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An Evidence-Based Approach to Complex Groin Wounds: Optimizing Flap Selection in Salvage and Prophylactic Muscle Flaps
John P. Fischer, MD, Michael N. Mirzabeigi, MS, Jonas A. Nelson, MD, Edward Y. Woo, MD, Stephen J. Kovach, MD, Liza C. Wu, MD, Joseph M. Serletti, MD, Suhail Kanchwala, MD.
Hospital of the Univesity of Pennsylvania, Philadelphia, PA, USA.
PURPOSE: Groin wound complications after vascular surgery procedures are common, morbid, and extremely costly. Our institution has experienced success with aggressive debridement and muscle flap coverage using the sartorius muscle flap (SMF) and rectus femoris (RF). To further reduce complications, these muscle flaps are used prophylactically (PMF) at the initial groin procedure in high-risk patients. The purpose of this study is to assess the clinical outcomes of a large patient cohort with complex groin wounds.
METHODS: A retrospective review of patients undergoing open, groin vascular surgery between 2005 and 2010 was performed. Patients receiving prophylactic muscle flaps were compared to those patients not receiving a flap (control), and a separate review of all patients receiving a salvage muscle flap was performed. Significant variables predicting complications from the control cohort were used to derive a risk scoring system. A separate outcomes assessment and analysis were performed based on wound etiology.
RESULTS: We compared 53 patients receiving PMFs to 178 control patients. Prophylactic flaps independently and significantly reduced groin wound complications (OR=0.17, p<0.001). Regression analysis demonstrated that obesity (OR=2.1, p=0.05), smoking (OR=2.7, p=0.004), re-operation (OR=3.5, p=0.007), and prosthetic graft reconstruction (OR=2.0, p=0.04) were associated with increased complications. These variables were used to construct the Penn Groin Assessment Scale (PGAS) (Table 1). A PGAS greater than 3 represents a significant threshold for complications and secondary salvage flaps (p<0.001). Overall, groin wound complications add \,677 each and using the PGAS our institutional savings approached \k.
We separately analyzed 175 consecutive flaps for complex groin wound coverage, including flaps for: draining seroma/lymphocele (43), infected wound (54), hematoma/pseudoaneurysm (10), and prophylactic coverage following vascular graft (68). Flap selection was based on timing of reconstruction, wound etiology, and defect size. Recurrent infection rate for groin infections was 3.8% for the RF versus 26.1% for all other flaps (p = 0.03). In a subgroup analysis comparing the RF and SMF, recurrent infection rates were 3.8% versus 19% (p = 0.12), respectively.
CONCLUSIONS: We present a large, evidence-based analysis of muscle flaps for managing complex groin wounds. PMFs are safe, efficacious, and reduce complications and costs in high-risk patients. The SMF is an ideal flap for prophylaxis due to its proximity, effectiveness, and low morbidity, whereas the RF is optimal for large, complicated, infected wounds given its size and robust blood supply. In our study, groin wound complications were morbid and costly, occurring at rates up to 77% and adding costs of \.1M. We present the Penn Groin Assessment Scale (PGAS), which is a sensitive tool able to predict complications. We also propose an evidence-based, algorithmic approach to the complex groin wound (Figure 1). Overall, tailoring muscle flaps based on patient risk assessment, wound size, and etiology optimize outcome.
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