Prophylactic Muscle Flaps in Vascular Surgery: The Penn Groin Assessment Scale

Divisions of Plastic Surgery and Vascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.
Plastic and Reconstructive Surgery (Impact Factor: 2.99). 02/2012; 129(6):940e-949e. DOI: 10.1097/PRS.0b013e31824ecb17
Source: PubMed


High-risk patients undergoing vascular procedures through inguinal incisions experience significant benefit from undergoing prophylactic muscle flaps. The authors present a risk assessment tool, an evidence-based algorithm for using prophylactic muscle flaps, and a comprehensive cost analysis.
Data derived from the authors' previously performed retrospective cohort study of patients undergoing open vascular groin surgery were used to construct an evidence-based risk assessment tool. A multivariate regression analysis identified significant, independent predictors of complications, which were used to construct a scoring system. An institutional cost analysis and preoperative assessment algorithm were derived based on patient risk stratification and statistical analyses.
Sixty-eight prophylactic flaps in 53 patients were compared with 195 open femoral access procedures without flaps in 178 patients. Multivariate regression demonstrated that obesity, smoking, reoperation, and prosthetic graft reconstruction are significant predictors of complications. A weighted risk factor score (0 to 7) was devised: obesity, for a value of 1; smoking, 2; reoperation for open groin surgery, 2; and prosthetic graft material, 2. Patients with higher scores had significantly more complications, infections, and more frequently required secondary salvage flap procedures. Using study data, the authors constructed an algorithm to guide preoperative groin assessment and use of prophylactic muscle flaps.
The authors provide an assessment tool, called the Penn Groin Assessment Scale, that accurately predicts groin complications. They also describe a simple algorithm to assess for prophylactic muscle coverage. Their results suggest that patients with two or more risk factors will benefit from prophylactic muscle flaps.
Risk, II.

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    ABSTRACT: Complex groin wounds present a significant challenge to the reconstructive surgeon. We present a large experience of flaps for managing complex groin wounds. The purpose of our study was to assess outcomes with respect to flap selection and indication (prophylactic versus salvage). A retrospective review of all patients receiving flaps for complex groin wounds between 2005 and 2011 was performed. Two types of procedures were evaluated: prophylactic muscle flaps (PMFs) and salvage flaps. We performed an outcome analysis of complications based on flap timing and selection. A total of 244 flaps were performed during the study period: 146 flaps for salvage and 98 for prophylaxis. Flaps included: sartorius muscle flap (SMF) (N = 132), rectus femoris flap (RFF) (N = 99), and antero-lateral thigh (ALT) (N = 13). Salvaged wounds had higher rates of major wound dehiscence compared to prophylactic wounds (P = 0.002). The SMF (N = 132) and RFF (N = 99) cohorts were similar with respect to patient and operative characteristics, however, the RFF cohort tended to be obese (P = 0.002), used for salvage (P = 0.0005), endarterectomy procedures (P = 0.018), and culture positive wounds (P = 0.09). Major limb related complications (graft loss, limb loss, and reoperation) were significantly lower in the RFF group (P = 0.03). Muscle flaps for complex groin wounds can be safely performed with excellent outcomes. We suggest use of the SMF in the prophylactic setting and for smaller salvage wounds. The RFF may be better suited to address larger, more complex wounds. PMFs in select, high-risk patients optimize wound healing relative to patients undergoing groin wound salvage. Prognostic/risk category, level III.
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    ABSTRACT: Abstract Groin wound complications after open vascular surgery procedures are common, morbid, and costly. The purpose of this study was to generate a simple, validated, clinically usable risk assessment tool for predicting groin wound morbidity after infra-inguinal vascular surgery. A retrospective review of consecutive patients undergoing groin cutdowns for femoral access between 2005-2011 was performed. Patients necessitating salvage flaps were compared to those who did not, and a stepwise logistic regression was performed and validated using a bootstrap technique. Utilising this analysis, a simplified risk score was developed to predict the risk of developing a wound which would necessitate salvage. A total of 925 patients were included in the study. The salvage flap rate was 11.2% (n = 104). Predictors determined by logistic regression included prior groin surgery (OR = 4.0, p < 0.001), prosthetic graft (OR = 2.7, p < 0.001), coronary artery disease (OR = 1.8, p = 0.019), peripheral arterial disease (OR = 5.0, p < 0.001), and obesity (OR = 1.7, p = 0.039). Based upon the respective logistic coefficients, a simplified scoring system was developed to enable the preoperative risk stratification regarding the likelihood of a significant complication which would require a salvage muscle flap. The c-statistic for the regression demonstrated excellent discrimination at 0.89. This study presents a simple, internally validated risk assessment tool that accurately predicts wound morbidity requiring flap salvage in open groin vascular surgery patients. The preoperatively high-risk patient can be identified and selectively targeted as a candidate for a prophylactic muscle flap.
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