15-year experience with soft tissue expansion in total knee arthroplasty

Outcomes of Total Knee Arthroplasty Following a Sham Incision Procedure in Patients with Previous Knee Incisions

BACKGROUND

Tenuous blood supply carries a risk of wound-healing problems and subsequent infection following total knee arthroplasty (TKA). This risk may be increased by the presence of previous incisions. Performing a sham incision procedure allows for detection of wound-healing problems prior to performing TKA. The purpose of this retrospective case series is to describe the indications for and technique of a sham incision procedure in patients with previous knee incisions who underwent TKA following this procedure and to report the clinical outcomes observed in these patients following further surgery.

METHODS

Patients who had prior knee incisions, had undergone a sham incision prior to TKA, and had a minimum follow-up of 2 years were identified, and their cases were retrospectively reviewed. The identified cases typically adhered to the surgeon's standard protocol, which consisted of making a midline incision adventitious to TKA, dissecting down to deep fascia, and closing the wound with suture. Incisions were then observed for at least 4 weeks to determine the viability of the skin flaps before TKA was performed via the same incision.

RESULTS

A total of 47 knees in 47 patients were included in the study cohort. TKA was performed at an average of 21.1 weeks (range, 4 to 163 weeks) following the sham incision. There were no cases of skin necrosis or periprosthetic joint infection at an average follow-up of 4.6 years (range, 2 to 12 years) after sham incision. A total of 11 patients (23.4%) required manipulation under anesthesia for stiffness.

CONCLUSIONS

In our series, no patients developed skin necrosis or periprosthetic joint infection following TKA subsequent to a sham incision procedure, suggesting that healed sham incisions are safe to use for TKA and may be considered prior to TKA in cases in which local previous incisions increase the risk of wound-healing problems.

LEVEL OF EVIDENCE

Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Total Knee Arthroplasty in Patients Who Have Ankylosed Knees: A 10-Year Retrospective Study

BACKGROUND

Knee ankylosis can result in major functional impairment, and surgical treatment of knee ankylosis is often regarded as a tremendous challenge due to technical difficulties such as difficult joint exposure and a high incidence of complications. The objective of this study was to review the results of preoperative and postoperative functional scores, range of motion (ROM), and complications of total knee arthroplasty (TKA) for the treatment of knee ankylosis.

METHODS

Between January 2007 and January 2021, 19 patients (17 patients, 11 women, and 6 men) who had knee ankylosis underwent TKA. The mean age of the patients was 52 years (range, 31 to 71), and the mean follow-up period was 10.2 years (range, 3.1 to 13.9). The surgical procedure involved a TKA, performed via a medial parapatellar approach, a quadriceps snip, and a secondary osteotomy with soft tissue release. The postoperative clinical outcomes and complications were evaluated using a range of methods, including ROM assessment, Hospital for Special Surgery Knee Score, and visual analog scale scores.

RESULTS

At the final follow-up, the mean Hospital for Special Surgery Knee score improved significantly from the preoperative score of (33.6 ± 8.7) to (88.1 ± 5.2) (P < 0.001), ROM improved from (0 ± 0°) to (100.9 ± 14.1°) (P < 0.001), the visual analog scale score improved from a preoperative score of 0 to (1.0 ± 0.94) (P < 0.001), and radiographs showed no aseptic loosening of the knee. There were 8 knees (42.1%) that had postoperative complications.

CONCLUSIONS

Total knee arthroplasty (TKA) in patients who have ankylosing knees resulted in significant improvements in flexion and extension, mobility, and quality of life, despite a high incidence of complications such as skin necrosis.

Soft Tissue Expansion in Total Knee Arthroplasty Due to Extensive Scarring and Fibrosis in Multiple-Operated Knee

BACKGROUND

Inadequate wound closure is a feared complication following total knee arthroplasty (TKA). A knee with a multiple operative history, excessive scarring, and fibrosed surrounding soft tissue presents a significant challenge. In cases with preoperative uncertainty for sufficient soft tissue coverage because of ischemia and tension on closure, soft tissue expansion (STE) has been reported to be an effective tool for optimizing successful closure.

CASE REPORT

For the case in this report, STE was performed on a knee with multiple scars, potential ischemia, fibrosis, and soft tissue contractures prior to TKA.

CONCLUSIONS

In cases of uncertain soft tissue coverage in TKA, the use of STE can be a useful method in creating adequate wound closure.

Soft Tissue Procedures in the Multiply Operated on Knee Replacement Patient

In the multiply operated on knee replacement, no one soft tissue procedure is vastly superior to another. The most extensive literature available is in relation to muscle flaps, which will continue to be the workhorse technique for orthopedic and plastic reconstructive surgeons for the foreseeable future. Closed incision negative pressure wound therapy may prove to be a superior method in time but further large-scale studies are required to expand our understanding of this technique. The continued use of a combination of these techniques, tailored to the specific patient, is likely to be the best approach to the multiply operated on knee into the future.

Systematic Review of Tissue Expansion: Utilization in Non-breast Applications

Background

Tissue expansion is a versatile reconstructive technique providing well-vascularized local tissue. The current literature focuses largely on tissue expansion for breast reconstruction and in the context of burn and pediatric skin/soft tissue replacement; however, less traditional applications are also prevalent. The aim of this study was to systematically review the utilization of tissue expansion in such less well-characterized circumstances.

Methods

The authors conducted a systematic review of all publications describing non-breast applications of tissue expansion. Variables regarding expander specifications, expansion process, and complications were collected and further analyzed.

Results

A total of 565 publications were identified. Of these, 166 publications described tissue expansion for "less traditional" indications, which fell into 5 categories: ear reconstruction, cranioplasty, abdominal wall reconstruction, orthopedic procedures, and genital (penile/scrotal and vaginal/vulva) reconstruction. While lower extremity expansion is known to have high complication rates, tissue expander failure, infection, and exposure rates were in fact highest for penile/scrotal (failure: 18.5%; infection: 15.5%; exposure: 12.5%) and vaginal/vulva (failure: 20.6%; infection: 10.3%; exposure: 6.9%) reconstruction.

Conclusions

Tissue expansion enables index operations by providing additional skin before definitive reconstruction. Tissue expanders are a valuable option along the reconstructive ladder because they obviate the need for free tissue transfer. Although tissue expansion comes with inherent risk, aggregate outcome failures of the final reconstruction are similar to published rates of complications without pre-expansion. Thus, although tissue expansion requires a staged approach, it remains a valuable option in facilitating a variety of reconstructive procedures.

The Use of Soft Tissue Expanders Prior to Total Ankle Arthroplasty

Soft tissue coverage and tension-free closure can often be challenging in patients with ankle arthropathy being considered for total ankle arthroplasty. We present 2 patients with severe posttraumatic ankle arthropathy who underwent placement of a soft tissue expander to assist with soft tissue coverage prior to total ankle arthroplasty.

LEVELS OF EVIDENCE

Level IV.

Acute Wound Complications After Total Knee Arthroplasty: Prevention and Management

Normal wound healing with avoidance of early wound complications is critical to the success of total knee arthroplasty. The severity of acute complications includes less morbid problems, such as quickly resolved drainage and small superficial eschars, to persistent drainage and full-thickness tissue necrosis, which may require advanced soft-tissue coverage. To achieve proper healing, surgeons must respond to persistent drainage by addressing modifiable patient risk factors, using meticulous surgical technique, and implementing an algorithmic approach to treatment.