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Alessandri-Bonetti M, Giorgino R, Costantino A, Amendola F, De Virgilio A, Mangiavini L, Peretti GM, Vaienti L, Azoury SC, Egro FM. Soft tissue flap reconstruction in infected or exposed total knee arthroplasty: A systematic review and network meta-analysis. Knee 2025; 52:9-21. [PMID: 39514982 DOI: 10.1016/j.knee.2024.10.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Revised: 08/12/2024] [Accepted: 10/18/2024] [Indexed: 11/16/2024]
Abstract
BACKGROUND Total knee arthroplasty (TKA) infection or exposure associated with soft tissue deficiency represents a challenging scenario for the reconstructive surgeon. The aim of the study is to determine the most successful reconstructive option for infected or exposed TKA comparing local muscle flaps (LMF), local fasciocutaneous flaps (LFF), and free muscle flaps (FMF). METHODS A systematic review and single-arm network meta-analysis (PRISMA) was conducted to compare outcomes of complicated TKA requiring soft tissue coverage with either LMF, LFF and FMF. The protocol was registered on PROSPERO (CRD42023388731). PubMed, Embase, Web of Science and Cochrane Library were queried. MINORS criteria were employed for bias assessment. Outcomes included infection recurrence, TKA failure, above-knee amputation, and arthrodesis. RESULTS A total of 30 studies and 555 flaps were included. Pooled prevalence was 0.18 (95% CI: 0.11-0.26) for infection recurrence, 0.18 (95% CI: 0.11-0.28) for arthroplasty failure, 0.10 (95% CI: 0.08-0.13) for above-knee amputation and 0.10 (95% CI: 0.08-0.13) for arthrodesis. Local fasciocutaneous flaps demonstrated the lowest risk of infection recurrence (LFF = 0.04 ± 0.037, LMF = 0.27 ± 0.043, FMF = 0.26 ± 0.092), arthroplasty failure (LFF = 0.11 ± 0.068, LMF = 0.28 ± 0.045, FMF = 0.22 ± 0.094) and knee arthrodesis (LFF = 0.03 ± 0.027, LMF = 0.14 ± 0.03, FMF = 0.08 ± 0.06) after flap coverage of infected TKA. Free muscle flaps were associated with the lowest risk of above knee amputation (FMF = 0.08 ± 0.07, LFF = 0.10 ± 0.07, LMF = 0.11 ± 0.03). The mean MINORS score was 11.1 (95% CI: 11-12) with major weakness being the lack of prospective enrollment of the patients. CONCLUSION Based on the available literature, when appropriate, LFF appear to be the best reconstructive choice for soft tissue reconstruction in complicated TKA.
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Affiliation(s)
- Mario Alessandri-Bonetti
- Department of Plastic Surgery, University of Pittsburgh Medical Center, 3550 Terrace Street 6B Scaife Hall, Pittsburgh, PA 15261, USA; Department of Plastic Surgery, IRCCS Ospedale Galeazzi - Sant'Ambrogio, Via Cristina Belgioioso 173, 20161, Milan, Italy
| | - Riccardo Giorgino
- IRCCS Ospedale Galeazzi - Sant'Ambrogio, Via Cristina Belgioioso 173, 20161 Milan, Italy.
| | - Andrea Costantino
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090 Pieve Emanuele Milan, Italy
| | - Francesco Amendola
- Department of Plastic Surgery, IRCCS Ospedale Galeazzi - Sant'Ambrogio, Via Cristina Belgioioso 173, 20161, Milan, Italy
| | - Armando De Virgilio
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090 Pieve Emanuele Milan, Italy
| | - Laura Mangiavini
- IRCCS Ospedale Galeazzi - Sant'Ambrogio, Via Cristina Belgioioso 173, 20161 Milan, Italy; Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
| | - Giuseppe M Peretti
- IRCCS Ospedale Galeazzi - Sant'Ambrogio, Via Cristina Belgioioso 173, 20161 Milan, Italy; Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
| | - Luca Vaienti
- Department of Plastic Surgery, IRCCS Ospedale Galeazzi - Sant'Ambrogio, Via Cristina Belgioioso 173, 20161, Milan, Italy; Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
| | - Saïd C Azoury
- Division of Plastic and Reconstructive Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Francesco M Egro
- Department of Plastic Surgery, University of Pittsburgh Medical Center, 3550 Terrace Street 6B Scaife Hall, Pittsburgh, PA 15261, USA
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Hamrouni N, Højvig JH, Knudsen UK, Skovgaard KK, Jensen LT, Bonde CT, Odgaard A. Microvascular free flap coverage of complex soft tissue defects after revision total knee arthroplasty: a cross-sectional observation study. Acta Orthop 2024; 95:186-191. [PMID: 38630868 PMCID: PMC11024721 DOI: 10.2340/17453674.2024.40183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 02/10/2024] [Indexed: 04/19/2024] Open
Abstract
BACKGROUND AND PURPOSE Soft tissue defects after total knee arthroplasties (TKA) represent a major orthopedic challenge with amputation as a feared outcome. Microvascular free flap coverage (FFC) can increase limb salvage rates, but complications related to the procedure are yet to be explored further. We aimed to review a single-center experience with FFC for soft tissue defects related to revision total knee arthroplasty. METHODS Through a retrospective chart review from 2006 to 2021, we identified all patients who had FFC of a knee with an existing TKA. Typically, patients underwent 2-stage revision arthroplasty. To identify areas of intervention, we divided the entire regimen into 2 phases divided by the free flap surgery (pre- and post-free flap). RESULTS We identified 18 patients with a median age at free flap surgery of 69 years (range 39-85), who were followed for a median of 5.1 years (range 2 months to 10.6 years). The median duration from primary TKA to their final operation was 17.5 months (range 19 days to 7 years). Patients underwent a mean of 7.6 surgical procedures on their knee with 3.6 orthopedic revisions prior to the FFC and 0.6 after. Soft tissue coverage was achieved in all patients and no patients underwent amputation. One-third of patients experienced early complications at recipient site after free flap surgery. There were no donor site complications. CONCLUSION Microvascular FFC of complex soft tissue defects after revision total knee arthroplasty proved achievable in all patients with successful limb salvage in all patients.
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Affiliation(s)
- Nizar Hamrouni
- Department of Plastic Surgery and Burns Treatment, Center of Head, Neck and Orthopedics, University Hospital of Copenhagen, Rigshospitalet, Copenhagen.
| | - Jens H Højvig
- Department of Plastic Surgery and Burns Treatment, Center of Head, Neck and Orthopedics, University Hospital of Copenhagen, Rigshospitalet, Copenhagen
| | - Ulrik K Knudsen
- Department of Orthopedic Surgery, Center of Head, Neck and Orthopedics, University Hospital of Copenhagen, Rigshospitalet, Copenhagen
| | - Kurt K Skovgaard
- Department of Orthopedic Surgery, Center of Head, Neck and Orthopedics, University Hospital of Copenhagen, Rigshospitalet, Copenhagen
| | - Lisa T Jensen
- Department of Plastic Surgery and Burns Treatment, Center of Head, Neck and Orthopedics, University Hospital of Copenhagen, Rigshospitalet, Copenhagen
| | - Christian T Bonde
- Department of Plastic Surgery and Burns Treatment, Center of Head, Neck and Orthopedics, University Hospital of Copenhagen, Rigshospitalet, Copenhagen
| | - Anders Odgaard
- Department of Orthopedic Surgery, Center of Head, Neck and Orthopedics, University Hospital of Copenhagen, Rigshospitalet, Copenhagen; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Charlès L, Lupon E, Sheth T, Camuzard O, Lellouch AG, Shende C, Farquharson S, Safa K, Cetrulo CL. Immunosuppressant drug monitor: A non-invasive device to measure tacrolimus level in the saliva of transplanted patients. Int J Pharm 2024; 653:123858. [PMID: 38286196 DOI: 10.1016/j.ijpharm.2024.123858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 01/22/2024] [Accepted: 01/24/2024] [Indexed: 01/31/2024]
Abstract
Solid organ and vascularized composite allograft transplantation are pivotal in enhancing both life expectancy and quality of life. However, the significant risk of donor tissue rejection requires lifelong immunosuppressive therapy. Tacrolimus, a common component of immunosuppressive regimens, offers effectiveness in preventing organ rejection but poses challenges due to its narrow therapeutic window and toxicity, making it essential to carefully monitor its concentration. Tacrolimus trough levels are currently measured in blood, requiring frequent blood draws from patients, and results are available after 3 to 6 h. To address the need for a fast, minimally-invasive, and simple method to monitor tacrolimus concentrations, we have assessed a new device for at-home analysis, the Immunosuppressant Drug Monitor (IDM) that can extract, identify and quantify tacrolimus in saliva within 15 min. We included males and females hospitalized at Massachusetts General Hospital Transplant Unit, between the ages of 21 and 65 years, and treated with Tacrolimus. Informed consent, demographic and treatment data were collected. Each subject was asked to provide a 5 mL saliva sample that was de-identified and processed by the IDM, while a 5 mL blood sample was drawn and supplied to the MGH clinical lab for analysis by the current standard, immunoassays. The predicted tacrolimus concentration found in saliva was compared to the blood trough level results. 62 samples from 31 different patients were obtained. The male to female ratio and ethnicity distribution were well balanced. The majority of patients were within 30 days of initiating tacrolimus treatment. After IDM calibration and exclusion, 21 samples were measured by the IDM. Using an exponential function fit, the IDM showed a correlation of R2 = 0.39 between the saliva Test Line absorption and the measured tacrolimus concentration in blood, with an average absolute error of 1.8 ng/mL. Our results demonstrate a clear correlation between blood and saliva measurements. The IDM provided promising results to monitor immunosuppressant drug concentrations in patients after transplantation. Future larger studies will further develop the correlation, and the IDM's potential impact on patient outcomes.
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Affiliation(s)
- Laura Charlès
- Vascularized Composite Allotransplantation Laboratory, Center for Transplantation Sciences, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
| | - Elise Lupon
- Vascularized Composite Allotransplantation Laboratory, Center for Transplantation Sciences, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Department of Plastic and Reconstructive Surgery, Institut Universitaire Locomoteur et du Sport, Pasteur 2 Hospital, University Côte d'Azur, Nice, France; Department of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Tia Sheth
- Vascularized Composite Allotransplantation Laboratory, Center for Transplantation Sciences, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Olivier Camuzard
- Department of Plastic and Reconstructive Surgery, Institut Universitaire Locomoteur et du Sport, Pasteur 2 Hospital, University Côte d'Azur, Nice, France.
| | - Alexandre G Lellouch
- Vascularized Composite Allotransplantation Laboratory, Center for Transplantation Sciences, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Department of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Boston, MA, USA; Innovative Therapies in Haemostasis, INSERM UMR-S 1140, University of Paris, Paris F-75006, France.
| | - Chetan Shende
- Real-Time Analyzers Inc., 362 Industrial Park Road, Unit 8, Middletown, CT 06457, USA.
| | - Stuart Farquharson
- Real-Time Analyzers Inc., 362 Industrial Park Road, Unit 8, Middletown, CT 06457, USA.
| | - Kassem Safa
- Division of Nephrology & Transplant Center, Massachusetts General Hospital, Boston, MA, USA.
| | - Curtis L Cetrulo
- Vascularized Composite Allotransplantation Laboratory, Center for Transplantation Sciences, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Department of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Boston, MA, USA.
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Ha Y, Lee BH, Park JA, Kim YH. Reconstruction of soft tissue defect around knee with thoracodorsal artery perforator flap and muscle-sparing latissimus dorsi flap. Microsurgery 2023; 43:665-675. [PMID: 36789684 DOI: 10.1002/micr.31024] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Revised: 12/15/2022] [Accepted: 02/02/2023] [Indexed: 02/16/2023]
Abstract
INTRODUCTION Around the knee reconstruction is challenging for reconstructive surgeons. Several methods have been proposed, including perforator and muscle flaps; however, all have advantages and disadvantages. As the success rate of free-flap surgery increases, reconstruction around the knee using this method is becoming increasingly popular. Nevertheless, there are no large-scale case reports in the previous literature using either a thoracodorsal artery perforator flap (latissimus dorsi (LD) perforator flap) or a muscle-sparing latissimus dorsi (msLD) flap for reconstruction around the knee. In this retrospective report, we describe our clinical experiences and present an algorithm regarding recipient vessel choice in free-flap reconstructive surgery of around the knee defects. PATIENT AND METHODS Fifty-six cases in which a flap from the lateral thoracic area was used to reconstruct an around the knee defect between January 2016 and March 2022 were reviewed. The patients were aged 18-87 years (mean, 52.13 years), and of the 56 patients, 36 were male and 20 were female. Injuries were caused by trauma, contracture, rheumatoid vasculitis, tumor, infection, burns, sunken deformity, and pressure sores. The 56 cases included 22 with a defect including the knee, 14 with a defect below the knee (7 of the primary below-knee amputation [BKA] and 7 of the secondary BKA), 9 involving the distal medial thigh, 8 involving the distal lateral thigh, 2 involving the popliteal area, and 1 involving the middle thigh. Most cases were reconstructed using a single LD perforator flap or msLD flap. Chimeric or supplementary flaps were used when extensive coverage or dead space obliteration was required. The average size of the defect area was 253.6 cm2 (range: 5 × 6-21 × 39 cm2 ). RESULTS In the cases, the recipient artery used included the following: descending genicular artery (23), superficial femoral artery (14), descending branch of the lateral circumflex femoral artery (14), anterior tibial artery (2), popliteal artery (2), and posterior tibial artery (1). The recipient vein included the greater saphenous vein (24), descending branch of the lateral circumflex femoral vein (14), superficial femoral vein (7), descending genicular vein (6), anterior tibial vein (2), popliteal vein (2), and posterior tibial vein (1). The average flap size was 281.8 cm2 (range: 4 × 8-35 × 19 cm2 ). All flaps survived; however, seven complications occurred, including 2 partial flap losses, 1 arterial insufficiency, 1 hematoma, 1 minor dehiscence, 1 donor-site graft loss, and 1 short BKA. Normal knee range of motion (121-140°) was observed in 34 patients and 16 showed varying degrees of limited range of motion. Motion was not observed in four patients who underwent knee fusion and could not be evaluated in two patients who underwent above-knee amputation. The mean follow-up duration was 24.6 months (range: 4-72 months). CONCLUSION The LD perforator flap is ideal for the reconstruction of around the knee defects because it enables a long pedicle, large flap, and chimeric design. The msLD flap is ideal because it enables strong stump support, dead-space obliteration, and infection control. Moreover, since the two flaps are distant from the knee, this method is advantageous in terms of postoperative rehabilitation and there is minimal donor-site morbidity due to the thin nature of the LD muscle. In addition, the flap can be elevated in three positions and the operation can be completed without positional changes in various recipient vessel locations. Based on our experience, we conclude that the LD flap has the potential to be used as widely as or in preference to the anterolateral thigh flap in the reconstruction of around the knee defects.
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Affiliation(s)
- Yooseok Ha
- Department of Plastic and Reconstructive Surgery, College of Medicine, Chungnam National University, Daejeon, Republic of Korea
| | - Bo Hyun Lee
- Department of Plastic and Reconstructive Surgery, College of Medicine, Hanyang University, Seoul, Republic of Korea
| | - Ji Ah Park
- Design Lab of Technology Commercialization Center, Industry-University Cooperation, Foundation of Hanyang University, Seoul, Republic of Korea
| | - Youn Hwan Kim
- Department of Plastic and Reconstructive Surgery, College of Medicine, Hanyang University, Seoul, Republic of Korea
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Chandra AA, Romanelli F, Tang A, Menken L, Zhang M, Feintisch A, Liporace FA, Yoon RS. A comparison of healing and complication rates between common flaps utilized in total knee arthroplasty: a review of the literature. Knee Surg Relat Res 2022; 34:15. [PMID: 35346398 PMCID: PMC8961959 DOI: 10.1186/s43019-022-00145-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 03/11/2022] [Indexed: 11/12/2022] Open
Abstract
Background Flap reconstruction with perforator, fasciocutaneous, muscular, and/or free microvascular flaps is utilized to cover wound defects and improve vascularization and antibiotic/nutrient delivery. Flap use in revision procedures for total knee arthroplasty has been explored previously; however, current data are limited and studies comparing healing and complication rates between different flap types are lacking. Methods A literature review was performed using PubMed on 13 January 2022. Studies were included if they reported healing and complication rates for either gastrocnemius, rectus abdominis, latissimus dorsi, fasciocutaneous, chimeric, or gracilis flaps in the setting of revision total knee arthroplasty (TKA). Results The final cohort included gastrocnemius (n = 421, healing rate 73.8%, complication rate 59.9%), gracilis (n = 9, healing rate 93%, complication rate 55.6%), latissimus dorsi (n = 41, healing rate 67%, complication rate 46.3%), rectus abdominis (n = 3, healing rate 100%, complication rate 0%), fasciocutaneous (n = 78, healing rate 70%, complication rate 19.2%), and chimeric flaps (n = 4, healing rate 100%, complication rate 25%). There was no significant difference when comparing healing rates across flap types (p = 0.39). There was a significant difference when comparing complication rates across flap types (p < 0.0001), with a significant difference being noted between gastrocnemius and fasciocutaneous complication rates (p < 0.0001). All other comparisons between flap types by complication rate were not significantly different. Conclusions Gastrocnemius flaps are the workhorse flap in the setting of revision TKA, as evidenced by this review. Healing rates did not vary significantly across flap types, which suggests that determining the appropriate flap for coverage of soft-tissue defects in revision TKA should be driven by defect size and location as well as physician experience and patient tolerance.
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Rovere G, Smakaj A, Calori S, Barbaliscia M, Ziranu A, Pataia E, Maccauro G, De Mauro D, Liuzza F. Use of muscular flaps for the treatment of knee prosthetic joint infection: A systematic review. Orthop Rev (Pavia) 2022; 14:33943. [PMID: 35774925 PMCID: PMC9239382 DOI: 10.52965/001c.33943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Accepted: 12/28/2021] [Indexed: 11/06/2022] Open
Abstract
Deep periprosthetic infection after total knee arthroplasty is a serious and challenging complication for the orthopedic surgeon. Muscular flaps may represent a valid treatment option for the treatment of this condition. We present a systematic literature review about the use of muscular flaps for the treatment of knee prosthetic joint infection. The review is reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. 70 articles, out of 589 titles, were considered eligible for the full-text analysis. Finally, 27 studies that met inclusion criteria were included in this review. Overall, 345 patients (139 males, 206 females) suffering from TKA infection treated with muscular flaps were collected. The mean age was 57.3 years. Mean follow-up, reported in all studies, was 30.1 months. The results presented by the different authors, highlight the effectiveness of muscular flaps for the treatment of periprosthetic infection, in terms of function, limb salvage, prevention of recurrences, cost-effectiveness, and quality of life postoperatively. Muscle flaps provide an excellent management option for patients with persistent infection after total knee arthroplasty.
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Affiliation(s)
- Giuseppe Rovere
- Department of Orthopedics and Traumatology Fondazione Policlinico Universitario A. Gemelli IRCSS, Roma, Italia; Università Cattolica Del Sacro Cuore, Roma, Italia
| | - Amarildo Smakaj
- Department of Orthopedics and Traumatology Fondazione Policlinico Universitario A. Gemelli IRCSS, Roma, Italia; Università Cattolica Del Sacro Cuore, Roma, Italia
| | - Sara Calori
- Department of Orthopedics and Traumatology Fondazione Policlinico Universitario A. Gemelli IRCSS, Roma, Italia; Università Cattolica Del Sacro Cuore, Roma, Italia
| | - Marco Barbaliscia
- Department of Orthopedics and Traumatology Fondazione Policlinico Universitario A. Gemelli IRCSS, Roma, Italia; Università Cattolica Del Sacro Cuore, Roma, Italia
| | - Antonio Ziranu
- Department of Orthopedics and Traumatology Fondazione Policlinico Universitario A. Gemelli IRCSS, Roma, Italia; Università Cattolica Del Sacro Cuore, Roma, Italia
| | - Elisabetta Pataia
- Department of Orthopedics and Traumatology Fondazione Policlinico Universitario A. Gemelli IRCSS, Roma, Italia; Università Cattolica Del Sacro Cuore, Roma, Italia
| | - Giulio Maccauro
- Department of Orthopedics and Traumatology Fondazione Policlinico Universitario A. Gemelli IRCSS, Roma, Italia; Università Cattolica Del Sacro Cuore, Roma, Italia
| | - Domenico De Mauro
- Department of Orthopedics and Traumatology Fondazione Policlinico Universitario A. Gemelli IRCSS, Roma, Italia; Università Cattolica Del Sacro Cuore, Roma, Italia
| | - Francesco Liuzza
- Department of Orthopedics and Traumatology Fondazione Policlinico Universitario A. Gemelli IRCSS, Roma, Italia; Università Cattolica Del Sacro Cuore, Roma, Italia
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Macken AA, Lans J, Miyamura S, Eberlin KR, Chen NC. Soft-tissue coverage for wound complications following total elbow arthroplasty. Clin Shoulder Elb 2021; 24:245-252. [PMID: 34875731 PMCID: PMC8651597 DOI: 10.5397/cise.2021.00409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 08/20/2021] [Indexed: 11/25/2022] Open
Abstract
Background In patients with total elbow arthroplasty (TEA), the soft-tissue around the elbow can be vulnerable to soft-tissue complications. This study aims to assess the outcomes after soft-tissue reconstruction following TEA. Methods We retrospectively included nine adult patients who underwent soft-tissue reconstruction following TEA. Demographic data and disease characteristics were collected through medical chart reviews. Additionally, we contacted all four patients that were alive at the time of the study by phone to assess any current elbow complications. Local tissue rearrangement was used for soft-tissue reconstruction in six patients, and a pedicle flap was used in three patients. The median follow-up period was 1.3 years (range, 6 months–14.7 years). Results Seven patients (78%) underwent reoperation. Four patients (44%) had a reoperation for soft-tissue complications, including dehiscence or nonhealing of infected wounds. Five patients (56%) had a reoperation for implant-related complications, including three infections and two peri-prosthetic fractures. At the final follow-ups, six patients (67%) achieved successful wound healing and two patients had continued wound healing issues, while two patients had an antibiotic spacer in situ and one patient underwent an above-the-elbow amputation. Conclusions This study reports a complication rate of 78% for soft-tissue reconstructions after TEA. Successful soft-tissue healing was achieved in 67% of patients, but at the cost of multiple surgeries. Early definitive soft-tissue reconstruction could prove to be preferable to minor interventions such as irrigation, debridement, and local tissue advancement, or smaller soft-tissue reconstructions using local tissue rearrangement or a pedicled flap at a later stage.
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Affiliation(s)
- Arno A Macken
- Orthopedic Hand and Upper Extremity Service, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Jonathan Lans
- Orthopedic Hand and Upper Extremity Service, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Satoshi Miyamura
- Orthopedic Hand and Upper Extremity Service, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Kyle R Eberlin
- Plastic, Reconstructive and Hand Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Neal C Chen
- Orthopedic Hand and Upper Extremity Service, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Addressing common orthopaedic calamities with microsurgical solutions. Injury 2021; 52:3561-3572. [PMID: 34030865 DOI: 10.1016/j.injury.2021.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 05/04/2021] [Indexed: 02/02/2023]
Abstract
Reconstructive microsurgery has been an essential aspect of orthopaedic surgery and extremity reconstruction since the introduction of the operating microscope in the mid-20th century. The reconstructive ladder ranges from simple healing by secondary intention to complex procedures such as free tissue transfer and vascularized composite allotransplantation. As orthopaedic surgery has evolved over the past 60 years, so too have the reconstructive microsurgical skills that are often needed to address common orthopaedic surgery problems. In this article, we will discuss a variety of complex orthopaedic surgery scenarios ranging from trauma to infection to tumor resection as well as the spectrum of microsurgical solutions that can aid in their management.
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The Usage of Pedicled or Free Muscle Flaps Represents a Beneficial Approach for Periprosthetic Infection After Knee Arthroplasty. Ann Plast Surg 2020; 85:539-545. [PMID: 32079811 DOI: 10.1097/sap.0000000000002293] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Periprosthetic joint infection (PJI) is a severe complication after a total knee replacement that is primarily associated with soft tissue defects. Finding an appropriate therapy for PJI is a major challenge because of the lack of guidelines and research comparing treatment options. METHODS In this study, we retrospectively compared 78 patients who had a knee prosthetic infection within a mean follow-up period of 24 months. Group A received a soft tissue coverage in addition to orthopedic surgical therapy with or without a component replacement (CR) of the prosthesis. Group B received the same orthopedic treatment without plastic surgery for soft tissue coverage. RESULTS Only 21% of the patients in group A received a CR compared with 70% in group B (P = 0.0001). In group A, 83% did not have a recurrent infection, and in group B, 57% of the patients had no further infection and regained joint function (P = 0.0376). In group A, only 15% of the patients who received a CR had a significant complication within the follow-up period of 2 years, whereas in group B, 75% of patients exhibiting a major complication (P = 0.0048*). CONCLUSIONS Soft tissue coverage improves the outcome after PJI of the knee with soft tissue defects. Patients who simultaneously needed plastic surgery for defect coverage and orthopedic surgery for CR had the lowest number of complications overall. Based on the results of this study, a therapy algorithm could be identified considering the soft tissue defect grade leading to the lowest major complication rates and maximizing the outcome of knee prosthesis infection therapies.
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Amin NH, Speirs JN, Simmons MJ, Lermen OZ, Cushner FD, Scuderi GR. Total Knee Arthroplasty Wound Complication Treatment Algorithm: Current Soft Tissue Coverage Options. J Arthroplasty 2019; 34:735-742. [PMID: 30665832 DOI: 10.1016/j.arth.2018.12.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Revised: 12/10/2018] [Accepted: 12/12/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Wound complications associated with soft tissue defects following total knee arthroplasty present challenges for the orthopedic surgeon. The scale of early complications include less morbid problems, such as quickly resolving drainage and small superficial eschars, to persistent drainage and full-thickness tissue necrosis, which may require advanced soft tissue coverage. METHODS This review outlines current wound management strategies and provides an algorithm to help guide treatment and clinical decision-making. CONCLUSION A surgeon's understanding of soft tissue coverage options is essential in protecting the knee prosthesis from a deep infection and to obtain an optimal functional outcome.
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Affiliation(s)
- Nirav H Amin
- Department of Orthopedic Surgery, Loma Linda University, Loma Linda, CA
| | - Joshua N Speirs
- Department of Orthopedic Surgery, Loma Linda University, Loma Linda, CA
| | - Matthew J Simmons
- Department of Orthopedic Surgery, Sierra Pacific Orthopedic Center, Fresno, CA
| | - Oren Z Lermen
- Department of Plastic Surgery, Lenox Hill Hospital, New York, NY
| | - Fred D Cushner
- Department of Orthopedic Surgery, Lenox Hill Hospital, New York, NY
| | - Giles R Scuderi
- Department of Orthopedic Surgery, Lenox Hill Hospital, New York, NY
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Phillips JRA, Al-Mouazzen L, Morgan-Jones R, Murray JR, Porteous AJ, Toms AD. Revision knee complexity classification-RKCC: a common-sense guide for surgeons to support regional clinical networking in revision knee surgery. Knee Surg Sports Traumatol Arthrosc 2019; 27:1011-1017. [PMID: 30850881 DOI: 10.1007/s00167-019-05462-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2018] [Accepted: 03/04/2019] [Indexed: 01/18/2023]
Abstract
PURPOSE There is considerable variation in practice throughout Europe in both the services provided and in the outcomes of Revision Knee Surgery. In the UK, a recent report published called get it right first time (GIRFT) aims to improve patient outcomes through providing high quality, cost-effective care, and reducing complications. This has led to the development of a classification system that attempts to classify the complexity of revision knee surgery, aiming to encourage and support regional clinical networking. METHODS The revision knee classification system (RKCC) incorporates not only complexity, but also patient factors, the presence of infection, the integrity of the extensor mechanism, and the soft tissues. It then provides guidance for clinical network discussion. Reliability and reproducibility testing have been performed to establish the inter- and intra-observer variabilities using this classification. RESULTS Good correlation between first attempt non-expert and experts, good intra-observer variability of non-expert, and an excellent correlation between second attempt non-expert and experts has been achieved. This supports the use of RKCC by both inexperienced and experienced surgeons. CONCLUSIONS The revision knee complexity classification has been proposed that offers a common-sense approach to recognize the increasing complexity in revision TKR cases. It provides a methodological assessment of revision knee cases and support regional clinical networking and triage of appropriate cases to revision units or specialist centres. LEVEL OF EVIDENCE Expert opinion, Level V.
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Affiliation(s)
- J R A Phillips
- Exeter Knee Reconstruction Unit, Princess Elizabeth Orthopaedic Centre, Royal Devon and Exeter Hospital, Barrack Road, Exeter, UK.
| | - L Al-Mouazzen
- Southmead Hospital, Southmead Road, Westbury-on-Trym, Bristol, UK
| | | | - J R Murray
- Southmead Hospital, Southmead Road, Westbury-on-Trym, Bristol, UK
| | - A J Porteous
- Southmead Hospital, Southmead Road, Westbury-on-Trym, Bristol, UK
| | - A D Toms
- Exeter Knee Reconstruction Unit, Princess Elizabeth Orthopaedic Centre, Royal Devon and Exeter Hospital, Barrack Road, Exeter, UK
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12
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Perrault D, Manrique OJ, Lee G, Carre AL, Oakes DA, Wong AK. Complex Reconstruction of the Knee with a Free Vertical Rectus Abdominis Flap after Periprosthetic Soft Tissue Necrosis. Cureus 2019; 11:e3969. [PMID: 30956921 PMCID: PMC6438685 DOI: 10.7759/cureus.3969] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Periprosthetic joint infection (PJI) is limb threatening and difficult to treat. Although a two-stage re-implantation is accepted as the standard of care for PJI, extensive debridement, numerous surgeries, or liquifactive necrosis from the infection can result in a tissue defect. With a large tissue defect, soft tissue coverage is required to protect the prosthesis, fill any dead space, and obtain a satisfactory wound closure. With defects too large for local or regional flap coverage, free tissue transfer is the best option. We present a case in which soft tissue coverage with both medial and lateral gastrocnemius muscle flaps was not sufficient; free tissue transfer was necessary for both wound closure and creation of an adequate soft tissue envelope for the future placement of a prosthesis. Regardless of the complicated surgical history and extensive soft tissue damage, limb function was restored and the patient regained his independence.
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Affiliation(s)
- David Perrault
- Plastic Surgery, Keck School of Medicine of USC, Los Angeles, USA
| | | | - Gene Lee
- Plastic Surgery, Keck School of Medicine of USC, Los Angeles, USA
| | - Antione L Carre
- Plastic Surgery, Keck School of Medicine of USC, Los Angeles, USA
| | - Daniel A Oakes
- Orthopaedics, Keck School of Medicine of USC, Los Angeles, USA
| | - Alex K Wong
- Plastic Surgery, Keck School of Medicine of USC, Los Angeles, USA
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13
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Zhao Y, Qi BW, Wang YQ, Liu D, Chen F, Huang Z, Pan ZY. Hardware removal or preservation? Decision making based on a newly developed rating scale. Injury 2018; 49:1999-2004. [PMID: 30193911 DOI: 10.1016/j.injury.2018.08.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Accepted: 08/29/2018] [Indexed: 02/02/2023]
Abstract
Hardware exposure following open reduction and internal fixation (ORIF) surgery is a tricky problem. It is always hard for surgeons to decide whether to keep or remove the hardware. In this study, a rating scale and corresponding clinical path is developed based on former published paper as well as our own experience. New admitted patients are first evaluated and scored once they enter the department. Based on the score they get, patients are assigned to different therapeutic schedule, i.e. (1) hardware preservation with pedicel flap transplantation, (2) debridement for further reevaluation and (3) hardware removal with external fixation. Satisfying clinical outcome is achieved that is characterized with high osseous consolidation rate and low complication rate. The result showed that this newly developed rating scale and the related therapeutic schedule could be an available tool to help surgeons to make decisions in the treatment of hardware exposure.
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Affiliation(s)
- Yong Zhao
- Department of Orthopedics, Zhongnan Hospital of Wuhan University, Wuhan 430072, China
| | - Bai-Wen Qi
- Department of Orthopedics, Zhongnan Hospital of Wuhan University, Wuhan 430072, China
| | - Yao-Qing Wang
- Department of Orthopedics, Zhongnan Hospital of Wuhan University, Wuhan 430072, China
| | - Di Liu
- Department of Orthopedics, Zhongnan Hospital of Wuhan University, Wuhan 430072, China
| | - Fan Chen
- Department of Orthopedics, Zhongnan Hospital of Wuhan University, Wuhan 430072, China
| | - Zhen Huang
- Department of Orthopedics, Zhongnan Hospital of Wuhan University, Wuhan 430072, China
| | - Zhen-Yu Pan
- Department of Orthopedics, Zhongnan Hospital of Wuhan University, Wuhan 430072, China.
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14
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Philandrianos C, Mattei JC, Rochwerger A, Bertrand B, Jaloux C, Casanova D. Free antero-lateral thigh flap for total knee prosthesis coverage after infection complicating malignant tumour resection. Orthop Traumatol Surg Res 2018; 104:713-717. [PMID: 29929015 DOI: 10.1016/j.otsr.2018.05.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2017] [Revised: 02/18/2018] [Accepted: 05/22/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND Infection is a common complication of major lower limb-sparing surgery with massive total knee prosthesis (MTKP) reconstruction after extensive tumour resection. When free tissue transfer is required to cover the prosthesis, musculo-cutaneous flaps are usually preferred based on proven efficacy when used in both one-stage and two-stage procedures. The use of a free fascio-cutaneous antero-lateral thigh (FC-ALT) flap in 3 patients with infected knee reconstructions is reported here. MATERIAL AND METHOD A retrospective study was performed of 3 patients in whom a free FC-ALT flap was used during a two-stage procedure to treat MTKP infection after femoral sarcoma resection. RESULTS Free FC-ALT flap transfer and exchange arthroplasty were successful in all 3 patients. Two years after the procedure, no patient had required amputation or experienced recurrent infection. CONCLUSION A free FC-ALT flap can provide adequate coverage of infected MTKP and deserves to be viewed as a valid alternative to free muscle flaps.
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Affiliation(s)
- Cécile Philandrianos
- Aix-Marseille université, 13284 Marseille, France; Service de chirurgie plastique et réparatrice, AP-HM, hôpital Conception, 13005 Marseille, France.
| | - Jean-Camille Mattei
- Aix-Marseille université, 13284 Marseille, France; Service de chirurgie orthopédique, AP-HM, hôpital Nord, 13915 Marseille, France
| | - Alexandre Rochwerger
- Aix-Marseille université, 13284 Marseille, France; Service de chirurgie orthopédique, AP-HM, hôpital Nord, 13915 Marseille, France
| | - Baptiste Bertrand
- Aix-Marseille université, 13284 Marseille, France; Service de chirurgie plastique et réparatrice, AP-HM, hôpital Conception, 13005 Marseille, France
| | - Charlotte Jaloux
- Aix-Marseille université, 13284 Marseille, France; Service de chirurgie plastique et réparatrice, AP-HM, hôpital Conception, 13005 Marseille, France
| | - Dominique Casanova
- Aix-Marseille université, 13284 Marseille, France; Service de chirurgie plastique et réparatrice, AP-HM, hôpital Conception, 13005 Marseille, France
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15
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Parra L, Andrés J, Robustillo M, García C, Iglesias I, Díaz A. Ipsilateral Arteriovenous Loop and Latissimus Dorsi Free Flap for Knee Reconstruction in an Elderly Patient: A Case Report. World J Plast Surg 2018; 7:377-381. [PMID: 30560081 PMCID: PMC6290313 DOI: 10.29252/wjps.7.3.377] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Herein, we report an unusual indication of an arteriovenous (AV) loop with a latissimus dorsi free flap after wound-edge necrosis in an 81 year old patient. The patient underwent multiple revision procedures after total knee arthroplasty and total hip arthroplasty. After a dramatic reduction of femoral bone, a total femoral replacement was performed. The lateral knee incision wound was broke down and the hardware became exposed. Local flaps were not available and a free flap with an ipsilateral AV loop from the great saphenous vein was used to cover the large defect. The functional status of the hip and knee joints was good after 6 months, and enough the patient was able to ambulate without any assistance. The patient did not show any signs of infection.
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Affiliation(s)
- Luis Parra
- Department of Plastic and Reconstructive Surgery, 12 de Octubre University Hospital, Madrid, Spain
| | - Juan Andrés
- Department of Plastic and Reconstructive Surgery, 12 de Octubre University Hospital, Madrid, Spain
| | - Manuel Robustillo
- Department of Plastic and Reconstructive Surgery, 12 de Octubre University Hospital, Madrid, Spain
| | - Carlos García
- Department of Plastic and Reconstructive Surgery, 12 de Octubre University Hospital, Madrid, Spain
| | - Israel Iglesias
- Department of Plastic and Reconstructive Surgery, 12 de Octubre University Hospital, Madrid, Spain
| | - Antonio Díaz
- Department of Plastic and Reconstructive Surgery, 12 de Octubre University Hospital, Madrid, Spain
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16
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Sazegari MA, Mirzaee F, Bahramian F, Zafarani Z, Aslani H. Wound dehiscence after total knee arthroplasty. Int J Surg Case Rep 2017; 39:196-198. [PMID: 28854408 PMCID: PMC5575444 DOI: 10.1016/j.ijscr.2017.08.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Revised: 08/17/2017] [Accepted: 08/17/2017] [Indexed: 11/27/2022] Open
Abstract
Any of the wound complications (drainage, hemarthrosis, skin necrosis, and dehiscence) potentially related to diabetes. Wound dehiscence is a complication after total knee arthroplasty especially in diabetic patient. Postoperative care after knee replacement should be more considered in diabetic patients. Introduction Wound dehiscence is one of the most common complications of surgical ulcer, involving the breaking open of the surgical incision along the stitch. This condition is a severe complication of total knee arthroplasty. Presentation of case We report a case of a 59-year-old female patient with diabetes who underwent a total knee arthroplasty in which all layers of wounds were dehiscence and prosthetic was exposed. Discussion Wound dehiscence is a complication after total knee arthroplasty especially in diabetic patient. So, patients with diabetes more susceptible to development of wound dehiscence following total knee arthroplasty and should be followed particularly postoperatively care. Conclusion Postoperative care after knee replacement should be more considered in diabetic patients. Finally the patient was successfully treated with irrigation and debridement (I&D) and polyethylene insert exchange.
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Affiliation(s)
| | - Fateme Mirzaee
- Knee and Sport Medicine Research and Education Center, Milad Hospital, Tehran, Iran
| | - Fateme Bahramian
- Knee and Sport Medicine Research and Education Center, Milad Hospital, Tehran, Iran
| | - Zohreh Zafarani
- Knee and Sport Medicine Research and Education Center, Milad Hospital, Tehran, Iran
| | - Hamidreza Aslani
- Knee and Sport Medicine Research and Education Center, Milad Hospital, Tehran, Iran.
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17
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Helito CP, Bonadio MB, Gobbi RG, Demange MK. Letter regarding "Management of the exposed total knee prosthesis, a six-year review". Knee 2017; 24:163. [PMID: 27427237 DOI: 10.1016/j.knee.2016.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Accepted: 06/23/2016] [Indexed: 02/02/2023]
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18
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Strategies for Soft-Tissue Management of Complex Joint Revision Arthroplasty. Plast Reconstr Surg 2016; 138:1344-1351. [DOI: 10.1097/prs.0000000000002762] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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19
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Abstract
Wound healing complications associated with total knee arthroplasty present a considerable challenge to the orthopaedic surgeon. To ensure preservation of a functional joint, the management of periprosthetic soft-tissue defects around the knee requires rapid assessment, early and aggressive débridement, and durable, contoured coverage. Several reconstructive options are available to tailor soft-tissue coverage to the location, size, and depth of the wound. Special consideration should be given to the timing of the intervention, management of infection, and prosthesis salvage. The merits of each reconstructive option, including perforator, fasciocutaneous, muscular, and free microvascular flaps, should be weighed to select the most appropriate option. The proposed approach can guide surgeons in treating patients with these complex soft-tissue defects.
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20
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Young K, Chummun S, Wright T, Darley E, Chapman TW, Porteous AJ, Murray JRD, Khan U. Management of the exposed total knee prosthesis, a six-year review. Knee 2016; 23:736-9. [PMID: 27225442 DOI: 10.1016/j.knee.2016.04.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2015] [Accepted: 04/04/2016] [Indexed: 02/02/2023]
Abstract
INTRODUCTION An exposed knee prosthesis is a limb threatening condition. Our unit manages such cases according to a multidisciplinary orthoplastic protocol. Whilst early prosthetic joint infection with dehiscence may be managed by Debridement, Antibiotics and Implant Retention (DAIR) and soft tissue coverage, the majority of these cases are chronic and in our unit are managed by Debridement, Explantation, Antibiotics (spacer and systemic) and Flap (DEAF). PATIENTS AND METHODS We report our experience of managing 17 of these challenging cases, 16 DEAFs and one DAIR and flap. Outcomes were assessed clinically and using the 36-item Short Form Health Survey (SF-36). RESULTS The mean time from arthroplasty to presentation in our unit was 19months (range: 0.5-80). Whilst an open knee replacement is by definition 'infected', significant microbiological growth from deep tissue/fluid samples was only detected in 14 patients (82%). Five patients (29.4%) subsequently underwent an amputation. Of these five, three patients were extensor deficient at presentation. At follow-up, health-related quality of life scoring using the Short Form-36 demonstrated poor physical function and highlighted differences in emotional function and pain levels between patients whose limbs were salvaged and patients who underwent amputation. CONCLUSION An exposed total knee prosthesis is a devastating complication, which despite our multidisciplinary salvage approach, has a high rate (5/17=29%) of amputation in this series. Quality of life in this patient group is poor irrespective of limb salvage. Salvage surgery was associated with worse pain, but better emotional profile than patients with an above knee amputation.
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Affiliation(s)
- Katie Young
- Department of Reconstructive Plastic Surgery, Southmead Hospital, North Bristol NHS Trust, Bristol, United Kingdom; Department of Medical Microbiology, Southmead Hospital, North Bristol NHS Trust, Bristol, United Kingdom.
| | - Shaheel Chummun
- Department of Reconstructive Plastic Surgery, Southmead Hospital, North Bristol NHS Trust, Bristol, United Kingdom
| | - Thomas Wright
- Department of Reconstructive Plastic Surgery, Southmead Hospital, North Bristol NHS Trust, Bristol, United Kingdom
| | - Elizabeth Darley
- Department of Medical Microbiology, Southmead Hospital, North Bristol NHS Trust, Bristol, United Kingdom
| | - Thomas W Chapman
- Department of Reconstructive Plastic Surgery, Southmead Hospital, North Bristol NHS Trust, Bristol, United Kingdom
| | - Andrew J Porteous
- Avon Orthopaedic Centre, Southmead Hospital, North Bristol NHS Trust, Bristol, United Kingdom
| | - James R D Murray
- Avon Orthopaedic Centre, Southmead Hospital, North Bristol NHS Trust, Bristol, United Kingdom
| | - Umraz Khan
- Department of Reconstructive Plastic Surgery, Southmead Hospital, North Bristol NHS Trust, Bristol, United Kingdom
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21
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Rao AJ, Kempton SJ, Erickson BJ, Levine BR, Rao VK. Soft Tissue Reconstruction and Flap Coverage for Revision Total Knee Arthroplasty. J Arthroplasty 2016; 31:1529-38. [PMID: 27038863 DOI: 10.1016/j.arth.2015.12.054] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2015] [Revised: 12/22/2015] [Accepted: 12/28/2015] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Total knee arthroplasty is a successful operation for treatment of arthritis. However, devastating wound complications and infections can compromise the knee joint, particularly in revision situations. METHODS Soft tissue loss associated with poor wound healing and multiple operations can necessitate the need for reconstruction for wound closure and protection of the prosthesis. RESULTS Coverage options range from simple closure methods to complex reconstruction, including delayed primary closure, healing by secondary intention, vacuum-assisted closure, skin grafting, local flap coverage, and distant microsurgical tissue transfer. CONCLUSION Understanding the advantages and pitfalls of each reconstructive option helps to guide treatment and avoid repeated operations and potentially devastating consequences such as knee arthrodesis or amputation.
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Affiliation(s)
- Allison J Rao
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Steven J Kempton
- Division of Plastic Surgery, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
| | - Brandon J Erickson
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Brett R Levine
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Venkat K Rao
- Division of Plastic Surgery, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
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22
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Meaike JD, Kaufman MG, Izaddoost SA. Orthopedic Prosthetic Infections: Plastic Surgery Management. Semin Plast Surg 2016; 30:73-7. [PMID: 27152099 DOI: 10.1055/s-0036-1580728] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Orthopedic prosthetic infections are potentially devastating complications. Plastic surgeons are frequently consulted to aid in the management of the soft tissue defects that are created by these infections. A review of the existing literature was performed to identify established treatment methods for soft tissue coverage of orthopedic hardware infections for a variety of anatomic locations. The following treatment guidelines and soft tissue reconstructive options were identified as viable options for the management of exposed or infected orthopedic hardware. This review provides descriptions of the various soft tissue reconstructive options available as well as adjunctive treatment methods.
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Affiliation(s)
- Jesse D Meaike
- Division of Plastic and Reconstructive Surgery, Baylor College of Medicine, Houston, Texas
| | - Matthew G Kaufman
- Division of Plastic and Reconstructive Surgery, Baylor College of Medicine, Houston, Texas
| | - Shayan A Izaddoost
- Division of Plastic and Reconstructive Surgery, Baylor College of Medicine, Houston, Texas
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Long-Term Outcomes of Total Knee Arthroplasty following Soft-Tissue Defect Reconstruction with Muscle and Fasciocutaneous Flaps. Plast Reconstr Surg 2016; 137:177e-186e. [PMID: 26710050 DOI: 10.1097/prs.0000000000001929] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Insufficient soft-tissue coverage following total knee arthroplasty jeopardizes prosthesis retention and may lead to significant complications. The aim of this study was to evaluate the natural history of total knee arthroplasty following flap reconstruction of soft-tissue defects. METHODS A retrospective review of patients treated with flaps after failed total knee arthroplasty between 1998 and 2013 was conducted. Patients with preexisting soft-tissue defects who required reactive flap reconstruction were included in group 1. Patients with no preexisting soft-tissue defects, but with extensive débridement during revision total knee arthroplasty requiring immediate proactive flap coverage, were included in group 2. RESULTS Fifty-eight patients in group 1 were treated with 86 flaps, and 15 patients in group 2 were treated with 17 flaps. Mean length of follow-up was 67.0 and 54.7 months, respectively (p = 0.21). Flap-related complications and number of subsequent flap revisions were comparable in both groups. Patients in group 1 had a higher rate of implant reinfection (58 percent versus 27 percent; p < 0.05), amputations (25 percent versus 0 percent; p < 0.05), and subsequent prosthesis revisions (2.2 versus 0.9; p < 0.05). Functional joint was preserved in 54 percent and 80 percent of cases, respectively. Mean gain in range of motion and quality of life were significantly better in group 2 (p < 0.05). CONCLUSIONS Early proactive soft-tissue coverage of total-knee arthroplasty is critical to long-term success. In cases where reactive treatment is required, significantly worse outcomes and a high rate of complications should be expected. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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24
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Gravvanis A, Kyriakopoulos A, Kateros K, Tsoutsos D. Flap reconstruction of the knee: A review of current concepts and a proposed algorithm. World J Orthop 2014; 5:603-613. [PMID: 25405089 PMCID: PMC4133468 DOI: 10.5312/wjo.v5.i5.603] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2014] [Revised: 03/20/2014] [Accepted: 07/15/2014] [Indexed: 02/06/2023] Open
Abstract
A literature search focusing on flap knee reconstruction revealed much controversy regarding the optimal management of around the knee defects. Muscle flaps are the preferred option, mainly in infected wounds. Perforator flaps have recently been introduced in knee coverage with significant advantages due to low donor morbidity and long pedicles with wide arc of rotation. In the case of free flap the choice of recipient vessels is the key point to the reconstruction. Taking the published experience into account, a reconstructive algorithm is proposed according to the size and location of the wound, the presence of infection and/or 3-dimensional defect.
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25
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Open, combat-related loss, or disruption of the knee extensor mechanism: treatment strategies, classification, and outcomes. J Orthop Trauma 2014; 28:e250-7. [PMID: 24694556 DOI: 10.1097/bot.0000000000000121] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To report the outcomes of repair or reconstruction of high-energy, open knee extensor disruption or loss due to combat-related injuries. DESIGN Retrospective review. SETTING Tertiary (Level/Role V) Military Treatment Facility. PATIENTS Fourteen consecutive patients who sustained 17 complex, open knee extensor mechanism injuries during combat operations between March 2003 and May 2012. INTERVENTION Primary repair or staged allograft extensor reconstruction after serial debridement and closure or soft tissue coverage. MAIN OUTCOME MEASURES Final knee range of motion, extensor lag, ambulatory ability and assist devices, and complications requiring reoperation or salvage procedure. RESULTS The open knee extensor mechanism injuries required a mean of 11 procedures per injury. At a mean final follow-up of 39 months (range, 12-89 months), all patients achieved regular community ambulation, with 36% requiring assist devices due to concomitant or bilateral injuries. Average knee flexion was 92 degrees, and 35% of extremities had an extensor lag >10 degrees; however, 6 of 9 extremities with allograft reconstructions had extensor lags of <10 degrees, and 5 had no extensor lag. The presence of a major periarticular or patellar fracture was significantly associated with the knee requiring a subsequent extensor mechanism allograft reconstruction procedure. One extremity each underwent knee arthrodesis or transfemoral amputation due to severe infection. CONCLUSIONS High-energy, open knee extensor mechanism injuries are severe and rarely occur in isolation, but limb salvage is generally successful after multiple procedures. Patients who required staged allograft reconstruction, despite high complication rates, generally had favorable results. LEVEL OF EVIDENCE Therapeutic level IV. See instructions for authors for a complete description of levels of evidence.
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Abstract
Microsurgical free tissue transfer is playing a critical role in reconstruction of the soft tissue around the knee to salvage the limb, especially when the defects exist with a wide zone of injury or with a poor soft tissue condition, where local flaps are unavailable. For a successful free flap transfer, proper selection of a recipient vessel is essential and challenging. The survival and other outcomes of the transferred flaps were closely related to which recipient vessel was used and the location of anastomosis. In this article, we review most of the clinical reports about using free flaps to reconstruct the soft tissue around the knee, excluding the cases of postamputation, and discuss about the recipient vessels that can be used.
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27
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Suda AJ, Cieslik A, Grützner PA, Münzberg M, Heppert V. Flaps for closure of soft tissue defects in infected revision knee arthroplasty. INTERNATIONAL ORTHOPAEDICS 2014; 38:1387-92. [PMID: 24663397 DOI: 10.1007/s00264-014-2316-z] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/22/2014] [Accepted: 02/25/2014] [Indexed: 01/01/2023]
Abstract
PURPOSE Total knee arthroplasty revision has wound healing deficits of up to 20 %. Defects in the knee region of multimorbid patients are hard to treat as complete explantation and revision arthroplasty is often too burdensome for them. In this study, we present our results with flaps for the treatment of defects after knee replacement, arthrodesis or osteosynthesis. METHODS Twenty-five patients (26 knees) with defects in the knee region were treated with flaps. Mean follow-up was 37 months (13-61) and the patients had a mean age of 72 years (49-85). A total of 39 flaps were performed (27 muscle flaps, seven fascio-cutaneous flaps and five free flaps). RESULTS Patients with more than three comorbidities showed higher risk of complications after surgery. Fifteen patients showed no infection at last follow up. Five patients received an arthrodesis of the knee, two showed persistent infection of the implant with fistula, and three were amputated above the knee. CONCLUSIONS Amputation could be avoided in 22 cases (85 %). The gastrocnemius muscle flap showed good results in the treatment of defects after arthroplasty or arthrodesis of the knee in multimorbid patients. This procedure can be used if further revision surgery is not indicated.
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Affiliation(s)
- Arnold J Suda
- Department for Septic Surgery, Trauma Center Ludwigshafen, Ludwigshafen, Germany,
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28
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Pozzobon LR, Helito CP, Guimarães TM, Gobbi RG, Pécora JR, Camanho GL. Rotation flaps for coverage after total knee arthroplasty. ACTA ORTOPEDICA BRASILEIRA 2013; 21:219-22. [PMID: 24453672 PMCID: PMC3862006 DOI: 10.1590/s1413-78522013000400007] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/21/2012] [Accepted: 06/07/2013] [Indexed: 11/26/2022]
Abstract
OBJECTIVE: To evaluate the results obtained using local myocutaneous rotation flaps in cases of wound dehiscence after total knee arthroplasty. METHODS: Patients undergoing these surgical procedures were selected in the 2000-2012 period. The nine selected cases during this period were subjected to flap coverage due to skin dehiscence associated with infection. In eight cases we used rotation flaps of the medial gastrocnemius, and in one case we used advancing skin. RESULTS: Eighty nine percent of the cases were successful in the coverage of the prosthesis and the viability of the flaps. In four cases it was possible to maintain or review the prosthesis. Four other cases progressed to amputation due to failure on treatment of infections, and one case remained without the prosthesis. The functional evaluation showed an unsatisfactory outcome in 89% of cases. CONCLUSION: Coverage flaps are a good option for the treatment of cases of dehiscence with exposure of the prosthesis and the functional failure was associated with the inability to control the infection and the damage it caused. Level of Evidence IV, Case Series.
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Abstract
Since the advent of the operating microscope by Julius Jacobson in 1960, reconstructive microsurgery has become an integral part of extremity reconstruction and orthopaedics. During World War I, with the influx of severe extremity trauma Harold Gillies introduced the concept of the reconstructive ladder for wound closure. The concept of the reconstructive ladder goes from simple to complex means of attaining wound closure. Over the last half century microsurgery has continued to evolve and progress. We now have a microsurgical reconstructive ladder. The microsurgical reconstruction ladder is based upon the early work on revascularization and replantation extending through the procedures that are described in this article.
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Affiliation(s)
- Scott M Tintle
- University of Pennsylvania, Philadelphia, PA, United States
| | - L Scott Levin
- University of Pennsylvania, Philadelphia, PA, United States.
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Surgical technique: vastus medialis and vastus lateralis as flap transfer for knee extensor mechanism deficiency. Clin Orthop Relat Res 2013; 471:221-30. [PMID: 22992869 PMCID: PMC3528908 DOI: 10.1007/s11999-012-2532-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Loss of the quadriceps tendon, patella, and patellar tendon leaves a major anterior defect that is difficult to close and compromises knee extension strength. Gastrocnemius muscle transfer does not sufficiently cover such major defects. This paper describes a new surgical technique that addresses these defects and the results of eight cases of revision TKA managed with this new technique. DESCRIPTION OF TECHNIQUE The new procedure transfers the vastus medialis or the vastus lateralis and their tibial attachments or both muscles and their distal expansions combined with gastrocnemius and soleus flaps to cover major deficiencies in the anterior knee. Nine cadaver knee specimens were dissected to determine the effect of the transfer on nerve and blood supply of the muscles. METHODS Eight patients underwent the new procedure between 2005 and 2009. Four knees had vastus medialis transfer, two vastus medialis and vastus lateralis transfer, two vastus medialis and medial gastrocnemius transfer, and two medial gastrocnemius and medial ½ of the soleus muscle transfer. Minimum followup was 15 months (mean, 43 months; range, 15-74 months). Patients were evaluated for anterior knee pain, quality of knee closure, ROM, extensor lag, walking ability, use of assistive devices, and ability to climb stairs with the operated extremity. RESULTS All patients achieved closure of the knee without synovial leaks by 10 days postoperatively. Mean flexion contracture at last followup was 3° (range, 0°-7°). Mean extension lag was 22° (range, 5°-65°). Extension lag was less in those knees that included gastrocnemius or soleus muscle transfer. None of the flaps developed necrosis. CONCLUSIONS The vastus medialis and vastus lateralis muscles provide adequate coverage for anterior soft tissue deficits of the knee.
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Sönmez E, Kamburoǧlu HO, Aksu AE, Nasir SN, Evrenos MK, Şafak T, Keçik A. Soft-tissue management with immediate free flap transfer in segmental prosthetic replacement of proximal tibia sarcomas. Microsurgery 2011; 31:620-7. [PMID: 21919053 DOI: 10.1002/micr.20937] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2011] [Revised: 06/01/2011] [Accepted: 06/02/2011] [Indexed: 01/29/2023]
Abstract
Knee reconstruction with endoprosthesis after tumor resection is accepted as superior when compared with the other methods. But sometimes soft tissue reconstruction would be a challenging problem in this way of treatment. Five patients who were operated for tumor resection in this location, followed by reconstruction were presented with their one-year post operative results. Four latissimus dorsi and one rectus abdominis myocutaneous free flaps were used in these patients in order to manage soft tissue problems. All patients underwent chemotherapy in postoperative period. All flaps were successful in one year post operative examination. In this report we would like to stress the importance of surgical planning and soft tissue reconstruction of a specific patient population. We think that large musculocutaneous flaps such as latissimus dorsi and rectus abdominis musculocutaneous flaps should be preferred in soft tissue reconstruction of knee region after tumor resection followed by prosthetic replacement. Additionally, this way of treatment is superior when compared to the other methods in order to prevent complications such as prosthesis exposure or infection.
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Affiliation(s)
- Erhan Sönmez
- Department of Plastic Reconstructive and Aesthetic Surgery, Hacettepe University Faculty of Medicine, Ankara/Turkey
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Yoshida S, Yokoyama R, Sakamoto A. Treatment of pelvic defect and infection with endoprosthesis exposure by topical negative pressure and irrigation with myocutaneous flap. Microsurgery 2011; 31:655-8. [PMID: 21919051 DOI: 10.1002/micr.20932] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2010] [Revised: 05/06/2011] [Accepted: 05/16/2011] [Indexed: 01/13/2023]
Abstract
The treatment of wound complications and deep infection after hemipelvectomy is challenging. We describe a 17-year-old woman with Ewing sarcoma in the pelvis who underwent hemipelvectomy and reconstruction with an artificial hip joint and bone cement. After the operation, skin necrosis and deep infection with methicillin-resistant Staphylococcus aureus (MRSA) were observed. Debridement resulted in exposure of the artificial joint and bone cement. Topical negative pressure (TNP) and irrigation successfully eradicated the infection. The skin and soft-tissue defect was subsequently reconstructed using a combination of free latissimus dorsi myocutaneous flap and serratus anterior muscle flap. To our knowledge, this is the first described case of combined TNP and irrigation with myocutaneous flap for the treatment of pelvic infection and skin and soft-tissue defect with endoprosthesis exposure.
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Affiliation(s)
- Sei Yoshida
- Department of Plastic Surgery, National Hospital Organization, Kyushu Cancer Center, Fukuoka, Japan
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