Introduction

Repairing defects after severe hand trauma with extensive soft tissue loss demands immediate and skilled intervention. Despite the increasing variety and accessibility of free flaps, the groin flap introduced by McGregor and Jackson in 1972 remains in use [1]. While the groin flap was extensively discussed in publications during the 1980s, recent literature on the subject is limited. The groin flap’s advantages include its rapid and straightforward harvest, and for obese patients, the groin provides a notably thinner donor site compared to the flaps of other body areas [2].

Additionally, using the groin flap helps prevent further compromise of circulation in an already injured hand, which can be a risk with free flaps due to potential vascular injury during end-to-side anastomoses. Free flaps also necessitate high surgical expertise, which may not be available in all settings, and they require a longer initial surgery time [3].

Case Presentation

A 93-year-old woman was referred by her family doctor and admitted to another institution on January 31, 2023, due to increasing pain and significant swelling in her right hand. Examination revealed no trauma or open injuries. An abscess was identified and drained, with debridement and excision of the extensor tendon sheath performed on the day of admission. Over time, necrosis developed in the middle finger and dorsal hand, necessitating further debridement, amputation of the middle finger, and application of Vacuum-assisted closure (VAC) to the dorsal hand (Fig. 1). The patient had a medical history of Type 2 Diabetes Mellitus, arterial hypertension, rheumatoid arthritis, and previous bilateral hip TEP surgeries in 2009 and 2007. Due to the severity of her wound, she was transferred to our institution for further treatment.

Fig. 1. Debridement of Dorsal Hand and The Amputation of The Middle Finger.

On February 28^th, 2023, the patient was presented to our hospital with skin and soft tissue wound defect measuring approximately 9×8 cm on the back of right hand with exposed extensor tendons (Fig. 2). After taking Microbiological smear, the patient underwent debridement and irrigation of the wound down to the vital tissue with removal of diseased tissue on the skin and subcutaneous with applying VAC system. Microbiological smear revealed Staphylococcus epidermidis and the patient received antibiotics.

Fig. 2. Skin and soft tissue wound defect (approximately 9×8 cm) with exposed extensor tendons.

On March 3^rd, 2023, signs of inflammation and infection were resolved, so we were able to cover the defect with groin flap. The arterial inflow to the groin flap is provided by the superficial circumflex iliac artery (SCIA) (Fig. 3), a branch off the external iliac/superficial femoral artery at the level of the inguinal ligament (Fig. 4). The SCIA pierces the fascia at the medial aspect of the Sartorius muscle, making the Sartorius a key landmark in identifying the pedicle during dissection. The sartorius muscle, inguinal ligament, and iliac crest were all identified and marked to determine flap design. A pencil Doppler was used to determine the location of the arterial pedicle (Fig. 5), usually approximately a finger breadth below the inguinal ligament. The maximum width of the design was determined by pinching the skin to assess the potential tension of the closure after flap harvest. The Sartorius muscle was a key landmark in dissection.

Fig. 3. Anatomy of Superficial Circumflex Iliac Artery (SCIA) and the Sartorius Landmark (4).

Fig. 4. Landmarks of the flap.

Fig. 5. Landmarks of the flap.

Surgical procedure

Under general anesthesia, the patient was positioned in the dorsal decubitus position with a block placed under the ipsilateral buttock to facilitate better access to the donor site. Key anatomical landmarks were identified, including the anterior superior iliac spine, the pubic bone, the inguinal ligament, and the femoral artery. The limits of the flap were defined using a “2 fingers width” rule, corresponding to the transverse diameter of the patient’s index and middle fingers at the distal interphalangeal joint level. This rule helps locate the theoretical origin of the superficial circumflex iliac artery from the femoral artery, positioned 2 fingers width below the inguinal ligament. The flap’s upper limit is set 2 fingers width above the inguinal ligament, following a line defined by the superficial circumflex iliac artery’s course from its origin to the anterior superior iliac spine, which serves as the flap’s axis. The lower limit is 2 fingers width below the artery’s emergence, parallel to the axis. The lateral limit is determined by the size of the recipient site defect.

An estimation of the size of the flap to be harvested compared to the tissue loss was also made. The exact evaluation of the actual tissue loss to be covered is essential, and it must always be estimated after a careful debridement in hand. After identifying the emergence of the superficial iliac circumflex artery by palpation of the common femoral artery, we raised the flap from lateral to medial and transferred all subcutaneous tissue while remaining supra-fascial (Fig. 6). But, near the sartorius muscle, we made sure to include the fascia in the flap in order to avoid damaging the arteriovenous package [5]. Careful dissection stops at the medial edge of the sartorius muscle, but it is possible to incise the skin further for greater elasticity. At the medial aspect of the Sartorius, the fascial plane around the pedicle was incised and the artery and vein are dissected free to their origin (Fig. 7). The lateral cutaneous nerve of the thigh is protected at the lateral edge of the sartorius. The measurement of the flap thus lifted is 12 cm long by 8 cm wide. We then proceeded to the closure of the donor site with drain suction.

Fig. 6. Raising of the flap.

Fig. 7. Stop of dissection at the medial edge of the sartorius muscle.

At this step, tubing is carried out, preferably long, allowing the removal of the hand from the abdominal plane and a range of motion exercise of the hand. We then bring the hand to the inguinal region and adapt the flap to the defect before fixing the latter on the receiving site starting from the corner point (Fig. 8). Afterward, we sutured the more difficult posterior edge before the anterior edge. Beveling the fat at the edge of the skin before placing the flap decreases the tension at the suture line and the risk of necrosis of the edges. At the end, we applied tulle gras dressings on all the sutures, changed every 3 days, and a support effectively maintaining the upper limb was made to avoid any stretching on the pedicle of the flap in case of restless waking up. The hip on the inguinal flap side was kept in flexion, by placing the lower limb on an independent splint [6].

Fig. 8. Coverage of the defect by the flap.

Postoperative Follow-up

During the first 48 hours, observation of the flap was done every 6 hours for 48 hours for any wound changes of ischemia and fibrosis (Fig. 9). While the flap was still attached and the patient still hospitalized, the rehabilitation program consisted of supervised sessions twice daily. The patient tolerated the surgery and postoperative immobilization well and began passive- and active-assisted range-of motion (ROM) exercises of the fingers on postoperative day 1 as soon as the pain ceased, taking care to avoid torsion of the pedicle.

Fig. 9. Postoperative Monitoring.

After 2 weeks of flapping, pedicle compression by clamping of the flap (Fig. 10) was done for 3 minutes on the 1^st day, 5 minutes on the 2^nd day and 10 minutes on the 3^rd day and continued till the end of the 3^rd week for observation of any ischemia or necrosis of the flap. The flap showed no signs of ischemia or necrosis and continued to show good maintenance of perfusion with intact venous outflow of the flap. Once flap perfusion was not compromised by pedicle compression, we divided the flap. The division (Fig. 11) was done on the end of 3^rd week (day 21) [5].

Fig. 10. Clamping of the Flap.

Fig. 11. Division on Day 21.

The patient began ambulation training on postoperative day 7 and was discharged to rehabilitation on postoperative day 24 after tube division and final flap insetting. After her discharge, outpatient therapy was continued 3 times a week and included a home exercise program similar to that followed in the hospital.

Good preoperative planning helps avoiding the raising of a too large or too small flap as well as the preparation of a too long tubing causing a twist at its base or a too short one which would cause ischemia.

Results

The postoperative was uneventful, with a very satisfactory functional and appearance of the surgical reconstruction despite the co-morbidities of DM, Hypertension and rheumatoid arthritis (Fig. 12).

Fig. 12. The Final Result of the flap.

Discussion

Since its introduction in 1972 [1], the pedicled groin flap has become a widely used method for addressing soft-tissue defects in the hand and forearm. The technique is appreciated for its speed, simplicity, reliability, and low morbidity. It is especially beneficial for patients with arterial injuries or atherosclerosis because it eliminates the need for arterial anastomoses and minimizes the risk of flap steal in compromised distal circulation. However, older patients, who are more prone to atherosclerosis, face higher risks of shoulder and elbow stiffness and systemic complications post-procedure. Therefore, it is advised to avoid using pedicled groin flaps in individuals over the age of 50 [7].

This case report was performed in Department of plastic, reconstruction and Hand surgery, University hospital Magdeburg, Germany. We successfully used pedicled groin flaps in a 93-year-old female patient who had diabetes mellitus, hypertension, and rheumatoid arthritis, and had undergone bilateral hip TEP surgeries in 2009 and 2007. She required coverage for severe skin and soft-tissue defects on the dorsum of her hand due to a severe soft tissue infection. The groin flap, well-known for its dependability as both a pedicled and free flap for hand and forearm soft-tissue coverage, was harvested quickly and provided a reliable blood supply.

The patient’s successful functional recovery suggests that using pedicled groin flaps does not necessarily increase the risk of stiffness in elderly patients if certain precautions are observed. Firstly, utilizing the full length of the groin flap allows for the creation of a longer tubed segment, offering more length for the mobilization of the hand and arm, while ensuring careful attention to avoid twisting of the tubed segment. Secondly, early mobilization of the hand and arm through physical and occupational therapy helps to reduce joint stiffness and edema in both the injured hand and the flap. Lastly, aggressive therapy must be continued after the flap is divided to restore maximum motion in the upper extremity [8].

In our patient, these techniques yielded excellent results in covering soft-tissue defects and restoring upper extremity function without any systemic complications from the flap procedure.

Although Arner and Moller concluded that elderly patients (over 50 years) have a higher risk of systemic complications from pedicled groin flap procedures, they did not adjust for preexisting medical conditions in their series [9]. Reports indicate that free flaps have a higher risk of systemic complications in elderly patients compared to younger ones. However, this increased risk can be mitigated by correcting for preexisting medical conditions. Shorter, less stressful surgeries for patients with such conditions reduce the amount of anesthesia needed and eliminate the risk of returning to the operating room for vascular anastomosis revision if flap failure occurs [10].

Therefore, we believe that age alone should not determine the choice of procedure for soft-tissue coverage in elderly patients, nor should it rule out the use of a groin flap. The pedicled groin flap, with its shorter anesthetic requirement, may be preferable to a free-tissue transfer for elderly patients with multiple medical issues, despite the need for at least one additional, short procedure for pedicle division and final insertion.

The groin flap should be interpreted in light of its limitations, with the most significant being postoperative shoulder stiffness in elderly patients [11]. However, some studies have shown that early physiotherapy can prevent this stiffness. The position of the upper limb during the necessary time before division is uncomfortable [12, 6, 13]. Keeping the hand bandaged to the trunk for three weeks complicates postoperative care and can cause temporary hand edema, which usually resolves quickly due to the effective venous and lymphatic drainage in the groin area Another drawback is the requirement for multiple stages, including division followed by thinning procedures, which are often necessary for patients with a notable amount of adipose tissue. Moreover, there is a sensory loss associated with this flap, which can be particularly troublesome when affecting the thumb or other fingers [8]. However, Goertz et al. concluded in their study on the efficacy of pedicled groin flaps for hand defect treatment that the overall results were favorable, with most patients expressing satisfaction [14].

Conclusion

We are confident that the pedicled groin flap can be used safely and effectively in elderly patients without compromising function or significantly increasing the risk of systemic complications, provided that meticulous care is taken in positioning the flap and tubed pedicle, and comprehensive therapy is administered during the flap maturation process and after pedicle division.