Management of Infected Groin Wounds after Vascular
Surgery
Running title: Management of Infected Groin Wounds
Pin-Keng Shih, M.D. 1; Hsu-Tang Cheng, M.D. 1; Chao-I Wu, M.D. 1; Sophia
Chia-Ning Chang, M.D., Ph.D. 1; Hung-Chi Chen, M.D. 1; Hsin-Han Chen, M.D. 1,2
1Department
of Plastic and Reconstructive Surgery, China Medical University
Hospital
2Graduate
Institute of Clinical Medical Science, China Medical University, Taichung,
Taiwan
Corresponding author:
Hsin-Han Chen
Division of Plastic Surgery, China Medical University Hospital
2 Yuh Der Road, Taichung City, 404, Taiwan
Tel.: (886)-4-22052121 ext. 1638; Fax: (886)-4-22029083
E-mail: scapulachenhh@yahoo.com.tw
Abstract
Background Management of an infected groin wound after vascular surgery may be a
challenge. We report a retrospective series of cases for management of groin defects
and set up an algorithm according to our own experience and other related literature.
Patients and Methods A retrospective chart review from June 2008 to February 2012
of patients with infected groin wounds after vascular surgeries was included. There
were six patients with previous history of femoral cannulation or extracorporeal
membrane oxygenation (ECMO), one patient with femorofemoral bypass, one patient
with intra-aortic balloon pump (IABP), and one case with thoraco-abdominal
aneurysm post stent implantation. Exposure of femoral vessels was noted in seven
patients, and all wound cultures of nine patients showed positive findings.
Results The mean age of the nine patients (five males; four females) was 54.6 years
(range: 17 to 79). The mean follow-up was 13.56 months (range: 8 to 30 months).
Four patients received a pedicled gracilis flap; one received a local flap; one received
anterolateral thigh myocutaneous flap combined with partial tensor fascia lata (ALT
myocutaneous flap with TFL); one received primary closure; and two received
pedicled island anterolateral thigh myocutaneous flap (ALT myocutaneous flap). No
donor site complications were noted. There was partial skin cyanosis in ALT
myocutaneous flap with TFL case, which was alleviated one week later. In the regular
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follow-up, all the groin wounds healed well.
Conclusions Pedicled gracilis muscle flap is an ideal and effective option to cover
infected groin wounds of less than 10 cm with exposure of femoral vessels. According
to the literature review, sartorius muscle flap is another choice. Island ALT
myocutaneous flap is indicated for infected groin wounds larger than 10 cm with
exposure of femoral vessels. After reviewing the related literature, rectus abdominis
(RA) myocutaneous and rectus femoris (RF) muscle flaps are also suitable for groin
wounds larger than 10 cm. For bilateral groin wound reconstruction, bilateral ALT,
RA myocutaneous or RF muscle flaps are suggested. For infected groin wounds
without exposure of femoral vessels, local flap or primary closure are suggested
depending on the size of the defect.
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Introduction:
Management of infected groin wounds due to complications of vascular surgery,
malignant tumor excision, and irradiation therapy for recurrent cancers is a
considerable challenge to surgeons because while wound debridement is necessary,
this may be inadequate due to the difficulty in eradicating or excising infected tissue
completely around the vessel. Therefore, flap with abundant blood supply is suitable
for these kinds of wounds. Multiple case reports and experience with various flaps
including tensor fascia lata [1], anterolateral thigh [2], gracilis [3], sartorius [4-5],
rectus femoris [6] and rectus abdominis [7] have been presented with differing success
rates for complex groin wound management. In addition, more and more evidence has
shown local/regional muscle flaps supply good coverage for these nonhealing or
infected wounds because of the high infection resistance of the muscle flaps [8-9]. In
this study, we present our experience and set up an algorithm for the management of
infected groin defects after vascular surgery according to our experience and other
related literature.
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Patients and Methods
We reviewed charts from June 2008 to February 2012 by a retrospective method.
Nine patients (5 males, 4 females) with infected groin wounds who had undergone
reconstruction were included. The ages ranged from 17 to 79 years (54.5 years of age
on average). The mean follow-up was 13.56 months (range: 8 to 30 months). All groin
wounds had resulted from various vascular surgery, including CABG (coronary artery
bypass graft) surgery, ECMO (extracorporeal membrane oxygenation) implantation,
aneurysm bypass or stent implantation. Three of nine patients had undergone vascular
grafts (ePTFE 【expanded polytetrafluoroethylene】, vein graft or Endurant stent).
Wound cultures during operation showed positive findings in all cases. Of these nine
patients, six had a right groin wound; one patient had a left groin one; and the other
two had bilateral groin wounds. Femoral vessels exposure was found in seven cases.
Patient details are shown in Table 1.
Case reports
Case 1
A 28-year-old male was a case of tuberculosis-induced constrictive pericarditis
followed by pericardiectomy and ECMO insertion. Active bleeding over groin wound
with a pseudoaneurysm was noted four days after removal of ECMO. Emergent
operation with interposition of vein graft was performed. Four days later, wound
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dehiscence with exposure of vein graft was noted. Wound culture data showed
Escherichia coli. After debridement, local gracilis muscle flap was designed and
transposed for vessel coverage based on the medial circumflex femoral artery system.
Split-thickness skin graft (STSG) was harvested later for muscle surfacing. The donor
site was closed with a Jackson-Pratt drain insertion. The flap survived completely and
the wound healed uneventfully by the follow-up ten months later. (Fig. 1)
Case 2
A 79-year-old male was a case of left common iliac aneurysm followed by Endurant
bifurcated stent implantation. Due to difficulties in cannulating the contralateral limb
antegradely or retrogradely, Aorto-Uni-Iliac (AUI) stent graft was implanted followed
by femoro-femoral bypass (8mm ring PTFE) from the left to right side. Ischemic
bowel syndrome happened later treated by exploratory laparotomy with resection of
necrotic intestine. The lower abdominal wound with fascia defect was covered
temporarily with a Bogota bag. Non-healing wounds with exposure of femoral vessels
were noted over bilateral groin area. Culture of bilateral groin wounds showed
Proteus mirabilis, Enterococcus faecalis, and Acinetobacter baumannii. After
adequate debridements with graft preservation, anterolateral thigh myocutaneous flap
combined with partial tensor fascia lata (ALT myocutaneous flap with TFL) based on
the descending and transverse branch of lateral circumflex femoral artery was
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harvested from left thigh for bilateral groin wound coverage and lower abdominal
fascia reconstruction at the same time. The residual skin defect at the abdominal wall
was covered with split thickness skin graft. Cyanosis of the flap margin was noted
after operation but resolved one week later. At the fourteen months follow-up, no
complication was noted of either bilateral groin wounds or lower abdomen wound.
(Fig. 2)
Results
Of the nine patients, one patient underwent primary wound closure; one patient
underwent reconstruction with local flap; four patients underwent reconstruction with
pedicled gracilis muscle flaps followed by skin graft; two patients underwent ALT
myocutaneous flaps; and the other underwent reconstruction by ALT myocutaneous
flap with TFL. No donor site complications were noted. Partial skin cyanosis was
noted in the ALT myocutaneous flap with TFL case. The cyanotic skin alleviated one
week later. The vascular grafts in three patients were preserved. In regular follow-up,
all wounds completely healed. The outcomes are shown in Table 2.
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Discussion
Reconstruction of infected groin wounds after vascular surgery presents a challenge
to surgeons. The gold standard treatments are radical debridement, extra-anatomical
bypass or graft removal. However, extra-anatomical bypass or graft removal creates
further suffering for patients who must undergo an additional surgery. Therefore,
adequate debridement, better wound care, nutrition support and flap coverage can lead
to a better outcome.
The vacuum-assisted closure (VAC) system is considered not only a less invasive
way but also an alternative not to harvest the muscle flap. Pinocy et al. found the
positive findings of wound culture shifted from one hundred percent on day 0 to
twenty-five percent and zero on day 7 and day 14 respectively after VAC system usage,
while at the same time, the histological results demonstrated progressive granulation
tissue growth which matched its clinical findings [10]. Similar results have been
demonstrated in another study [11]. Although a VAC system is widely suggested, we
consider it is appropriate for groin wounds without femoral vessels exposure and
debridement is still necessary when the wound bed is not clear. The VAC system
might have the risk of bleeding when the vessels are exposed. For infected groin
wounds with exposure of femoral vessels, muscle or myocutaneous flaps provide not
only better infection resistance but also better vessel protection. Flaps also shorten the
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duration of hospitalization.
For wounds without femoral vessels exposure, primary closure is suggested when
the wound is smaller than 3 cm and the wound tension is not high. If the wound bed is
not clear, the VAC system would be used temporarily with or without debridement for
delayed primary closure. For groin wounds with higher tension or wound widths
larger than 3 cm, fasciocutaneous flap or local flap may be considered. Of our patients,
one case received primary closure and one case received local flap respectively
according to their defect size.
Of our patients, four underwent groin wound reconstruction with a pedicled gracilis
muscle flap followed by skin graft. Gracilis muscle flap has a type II vascular pattern
(one dominant and one minor pedicle) originating from the medial circumflex femoral
artery. Indications for gracilis muscle flap include obliteration of soft tissue defect [12],
coverage of bone or vessel exposure [13] and recovery of missing or diminished
functions [14]. For a groin defect with gracilis muscle flap reconstruction, several
studies have shown satisfactory results. Morasch et al. suggested that pedicled gracilis
muscle flaps transposition is an effective option to cover infected or exposed femoral
vessels or salvage of prosthetic graft material in the groin [3]. However, there are some
controversial points for the use of gracilis in groin wounds, including limited pedicle
length (may limit flap rotation), inadequate volume for soft tissue obliteration, and a
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two-stage operation (inadequate skin perforator). Hussey’s study showed the mean
entry point of the dominant arterial pedicle is 9.4 cm, with mean length and width of the
muscle recorded as 38.4 cm and 6.2 cm respectively, which suggests that the gracilis
muscle flap can supply adequate length and volume for groin defect reconstruction
less than 10 cm in width [15]. Because of unreliable skin paddle of gracilis
myocutaneous flap, gracilis muscle flap followed by skin graft is suggested to solve
this problem. In our four patients reconstructed with gracilis muscle flaps, good
coverage without complications was found at thirteen months follow-up.
TFL is class I flap with one dominant pedicle originating from ascending branch
of lateral circumflex femoral artery. The longer pedicle (10 ~ 20 cm) and bulky volume
(15 cm x 40 cm) make this flap reliable for obliteration of a large defect. In a case with
groin and urogenital defect, the TFL was used as a myocutaneous flap for groin defect,
and fascia extended as grafting for neourethra reconstruction [16]. For similar groin
defect resulting from dissection of malignant inguinal lymphadenopathy, TFL supplied
good wound coverage [1]. Due to its characteristics, TFL with or without vastus
lateralis (VL) muscle is suggested for groin wound with lower abdominal wall fascia
defect.
The ALT flap usually has a pedicle derived from the descending branch of the lateral
circumflex femoral artery. For groin defects, the ALT flap has many advantages: large
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rotation arc, minimal donor site morbidity and less functional muscle loss. Evriviades
et al. demonstrated a good result by using the ALT perforator flap for groin defect
resulting from dissection of malignant inguinal lymphadenopathy [2]. According to
our experience, in cases with infected groin wound and exposure of femoral vessels,
ALT myocutaneous flap was preferable for the reconstruction of groin wounds larger
than 10 cm. Although the outcome of bilateral groin wounds with fascia defect case
(reconstructed by ALT myocutaneous flap with TFL) was satisfactory, the distal end
of the flap may be subject to cyanosis. Therefore, we suggest the use of bilateral ALT
myocutaneous flaps for bilateral groin wound reconstruction.
Other choices, such as the rectus abdominis myocutaneous (RAM) flap, have been
reported. The RAM flap is supplied by two pedicles, the deep superior epigastric and
deep inferior epigastric arteries. By different requirements, this flap could be designed
for various skin paddles: vertical, periumbilical axial and transverse. The use of
contralateral RAM flap for groin defect reconstruction with good outcome has also
been reported. Qi et al. reported contralateral RAM flap for infected groin defect
resulting from vascular surgery, lymph node dissection and scar revision [17]. Khainga
also reported a case with contralateral RAM flap for groin defect due to a failed left
femoral aneurysm bypass procedure [18]. Ipsilateral RAM flaps for groin
reconstruction in few cases were also reported [19]. Therefore, RAM flap is a
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candidate for large groin defect reconstruction (>10 cm in width). No matter whether
RAM flaps are ipsilateral or contralateral, there is a risk of decreased abdominal
strength and possibility of ventral hernia.
According to previous studies, sartorius [20] and rectus femoris[6] muscle flaps
were choices for infected groin wound reconstruction. Rectus femoris muscle flap is
suggested for large groin defect reconstruction (>10 cm in width) although decreased
knee extensor strength was suspected. However, Gardetto et al. suggested that there
was no difference between the donor leg and the nonoperative leg [21]. The sartorius
muscle flap has several advantages: it is immediately adjacent to the groin; it is easy
to prepare; and the harvest causes minimal functional morbidity. However, due to
segmental blood supply (type IV) of the sartorius muscle, it is difficult to harvest long
sartorius muscle. Preservation of the proximal pedicle of the sartorius muscle makes
the rotation arc limited [22]. Therefore, sartorius muscle flap is suitable for small
groin defect reconstruction (<10 cm in width).
In summary, management of infected groin wound without femoral vessels
exposure is suggested to be achieved by primary closure or local flap (primary closure
for wound < 3cm in width; local flap for wound >3cm in width). VAC with or without
debridement is suggested as an alternative method in the unclear wound bed without
vessel exposure. For single groin wound with femoral vessels exposure, gracilis or
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sartorius muscle flap followed by STSG are suggested for wounds <10 cm in width,
while ALT myocutaneous, RA myocutaneous, or RF muscle flaps are suggested for
wounds >10 cm in width. TFL with or without VL is suggested for cases with both
groin wound and lower abdominal fascia defect. For bilateral groin wounds with
femoral vessel exposure, bilateral ALT, RA myocutaneous, or RF muscle flaps are
more reliable with a lower morbidity rate. The ALT myocutaneous flap with TFL for
simultaneous reconstruction of bilateral groin wounds and abdominal fascia defect is
not the first choice even though the outcome is satisfactory. The algorithm for
reconstruction of infected groin wounds after vascular surgery is shown in Figure 3.
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Address correspondence to:
Hsin-Han Chen
Division of Plastic Surgery, China Medical University Hospital
2 Yuh Der Road, Taichung City, 404, Taiwan
Tel.: (886)-4-22052121 ext. 1638; Fax: (886)-4-22029083
E-mail: scapulachenhh@yahoo.com.tw
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