Management of Infected Groin Wounds after Vascular Surgery

Clinical outcomes of different muscle flap reconstruction after inguinal tumor resection: A case series

PURPOSE

To introduce the clinical outcomes of adductor longus and sartorius muscle transfer alone and combined application for reconstruction of the inguinal region.

METHODS

This is a retrospective study of patients between January 2019 and December 2022 who underwent adductor longus flap transfer, sartorius muscle flap transfer, and combined transfer of adductor longus and sartorius muscle. The demographic data and surgical details were recorded.

RESULTS

Sixteen patients were included, with a mean age of 57.5 years. Nine patients performed adductor longus flap transfers, three patients performed sartorius muscle flap transfers, and four patients performed combined transfers. The average operation time was 238 min. The average length of stay was 6.7 days. The average follow-up period was 9.6 months (range 6-16). The overall early postoperative complication rate was 12.5% (one patient had excessive wound exudation and one patient had a wound infection). No delayed postoperative complications occurred during the follow-up.

CONCLUSION

The sartorius muscle flap, the adductor longus flap, and the combined application are suitable techniques for inguinal region reconstruction under different conditions. The combined application of the two flaps can fill the dead space and cover the neurovascular bundle efficaciously.

Reconstructive Surgery of Inguinal Defects: A Systematic Literature Review of Surgical Etiology and Reconstructive Technique

BACKGROUND/AIM

This study aimed to evaluate the literature regarding surgical etiology demanding inguinal reconstructive surgery, associated reconstructive techniques and outcomes.

MATERIALS AND METHODS

A systematic literature search was performed according to the PRISMA statement between 1996-2016.

RESULTS

A total of 64 articles were included, comprising 816 patients. Two main subgroups of patients were identified: Oncological resections (n=255, 31%), and vascular surgery (n=538, 66%). Oncological resection inguinal defects were treated with pedicled myocutaneous flaps (n=166, 65%), fasciocutaneous flaps (77, 31%), muscle flaps (7, 3%) and direct closure (3, 1%). Vascular surgery complications were treated with muscle flaps (n=513, 95%). Complications for the respective subgroup (oncological resections, vascular surgery) were: infection (24%, 14%), seroma (34%, 7.5%), flap dehiscence/delayed healing (20.6%, 40.8%,). The total reintervention rate was 20%.

CONCLUSION

Reconstruction of inguinal defects should be addressed on a case-by-case basis. Myocutaneous flaps were favoured after oncological resections, while muscle flaps were preferred after vascular surgery.

Use of Antibiotic-Impregnated Absorbable Beads and Tissue Coverage of Complex Wounds

The treatment of complex wounds is commonplace for plastic surgeons. Standard management is debridement of infected and devitalized tissue and systemic antibiotic therapy. In cases where vital structures are exposed within the wound, coverage is obtained with the use of vascularized tissue using both muscle and fasciocutaneous flaps. The use of nondissolving polymethylmethacrylate and absorbable antibiotic-impregnated beads has been shown to deliver high concentrations of antibiotics with low systemic levels of the same antibiotic. We present a multicenter retrospective review of all cases that used absorbable antibiotic-impregnated beads for complex wound management from 2003 to 2013. A total of 104 cases were investigated, flap coverage was used in 97 cases (93.3%). Overall, 15 patients (14.4%) required reoperation with the highest groups involving orthopedic wounds and sternal wounds. The advantages of using absorbable antibiotic-impregnated beads in complex infected wounds have been demonstrated with minimal disadvantages. The utilization of these beads is expanding to a variety of complex infectious wounds requiring high concentrations of local antibiotics.

Leg for life? The use of sartorius muscle flap for the treatment of an infected vascular reconstructions after VA-ECMO use. A case report

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Use of VA-ECMO systems may be encumbered by severe vascular complications.

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Infections developed after femoral arterial surgery cause significant morbidity.

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Coverage of vascular structures with a muscle flap can achieve site sterilization.

Introduction

Veno-arterial extracorporeal membrane oxygenation (VA-ECMO1) systems are a life-saving option in the treatment of acute respiratory distress syndrome (ARDS2), but may be encumbered by severe vascular complications in the groin.

Presentation of case

A pregnant woman was admitted with respiratory failure due to H1N1 influenza. VA-ECMO was inserted percutaneously by the intensivists and then accidentally removed by the patient after 8 days. 24 h later VA-ECMO was reinstalled with surgical denudation of femoral vessels in another department. 2 h later, due to active bleeding and signs of limb ischemia, the patient was referred to our department and emergency trombectomy and patch angioplasty with PTFE were performed. Evolution was further bad with wound infection (Pseudomonas, Proteus), which imposed large debridement, replacing the PTFE patch with 2 parallel venous patches and wound reconstruction through sartorius muscle rotation. The wound underwent negative pressure therapy for 10 days and was skin grafted. The patient recovered under systemic antibiotic and virostatic therapy.

Discussion

Major complications of using VA-ECMO devices are related to vascular access, most common bleeding at the puncture site and acute limb ischemia. In the groin, sartorius muscle flap is the most used for vascular coverage and small tissue defect reconstruction because of the ease in harvesting and low donor-site complications.

Conclusion

Although ischemic complications associated with VA-ECMO are accepted by intensivists under the slogan “leg for life”, for the repair of the femoral artery in the presence of groin infection the sartorius muscle remains an efficient solution for limb salvage.

Saving grace: distally pedicled gracilis muscular flap in lower limb salvage

During the 1970s, the incidence of limb amputation following surgery for sarcoma excision was as high as 50%. Two important developments have led to modern day limb salvage, namely chemotherapy and precision imaging techniques. We present a case of limb salvage in a patient with osteosarcoma plagued with recurrent infection after prosthetic revision. We discuss the use of the distally based pedicled gracilis muscular flap, which has little mention as a reconstructive option for defects around the knee.

The limited incision harvest of the rectus femoris flap for complex groin wound management

BACKGROUND

Muscle flaps can be effective in the protocol of complex groin wound management, yet donor-site morbidity remains a continued concern. The purpose of this study was to present a minimally invasive approach to the harvest of the rectus femoris flap (RFF) for groin wound vascularized tissue coverage.

PATIENTS AND METHODS

A retrospective study examined all patients undergoing RFF coverage and reconstruction of a complex groin wound between July 1, 2010, and December 31, 2011. During the study period, the senior author (S.K.K.) performed all RFF harvests through a minimally invasive approach, whereas all other surgeons performed the RFF harvest through a standard approach. Patients who underwent a minimally invasive RFF approach were compared with those who underwent the standard incision.

RESULTS

Forty-three patients underwent RFF coverage procedures, 11 of which were carried out using the minimally invasive technique. The patients in the minimally invasive cohort were older (P = 0.03) but had similar rates of medical comorbidities. Minimally invasive RFF harvests were more commonly performed in the planned, salvage setting (P = 0.03). No difference was found in the vascular surgery procedure type (P = 0.13), presence of exposed prosthetic graft material (0.2), or rate of culture-positive wound (P = 0.67). Importantly, no differences in operative time (184.4 [45.5] minutes vs 169.3 [31.7] minutes, P = 0.45) or postoperative complications were observed, with no graft losses or major limb-related morbidity in either group.

CONCLUSIONS

The RFF continues to be a workhorse flap for complex groin wounds, most often in the salvage setting. This study demonstrates that a minimally invasive approach can be used for flap harvest with equivalent results to that of the standard longitudinal incision.