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Identification of the Radial Artery Perforator for Coverage of the Scarred Median Nerve using Color Doppler Ultrasonography
Ema Onode, MD1, Kiyohito Takamatsu, MD, PhD1, Syoichiro Oyama, MD1, Kosuke Shintani, MD1, Takuya Uemura, MD, PhD2 and Kenichi Kazuki, MD, PhD1
1The Department of Orthopedic Surgery, Osaka City General Hospital, Osaka City, Japan, 2 Depertment of Orthopedic Surgery, Osaka City University Medical School, Osaka City, Japan
Introduction: Recurrent median nerve neuropathy at the wrist caused by adhesion, accompanied by wrist pain and hand numbness, remains a challenging problem. A distally based adipofascial flap is generally used for preventing readhesion of the median nerve. Recently, a radial artery perforator-based adiposal flap without fascia was reported for the coverage of the scarred median nerve. However, elevation of the perforator flap harvest and the anatomic variability of perforators contribute to technical challenges. Therefore, preoperative imaging is essential for adequate preoperative planning and decreasing intraoperative errors. Imaging modalities for identifying perforators before surgery, including MRA, CTA, and ultrasound, are increasing in popularity. In the past few years, some investigators have reported the utility of color Doppler ultrasound in planning the anterolateral thigh flap, gluteal artery, and deep inferior epigastric artery perforator flap. However, no research has investigated radial artery perforators using this technique. Background: This study aimed to assess the feasibility of preoperative color flow Doppler ultrasound in evaluating the location and direction of the radial artery perforators in the distal forearms. Methods: Ten healthy volunteers underwent color Doppler ultrasound of their distal forearm. All detected radial artery perforators were counted and analyzed for distance from wrist crease and the site of origin from the circumference of the radial artery (superficial or deep; radial or ulnar aspect). Cluster analysis was performed to determine the overall distribution of the perforators. Results: In total, 120 perforators were detected in 20 forearms. Of these, 36 (30%) were distributed on the radial aspect while 52 (43%) were distributed on the ulnar aspect. Furthermore, 17 (14%) and 15 (13%) originated from the superficial and deep aspects respectively. With regard to location, 30, 35, 19, 18, 17, and 17 perforators were identified 0–25 mm, 26–50 mm, 51–75 mm, 76–100 mm, 101–125 mm, and 126–150 mm, respectively, from the wrist crease. In total, 69 perforators were detected from the superficial and ulnar aspects; of these, 17 each (60.2%) were detected 0–25 mm and 26–50 mm, respectively, from the wrist crease. Conclusions: The involvement of perforators from the superficial and ulnar aspects is important in adiposal flaps for median nerve coverage. This study demonstrated that color Doppler ultrasound can detect a substantial number of perforators from the superficial and ulnar aspects located 0–50 mm from the wrist crease, indicating the feasibility of this technique for making decisions and planning radial artery perforator-based adiposal flaps for median nerve coverage.
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