on whether and how to use perioperative stress-dose GCs hard to reach.
Soft tissue reconstruction of the hand has always been uneasy for surgeons. The coverage of exposed muscle, tendon, and bone is challenging because of limited availability of local flaps. The posterior interosseous flap is a fasciocutaneous flap, which can be proximally or distally based as an island flap. Since first described by Lu et al,6 Penteado et al,7 and Zancolli and Angrigiani8 independently, and innovated by other surgeons afterward,9,10 it has become the prior choice for hand reconstruction in many institutions.11–13
This article seeks to present our experience of perioperative management in 6 patients on long-term steroid therapy for autoimmune diseases undergoing reversed posterior interosseous flap for soft tissue hand reconstruction.
MATERIALS AND METHODS
This study was approved by the ethics committee. Informed consent was obtained from each patient.
From March 2008 to September 2016, 6 patients with autoimmune diseases who have received long-term steroid therapy were referred to our department because of hand neoplasm. They were 4 women and 2 men with ages ranging from 34 to 73 years. The original autoimmune diseases were systemic lupus erythematosus in 3 patients, dermatomyositis in 2 patients, and scleroderma in 1 patient. Their prior steroid therapy period ranged from 10 to 67 months. Rheumatologists and dermatologists were consulted in all 6 cases: 4 patients continued their usual dose of GCs, and the other 2 patients decreased the dose of GCs to 30 mg prednisone per day until the morning of the operation day (Table 1).
Locations of neoplasms in the patients were as follows: dorsum of the hand in 3 patients, radial half of the hand in 1 patient, and ulnar half of the hand in 2 patients. The largest flap measured in our study was 9 × 6 cm, and the smallest flap was 5 × 2.5 cm. All the patients received preoperative Doppler test in order to exclude anatomical variations.
All the operations were conducted under general anesthesia. None of the patients received a stress dose of GCs during the operation. The surgical technique was described in other articles13–15 with no significant modification. The insetting of the flap was provided by splitting the skin bridge of the pivot point in all the cases, and the defects of donor sites were all skin grafted (Fig. 1).
All the patients resumed their routine steroid treatment on the second day after the operations. Blood pressure, electrolytes, and blood glucose were carefully monitored after the operations. Symptoms suggestive of adrenal insufficiency such as orthostatic hypotension, myalgia, nausea, vomiting, diarrhea, and asthenia were closely supervised. Conditions of the flap were assessed regularly after the operation. Any postoperative complication was recorded.
None of the patients developed hypotension, water-electrolyte imbalance, hypoglycemia, or other symptoms suggestive of adrenal insufficiency during the perioperative period. Recurrence of the original autoimmune diseases was not observed in any patient.
The posterior interosseous flaps survived in all the cases. No flap infection, venous congestion, or complete or partial loss of flap was observed in any patient. Effusion underneath the flap was noticed in 1 patient and cured by proper drainage (Table 2). Skin grafted on the donor sites survived in all the cases. All the patients were evaluated in terms of pinch and grip functions as long as the temperature, turgor, and color of the flaps in the follow-up. The longest follow-up period was 24 months, and the shortest was 5 months. At the end of follow-up, all cases showed no significant functional limit. All flaps provided stable coverage and reasonable contour. No patient reported donor skin graft color mismatch. All the patients were satisfied with their functional and aesthetic outcomes.
The definite perioperative management of patients on long-term steroid therapy has not reached a consensus. Furthermore, there are few data available regarding the true incidence of perioperative adrenal insufficiency, especially in the field of reconstructive surgery. Since the potential danger of long-term steroid therapy in surgical patients was described by Fraser et al16 and Lewis et al17 in 1952 and 1953, a stress dose of GCs was advised to prevent adrenal insufficiency perioperatively. According to Salem et al,18 the dose of perioperative steroid coverage depends on the degree of surgical stress. Based on this theory, long-term GC–treated patients preparing for a reversed posterior interosseous flap reconstruction need an extra 50 to 75 mg hydrocortisone or equivalent. However, recent studies revealed that patients receiving therapeutic doses of GCs did not routinely require stress doses perioperatively as long as they continue to receive their usual daily dose.4,5 In 2 independent studies, patients even stopped steroid therapy before the surgery, and there was no significant difference in regard to adrenal insufficiency.19,20 In our study, stress-dose GCs were not administered in any patient. The patients either received their usual dose or decreased dose of GCs before the surgeries according to the advice of rheumatologists and dermatologists. None of the patients experienced hypotension or other symptoms suggestive of adrenal insufficiency. Furthermore, the progress of the original autoimmune disease was not detected in any patient. Our result is in coincidence with the studies above.
The patients' conditions might be one of the reasons why stress dose of GCs was not necessary in our study; there were no trauma-caused hand defects, unlike in many other studies. The requirement of supplemental GCs for stress might be less in a delicate tumor removal operation than that in a trauma-caused emergency surgery. All the patients in our study were receiving therapeutic dose of GCs owing to primary autoimmune diseases, and none of them received replacement dose of GCs for hypothalamic-pituitary-adrenal axis hypofunction. For those on physiologic replacement dose of GCs, a supplemental dose in the perioperative period might be required.4
Another major concern is the association between long-term steroid therapy and the increased postoperative morbidity.2 Fortunately, none of our patients experienced any major complications after surgery. Generally, the posterior interosseous flap reconstruction is a moderate operation that only mildly interferes with internal environment compared with a major surgery, thus leading to a lower complication rate.
The effect of GCs on flap reconstruction is complicated. On the one hand, additional GCs are able to reduce inflammation, thus preventing flap edema and consequent venous congestion in an early set. On the other hand, extra GCs would increase the probability of infection, which might directly lead to failure of flap reconstruction. In our study, prophylactic antibiotics were given for 24 hours after the operation, and no flap infection was noticed. The only complication observed was effusion underneath the flap in a single case and was successfully managed by proper drainage. However, no evidence suggested that the effusion was directly associated with GC treatment.
Local extended resection is the primary treatment for hand malignant tumor, while wound coverage of secondary defects can be challenging. The reversed posterior interosseous flap is an axial flap, based on the retrograde posterior interosseous artery, to provide coverage of the hand. It is proved to have many distinct advantages including its easy preparation, single-stage procedure, and nonrequirement for microvascular anastomosis. Besides, it achieves an excellent skin texture and does not require the sacrifice of radial or ulnar artery, making it an excellent option for hand reconstruction.11–13 Costa et al12 concluded that the major indications of reversed posterior interosseous flap are reconstruction of the first web space up to the interphalangeal joint of the thumb, dorsal hand defects up to the metacarpal joints, and large defects on the palm-ulnar border of the hand. The location of defects in our study involves multiple hand subunits including dorsum, radial, and ulnar half of the hand. According to Zhang et al,21 anatomical variations were observed in only 2 patients so far. In consistence to previous studies, we found no anatomical variations in all 6 cases, suggesting its reliable blood supply. However, perioperative Doppler examination is still an essential step in this method. Another advantage of the reversed posterior interosseous flap is a guaranteed quality of the skin paddle suitable for volar wrist, dorsum of the hand up to base of fingers, and dorsum of the thumb.
In our clinical study, we have demonstrated that reversed posterior interosseous flap is not only an excellent tool to cover hand defects, but also causes little biological stress to patients with autoimmune diseases and is not compromised by chronic steroid treatment. Based on the reasons above, we believe that reversed posterior interosseous flap is a prior choice among all existing hand reconstruction techniques.
In conclusion, our study demonstrated that reversed interosseous flap is safe, reliable, and versatile to repair hand defects in patients on long-term steroid therapy for autoimmune diseases. A stress dose of GCs is not necessary in these patients.
1. Jabbour SA. Steroids and the surgical patient. Med Clin North Am
2. Wakim JH, Sledge KC. Anesthetic implications for patients receiving exogenous corticosteroids. AANA J
3. Nicholson G, Burrin JM, Hall GM. Peri-operative steroid supplementation. Anaesthesia
4. Marik PE, Varon J. Requirement of perioperative stress doses of corticosteroids: a systematic review of the literature. Arch Surg
5. Kelly KN, Domajnko B. Perioperative stress-dose steroids
. Clin Colon Rectal Surg
6. Lu LJ, Wang SF, Yang J, et al. The posterior interosseous flap
: a report of 6 cases. The Second Symposium of the Chinese Association of Hand Surgery, Tsingtao City
7. Penteado CV, Masquelet AC, Chevrel JP. The anatomic basis of the fascio-cutaneous flap of the posterior interosseous artery. Surg Radiol Anat
8. Zancolli EA, Angrigiani C. Posterior interosseous island forearm flap. J Hand Surg Br
9. Fujiwara M, Kawakatsu M, Yoshida Y, et al. Modified posterior interosseous flap
in hand reconstruction
. Tech Hand Up Extrem Surg
10. Balakrishnan G, Kumar BS, Hussain SA. Reverse-flow posterior interosseous artery flap revisited. Plast Reconstr Surg
11. Agir H, Sen C, Alagöz S, et al. Distally based posterior interosseous flap
: primary role in soft-tissue reconstruction of the hand. Ann Plast Surg
12. Costa H, Pinto A, Zenha H. The posterior interosseous flap
—a prime technique in hand reconstruction
. The experience of 100 anatomical dissections and 102 clinical cases. J Plast Reconstr Aesthet Surg
13. Mago V. Retrograde posterior interosseous flap
. Iowa Orthop J
14. EI-Sabbagh AH, Zeina AA, EI-Hadidy AM, et al. Reversed posterior interosseous flap
: safe and easy method for hand reconstruction
. J Hand Microsurg
15. Wang JQ, Cai QQ, Yao WT, et al. Reverse posterior interosseous artery flap for reconstruction of the wrist and hand after sarcoma resection. Orthop Surg
16. Fraser CG, Preuss FS, Bigford WD. Adrenal atrophy and irreversible shock associated with cortisone therapy. J Am Med Assoc
17. Lewis L, Robinson RF, Yee J, et al. Fatal adrenal cortical insufficiency precipitated by surgery during prolonged continuous cortisone treatment. Ann Intern Med
18. Salem M, Tainsh RE Jr, Bromberg J, et al. Perioperative glucocorticoid coverage. A reassessment 42 years after emergence of a problem. Ann Surg
19. Jasani MK, Freeman PA, Boyle JA, et al. Studies of the rise in plasma 11-hydroxycorticosteroids (11-OHCS) in corticosteroid treated patients with rheumatoid arthritis during surgery: correlations with the functional integrity of the hypothalamo-pituitary-adrenal axis. Q J Med
20. Kehlet H, Binder C. Adrenocortical function and clinical course during and after surgery in unsupplemented glucocorticoid-treated patients. Br J Anaesth
21. Zhang YX, Qian Y, Pu Z, et al. Reverse bipaddle posterior interosseous artery perforator flap. Plast Reconstr Surg