Author Insights: Patient Selection and Procedure Selection for the Pedicled Groin Flap

Dr Mitchell Pet discusses the importance of patient selection and procedure selection when considering a pedicled groin flap for reconstruction of combined first webspace and dorsal hand contracture.

Mitchell Pet: Hello, my name's Mitchell Pet. I'm a hand and microsurgeon at Washington University in St. Louis.

Prompt 1: How do you manage the stress that comes with a pedicled groin flap where the arm is held for 3 weeks?

Mitchell Pet: So the three weeks after a groin flap are indeed a risky and potentially stressful time for the patient, they have challenges associated with wound care with impaired mobility, with fear about pulling their [inaudible 00:00:40] groin and causing damage. They have issues with dressing and social presentability, and all of that really needs to be considered very strongly before you make the choice to do a pedicled groin flap. Once you've chosen to do it, if you haven't made a good choice or made a good plan, in my opinion, you have a very high risk of failure, and your only chance to get this right really comes before surgery.

And so the most important thing about getting success, when you try something like this is patient selection, preoperative communication, and then making sure that you've chosen for the right procedure. And I would state, as I stated in this article, that my preference in these situations is basically always microsurgery. Doing a free tissue transfer in children, teenagers, adults, is almost always preferable from my perspective. But this article was written with the understanding that sometimes that's just not a good choice, and you have to be looking at a pedicled groin flap or something like that. And there are reasons to consider it.

Now, in these cases that we talked about, the reasons for consideration were varied. Some of them were patients that had just been through an enormous amount of hospitalization and just couldn't stomach. The idea of having to be an inpatient for a full long period of time, or having to go back to the ICU was so noxious to them that they didn't want it. Or maybe it's limited recipient vessel availability. But the first key to not having a failed groin flap, or to managing the post-op stress is don't do one if you don't have to. And in these cases, there was a good reason to do it.

So all of that said, I can talk about when you're approaching, man, this might be the case where I want to do a pedicled groin flap, or this might be the right thing for my patient. Well, how do I manage that? With the understanding that presumes that you've made it past my first choice, which is to do a microsurgical procedure. When I talk about this with my patients I consider it really only in patients with whom I have an existing rapport, patients whom I know things about, and I know how they're going to respond to stresses, patients who trust me to tell them the truth. And I do that. I tell them exactly what's going to happen as best as I understand it. I don't use euphemisms. I talk to them about the challenges that they're going to face. I talk to them about dressing. I talk to them about exactly where their hand's going to be and the things that may be uncomfortable with that. I'll show them pictures of what that looks like.

I'll give them realistic timescales of when this is going to start and when it's going to end. We'll talk about cleaning. I'll give them a chance to go to the store and buy clothing garments that are going to suit their needs. We choose the timing for this type of intervention, very carefully, such that they're not trying to go to dinner three days later, or having expectations that they can't meet with this type of procedure. And ultimately I'd like to educate them about this type of stuff. And it's my goal usually to offer them both a microsurgical procedure and a pedicled groin flap in these situations.

And then, if they choose a pedicled groin flap, then not only have they chosen something with full information, but they're also invested to the point that they've chosen it. I would never offer this in a patient who didn't have a good understanding of what surgical care meant, or in a patient who didn't trust themselves, or I didn't trust them to sort of weigh the different considerations thoughtfully, and understand what it's going to mean for them. So that's a little bit of a wandering answer, but I think it hopefully explicates my process for considering the ups and downs of offering this type of procedure, and the communication necessary beforehand to get it right.

Prompt 2: Are there unique concerns or approaches for children and teenagers?

Mitchell Pet: Children and teenagers, I think there are unique concerns. However, I would emphasize that the rules are very much the same, in that you have to be able to engage with the patient, and the patient, not just the parent, about what this type of procedure would mean.

And I think the first thing is that you can say children or teenagers broadly, but a young child who doesn't have the capacity to participate with care, I personally would not ever choose this procedure in the absence of a situation where I had absolutely no other options to save a limb. Trying to coax a four year old or a three year old to understand that their hand is going to be somewhere totally non anatomic and that their activity is going to be totally disrupted, and then even one instance of frustration or fear can result in a disaster. It's just not likely to pan out well. And so I have not, I'll stop short of saying I would not, but I have not, and don't anticipate many instances where I would offer this to a young child, because I just don't think that they really have the agency to understand what you're talking from about, and then participate reliably.

Teenagers are different. Teenagers, I think there's a much wider range of teenagers out there that have different capacity to understand and participate. And I think that offering a teenager, a microsurgical procedure wherein they're an inpatient for a prolonged period of time, and then offering this type of procedure where maybe they're able to go home quicker and spend time in their environment, but it is perhaps a longer and more unusual experience. They have the capability to understand that. And that's how I've dealt with it. I talk to them about it. And I think it's a two way street. They size me up and figure out what type of engagement they want to have with me and with surgery. And I size them up and I decide which type of procedure are they likely going to do better with. And in some cases it does end up being this pedicle type of groin flap that has an unusual post-op course. And then we proceed in that direction. But I do think it's a mutual kind of decision.

And then there are certainly teenage where I think that this is very, it's a very bad idea. And the prototypical bad idea would be the young impulsive male, maybe with oppositional characteristics, or fleeting instances of cooperation. And I would emphasize that just because they agreed to it one time does not mean that they're going to do well. You have to have someone who has a demonstrated ability to follow through on adherence to surgical recommendations, and a demonstrated understanding that if they are unable to participate well, that there will be negative consequences for them, rather than just for the surgeon or the parents.

And so that's how I approach it. I would note one thing is that there have been propositions before of using external fixators between the radius and the anterior superior iliac spine or [inaudible 00:08:39] between those two structures to try and force adherence, especially in younger patients or even in adults with behavioral issues or substance dependence. For me, that doesn't really fit with my approach. And I have not chosen to undertake that type of forceful approach to gaining adherence, as I think that usually if you take someone who doesn't want to de controlled, and then you just try to control them with metal, that usually ends poorly. And so I have not chosen that approach, but I've instead erred on the side of a patient selection and procedure selection type of algorithm.

Prompt 3: What are some key takeaways from this report?

Mitchell Pet: A few key takeaway from this report I think, the first is that I'll echo some of the things I've already mentioned, is that patient and procedure selection are of paramount importance. I would emphasize that microsurgical solutions to these type of issues are certainly what I do most often, and they are my preference. However, I really try to respect the cases where this is not the right solution for patients, even though it's something that I'm very comfortable with. And times where that has come up, and times where that may come up in your practice are patients who are burnt out on being in the hospital, and are not good candidates to go back to the ICU or whatever your monitoring unit is because of things like prolonged previous hospitalizations or PTSD related to major trauma, which is not uncommon in patients who are indicated here.

And so, while I fancy myself, someone who likes to use more advanced solutions when I can, there are good reasons to consider old standbys, and this is one of them. And writing about this was an attempt to recognize that there is still a role for these procedures in some cases, and to be on the lookout for them, rather than just hitting harder and harder with the microsurgical hammer.

The second takeaway is that perhaps more on the technical side of this undertaking, is that you have to be very thoughtful in sequencing and understanding the soft tissue and bony and muscular tendonous portions of a defect. And then understanding them all ahead of time, and then releasing them and correcting them in a reasonable sequence, such that you are able to get a full correction, and also get full coverage. That's a little bit easier when you're doing microsurgery, because the answer is release everything, put the skeleton where it needs to go, and then cover the defect. And it all just happens all at once. And it doesn't really require a lot of planning. When you are doing a pedicled groin flap type of reconstruction for the first web space and dorsal hand, this is a bit more challenging, because you can't cover the entire defect that is necessary to create all at once. And you often can't do all of the release at once.

And so I talked about, or our group talked about in this manuscript, that we did a sort of a dorsal approach first, creating the dorsal defect. And then once the flap was mature, we were able to complete our thumb positioning and our volar defect creation at the second surgery before our inset. And that just requires some additional planning. And I guess there are different ways to look at that, and probably different ways to do it by the way. But I think that the underlying takeaway is even if you can't do it all at once, or even if you feel as you though, you're handicapped because you can't use your preferred microsurgical solution, there are still ways. And it's still important to correct all of the defects in all of the tissues, and get yourself an ideally positioned thumb ray, and good soft issue where you need it.

And so I think I would leave it at that, as my two takeaways involve patient selection, procedure selection, and then a technical point on making sure that you are able to do all the things that you would in a single stage. And it's just a little bit harder when you have to plan it in a two stage procedure.