Reply to “Management of Infected Groin Wounds after Vascular Surgery”

To the Editor:

We congratulate Shih et al. for their manuscript entitled, “Management of Infected Groin Wounds after Vascular Surgery” [1]. In this work, the authors describe their retrospective review of nine patients who underwent groin reconstruction for wound complications following vascular surgery and suggest a potential algorithm for management of such wounds. Included in this series were two patients who received prosthetic stents and/or grafts and one patient who received a (presumably autogenous) vein graft, all of which were salvaged following reconstruction. Of the nine patients included, seven underwent reconstruction with pedicled gracilis, anterolateral thigh (ALT), or ALT/tensor fascia lata (TFL) flaps.

In previous work, we have reported our experience with muscle transposition flaps for groin wound reconstruction following lower extremity revascularization [2]. In our series, 29 flaps were performed in 24 patients, 19 of whom had a groin wound infection. Sartorius flaps were utilized in 21 patients, rectus femoris flaps in six patients, and gracilis flaps in two patients. Muscle transposition flaps were performed prophylactically (i.e., in the absence of infection) in seven patients who were deemed to be at high-risk for wound healing complications. Following reconstruction in the setting of infection, graft salvage rates were 92% for synthetic graft and 100% for autogenous graft.

Contrary to the views expressed by Shih et al., we believe the sartorius muscle to be the ideal selection for reconstruction of small groin wounds due to its ease of harvest, proximity to the groin (i.e., its presence in the surgical field), and lack of donor site morbidity following transposition. It was for these reasons that 21 of the 29 flaps performed in our series were of this type [2]. Similarly, in the recent large retrospective review by Fischer et al. [3] of 244 flaps performed for management of complex groin wounds (either prophylaxis or salvage), 132 flaps included in this series were sartorius muscle flaps. Because of the minimal donor site morbidity, this flap has been increasingly used prophylactically in patients at high risk for infection during open revascularization via the groin [2, 3].

In further contrast to the present group, although the gracilis muscle can at times provide adequate soft tissue coverage, we believe that its limitations, including the non-trivial donor site morbidity it produces, the additional incision required for harvest, and its small size, reduce its utility in this setting.

Absent in the series by Shih et al. were rectus femoris flaps [1]. The rectus femoris flap has several advantages, including muscle bulk and robust vascular supply [3, 4]. We prefer this flap for larger groin wounds, where a sizeable volume of soft tissue coverage is required. In addition, Fischer et al. reported that in their series, when compared with the sartorius flap, the rectus femoris flap was associated with decreased rates of major limb-related complications and overall graft loss [3]. Although once believed to decrease knee extensor function by its harvest, multiple groups have demonstrated that transfer of the rectus femoris muscle does not result in any relevant functional defect [5, 6].

Lastly, we believe the ALT is a suboptimal choice for groin wound reconstruction. Although large in surface area, this flap requires substantially more time to elevate compared with either a sartorius or rectus femoris flap, both of which may be dissected rapidly. Furthermore, split-thickness skin grafting may be required for donor site closure of the ALT.

In conclusion, Shih et al. have performed a relatively limited review of their experience with reconstruction of infected groin wounds [1]. Their work underscores the need for further studies to clearly delineate the optimal therapeutic approach to wound complications in this challenging anatomic region.