Interactive CardioVascular and Thoracic Surgery (2018) 1–3 BEST EVIDENCE TOPIC

doi:10.1093/icvts/ivy300

Cite this article as: Katsogridakis E, Pokusevski G, Perricone V. The role of sartorius muscle flaps in the management of complex groin wounds. Interact CardioVasc
Thorac Surg 2018; doi:10.1093/icvts/ivy300.

VASCULAR
The role of sartorius muscle flaps in the management of
complex groin wounds

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Emmanuel Katsogridakisa,b,*, Goran Pokusevskic and Vittorio Perriconea
a
Department of Vascular Surgery, The Royal Blackburn Hospital, East Lancashire Hospitals NHS Trust, Blackburn, UK
b
Academic Surgery Unit, Education and Research Centre, University Hospital of South Manchester, Manchester, UK
c
Department of Surgery, Tameside and Glossop Integrated Care NHS Foundation Trust, Tameside, UK

* Corresponding author. Academic Surgery Unit, Education and Research Centre, University Hospital of South Manchester, Southmoor Road, M239LT, Manchester,
UK. Tel: 0044(0)1254 263555; e-mail: e.katsogridakis@nhs.net (E. Katsogridakis).

Received 29 January 2018; received in revised form 15 August 2018; accepted 29 September 2018

Summary
A best evidence topic in vascular surgery was written according to a structured protocol. The question addressed was whether sartorius
muscle flaps (SMF) can be effectively used in the setting of complex groin wounds with exposed prosthetic grafts for graft salvage and limb
salvage. The literature review identified 33 articles reporting on the use of SMF for complex vascular wounds. Of these, 7 articles reporting
on the use of 539 SMFs were considered the best evidence to answer the clinical question. Indications included surgical site infections with
or without wound dehiscence, lymph leaks, graft infection and groin pseudoaneurysms, whereas in 98 of the included 539 cases, the flaps
were performed prophylactically. Vacuum-assisted closure systems were used in 25 cases to promote healing. The use of an SMF is associ-
ated with low rates of muscle flap and graft complications, whereas outcomes seem to be independent of the presence of occlusive disease
in the superficial femoral artery. They can be effectively combined with aggressive debridement strategies and vacuum-assisted closure
devices to optimize outcomes. The published literature supports the use of SMF in the management of complex groin wounds following
vascular reconstruction and is associated with encouraging flap, limb and graft salvage rates.
Keywords: Review • Sartorius muscle flap • Myoplasty • Rotational flap

INTRODUCTION SEARCH STRATEGY

A best evidence topic was constructed according to a structured
protocol. This is fully described in the ICVTS [1].
THREE-PART QUESTION
A literature search was performed on the MEDLINE and EMBASE
databases from 1974 to March 2018 using the OVID interface
with the terms [sartorius muscle.mp.] AND [Surgical Flaps/or
Reconstructive Surgical Procedures/or myoplasty.mp. or
MYOCUTANEOUS FLAP/or flap.mp. or transposition.mp.].

In [patients with exposed or infected prosthetic femoral grafts], is

[the use of sartorius muscle flaps] associated with [limb salvage
and graft salvage]?
CLINICAL SCENARIO
On your routine round of the vascular ward, you review a patient
who has been admitted with a complex non-healing right femo-
ral wound following a right femoropopliteal bypass graft for criti-
cal limb ischaemia. Previous attempts to heal the wound have
failed, and the prosthetic graft is now exposed. You consider us-
ing a sartorius muscle flap (SMF) to cover the exposed graft and
wonder what is the evidence to support this strategy. You resolve
to search the literature.
SEARCH OUTCOME
Two hundred and forty-three papers were found using the
reported search. After removing duplicates and screening the
titles and abstracts of the papers, 33 papers were reviewed in de-
tail. Of these, 7 papers were identified that provided the best evi-
dence to answer the question. These are presented in Table 1.
RESULTS
The influence of timing of the SMF grafts on limb salvage was in-
vestigated by Armstrong et al. [2] who treated patients presenting
with complex wounds with soft tissue defects, persistent

C The Author(s) 2018. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
V
2 E. Katsogridakis et al. / Interactive CardioVascular and Thoracic Surgery
Table 1: Best evidence papers
Author, date, journal
and country
Study design and type
(level of evidence)
Armstrong et al. (2007),
J Vasc Surg, USA [2]
Retrospective design
Case series
(level 4)
Landry et al. (2009),
Am J Surg, USA [3]
Retrospective design
Case series
(level 4)
Topel et al. (2011),
J Vasc Surg, Germany [4]
Retrospective design
Case control
(level 4)
Fischer et al. (2013),
J Plast Reconstr Aesthet
Surg, USA [5]
Retrospective design
Case series
(level 4)
Mirzabeigi et al. (2017),
Ann Vasc Surg, USA [6]
Retrospective design
Case series
(level 4)
Brewer et al. (2015),
Am Surg, USA [7]
Retrospective design
Case series
(level 4)
Ryu et al. (2016), Vasc
Specialist Int, Korea [8]
Retrospective design
Case series
(level 4)
RFF: rectus femoris flap; SD: standard deviation; SFA: superficial femoral artery; SMF: sartorius muscle flap; VAC: vacuum-assisted closure.
Patient group Outcomes Key results Comments
Study period: 1994–2006 Flap loss 6/89 flaps (6.7%) 2 patient subgroups based on the
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Total flaps: 89 timing of flap fashioning (early ver-
Graft loss Not reported sus late)
Szilagy grade: II and III
Limb loss 0%
43 flaps were performed for wounds with soft
tissue defects
6 flaps were performed for persistent lymphoceles
40 flaps were performed for late graft infection
Study period: 2005–2008 Flap loss 3/21 groin wounds (14%) The median time from the initial sur-
Total flaps: 21 gery to flap: 25 days
Graft loss 0/21 grafts (0%)
Szilagy grade: not reported Mean follow-up: 9.5 months (SD:
Limb salvage 21/21 limbs (100%) 10.5 months)
17 flaps were performed for graft infection
Study period: 2007–2010 Flap loss 0/23 (patent SFA, 0%) Compared outcomes in patients
Total flaps: 56 flaps 2/33 (occluded SFA, 6%) with patent SFA versus patients
(overall 2/56, 3.5%) with SFA occlusion
Szilagy grade: III
Graft loss 2/23 (patent SFA, 9%)
34 flaps were performed for graft infection 3/33 (occluded SFA, 9%)
13 flaps were performed for grafts at risk (overall 5/56, 9%)
9 flaps were performed for lymphorrhea
Limb salvage 23/23 (patent SFA, 100%)
29/33 (occluded SFA, 88%)
(overall 52/56, 93%)
Study period: 2005–2011 Flap loss SMF: 5/132 (3.7%) 64 flaps were done prophylacti-
Total flaps: 132 RFF: 3/99 (3%) cally and 68 flaps were done for
infection
Szilagy grade: not reported Graft loss SMF: 5/132 (3.7%)
RFF: 1/99 (1%)
105 flaps were performed to salvage prosthetic
grafts Limb loss SMF: 8/32 (6%)
RFF: 2/99 (2%)
Study period: 2005–2014 Flap loss SMF: not reported No significant differences in SFA
Total flaps: 108 RFF: not reported disease in the group of patients
with complications versus the
Szilagy grade: II and III Graft loss SMF: 10/108 (16.1%) group without
RFF: 11/86 (21.6%)
42 flaps were performed to salvage prosthetic
grafts Limb loss SMF: 4/108 (3.7%)
RFF: 5/86 (5.8%)
Study period: 1997–2012 Flap loss 11/103 flaps (11%) 47 flaps for prosthetic graft infection
Total flaps: 103
Graft loss 28/103 grafts (27%) Follow-up interval was not reported
Szilagy grade: not reported
Limb loss Not reported
21 flaps were performed for prophylaxis
62 flaps were performed for graft infection
20 grafts were performed for non-infectious
reasons
Study period: 2000–2009 Flap loss Not reported The mean follow-up interval was
Total flaps: 30 14.1 months
Graft loss Not reported VAC was used in 20/30 cases
Szilagy grade: not reported
Limb loss 1/30 limbs (3%) 1 mortality (necrotizing fasciitis)
24 patients were presented with soft tissue
infection
 E. Katsogridakis et al. / Interactive CardioVascular and Thoracic Surgery
lymphoceles or late prosthetic graft infection. Interestingly, all
flap failure cases were observed in patients where the flaps were
performed in the early period (defined as being within 4 months
from the initial surgery). Despite the need for aggressive debride-
ment and total or partial graft excisions, their reported limb sal-
vage rate was 100%.
Landry et al. [3] performed 21 SMFs on 20 patients between
2005 and 2008. The indications for performing an SMF were
non-infected femoral haematomas/seromas (n = 9), wound infec-
tion and/or dehiscence (n = 8) and femoral pseudoaneurysm
(n = 4). It should be noted that of the 21 SMFs, 17 were done to
cover the exposed prosthetic grafts, whereas in the remaining 4
patients, autologous vein grafts had been used. Complete healing
was achieved in 18 of the 20 patients, and although 3 of the 21
SMFs ultimately failed, there was no graft loss or limb loss.
The sartorius muscle obtains its arterial supply from segmental
branches of the superficial femoral artery. Topel et al. [4] investi-
gated the outcomes of SMFs performed in patients with occlusive
disease of this vessel. In a series of 56 SMFs performed on 53
patients over a 3-year period (2007–2010), Topel et al. reported a
higher rate of flap failure, graft loss and limb loss in the group of
patients with occlusive arterial disease. However, the differences
were not statistically significant (P-values 0.513, 1.000 and 0.891
for flap failure, graft loss and limb loss, respectively).
Similar results on the effect of occlusive arterial disease on
SMF outcomes were also reported in 2 case series that were pub-
lished by the same group and are reported in Refs. [5] and [6]. In
their first publication, Fischer et al. [5] report on the use of rectus
femoris flaps (n = 99) and SMF (n = 132) performed prophylacti-
cally and/or for graft salvage. They conclude that SMF has a role
for smaller and more superficial complex wounds and that their
use is more appealing as it can be harvested from the same inci-
sion and results in little donor site morbidity, without expertise in
plastic surgery being a prerequisite. In a subsequent communica-
tion [6], they report their outcomes on 108 SMFs that were per-
formed for infected groin wounds following vascular intervention
(Szilagy II and III) with similar results.
Across a 15-year period, Brewer et al. [7] performed 103 SMFs,
62 of which were performed for infectious reasons, 20 for non-
infectious reasons and 21 prophylactically. The worst outcomes
were observed in those patients in whom SMFs were performed
for infectious reasons. However, further comparisons are hin-
dered by the fact that vacuum-assisted closure systems were
used for some of the cases.
A combined approach to treating complex groin wounds was
adopted by Ryu et al. [8] who combined SMFs with a vacuum-as-
sisted closure system in 20 of the 30 patients who were treated
for groin wound infections following vascular reconstructions
(n = 27), cardiac stenting (n = 2) and penile cancer lymph node
3
dissection (n = 1). Limb salvage was achieved in 97% of their
patients, with 3 patients requiring revision due to infection, one
of them losing their limb and ultimately succumbing to necrotiz-
VASCULAR
ing fasciitis.
CLINICAL BOTTOM LINE
The management of complex groin wounds remains a challenge,
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but because of the infrequency of this problem, there is a paucity
of evidence beyond level 4. However, SMFs can be safely and ef-
fectively used to provide muscle coverage of exposed native ves-
sels, autologous or prosthetic grafts and are associated with a low
rate of flap, graft and limb loss complications. As no expertise in
plastic surgery is required to perform SMFs, the outcomes of
SMFs are not influenced by superficial femoral artery occlusive
disease, and their harvest can be done from the same incision
with minimal donor site morbidity; also, they are a helpful ad-
junct in the management of complex wounds following vascular
surgery.
Conflict of interest: none declared.
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