External Fixation in Complicated Groin Flap Surgery

Abstract

Sir: The pedicled superficial circumflex iliac artery flap (groin flap) is an axial flap usually harvested on the same side as the injured hand/upper extremity.1 However, immobilization may be demanding. Usually, patients' compliance and close supervision are enough to achieve reasonable results following groin flap surgery. However, we encountered two occurrences of rupture of a left pedicled groin flap on postoperative days 4 and 9 following groin flap surgery to cover a defect on the distal ulna. The patient had a third-degree burn injury of 60 percent of his body surface area, necessitating several skin grafting procedures and finger amputations with a 3 × 5-cm defect on the ulnar aspect of his left forearm. The groins were uninjured and therefore superficial circumflex iliac artery flap surgery was performed. Despite external bandage of the torso in a Gilchrist-like plaster cast, the patient managed to rupture the pedicled groin flap twice from the defect to cover. During the second revision operation, we performed a reattachment of the pedicled groin flap after thorough débridement. External fixation was performed using a pelvic external fixator with two Schanz screws in the iliac crest and two Schanz screws in the radius (Fig. 1). A tube-to-tube connector was installed to achieve a rigid fixation, allowing optimal tension-free perfusion of the flap. Noninvasive combined laser Doppler and spectrophotometry (Oxygen-to-See; LEA Medizintechnik, Giessen, Germany) was performed to assess groin flap perfusion (Table 1). After external fixation, superior flap perfusion was noted by increased capillary blood flow, superior tissue oxygenation, and reduced postcapillary venous filling pressures. Slight modifications of the external fixation were performed based on the microcirculatory monitoring to achieve optimal microcirculatory perfusion and venous clearance. Pedicle division was performed on postoperative day 21 after a thorough preconditioning of the pedicled groin flap. External fixation is a valid option in groin flap surgery in patients with poor compliance, achieving optimal tissue perfusion and oxygenation.Fig. 1.: External fixation of the pelvis and the radius to ensure optimal perfusion of the pedicled groin flap after two occurrences of rupture of the flap. Noninvasive microcirculatory monitoring is performed using a probe with a combined laser Doppler and spectrophotometry system (Oxygen-to-See).Table 1: Noninvasive Combined Laser Doppler and Spectrophotometry Testing for Groin Flap Perfusion of the Distal and Proximal Pedicle after External Fixation of the Pelvis and the Forearm in Contrast to Medial Groin Skin in a Patient Suffering 60 Percent Third-Degree Burn InjuryKarsten Knobloch, M.D. Andreas Gohritz, M.D. Marcus Spies, M.D., Ph.D. Mehmet A. Altintas, M.D. H. Oliver Rennekampff, M.D., Ph.D. Peter M. Vogt, M.D., Ph.D