Groin Reconstruction Research Articles

Case Series: Pedicled Anterolateral Thigh Flaps for Groin Reconstruction

Objective: Groin reconstruction poses a challenge to the plastic surgeon given the comorbidities and prior surgeries typically present in patients with groin wounds, as well as the coverage demands that exposed vascular graft prosthetics and/or native vessels require. Muscle flaps such as the sartorius, rectus abdominis, and rectus femoris have classically been used to reconstruct groin defects, however these require muscle sacrifice and potential donor site morbidity. The anterolateral thigh flap (ALT) has emerged as a versatile flap for locoregional and free flap reconstruction, in this case groin reconstruction, with minimal donor site morbidity. Methods: Patients of the Spectrum Health Plastic Surgery Residency Academic Service from 2017 to 2021 with groin wounds reconstructed with pedicled ALT flaps were retrospectively reviewed in this case series. Five patients were included. The etiology of their wounds, comorbidities, dimensions of flap, time from initial debridement to flap, complications, and outcomes were assessed. Results: The mean age of the patients was 68 years old (range 56 – 76 years). Two of the patients developed groin wounds after repair of ruptured femoral pseudoaneurysms, two presented after infected vascular prosthetic debridement, and one after wound dehiscence following liposarcoma excision with adjuvant radiation. Flap sizes ranged from 10cm x 5cm to 27 centimeters x 9 centimeters. A cuff of vastus lateralis muscle was included in all flaps to provide flap bulk and incorporate musculocutaneous perforators. All donor sites were closed primarily. One patient redeveloped a pseudoaneurysm rupture after groin reconstruction although the overlying ALT survived. One flap developed venous congestion requiring leech therapy and subsequent debridement. One patient developed post-operative cellulitis which resolved. All patients went on to heal their groin wounds. There were no donor site complications. Average follow-up time was 104 days. Conclusion: All five patients had successful groin wound reconstruction with pedicled ALT flaps. This case series demonstrates the utility of the pedicled anterolateral thigh flap in groin reconstruction as a reliable locoregional flap option with minimal donor site morbidity and accommodating flap size. The pedicled ALT should be a first line option for groin reconstruction even in patients with comorbidities or altered vascular anatomy. Corresponding Author: Matthew E. Braza, 100 Michigan Street NE, MC 188, Grand Rapids, MI 49503, [email protected], 414-218-0645

A Pilot Randomized Clinical Trial of Early Ambulation after Groin Reconstruction with Sartorius Muscle Flaps

We performed a pilot randomized trial to analyze the effect of early ambulation on postoperative outcomes in patients who had groin reconstruction with sartorius muscle flaps following infrainguinal vascular surgery at our academic institution. Fourteen patients were randomized to standard ambulation (on postoperative day 6), and 14 patients were randomized to early ambulation (on postoperative day 2). The treatment arms were similar with respect to age, body mass index, risk category, smoking status, and comorbidities. Median length of stay was 6 days in the early group versus 7 days in the standard group. Immediate and long-term physical function and general health were better in the early group There were slightly more wound complications in the standard (57.1%) versus the early group (42.9%), and the early group had more lymphatic complications (35.7% versus 14.3%). The decision to ambulate a patient after this surgery continues to be a decision between the vascular and plastic surgeons. However, this pilot trial has shown the safety profile of early ambulation and that it should be considered for specific patients. Additionally, this trial has provided valuable information for performing a larger scale randomized controlled trial to determine the optimal postoperative protocol for patients with these reconstructions.

Lymphatic Function of the Lower Limb after Groin Dissection for Vulvar Cancer and Reconstruction with Lymphatic SCIP Flap.

Simple SummaryInguinal lymphadenectomy for vulvar cancer is often followed by secondary lower limb lymphedema. This significant treatment-related morbidity cannot be healed and worsens over time, causing symptoms significantly affecting the patients’ quality of life and creating disability, economic burden for physical therapies, infections and reduction of presence and performance at work. This study aimed to reveal the incidence and severity of lower limb lymphedema in patients who have undergone inguinal lymphadenectomy and immediate groin reconstruction with the Lymphatic Superficial Circumflex Iliac Perforator flap. In our series of patients, a significant protective effect of the lymphatic SCIP flap-based immediate reconstruction of the inguinal area emerged, and our results suggest that this easy and quick technique can reduce the incidence and severity of secondary lower limb lymphedema after groin dissection for vulvar cancer.Inguinofemoral lymphadenectomy, frequently performed for vulvar cancer, is burdened with substantial immediate and long-term morbidity. One of the most disabling treatment-related sequelae is lower limb lymphedema (LLL). The present study aims to describe the wound complications and the severity of LLL in patients who have undergone groin dissection for vulvar cancer and immediate inguinal reconstruction with the Lymphatic Superficial Circumflex Iliac Perforator flap (L-SCIP). We retrospectively reviewed the data of patients who underwent bilateral groin dissection and unilateral inguinal reconstruction with the L-SCIP. The presence and severity of postoperative LLL during the follow-up period were assessed by lymphoscintigraphy and limbs’ volume measurement. In addition, immediate complications at the level of the inguinal area were registered. The changes between preoperative and postoperative limb volumes were analyzed by Student’s t test. p values < 0.05 were considered significant. Thirty-one patients were included. The mean variation of volume was 479 ± 330 cc3 in the side where groin reconstruction had been performed, and 683 ± 425 cc3 in the contralateral side, showing smaller variation in the treated side (p = 0.022). Lymphoscintigraphy confirmed the clinical findings. Based on our results, inguinal reconstruction with L-SCIP performed at the same time of groin dissection in patients treated for vulvar cancer can provide a significant protective effect on LLL.

Use of flaps in inguinal lymphadenectomy in metastatic penile cancer.

ABSTRACTPurpose:Reviewing surgical procedures using fasciocutaneous and myocutaneous flaps for inguinal reconstruction after lymphadenectomy in metastatic penile cancer.Material and Methods:We reviewed the current literature of the Pubmed database according to PRISMA guidelines. The search terms used were “advanced penile cancer”, “groin reconstruction”, and “inguinal reconstruction”, both alone and in combination. The bibliographic references used in the selected articles were also analyzed to include recent articles into our research.Results:A total of 54 studies were included in this review. About one third of penile cancers are diagnosed with locally advanced disease, often presenting with large lymph node involvement. Defects in the inguinal region resulting from the treatment of metastatic penile cancer are challenging for the surgeon and cause high patient morbidity, rendering primary closure unfeasible. Several fasciocutaneous and myocutaneous flaps of the abdomen and thigh can be used for the reconstruction of the inguinal region, transferring tissue to the affected area, and enabling tensionless closure.Conclusions:The reconstruction of defects in the inguinal region with the aid of flaps allows for faster postoperative recovery and reduces the risk of complications. Thus, the patient will be able to undergo potential necessary adjuvant treatments sooner.

Vacuum-Assisted Incisional Closure Therapy After Groin Reconstruction With Muscle Flap.

BackgroundGroin reconstruction with muscle flap coverage is associated with high wound complication rates. Incisional vacuum-assisted closure (iVAC) therapy may lower wound complications. We evaluated the impact of iVAC on postoperative outcomes in patients following groin reconstruction with muscle flap coverage.MethodsWe conducted a retrospective review of patients who underwent groin reconstruction with muscle flap coverage in 2012-2018. Patients were divided into those who received iVAC therapy and those who received standard sterile dressings (SSD).ResultsOf the 57 patients included, most received iVAC therapy (71%, n = 41) and the rest received SSD (28%, n = 16). The iVAC group had higher rates of diabetes, hypertension, coronary artery disease, and peripheral artery disease (p < 0.05). However, iVAC patients had comparable length of hospital stay (12 vs 8.5 days p = 0.0735), reoperations (34% vs 31%, p = 0.8415), and readmissions (32% vs 37%, p = 0.6801) with SSD patients. iVAC placement was less likely in prophylactic flaps (odds ratio 0.08, p = 0.0049).ConclusionPatients with a prophylactic flap were less likely to receive vacuum therapy, which may highlight a selection bias where surgeons pre-emptively use iVAC therapy in surgical candidates identified as high risk. The pre-emptive use of iVAC may minimize adverse postoperative outcomes in high-risk patients.

Reconstruction of Complex Groin Defects After Sarcoma Resection.

Complex groin defects after sarcoma resection require reconstruction of multiple vital structures that can include the major vessels, the overlying skin, the abdominal wall, and the hip joint. We investigated the feasibility of limb preservation after complex groin reconstruction. The subjects were 12 consecutive patients who underwent complex groin reconstruction after sarcoma resection. In all patients, the defect included a major artery (external iliac or femoral) and overlying skin. The defect included the abdominal wall in 5 patients and the hip joint in 2. Arterial reconstruction was performed with an autologous vein graft in 9 patients and with an expanded polytetrafluoroethylene graft in 3. Soft-tissue coverage was performed with a pedicled rectus abdominis musculocutaneous flap in 7 patients, a free latissimus dorsi musculocutaneous flap in three, and a free anterolateral thigh flap in 2. Postoperative complications occurred in 7 patients (58.3%). Limb salvage was possible in 8 patients (66.7%) with 39 months' median follow-up. Two patients required amputation because of wound problems, and 2 required amputation because of local recurrence of the tumor. Limb salvage is possible even after extensive resection of groin sarcoma, although the rate of postoperative wound complications is substantial. Proper selection of the arterial conduit and the soft-tissue flap, depending on the components of the defect, are mandatory for successful reconstruction.

Bilateral Pedicled Superficial Inferior Epigastric Artery Flap in the Treatment of Hidradenitis Suppurativa

Summary:The authors present a new technique in surgically treating hidradenitis suppurativa (HS), a debilitating skin condition. In HS, surgical treatment is often the best option because of the high recurrence rates despite extensive medical treatment. A commonly successful surgical method is using skin flaps after excision of the affected area. A superficial inferior epigastric artery flap is demonstrated here as a new alternative approach to treating a case of extensive HS of the groin. By using the pedicled superficial inferior epigastric artery flap for groin reconstruction, inguinal HS can be widely excised and reconstructed with minimal donor-site morbidity and a good aesthetic outcome.

Groin reconstruction using a pedicled anterolateral thigh flap

This article describes an attractive approach to the reconstruction of the groin after loss of substance: the skin, subcutaneous tissue and fascia of the rectus abdominis and oblique muscles were reconstructed using an anterolateral thigh flap based on a proximal vascular pedicle. A 70-year-old female with a strangulated inguinal hernia that had been neglected for eight days presented initially with intestinal necrosis and necrotizing infection of the abdominal wall in the right groin. After debridement of necrotic tissue, reconstructive surgery was necessary. We opted for an anterolateral thigh flap based on a proximal vascular pedicle. In this case, there was a major loss of substance that included the rectus abdominis fascia below the level of the arcuate line. This situation required a fascial reconstruction of the abdominal wall; a defect of this size would typically require synthetic mesh for closure. The anterolateral thigh flap allowed us to avoid the use of foreign material by repairing the defect with a pedicle flap including fascia lata and the quadriceps aponeurosis. The use of an anterolateral thigh flap based on a proximal vascular pedicle seems to be a simple straightforward solution for reconstruction of the skin and fascia of the inguinal region.

Algorithmic approach to lower abdominal, perineal, and groin reconstruction using anterolateral thigh flaps.

Lower abdominal, perineal, and groin (LAPG) reconstruction may be performed in a single stage. Anterolateral thigh (ALT) flaps are preferred here and taken as fasciocutaneous (ALT-FC), myocutaneous (ALT-MC), or vastus lateralis myocutaneous (VL-MC) flaps. We aim to present the results of reconstruction from a series of patients and guide flap selection with an algorithmic approach to LAPG reconstruction that optimizes outcomes and minimizes morbidity. Lower abdomen, groin, perineum, vulva, vagina, scrotum, and bladder wounds reconstructed in 22 patients using ALT flaps between 2000 and 2013 were retrospectively studied. Five ALT-FC, eight ALT-MC, and nine VL-MC flaps were performed. All flaps survived. Venous congestion occurred in three VL-MC flaps from mechanical cause. Wound infection occurred in six cases. Urinary leak occurred in three cases of bladder reconstruction. One patient died from congestive heart failure. The ALT flap is time tested and dependably addresses most LAPG defects; flap variations are suited for niche defects. We propose a novel algorithm to guide reconstructive decision-making.

Bilateral groin reconstruction with a single anterolateral thigh perforator flap as an alternative to traditional myocutaneous flaps

•We describe bilateral groin reconstruction with a single anterolateral thigh flap.•Anatomy and surgical technique of the anterolateral thigh flap are discussed.

Minimal Thoracotomy Thoracic Bifemoral Bypass in the Endovascular Era

Endoluminal revascularization has supplanted open techniques for most aortoiliac occlusive disease with open surgery reserved for endovascular failure or long-segment aortoiliac occlusions. A number of clinical and anatomic issues can preclude the use of the infrarenal aorta for inflow. Our approach in these select patients is minimal thoracotomy thoracic bifemoral (mini-TBF) bypass. Mini-TBF bypass used a 2-team approach. The cardiac surgery team focused on arterial inflow from the distal descending aorta via a ≤8-cm thoracotomy at ninth interspace. The vascular surgery team focused on groin reconstruction and graft tunneling. The body of the graft was tunneled through the posterior left hemidiaphragm. The left limb was tunneled retroperitoneal over the psoas and the right limb anterior to the abdominal fascia below the umbilicus to the groin. Thirteen patients (mean age, 64; 82% male) underwent mini-TBF bypass between 2009 and 2012 for claudication in 9 (69%) and critical limb ischemia in 4 (31%). Five patients had prior failed iliac endovascular revascularizations and 2 patients had failed prior infrarenal aortobifemoral bypass. The indication for use of thoracic aortic inflow was prior abdominal operations in 4 (31%), pelvic anatomy with a critical inferior mesenteric artery (IMA) in 5 (38%), and the condition of the infrarenal/juxtarenal aorta in 4 (31%). Median operative time was 240 min (range 181-513 min). Median length of stay was 8 days. There was no perioperative mortality. Postoperative complications occurred in 5 patients, stroke 1, pulmonary 2 (both contralateral lung issues), and 2 limb occlusion secondary to outflow disease. At median follow-up of 18 months, 2 patients required amputations, both from preexisting tissue loss despite secondary patent grafts. Mini-TBF bypass provides another alternative to successfully revascularize Trans-Atlantic Inter-Society Consensus II type D lesions in patients with prior abdominal revascularization, pelvic anatomy with a critical IMA, or calcification/thrombus of the infrarenal/juxtarenal aorta precludes control.

Sports hernia or groin disruption injury? Chronic athletic groin pain: a retrospective study of 100 patients with long-term follow-up

Chronic groin pain (athletic pubalgia) is a common problem in sports such as football, hockey, cricket, baseball and athletics. Multiple co-existing pathologies are often present which commonly include posterior inguinal canal wall deficiency, conjoint tendinopathy, adductor tendinopathy, osteitis pubis and peripheral nerve entrapment. The mechanism of injury remains unclear but sports that involve either pivoting on a single leg (e.g. kicking) or a sudden change in direction at speed are most often associated with athletic pubalgia. These manoeuvres place large forces across the bony pelvis and its soft tissue supports, accounting for the usual clinical presentation of multiple symptomatic abnormalities forming one pattern of injury. The diagnoses encountered in this series of 100 patients included rectus abdominis muscle atrophy/asymmetry (22), conjoint tendinopathy (16), sports (occult, incipient) hernia (16), groin disruption injury (16), classical hernia (11) traumatic osteitis pubis (5), and avulsion fracture of the pubic bone (4). Surgical management was generally undertaken only after failed conservative therapy of 3-6 months, but some professionals who have physiotherapy during the football season went directly to surgery at the end of the football season. A variety of operations were performed including groin reconstruction (15), open hernia repair with or without mesh (11), sports hernia repair (Gilmore) (7) laparoscopic repair (3), conjoint tendon repair (3) and adductor tenotomy (3). Sixty-six patients were available for follow at an average of 13 years after initial consultation and the combined success rate for both conservative treatment and surgery was 94%. The authors believe that athletic pubalgia or sports hernia should be considered as a 'groin disruption injury', the result of functional instability of the pelvis. The surgical approach is aimed at strengthening the anterior pelvic soft tissues that support and stabilise the symphysis pubis.

Reconstruction of Groin Defects Following Radical Inguinal Lymphadenectomy: An Evidence Based Review

Inguinal lymph node involvement is an important prognostic and predictive factor in various neoplasms of the genitalia and lower limb. As part of the multimodality approach, these patients undergo surgery and adjuvant radiotherapy. Morbidity of inguinal lymphadenectomy includes lymphedema, lymphorrhea and infection; however the most common distressing complication is skin necrosis. Myocutaneous flaps have been the most popular form of primary or delayed groin reconstruction. This paper aims to critically review the different myocutaneous flaps used in groin reconstruction, discuss evidence based data on the versatility and utility of these flaps and discuss ways in which modifications maybe incorporated in treatment and radiation planning following groin reconstruction. A comprehensive search of the scientific literature was carried out using PubMed to access all publications related to groin reconstruction. The search focused specifically on current management, technique, safety and complications of these procedures. Keywords searched included "inguinal lymphadenectomy", "primary reconstruction", "musculocutaneus flap", "myocutaneous flap", "tensor fascia lata flap", "anterolateral thigh flap", "rectus abdominis flap". Low to middle income countries witness a huge burden of locally advanced genital malignancies and melanoma of the lower extremity. Higher tumor burden both at the primary site as well as the inguinal basin requires surgery as the primary modality of treatment. Groin reconstruction is required not only to prevent femoral blowouts but also for early administration of adjuvant radiation. The versatility of tensor fascia lata, anterolateral thigh, and rectus abdominis flaps is useful to cover the defect, provide radiation, eradicate pain and achieve good palliation. Assessment of aesthetic and functional outcomes of one flap over the other and the "ideal" form of reconstruction for groin defects needs additional investigation.

Spontaneous perforation of pyometra due to acute necrotising endometritis

A 64-year-old woman presented with a 1-day history of severe lower abdominal pain and pyrexia. Her medical history included a sarcoma of her left thigh treated with neo-adjuvant radiotherapy and subsequent surgical resection 2 years earlier. Wound necrosis requiring left groin reconstruction with a right rectus abdominis myocutaneous fl ap complicated her postoperative course. A massively distended air and fl uid-fi lled endometrial cavity, with marked thickening and enhancement of the myometrium was shown at CT. In the region of the left uterine fundus, there was a transmural defect containing multiple locules of air, suggesting a localised uterine perforation (Figure 1). Free intraperitoneal air and fl uid was present, with further locules of air and interloop fl uid identifi ed in the region of the duodenojejunal fl exure. An area of polypoid soft tissue was identifi ed in the lower uterine segment on the right, projecting into the uterine cavity (Figure 2). Pyometra with associated uterine perforation was suspected, and, given the history of prior sarcoma, the possibility of an underlying necrotic, perforated uterine tumour was considered. Th e diff erential diagnosis also included a secondary, localised small bowel perforation in the region of the duodenojejunal fl exure and interloop abscess. At laparotomy, there were 2 litres of frank pus in the peritoneal cavity. Th e uterus was grossly distended and a left myometrial perforation oozed purulent discharge. Secondary peritonitis involving the small and large bowel with multiple pockets of intramesenteric pus and locules of gas was also present, although there was no evidence of overt bowel perforation. In addition, signifi cant radiotherapy eff ect was present in the pelvic tissues. A total abdominal hysterectomy and bilateral salpingooophorectomy along with extensive peritoneal lavage was performed. Histological examination of the resected specimen showed marked myometrial thickening associated with dilatation of the endometrial cavity. Th e endometrium was ulcerated and covered with a haemorrhagic, grey – green exudate. Th e fi nal histological diagnosis was acute suppurative necrotising endometritis with abscess formation, full thickness necrosis of the uterine wall and serositis. Th ere was no evidence of malignancy. A 1.8 1.0 0.6 cm polypoid sub-mucosal fi broid was present in the lower uterine segment on the right, corresponding with the CT fi ndings. Its position, together with the adjacent radiotherapy eff ect, seemed to contribute to impaired drainage of the uterine cavity and subsequent development of pyometra in this patient.

From the Desk of the Editor

Steady progress continues in the field of oncology and this issue of IJSO highlights management Urological cancers, through experts in the field both in this country as well as across the globe. The changing trends scene in this country, from penile cancer which is very dominant we are seeing the increased TREND of the documentation of prostatic cancer in the Indian registry. The quality of life is a concern and reduction in the morbidity due to treatment Minimal access surgery endeavors to minimize the morbidity to the patient, while achieving outcomes similar to conventional technique. Robotic surgery in urological malignance has brought in revolution in management and good evidence base results available. Especially Robotic prostatectomy is considered aa gold standard treatment in management of early prostatic cancer. This highlights developments of Urology in Indian subcontinent and all aspects of Robotic surgery from kidney, bladder and prostatic technique, advantages disadvantages are highlighted. Today patient safety and quality care is bridging the gap for better patient care and it is a constant reminder to work systematically. The topics were chosen were related not only in advanced technique of minimal invasive and robotic surgery, but also reconstructive surgery of Groin as every one sees advanced metastasis inguinal lymph nodes in our subcontinent and authors have brought out advantage disadvantages of various flap in groin reconstruction. At present PSA is the best test available for early diagnosis, screening, treatment monitoring and in no other way one can identify prostate cancer in its curable stage now available the authors have highlighted the points. The guest editorial is authored by Dr. Murali Kamat, senior surgical oncologist who is responsible for development of Uro oncology in India. I also thank Dr. Jagadish Kulakarni present president of urological society of India who helped me to plan this issue on uro oncology. The authors were chosen who has vast experience in treating this disease for more than two decades; some of them have done pioneering work in developing the various techniques in robotic urological surgery, and also experienced in training, teaching and development of training model and various protocols. They had put in all efforts to cover the state of the art and evidence based management of urological malignancies. On behalf of the editorial committee, I thank the guest editors who accepted the invitations and brought out the issue on this subject in a able manner and assembled an excellent group of reviews that should be informative and enlighting to every one who is interested in this speciality. I also thank the contributing authors for their valuable support in sending articles in time to acquire the knowledge and skill. This editions of the IJSO will give the members of the association an over view of the contemporary state of art in the management of Urological oncology. I appreciate excellent work and professionalism in bringing out the issue of IJSO. I always say your constructive criticism for progress of science is always welcome. With regards, K. S. Gopinath

Hybrid Aortoiliac Revascularization to Avoid Nonautogenous Groin Reconstruction in an Intravenous Drug Abuser

Traditional methods for revascularization of an occluded aortoiliac system have necessitated either in-line aortic reconstruction through an aortobifemoral bypass or extra-anatomic bypass. However, both these approaches require artificial material to be placed in the groin. The consequence of groin infection can be devastating leading to high rates of both limb loss and mortality. One of the most feared patient populations presenting with groin complications is that of the intravenous drug abuser. We present the case of a patient with a long history of intravenous drug abuse with severe aortoiliac disease. Instead of resorting to a more traditional open surgical approach necessitating artificial reconstruction in the groin, we chose to proceed with a hybrid open and endovascular procedure through a direct open surgical access to the aortic bifurcation. This allowed for revascularization without the placement of artificial material in the groin.

Myoepithelial Carcinoma of the Vulva Mimicking Bartholin Gland Abscess in a Pregnant Woman

Myoepithelial tumors of the vulva are extremely rare, with only 8 cases reported in the literature to date. We report the first case of a high-grade myoepithelial vulvar carcinoma diagnosed in a 35-year-old woman during the 27th week of her pregnancy. The patient initially underwent a wide local excision of the lesion but noted rapid regrowth of the vulvar mass during the next 2 months before her delivery. Shortly thereafter, she underwent a classic radical Taussig-Basset total radical vulvectomy, bilateral superficial and deep inguinal groin node dissection, partial vaginectomy, and reconstruction of the vulva. However, the patient rapidly developed both locoregional and distant mestatatic disease, despite aggressive chemoradiotherapy, and she eventually succumbed to disseminated disease almost 20 months after her initial diagnosis.

Sportsman hernia: what can we do?

Sportsman (sports) hernia is a medially located bulge in the posterior wall of the inguinal canal that is common in football players. About 90% of cases occur in males. The injury is also found in the general population. The presenting symptom is chronic groin pain which develops during exercise, aggravated by sudden movements, accompanied by subtle physical examination findings and a medial inguinal bulge on ultrasound. Pain persists after a game, abates during a period of lay-off, but returns on the resumption of sport. Frequently, sports hernia is one component of a more extensive pattern of injury known as 'groin disruption injury' consisting of osteitis pubis, conjoint tendinopathy, adductor tendinopathy and obturator nerve entrapment. Certain risk factors have been identified, including reduced hip range of motion and poor muscle balance around the pelvis, limb length discrepancy and pelvic instability. The suggested aetiology of the injury is repetitive athletic loading of the symphysis pubis disc, leading to accelerated disc degeneration with consequent pelvic instability and vulnerability to micro-fracturing along the pubic osteochondral junction, periosteal stripping of the pubic ligaments and para-symphyseal tendon tears, causing tendon dysfunction. RADIOLOGY: Diagnostic imaging includes an erect pelvic radiograph (X-ray) with flamingo stress views of the symphysis pubis, real-time ultrasound and, occasionally, computed tomography (CT) scanning and magnetic resonance imaging (MRI), but seldom contrast herniography. Other imaging tests occasionally performed can include nuclear bone scan, limb leg measurement and test injections of local anaesthetic/corticosteroid. PREVENTION AND TREATMENT: The injury may be prevented by the detection and monitoring of players at risk and by correcting significant limb length inequality. Groin reconstruction operation consists of a Maloney darn hernia repair technique, repair of the conjoint tendon, transverse adductor tenotomy and obturator nerve release. Rehabilitation involves core stabilisation exercises and the maintenance of muscle control and strength around the pelvis. Using this regimen of groin reconstruction and post-operative rehabilitation, a player would be anticipated to return to their pre-injury level of activity approximately 3 months after surgery.

Management of Inguinal Lymphadenopathy

Inguinal lymphadenectomy is associated with considerable morbidity, and several attempts have been made to minimize the morbidity by well-vascularized flaps of adequate bulk to obliterate the dead space and promote wound healing. In the case of recurrence, the overlying skin is usually involved and the reconstructive surgeon is confronted with exposed femoral vessels and complex groin defects. We report a series of 40 patients that underwent inguinal lymphadenectomy and immediate sartorius transposition for skin malignancies, and 4 patients with recurrence that was treated with radical surgical excision and pedicled anterolateral thigh flap (ATL). We examined complications such as infection, skin necrosis, lymphorea, lymphoedema, and wound healing time. The immediate sartorius transposition was associated with 7.5% infection rate, 5% superficial skin edge necrosis, 0% of persistent lymph, and 27.5% of mild lymphoedema. All ALT flaps survived completely and wounds healed uneventfully within 2 weeks without any signs of infection, seroma, or wound dehiscence.Sartorius and ALT flap are reliable methods to reconstruct the groin following inguinal lymphadenectomy. They ensure low complication rate with no donor site morbidity, and should be the first line treatment of immediate and secondary groin reconstruction, respectively.

Extended pedicle rectus abdominis myocutaneous flap for groin reconstruction: Case report

Reconstruction of left groin defect following a failed left femoral aneurysm bypass procedure. The defect was occasioned by excision of a saccular aneurysm of left femoral artery, and repair with PTFE graft for an ilio femoral bypass. On the second postoperative day, the wound became septic and the graft extruded with a resultant wound defect of about 20 x 10 cm. The graft was later removed and wound coverage achieved by an extended contralateral pedicled rectus abdominis myocutaneous flap.