The rectus femoris muscle flap is an underused tool in the vascular surgeon's armamentarium

Abstract

Mrs Havercamp aFictitious.aFictitious. presents to clinic at 4:00 pm today for an unscheduled appointment. She is a 67-year-old obese diabetic woman who is 10 days status post right common femoral endarterectomy with Dacron patch angioplasty and retrograde iliac stenting for rest pain. Today, she reports increasing pain and drainage from the groin wound. On examination, there is erythema and dehiscence of the skin edges. Cloudy fluid emanates from the wound. I sigh. “Mrs Havercamp, when was the last time you had anything to eat or drink?” Groin wound complications—alarmingly common, occasionally lethal. Amputation may result, but regardless of the outcome, a significant commitment of time, effort, and cost ensues for the patient and the surgeon. That muscle flaps are a valuable adjunct in the treatment of groin wound complications is incontrovertible. Virtually every vascular surgeon has rotated a sartorius flap, usually with success. But what if the sartorius flap fails? or is unavailable? Most of us will have exhausted our toolbox and require the assistance of a plastic surgeon colleague. Indeed, there are myriad reports of other types of muscle flaps used in the management of groin wounds—tensor fascia lata, gracilis, anterolateral thigh myocutaneous, rectus femoris, rectus abdominis, and others. Common among these reports is that they are performed by plastic surgeons in the majority of cases. This study by Ryer and colleagues1Ryer E.J. Garvin R.P. Kapadia R.N. Jorgensen B.D. Green J.O. Fluck M. et al.Outcome of rectus femoris muscle flaps performed by vascular surgeons for the management of complex groin wounds after femoral artery reconstructions.J Vasc Surg. 2020; 71: 905-911Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar describes 24 rectus femoris flaps performed exclusively by vascular surgeons for treatment of complex groin wounds after femoral artery reconstruction. As expected, obesity, diabetes, and chronic real disease were common in this cohort of patients, and more than half of the surgical procedures were performed in fields previously operated on. Outcomes were largely favorable and comparable to other publications for patient survival and limb salvage. There were no instances of flap necrosis, nor were any complications related to flap rotation identified. The technique for creation of these flaps is described and is straightforward. The authors acknowledge a potential disadvantage of the rectus femoris flap: a decrement in knee extension strength. The authors did not attempt to quantify it, and they appear to dismiss its importance among chronically ill patients who engage in little strenuous activity. On the contrary, maintaining all residual strength among these patients whose reserve is marginal may be critically important to maintaining mobility. This study sheds no light on this issue. In addition, harvesting and rotating this flap almost certainly take more time than creating a sartorius flap and do involve a fairly generous counterincision in the thigh. Nevertheless, I suspect that these potential downsides practically have little impact. Will I abandon the sartorius flap? Certainly not, and I suspect the authors will not either. There is clearly a role for this simple flap under the right circumstances. Will I add the rectus femoris flap into my own armamentarium? Absolutely. The opinions or views expressed in this commentary are those of the author and do not necessarily reflect the opinions or recommendations of the Journal of Vascular Surgery or the Society for Vascular Surgery. Outcome of rectus femoris muscle flaps performed by vascular surgeons for the management of complex groin wounds after femoral artery reconstructionsJournal of Vascular SurgeryVol. 71Issue 3PreviewGroin wound complications after femoral artery reconstructions are highly morbid and notoriously difficult to treat. Successful techniques include long-term antibiotic therapy, operative débridement, and muscle flap coverage. Historically, more complex muscle flap coverage, such as a rectus femoris muscle flap (RFF), has been performed by plastic and reconstructive surgeons. In this study, the experience of vascular surgeons performing RFF in the management of wound complications after femoral artery reconstructions is reported. Full-Text PDF