Use of Muscle Flaps for Salvage of Groin Wound Infection Following Vascular Surgery: A Systematic Review and Meta-Analysis

Abstract

Background

Groin wound infections in vascular surgery are still a common complication and challenging problem. This systematic review aimed to establish a complete view of patient characteristics and clinical outcomes for infected groin wounds following vascular surgery reconstruction using muscle flaps and to evaluate the differences in outcomes between the sartorius muscle flap (SMF), rectus femoris muscle flap (RFF), and gracilis muscle flap (GMF).

Methods

PubMed, Scopus, and Web of Science were systematically searched from inception to April 2021. Random-effects meta-analysis for comorbidities and outcomes and subgroup analyses for outcomes were performed.

Results

Thirty studies were included in qualitative and quantitative syntheses. Overall pooled data showed the following outcome rates: 4.5% muscle flap necrosis (95% confidence interval [CI], −3.4–12.3%; I² = 0%), 21.8% overall complications (95% CI, 15.8–27.7%; I² = 0%), 8.0% limb loss (95% CI, 1.9–14.1%; I² = 0%), 15.4% graft loss (95% CI, 5.0–25.3%; I² = 37.9%), and 7.4% 30-day mortality (95% CI, −.9–15.6%; I² = 0%). The rates of overall complications were 20.3% (95% CI, 12.1–28.2%; I² = 0%), 23.2% (95% CI, 11.2–34.5%; I² = 10.2%), and 18.0% (95% CI, −3.537.8%; I² = 0%) for the SMF, RFF, and GMF, respectively. The rate of limb loss was highest for the GMF (17.2%; 95% CI, −4.237.2%; I² = 0%). The rate of graft loss for the RFF was the highest (20.7%; 95% CI, .6–39.1%; I² = 53.9%). The rate of 30-day mortality was the lowest for the SMF (5.3%; 95% CI, −6.1–16.6%; I² = 0%).

Conclusions

The effectiveness and safety of muscle flap reconstruction for infected groin wounds following vascular surgery are clearly positive. This review indicated a tendency for lower complication rates with the SMF than with other muscle flaps.

Keywords

groin wound infection prosthetic graft infection sartorius muscle flap rectus femoris muscle flap gracilis muscle flap

Introduction

The groin is the most common region of wound infections following various vascular surgeries. The incidence of these groin infections ranges from 17% to 44%.^1,2 Infections involving vascular grafts lead to an increased risk of lower limb amputation and mortality due to septicemia, and they represent the most challenging problem in managing infected groin wounds to avoid limb-threatening and life-threatening conditions. Since the 1960s, traditional treatments for this problem have been the administration of systemic antibiotics, infected graft excision, and revascularization with an extra-anatomic bypass.³ Despite these procedures, amputation and mortality rates have been reported to range from 9% to 52% and 9% to 36%, respectively.^4,5 Although graft infection often resulted in devastating incidents for patients, the use of muscle flaps drastically changed this problem in a favorable way. In 1980, Fernandez et al⁶ first reported 2 successful cases in which an infected groin wound-exposed prosthetic graft was covered by a sartorius muscle flap (SMF). In 1989, Mixter et al⁷ were the first to report use of the rectus femoris muscle flap (RFF) for infected vascular grafts in the groin. Several muscle flaps other than the SMF and RFF have also been described for this purpose, including the gracilis muscle flap (GMF), rectus abdominus muscle flap, and tensor fascia lata flap.³ The mainstay of treating this problem has increasingly varied from traditional treatments to the use of muscle flaps. The SMF and RFF are the most commonly used muscle flaps; however, the GMF has recently become a commonplace option, and other muscle flaps are reported to be used significantly less than the aforementioned 3 muscle flaps. As stated earlier, the recent trend in this topic is the use of 3 muscle flaps, each with its own advantages and disadvantages: the SMF, RFF, and GMF.

To date, Wubbeke et al⁸ have reported a systematic review comparing SMF and RFF reconstruction for infected groin wounds after vascular surgery, and they found no significant difference in amputation or mortality rates between both muscle flaps. On the assumption that the outcomes from the reconstruction are slightly different between muscle flaps, it is difficult to grasp a complete view of this topic because the outcomes of any muscle flap were lacking in this systematic review. Furthermore, there is uncertainty regarding the effectiveness of the GMF compared with the SMF and RFF, and the overall complications, including donor-site complications, remain unknown. Because groin wound infections in vascular surgery are still a common complication and challenging problem, it is important to fill the aforementioned data gap to maximize clinical practice. Therefore, this systematic review aimed to establish a complete view of patient characteristics and clinical outcomes in the reconstruction of infected groin wounds following vascular surgery, and to evaluate the differences in outcomes between the 3 muscle flaps.

Methods

This systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines.⁹

Search Methods

An initial electronic search was performed using PubMed, SCOPUS, and Web of Science to identify relevant articles from inception to April 2021, referring to a previous systematic review.⁸ The following search terms were used: [“groin infection”] AND [“vascular graft” OR “wound” OR “prosthetic graft”] AND [“muscle flap” OR “sartorius muscle” OR “rectus femoris muscle” OR “gracilis muscle” OR “myoplasty”]. The reference lists of the retrieved articles were also screened for relevant articles that were not identified in the primary search. This search was independently performed by 2 separate authors (K.S. and H.K.).

Inclusion and Exclusion Criteria

All resulting articles were screened, and articles reporting on 3 muscle flaps (the SMF, RFF, and GMF) for salvage of groin wound infection following vascular surgery that mentioned the comorbidities and outcomes described in the following section were included. The exclusion criteria were as follows: (1) duplicate titles, non-English articles, review articles, case series with < 5 patients and/or < 5 muscle flaps that were most commonly used, case reports, and other forms of publications (e.g., letters, commentaries, editorials, and opinions); (2) articles reporting on other muscle flaps or combined muscle flaps or those that did not differentiate between the 3 muscle flaps regarding clinical outcomes; (3) articles reporting on groin reconstruction not associated with wound infection following vascular surgery or those that did not differentiate the groin from other regions regarding clinical outcomes; and (4) articles presenting incomplete information. Only the most recent study with the largest sample was selected when studies were published by the same author with overlapping patients.

Data Collection and Quality Assessment

The following variables were extracted from the included studies by 2 independent authors (K.S. and H.K.): the publication year, number of patients, number of classified flaps (sartorius muscle flap (SMF), rectus femoris muscle flap (RFF), or gracilis muscle flap (GMF)), preoperative characteristics (e.g.,, proportion of prosthetic material), comorbidities (coronary artery disease (CAD), peripheral artery disease (PAD), dyslipidemia, diabetes, obesity, smoking, chronic kidney disease (CKD), and history of groin surgery), outcomes (muscle flap necrosis, overall complications, limb loss, graft loss, and 30-day mortality), and follow-up duration in months. Overall complications were defined as groin wound and donor-site complications, including muscle flap necrosis but exclusive of limb loss, graft loss, and 30-day mortality. Two independent authors (K.S. and H.K.) assessed the study design and the risk of bias (RoB). To evaluate methodological quality, we used 7 item-based Risk of Bias in Non-randomized Studies of Interventions risk-of-bias assessment tool.¹⁰ Disagreements were resolved by consulting a third independent author (I.K.).

Meta-Analysis and Statistical Analysis

We performed separate meta-analyses of patients whose groin wound infection following vascular surgery was repaired with the following 3 muscle flaps: the SMF, RFF, and GMF. However, studies that met the following criteria were not synthesized: < 4 classified muscle flaps and the presence of a serious and critical risk of bias. Furthermore, we performed a meta-analysis of the total muscle flaps to obtain a complete view of this topic. The pooled outcome proportions and confidence intervals (Cis) were calculated based on the random-effects model, without comparing the 3 methods in an actual meta-analysis. Statistical heterogeneity was evaluated using the I² statistic: I² values < 25%, no heterogeneity; I² values = 25–50%, low heterogeneity; I² values = 50–75%, moderate heterogeneity; and I² values > 75%, significant heterogeneity. Statistical significance was set at P < .05. Analyses were performed using the meta package in R version 3.6.2 (The R Foundation for Statistical Computing, Vienna, Austria).

Results

Study Characteristics

In total, 1210 articles were identified in our search using the selected terms and inclusion criteria. We compiled these data with 17 articles from a previous systematic review.⁸ After duplicate removal, 71 titles were identified, and a further manual search of references of relevant articles revealed 3 more articles. Seventy-four abstracts were reviewed, and 18 articles were excluded. The full texts of the 56 articles were reviewed, and 30 articles comprising 1167 patients with 1207 muscle flaps were included in the qualitative and quantitative syntheses (Figure 1).^7,11-39 Overall, the included studies were non-randomized, consisting of 29 retrospective cohort studies and 1 case series. The study characteristics and quality assessments are summarized in Supplementary Table S1. Of all the included studies for which the RoB was analyzed, 4 studies were considered to have a low RoB, while 26 studies were considered to have a moderate RoB. Grading of Recommendations, Assessment, Development and Evaluations assessments were low for selected studies in this systematic review because of the study design, as aforementioned. The SMF was the most commonly used flap and was reported in 24 studies comprising 730 muscle flaps (60.5%). RFF reconstruction was described in 11 studies of 382 muscle flaps (31.6%), while the GMF was the least commonly used flap and reported in 5 studies comprising 95 muscle flaps (7.9%). Twenty-two studies reported outcomes of only single muscle flap reconstruction, and 8 studies reported outcomes of 2 or more muscle flaps of interventions. Other muscle flaps were used for reconstruction in 6 studies (n = 21), and they were excluded from the present analysis.

Figure 1.

Preferred Reporting Items for Systematic Reviews and Meta-analyses flow diagram of the process for selecting articles for the systematic review.

Patient Characteristics

A summary of the preoperative characteristics and comorbidities of the included studies is provided in Supplementary Table S2. Although 3 studies did not describe the type of graft material, 783 wounds contained prosthetic material (67.9%). Eight studies did not state the microbiology findings and were differentiated from the data; however, 622 wounds were found to be positive for microbiology (65.1%). The indication for muscle flaps was specified as only infection in 23 studies, while 7 studies described signs of infection such as lymphoceles and seromas. The degrees of infection were described as Szilagyi III infections in 14 studies, Szilagyi I–III infections in 2 studies, and unknown in 14 studies. The Szilagyi grading system was classified as follows: grade I infections had only dermal involvement, grade II infections extended into the subcutaneous region but did not invade the arterial implant, and grade III infections involved the arterial graft4. Overall pooled data showed the following comorbidity rates: 54.0% (95% CI, 45.7–61.4%; I² = 49.2%), CAD; 69.8% (95% CI, 61.676.6%; I² = 49.9%), PAD; 59.0% (95% CI, 43.4–71.1%; I² = 81.7%), dyslipidemia; 42.9% (95% CI and I² were not calculated), diabetes; 38.9% (95% CI, 31.7–45.6%; I² = 0%), obesity; 60.5% (95% CI and I² were not calculated), smoking; 20.3% (95% CI, 13.2–27.2%; I² = 0%), CKD; and 69.5% (95% CI, 25.3–89.7%; I² = 97.5%), history of groin surgery. Obesity and CKD showed no heterogeneity, CAD and PAD showed low heterogeneity, dyslipidemia and history of groin surgery showed significant heterogeneity, and the heterogeneities of diabetes and smoking were not calculated (Table 1).

Table 1.

Pooled analysis of comorbidities.

Comorbidity	Number of Available Studies	Number of Available Patients	Rate, %	95% CI	Heterogeneity
Comorbidity	Number of Available Studies	Number of Available Patients	Rate, %	95% CI	P	I ²
CAD	17	891	54.0	45.7-61.4%	.01	49.2
PAD	6	494	69.8	61.6-76.6%	.08	49.9
Dyslipidemia	8	624	59.0	43.4-71.1%	< .0001	81.7
Diabetes	19	970	42.9	*	*	*
Obesity	7	592	38.9	31.7-45.6%	.87	0
Smoking	13	843	60.5	*	*	*
CKD	13	756	20.3	13.2-27.2%	.93	0
History of groin surgery	8	530	69.5	25.3-89.7%	< .0001	97.5

CAD, coronary artery disease; PAD, peripheral artery disease; CKD, chronic kidney disease.

*Not calculated.

Outcomes

Each study outcome is provided in Supplementary Tables S3 and S4, and the pooled outcomes are shown in Table 2. No comparative statistical analysis was performed because only 2 studies directly compared the 3 muscle flap groups.

Table 2.

Pooled analysis of clinical outcomes.

		Number of Available Studies	Number of Available Flaps	Rate, %	95% CI	Heterogeneity
		Number of Available Studies	Number of Available Flaps	Rate, %	95% CI	P	I ²
Muscle flap necrosis	SMF	17	449	3.4	−6.5-13.1%	1.0	0
	RFF	4	141	7.5	−9.7-24.3%	.96	0
	GMF	2	88	5.6	−15.9-26.6%	.84	0
	Any MF	20	679	4.5	−3.4-12.3%	1.0	0
Overall complications	SMF	18	597	20.3	12.1-28.2%	.89	0
	RFF	7	323	23.2	11.2-34.5%	.35	10.2
	GMF	2	88	18.0	−3.5-37.8%	.55	0
	Any MF	24	1050	21.8	15.8-27.7%	.82	0
Limb loss	SMF	19	612	6.0	−2.3-14.3%	1.0	0
	RFF	10	369	7.4	−3.2-17.9%	1.0	0
	GMF	2	88	17.2	−4.2-37.2%	.73	0
	Any MF	26	1095	8.0	1.9-14.1%	1.0	0
Graft loss	SMF	16	398	12.0	1.6-22.2%	.82	0
	RFF	9	310	20.7	.6-39.1%	.027	53.9
	GMF	2	88	9.1	−12.5-29.8%	.96	0
	Any MF	21	800	15.4	5.0-25.3%	.04	37.9
30-day mortality	SMF	17	332	5.3	−6.1-16.6%	1.0	0
	RFF	7	183	10.0	−5.4-24.9%	1.0	0
	GMF	2	88	10.5	−11.1-31.1%	.63	0
	Any MF	18	607	7.4	−.9-15.6%	1.0	0

SMF, sartorius muscle flap; RFF, rectus femoris muscle flap; GMF, gracilis muscle flap; MF, muscle flaps.

Muscle Flap Necrosis

The rate of muscle flap necrosis for any muscle flap was described in 20 studies, and was 4.5% (95% CI, 3.2-33.3%; I² = 0%). The rate of muscle flap necrosis was the lowest for the SMF (3.4%; 95% CI, -6.513.1%; I² = 0%) and the highest for the RFF (7.5%; 95% CI, -9.7-24.3%; I² = 0%). However, these analyses showed no heterogeneity.

Overall Complications

The rate of overall complications for any muscle flap was described in 24 studies, and was 21.8% (95% CI, 15.8–27.7%; I² = 0%). The rates of overall complications were 20.3% (95% CI, 12.1–28.2%; I² = 0%), 23.2% (95% CI, 11.2–34.5%; I² = 10.2%), and 18.0% (95% CI, −3.537.8%; I² = 0%) for the SMF, RFF, and GMF, respectively. However, these analyses showed no heterogeneity.

Limb Loss

The rate of limb loss for any muscle flap was described in 26 studies, and was 8.0% (95% CI, 1.9-14.1%; I² = 0%). The rate of limb loss was highest for the GMF (17.2%; 95% CI, −4.237.2%; I² = 0%), whereas it was equally low for the SMF (6.0%; 95% CI, −2.3–14.3%; I² = 0%) and RFF (7.4%; 95% CI, −3.2–17.9%; I² = 0%). However, these analyses showed no heterogeneity.

Graft Loss

The rate of graft loss for any muscle flaps was described in 21 studies, and showed 15.4% (95% CI, 5.0–25.3%; I² = 37.9%) and low heterogeneity. The rate of graft loss for the RFF was the highest (20.7%; 95% CI, .6–39.1%; I² = 53.9%) and showed moderate heterogeneity, while that of the SMF (12.0%; 95% CI, 1.622.2%; I² = 0%) and GMF (9.1%, 95% CI, −12.529.8%; I² = 0%) showed no heterogeneity.

Thirty-Day Mortality

The 30-day mortality rate for any muscle flap was described in 18 studies, and was 7.4% (95% CI, −.9–15.6%; I² = 0%). The rate of 30-day mortality was the lowest for the SMF (5.3%; 95% CI, −6.1–16.6%; I² = 0%), followed by 10.0% for the RFF (95% CI, −5.4–24.9%; I² = 0%) and 10.5% for the GMF (95% CI, −11.1–31.1%; I² = 0%). However, these analyses showed no heterogeneity.

Discussion

The use of muscle flaps is a common treatment for infected groin wounds following vascular surgery. In the present systematic review, we established the complete view of patient characteristics and clinical outcomes in the reconstruction of infected groin wounds following vascular surgery and compared the outcomes of the SMF, RFF, and GMF.

View of Patient Characteristics and Outcomes

Although more than half of the patients had a history of CAD, PAD, dyslipidemia, smoking, and groin surgery, the data were unreliable for a history of dyslipidemia, smoking, and groin surgery because of significant or unknown heterogeneity. We revealed the comorbidities complicating this problem, but we could not demonstrate which comorbidity was the most influential on clinical outcomes. Mirzabeigi et al reported that CAD, dyslipidemia, and diabetes are associated with postoperative complications after reconstruction.³⁶ However, Ryu et al³⁵ showed no higher complication rates than other studies despite a rate of 100% for diabetes, and Seify et al²⁴ showed the highest limb loss (36.4%) despite low rates of dyslipidemia (22.7%) and diabetes (31.8%). Therefore, it is difficult to demonstrate which comorbidity had the most impact on postoperative complications because multiple factors, including comorbidities, affect postoperative complications. The current amputation rate has made a remarkable improvement compared with the amputation rate associated with traditional treatments, as previously mentioned (9–52%).^4,5 Although the current long-term mortality rates can be improved compared with those associated with traditional treatments, we could only reveal the 30-day mortality rate. The overall complication rate was relatively high, and the overall complications consisted mostly of recurrent groin infections in studies with higher overall complication rates.^{13,15,19,24,36,39} In particular, Taylor et al¹⁵ reported the highest overall complication rate (71.4%). The proportion of donor-site complications was reported in a few included studies: Fischer et al, Nelson et al, and Wübbeke et al reported donor-site complications of 7.5%, 7.0%, and almost 0%, respectively.^29,30,39 Thus, the benefits of muscle flap reconstruction overwhelmingly outweigh the disadvantages because donor-site complications and muscle flap necrosis rates are very low; nevertheless, recurrent groin infection may be a challenge to overcome.

Differences between the sartorius muscle flap, rectus femoris muscle flap, and gracilis muscle flap

The SMF was the most commonly used flap; the RFF was the second most commonly used flap, and the GMF was the least commonly used flap. The reason for using a familiar flap is thought to depend on the length of its history. Indeed, the SMF is a well-established technique for treating infected groin wounds following vascular surgery, and it can be easily used because it is located directly adjacent to the groin wound.³ In contrast, the RFF and GMF have more muscle bulk than the SMF, and they require an additional thigh incision to harvest; in particular, the RFF provides most muscle bulk with a wide arc of rotation that can easily reach the groin wound.^3,40 Although many potential advantages and disadvantages have been reported for these 3 muscle flaps, the superiority of either muscle flap has not been established. Indeed, no significant difference in clinical outcomes between the SMF and RFF has been reported in previous systematic reviews and other studies.^8,29,36,39 Based on the aforementioned outcomes, the SMF seems to be the safest flap because of the low rates of muscle flap necrosis, limb loss, and 30-day mortality. In contrast, the RFF seems to be the most risky flap because it has the highest rates of muscle flap necrosis, overall complications, and graft loss. Indeed, Mirzabeigi et al mentioned that the SMF should be used as a first-line reconstruction approach because it requires a less invasive procedure.³⁶ However, it is difficult to determine which muscle flap is the safest because these rates cannot be used to make a statistical comparison. In some studies, the SMF was recommended for use in smaller and lower-risk wounds, whereas the RFF was recommended for larger and more complicated wounds.^20,29 Furthermore, Reiffel et al proposed that the GMF is a substitute for the RFF if it is unavailable.⁴⁰ Given the bulk of each muscle flap, the GMF can be justified for use in infected groin wounds following vascular surgery.

Limitations

This systematic review has several limitations. First, most of the included studies were retrospective cohort studies (96.7%) with a moderate RoB (86.7%), which may affect the statistical power of our conclusions. Second, the number of cases was highly variable between the muscle flaps. Although a meta-analysis of outcomes may yield valuable information, each meta-analysis may be insufficient, which may influence the interpretation of the results. Third, some interventions other than comorbidities and the proportion of prosthetic material affected the outcomes. For example, additional revascularization and the initial procedure, either graft excision or preservation, might have affected the outcomes; however, these were stated in few studies. Furthermore, if the SMF was used for smaller- and lower-risk wounds, as aforementioned, it is convincing that the SMF tended to have lower complication rates than the other flaps. However, the groin wound size was not reported in any of the studies. Despite these limitations, this systematic review provides significant information about the whole view of patient characteristics and clinical outcomes in the reconstruction of infected groin wounds following vascular surgery.

Conclusions

The effectiveness and safety of muscle flap reconstruction for infected groin wounds following vascular surgery are clearly positive. This systemic review indicated a tendency for lower complication rates, particularly in muscle flap necrosis, limb loss, and 30-day mortality, with using the SMF than with using other muscle flaps. However, it should be noted that these conclusions are based on low-quality evidence and are not supported by statistically significant data. Further studies investigating the selection of muscle flaps depending on groin wound size are required to confirm the results of this systematic review and draw more robust scientific conclusions.

Supplemental Material

sj-pdf-1-ves-10.1177_15385744211068342 – Supplemental Material for Use of Muscle Flaps for Salvage of Groin Wound Infection Following Vascular Surgery: A Systematic Review and Meta-Analysis

Supplemental Material, sj-pdf-1-ves-10.1177_15385744211068342 for Use of Muscle Flaps for Salvage of Groin Wound Infection Following Vascular Surgery: A Systematic Review and Meta-Analysis by Keisuke Shimbo, Haruka Kawamoto and Isao Koshima in Vascular and Endovascular Surgery

Footnotes

Acknowledgments

We would like to thank Editage () for English language editing.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Keisuke Shimbo

Supplemental Material

Supplemental material for this article is available online.

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