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PubMed2005

Use of the femoral vein ('groin injecting') by a sample of needle exchange clients in Bristol, UK.

BACKGROUND: Use of the femoral vein for intravenous access by injecting drug users (IDUs) (commonly called 'groin injecting') is a practice that is often observed but on which little is written in the literature. The purpose of this study was to describe self-reported data from a sample of groin injectors on the natural history and rationale regarding their groin injecting, to inform future research and the development of appropriate harm reduction strategies. METHODS: A convenience sample of groin injectors willing to participate in a semi-structured interview were recruited through the Bristol Drugs Project Harm Reduction Service. The interviews were conducted over the period of one week. Data on transition to groin injecting, rationale for use and incidence of problems were collected. RESULTS: Forty seven IDUs currently injecting in their femoral vein ('groin') were interviewed, 66% (n = 31) male and 34% (n = 16) female. Their mean age was 31 yrs (range 17 to 50 yrs; SD = 7.7). The mean length of time since first injecting episode was 9.6 yrs (range 6 mths to 30 yrs; SD = 7.0). The mean length of time since use of the groin began was 2.6 years (range 1 mth to 15 yrs; SD = 3.3). The mean length of time between first injection and first use of the groin was 7.0 yrs (SD = 7.0). One person had used no other area for venous access prior to using the groin, nine people had used one, nine people had used two, 10 people had used three, five people had used four and 13 people had used more than four areas. The main reason given for starting to inject in the groin was that 'no other sites were left'. However further discussion identified this meant no other convenient sites were accessible. Practises such as the rotation of injecting sites, as advocated in many harm reduction leaflets, were reported to be difficult and unreliable. The risk of missing the vein and subsequently losing the 'hit' was considered high. Use of the non-dominant hand to administer injections was problematic and deterred rotation between arms. The groin site was reported to be convenient, provide quick access, with little mess and less pain than smaller more awkward veins. The formation of sinuses over time facilitated continued use of the groin. Approximately two thirds of participants had experienced difficulty gaining IV access at their groin. Common problem included scar tissue occlusion, swelling and pain. Some reported infections and past history of deep vein thrombosis. CONCLUSION: Use of the groin was perceived to be convenient by the study group. Problems following safer injecting advice were identified, including dexterity difficulties leading to fear of losing the 'hit'. Health problems at the groin site did not deter use. These results suggest further qualitative work is needed to explore the difficulties in following safer injecting advice in more detail and inform the development of more appropriate advice. Further quantitative work is necessary to establish the prevalence of groin injecting amongst IDUs and the incidence of associated problems. There is a need for a longitudinal study to examine the relationship between injecting technique and loss of patency of veins. If protective factors could be identified, evidence-based safer injecting advice could be established to preserve peripheral veins and reduce use of the groin site, which is high risk and associated with serious adverse consequences.

Journal Article↗
PubMed1992

Morbidity and recurrence with modifications of radical vulvectomy and groin dissection.

Vulvar carcinoma has been managed in recent years with modifications of radical vulvectomy and groin dissection. Separate groin incisions, superficial inguinal lymphadenectomy, unilateral groin dissection, and wide excision have been utilized to reduce the morbidity of treatment. In this study, the surgical management of 82 patients with vulvar squamous cell carcinoma was reviewed in order to assess morbidity and risk of recurrence. A modification of radical vulvectomy and groin dissection was employed in 67 patients, while 15 patients underwent classical en-bloc vulvar and groin dissection. Wound complications of the vulva occurred in 1 of 12 patients undergoing hemivulvectomy, in 8 of 55 undergoing radical vulvectomy, and in 7 of 15 who had en-bloc vulvar resection and groin dissection (P = 0.01). Among the 46 patients undergoing bilateral groin dissection through separate incisions, groin breakdown, lymphocyst, and lymphedema occurred in 10 (22%), 7 (15%), and 7 (15%), versus 0, 1 (7%), and 2 (13%) of the 15 who had unilateral groin dissection. Modification of vulvar resection did not increase the risk of local recurrence. Groin recurrence developed in 2 of 15 patients who underwent en-bloc groin dissection and in 1 of 46 who underwent bilateral groin dissection through separate incisions. Two of 15 who had a unilateral groin dissection recurred in the contralateral groin. The risk of recurrence as well as morbidity following modifications of radical vulvectomy with groin dissection should be considered when planning treatment.

Aged↗
PubMed2000

Complete groin lymphadenectomy with preservation of the fascia lata in the treatment of vulvar carcinoma.

OBJECTIVE: The goal of this study was to assess the local groin recurrence of vulvar carcinoma in patients treated by complete groin node dissection with preservation of the fascia lata (GNDPFL). METHODS: This study is a retrospective chart review of 60 patients with Stage I-IV vulvar carcinoma who underwent radical vulvectomy and GNDPFL between 1990 and 1998. All superficial inguinal nodes and the deep femoral nodes on the anterior and medial surfaces of the femoral vein within the fossa ovalis were removed en bloc while sparing the fascia lata and the cribriform fascia over the femoral artery. RESULTS: Of the 60 study patients, 14 patients had Stage I disease, 20 Stage II, 21 Stage III, and 5 Stage IV. The mean number of nodes removed was 10 per groin. Thirty-nine patients had benign nodes on groin dissection. None of these 39 patients developed cancer recurrence in the dissected groins. Twenty-one of the sixty study patients (34%) had malignant nodes on groin dissection. Of these 21 patients, 2 experienced cancer recurrence in the groins. Our study describes a groin recurrence rate of 7.6% in patients with fewer than three malignant unilateral groin nodes. Postoperatively, 13% of patients developed lymphedema and 15% formed lymphoceles. CONCLUSIONS: The zero groin recurrence rate in patients with negative nodes and the low rate of recurrence in patients with positive nodes indicate that groin lymphadenectomy with preservation of fascia lata is complete, therapeutic, and comparable to radical techniques of lymphadenectomy involving skeletonization of femoral vessels, resection of fascia lata, and muscle transposition.

Adult↗
PubMed2002

Prospective evaluation of positron emission tomography for the detection of groin node metastases from vulvar cancer.

OBJECTIVE: We set out to determine the ability of positron emission tomography with fluorodeoxyglucose to detect groin lymph node metastases from vulvar cancer. METHODS: From January 2000 to August 2001, patients with squamous cell cancer of the vulva undergoing radical excision and lymphadenectomy were offered preoperative positron emission tomography. The imaging and pathologic status of each patient and groin were compared, and the sensitivity, specificity, and predictive value of positron emission tomography in predicting nodal metastasis were determined. RESULTS: Fifteen patients underwent positron emission tomography prior to exploration of 29 groins. Six patients had positive scans, suggesting metastases in 8 groins. Pathologically, 5 patients had metastases in 9 groins, with positron emission tomography demonstrating metastases in 4 of 5 patients and 6 of 9 groins with disease. On a patient-by-patients basis, positron emission tomography had a sensitivity of 80%, specificity of 90%, positive predictive value of 80%, and negative predictive value of 90% in demonstrating metastases. On a groin-by-groin basis, positron emission tomography had a sensitivity of 67%, specificity of 95%, positive predictive value of 86%, and negative predictive value of 86%. Positron emission tomography was more accurate in detecting extranodal metastases than disease confined within the groin nodes (P = 0.048). CONCLUSIONS: Positron emission tomography is relatively insensitive in predicting lymph node metastasis, and a negative study is not a reliable surrogate for a pathologically negative groin. However, the high specificity suggests that positron emission tomography is useful in planning radiation therapy and as an adjunct to lymphatic mapping and sentinel lymph node dissection.

Aged↗
PubMed1997

Groin pain associated with lower lumbar disc herniation.

STUDY DESIGN: Retrospective clinical and magnetic resonance imaging study of patients with groin pain associated with lower lumbar disc herniation. OBJECTIVES: To demonstrate the clinical features and magnetic resonance imaging findings of these patients. SUMMARY OF BACKGROUND DATA: Patients with lumbar disc herniation sometimes report groin pain. Little mention has been made, however, regarding the clinical features of groin pain stemmed from lower lumbar disc herniation until now, with only Murphey referring to groin pain in disc disease. METHODS: A total of 512 patients were diagnosed with singular lower lumbar disc herniation (L4-L5 and L5-S1) at Kakegawa City General Hospital between July 1990 and December 1993. Of these patients, 21 (4.1%) reported groin pain. The characteristic clinical features and magnetic resonance imaging findings of the 21 patients were investigated and compared with the features and findings of patients with no groin pain. RESULTS: Patients with groin pain had a higher mean age and lower rate of low back pain, and L4-L5 discs were more likely to be involved than L5-S1 discs. In their magnetic resonance images, herniation tended to be more central than in patients with no groin pain. CONCLUSIONS: Elderly patients with L4-L5 protruding herniation of the anulus fibrosus were most likely to experience groin pain. The sinuvertebral nerve that innervates the posterior anulus fibrosus, the posterior longitudinal ligament, and the dura was indicated as the afferent nerve of groin pain.

Adult↗
PubMed2005

Management of complex groin wounds: preferred use of the rectus femoris muscle flap.

This study reviews our experience with the rectus femoris muscle flap for complex groin wound reconstruction. Over the past 5 years, the rectus femoris has become our routine method of groin wound reconstruction. The rectus femoris is harvested through a midanterior incision extending over the distal two-thirds of the thigh. The muscle is elevated on its pedicle and transposed into the groin wound defect either directly or through an intervening skin bridge. Hospital and outpatient records were reviewed for all patients undergoing groin wound reconstruction with this technique from 1999 through 2003. Thirty-seven rectus femoris muscle flaps were performed in 33 patients. The mean patient age was 65.3 years (range, 25 to 88 years). Thirty groin wounds (81.1 percent) occurred after infrainguinal revascularization, 23 (76.7 percent) of which contained prosthetic material. Five (21.7 percent) of these wounds had their prosthetic material removed at the time of reconstruction. The remaining seven groin wounds (18.9 percent) occurred after femoral vessel cannulation for either cardiac or transplant surgery. There were no intraoperative mortalities and no anastomotic hemorrhages. There were no flap losses. Thirty-five of the 37 treated wounds healed (94.6 percent), 26 primarily (70.3 percent) and nine (24.3 percent) after delayed healing and contracture. Reoperation was performed in one patient for flap readvancement and in three patients for prosthetic graft removal after initial flap reconstruction. Two patients (6.1 percent) died during their hospitalization with persistent open groin wounds after flap reconstruction. All muscle flap donor incisions healed, with only two (5.4 percent) experiencing minimal delayed healing. There were no donor-site wound infections and no donor sites required reoperation. Thirty-three groin wounds (89.2 percent) demonstrated culture-positive microbial infection, 15 (45.5 percent) of which were polymicrobial. The 30-day mortality rate was 15.2 percent and the 6-month mortality rate increased to 27.2 percent, with multisystem organ failure as the most common cause. The rectus femoris muscle flap is an effective and reliable means of complex groin wound reconstruction. The muscle flap is dependable and the donor site is not problematic, even in the presence of peripheral vascular disease. On the basis of our clinical results, we believe that the rectus femoris muscle flap is the flap of choice for groin wound reconstruction.

Adult↗
PubMedDate not supplied

Unilateral groin and pelvic irradiation for unilaterally node-positive women with vulval carcinoma.

It is essential that any patient with resected vulval cancer and significant nodal disease receive optimal adjuvant treatment with radiation. Adequate radiotherapy for such patients with unilateral positive groin nodes has not been defined. Whether both groins and pelvic sidewalls should be irradiated or only the affected (node positive) side remains unclear. From our registry, we identified all patients with primary, previously untreated squamous cell carcinoma of the vulva undergoing bilateral inguinofemoral lymphadenectomy (superficial and deep nodes) and having unilaterally positive groin nodes treated with unilateral groin and pelvic radiotherapy (44 Gy in 22 fractions). Clinical and pathologic records were reviewed to identify the anatomical site and timing of recurrences in these patients and determine whether unilateral groin and pelvic irradiation was sufficient for disease control on the node-negative side. From 1983 to 2002, 20 patients with unilateral positive nodes treated with unilateral groin and pelvic irradiation were identified. Nineteen patients were classed as having FIGO stage III disease and one as FIGO stage IV due to involvement of the rectal mucosa. There were nine patients with disease recurrences in this group (45%). The disease-free interval ranged from 4 to 31 months (median time to recurrence, 9 months). All nine patients had local or regional failures, the most common site being the ipsilateral groin (six of nine patients). One patient was also found to have distant metastases. There were no recurrences noted in the contralateral (nonirradiated) groin or pelvic sidewall. Recurrence was generally fatal. Eight of the nine patients subsequently died of their disease. The ninth patient died of another cause. There was a high incidence of regional failure after unilateral groin and pelvic radiotherapy, but there were no recurrences on the nonirradiated, node-negative side. Although a small series, we speculate that there is no apparent disadvantage to administering unilateral adjuvant radiotherapy for unilaterally positive groin nodes and encourage further studies in order to more confidently determine whether the tendency observed in our center holds true.

Adult↗
PubMed2001

Incidence of pubic bone marrow oedema in Australian rules football players: relation to groin pain.

OBJECTIVES: To examine the relation between the clinical features of groin pain and groin magnetic resonance imaging (MRI) appearances in a group largely comprising elite Australian Rules football players. The incidence of bone marrow oedema and other MRI findings in the pubic symphysis region was noted. The relation between a past history of groin pain and these other MRI findings was also examined. METHOD: In a prospective study, 116 male subjects (89 footballers, 17 umpires, 10 sedentary men) were examined before history taking and groin MRI. The clinical history was not known to the examiner (GMV) and radiologists (JPS, GTF). Clinical evidence of groin pain and examination findings were correlated with the presence of increased signal intensity within the pubic bone marrow. A past history of groin pain was correlated with the presence of other MRI findings such as cyst formation, fluid signal within the pubic symphysis disc, and irregularity of the pubic symphysis. RESULTS: Fifty two athletes (47 footballers, five umpires) had clinical features of groin pain with pubic symphysis and/or superior pubic ramus tenderness. A high incidence of increased signal intensity (77%) within the pubic bone marrow was identified in this group. There was an association between this group of athletes and the MRI finding of increased signal intensity (p<0.01). There was also an association between a past history of groin pain and the presence of other MRI findings (p<0.01). CONCLUSIONS: Athletes with groin pain and tenderness of the pubic symphysis and/or superior pubic ramus have clinical features consistent with the diagnosis of osteitis pubis. The increased signal intensity seen on MRI is due to pubic bone marrow oedema. An association exists between the clinical features of osteitis pubis and the MRI finding of pubic bone marrow oedema. A high incidence of pubic bone marrow oedema was also noted. Degenerative features visualised by MRI, such as subchondral cyst formation, were associated with a past history of groin pain. A stress injury to the pubic bone is the most likely explanation for these MRI findings and may be the cause of the clinical entity osteitis pubis.

Adolescent↗
PubMed2005

The use of tensor fascia lata pedicled flap in reconstructing full thickness abdominal wall defects and groin defects following tumor ablation.

BACKGROUND: The tensor fascia lata is a versatile flap with many uses in reconstructive plastic surgery. As a pedicled flap its reach to the lower abdomen and groin made it an attractive option for reconstructing soft tissue defects after tumor ablation. However, debate exists on the safe dimension of the flap, as distal tip necrosis is common. Also, the adequacy of the fascia lata as a sole substitute for abdominal wall muscles has been disputable. The aim of the current study is to report our experience and clinical observations with this flap in reconstructing those challenging defects and to discuss the possible options to minimize the latter disputable issues. PATIENTS AND METHODS: From April 2001 to April 2004, 12 pedicled TFL flaps were used to reconstruct 5 central abdominal wall full thickness defects and 6 groin soft tissue defects following tumor resection. In one case, bilateral flaps were used to reconstruct a large central abdominal wall defect. There were 4 males and 7 females. Their age ranged from 19 to 60. From the abdominal wall defects group, all repairs were enforced primarily with a prolene mesh except for one patient who was the first in this study. Patients presenting with groin defects required coverage of exposed vessels following tumor resection. All patients in the current study underwent immediate reconstruction. RESULTS: The resulting soft tissue defects in this study were due to resection of 4 abdominal wall desmoid tumors, a colonic carcinoma infiltrating the abdominal wall, 4 primary groin soft tissue sarcomas, a metastatic SCC of the leg to groin nodes, and a primary SCC of the groin. The size of the flaps used ranged from 20 x 10 cm to 31 x 18 cm. All flaps survived. However, distal flap necrosis occurred in 4 cases. Three of those cases developed in flaps reconstructing abdominal wall defects, and one case developed in a flap used to cover a groin defect. In the former 3 cases, the flap was simply transposed without complete islanding of the flap. In the latter case, a very large flap was harvested beyond the safe limits with its distal edge just above the knee. In addition, wound dehiscence of the flap occurred in 2 other cases from the groin 132 group. Nevertheless, all the wounds healed spontaneously with repeated dressings. Out of the 5 cases that underwent abdominal wall reconstruction, one case developed ventral hernia, in which bilateral TFL flaps were used without mesh enforcement. There was minimal donor site morbidity in the form of partial skin graft loss in 2 cases. The average follow up period in this study ranged from 6 months to 2 years. Only one patient died of distant metastasis of a SCC of the groin skin, 8 months postoperatively and another 2 patients with abdominal desmoid tumors developed local recurrence. CONCLUSION: The tensor fascia lata flap is a reliable and a versatile flap, with minimal donor site morbidity. Problems with the flap's vascularity of its distal part should not be encountered, if the flap is harvested within the safe limits and properly designed and the edges comfortably insetted to the defect. A pedicled flap would be appropriate for lower abdominal wall defects, and is better islanded to achieve extra mobilization and allow a tension free closure, while for groin defects, simple flap transposition should be enough. Nevertheless, reconstruction for full thickness abdominal wall defects by this flap is a static reconstruction. We therefore strongly recommend enforcing the repair with a synthetic mesh primarily to minimize the incidence of ventral hernia. However, further studies with larger number of cases are needed to confirm this observation.

Abdominal Neoplasms↗
PubMedDate not supplied

Routine computerized tomography scanning, groin ultrasound with or without fine needle aspiration cytology in the surgical management of primary squamous cell carcinoma of the vulva.

We set out to study whether computerized tomography (CT) scanning of the vulva and the groin and groin ultrasound scanning (USS) alone or with fine needle aspiration cytology (FNAC) (USS/FNAC) influenced or could influence the surgical management of primary squamous cell carcinoma of the vulva (SCCaV). Forty-four patients underwent surgery for primary SCCaV following radiologic imaging by one or more modalities. Patient details included the clinical assessment of the carcinoma, radiologic findings, the operation performed, and whether the decision regarding the type and extent of surgery for the vulval carcinoma and, in particular, for the groin node dissection was or could be influenced by the radiologic findings. The age range was 38-87 years, with a median of 74 years. A total of 75 groin dissections were performed. Twenty-five of the 44 patients (56.8%) did not have groin node metastasis, 14 had unilateral metastasis (31.8%), and 5 (11.4%) had bilateral metastasis. All cases with histologically proven nodal status were analyzed to compare the preoperative imaging status with the histology. The calculated sensitivity, specificity, negative predictive value, and positive predictive value for CT were 58%, 75%, 75%, and 58%, for USS alone-87%, 69%, 94%, and 48%, and for USS-guided FNAC-80%, 100%, 93%, and 100%, respectively. There was no patient in whom surgical planning for the vulval carcinoma or the groin nodes was or could be altered by the CT findings. The data do not support the routine use of CT scanning in patients with primary SCCaV, either in assessment of the primary vulval carcinoma or in detecting groin nodal metastases. For the groin nodes, USS/FNAC is superior to CT in assessing disease status. In contrast to CT, USS/FNAC may have a useful clinical role in the management of the groin nodes in vulval carcinoma.

Adult↗
PubMed2005

Groin pain in footballers: the association between preseason clinical and pubic bone magnetic resonance imaging findings and athlete outcome.

BACKGROUND: Groin pain and tenderness are common in athletes from a variety of codes of football, but little attention has been directed to the influence of magnetic resonance imaging and such clinical findings on athlete participation. HYPOTHESIS: Preseason groin pain, tenderness, and magnetic resonance imaging findings such as pubic bone marrow edema are associated with restricted training capacity and missed games. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: Fifty-two Australian footballers in the national competition were recruited. Preseason groin pain and focal tenderness were recorded, and magnetic resonance imaging of the groin was performed within 1 week of examination. Training restriction and games missed owing to groin pain were documented during the subsequent season. RESULTS: Magnetic resonance imaging showed pubic bone marrow edema in 19 of 52 (37%) footballers and linear parasymphyseal T2 hyperintensity in 16 of 52 (31%) footballers. Groin pain restricted training during the season in 22 of 52 (42%) footballers, and 9 of 52 (17%) footballers missed at least 1 game. Preseason pain (P = .0004), pubic bone tenderness (P = .02), and linear parasymphyseal T2 hyperintensity (P = .01) were associated with restricted training capacity during the subsequent season. Preseason groin pain (P = .03) was associated with missed games, but magnetic resonance imaging findings were not. CONCLUSION: Preseason pubic bone marrow edema, groin pain, and linear parasymphyseal T2 hyperintensity were associated with training restriction, but only preseason groin pain was associated with missed games.

Adolescent↗
PubMed1997

Endoscopic preperitoneal herniorrhaphy in professional athletes with groin pain.

INTRODUCTION: Surgical exploration of the groin with subsequent herniorrhaphy has been recommended for obscure groin pain in athletes. The purpose of this study was to evaluate the efficacy of endoscopic preperitoneal herniorrhaphy and, if indicated, contralateral groin exploration in professional athletes with groin pain. PATIENTS AND METHODS: Eight professional athletes presented with groin pain and underwent endoscopic preperitoneal herniorrhaphy between February 1994 and May 1996. All athletes were male with a median age of 25.1 years (range: 22-30). Seven of the athletes complained of unilateral groin pain while one patient had bilateral pain. Seven had undergone previous conservative treatment without success. Despite multiple examinations, only two patients had been diagnosed with hernias prior to referral to the surgeon. Of the remaining six patients, all were found to have small inguinal hernias in the symptomatic groin. Seven of the patients were noted to have bilateral pathology. RESULTS: Operative time averaged 55.3 min. All patients were ambulatory without significant difficulty within the first 24 h, discontinued oral narcotic use within 72 h of surgery, and were back to recreational activities within 1 week. Aerobic conditioning was resumed within a maximum of 2 weeks. Full conditioning and/or return to full competition occurred within a 2- to 3-week period. At the time of 4 week follow-up, all athletes reported no more than minimal postexertional discomfort, with near total relief of early postoperative symptoms. No athletes noted any impairment in their ability to perform at peak levels. CONCLUSIONS: Groin pain in athletes is a difficult problem requiring a multidisciplinary approach to diagnosis and treatment planning. Endoscopic preperitoneal herniorrhaphy is an effective treatment for obscure groin pain when the pain is associated with an inguinal hernia and allows for a short recovery time back to full athletic activity.

Adult↗
PubMed1993

Femoral vessel depth and the implications for groin node radiation.

PURPOSE: To quantify, based on pretreatment computer tomographic measurements, potential groin node depths, which will aid in optimal treatment planning for patients requiring groin node radiation. METHODS AND MATERIALS: The pretreatment computer tomographic scans of 50 gynecologic cancer patients were reviewed to determine the distance of each femoral vessel beneath the overlying skin surface, as an indicator of potential groin node depth. Correlative data regarding height and weight were obtained from patient medical records, and were used to calculate the Quetelet index, defined as (weight in kg)/(height in m)2. Treatment parameters of 5 patients who failed prophylactic groin radiation in a recently published study were assessed to determine if underdosage represented a possible cause of failure. RESULTS: Individual femoral vessel depths ranged from 2.0 to 18.5 cm. When the depths of all four femoral vessels were averaged in each patient, the mean "4-vessel average" depth for this patient population was 6.1 cm. The median Quetelet index for the group was 25.6, and there was a strong correlation between femoral vessel depth and patient Quetelet index. Recalculation of doses provided to the 5 patients failing prophylactic groin radiation in the Gynecologic Oncology Group study showed that all had received potential tumor doses < 4700 cGy, with 3 patients being underdosed by > 30%. CONCLUSION: While surgery is often indicated in the management of patients with potential groin node metastases, the role of prophylactic groin radiation should not be rejected. Data from this study may aid in the optimal design and implementation of groin node radiotherapy.

Adult↗