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Zink TM, Gonzalez AG, Coden G, Smith EL, Bono JV. Outcomes of Total Knee Arthroplasty Following a Sham Incision Procedure in Patients with Previous Knee Incisions. J Bone Joint Surg Am 2024:00004623-990000000-01211. [PMID: 39321307 DOI: 10.2106/jbjs.24.00114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/27/2024]
Abstract
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.
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Affiliation(s)
- Thomas M Zink
- Tufts Medical Center, Boston, Massachusetts
- Tufts University School of Medicine, Boston, Massachusetts
- New England Baptist Hospital, Boston, Massachusetts
| | | | - Gloria Coden
- New England Baptist Hospital, Boston, Massachusetts
| | - Eric L Smith
- Tufts University School of Medicine, Boston, Massachusetts
- New England Baptist Hospital, Boston, Massachusetts
| | - James V Bono
- Tufts University School of Medicine, Boston, Massachusetts
- New England Baptist Hospital, Boston, Massachusetts
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Kim BI, Wixted CM, Schwartz AM, Jiranek WA, Ryan SP, Seyler TM. Risk factors for failure after rotational muscle flap coverage for prosthetic knee infections. J Orthop Surg (Hong Kong) 2024; 32:10225536241230349. [PMID: 38279963 DOI: 10.1177/10225536241230349] [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] [Indexed: 01/29/2024] Open
Abstract
INTRODUCTION Soft tissue defects are a devastating complication of prosthetic joint infections (PJI) after total knee arthroplasty (TKA). Rotational flaps are commonly utilized to address these defects with variable reports of success. This study aimed to identify predictors of poor outcomes in rotational muscle flap placement after prosthetic knee infections. The authors hypothesized that outcomes may vary based on infecting pathogen and treatment characteristics. METHODS 44 cases of rotational muscle flaps for prosthetic knee infection were retrospectively evaluated at a tertiary referral hospital from 2007 to 2020. Muscle flap types included 39 medial and four lateral gastrocnemius, and one anterior tibialis. Minimum follow-up was 1 year (median: 3.4 years). Primary outcome was flap-related complications. Secondary outcomes included recurrent infection requiring additional surgery, final joint outcomes, and mortality. RESULTS One-year complication-free flap survivorship was 83.9%, recurrent infection-free survivorship was 65.7%, and amputation-free survivorship was 79%. Multivariable cox regression revealed that rheumatoid arthritis diagnosis (HR: 3.4; p = .028) and methicillin-resistant Staphylococcus aureus-positive culture (HR: 4.0; p = .040) had increased risk, while Coagulase-negative Staphylococcus infections had reduced risk for recurrent or persistent infection (HR: 0.2; p = .023). Final joint outcome was retained TKA implant in 18 (40.9%), amputation in 15 (34.1%) patients, and definitive treatment with articulating spacer in 10 (22.7%). 5-years survivorship from death was 71.4%. CONCLUSION Rotational muscle flaps for soft tissue coverage of the knee are often performed in limb salvage situations with poor survivorship from flap complications, reinfections, and amputation. When considering surgical options for limb salvage, patients should be counseled on these risks.
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Affiliation(s)
- Billy I Kim
- Department of Orthopaedic Surgery, Duke University, Durham, NC, USA
| | - Colleen M Wixted
- Department of Orthopaedic Surgery, Duke University, Durham, NC, USA
| | | | | | - Sean P Ryan
- Department of Orthopaedic Surgery, Duke University, Durham, NC, USA
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3
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Fijany AJ, Olsson SE, Givechian BK, Zago I, Bishay AE, Troia T, Page TS, Barnett A, Downey MW, Pekarev M. A Novel Orthoplastic Reconstruction of Relapsed Clubfoot With Total Ankle Arthroplasty. Cureus 2023; 15:e44796. [PMID: 37809200 PMCID: PMC10558358 DOI: 10.7759/cureus.44796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/06/2023] [Indexed: 10/10/2023] Open
Abstract
Congenital clubfoot is addressed in infancy and rarely persists into adulthood. Ankle arthroplasty is an increasingly popular surgical intervention for patients with ankle arthritis since it allows a natural ankle range of motion and completely replaces a degenerative hindfoot. Here, we describe the first successful total ankle arthroplasty (TAA) for a patient with previously treated congenital clubfoot that reverted later in life. To address the patient's poor soft-tissue integument and reduce the likelihood of post-surgical complications, a perioperative latissimus muscle-free flap was performed. This two-staged, novel orthoplastic intervention addressed our patient's ankle issues and appears to be a viable option for clubfoot patients.
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Affiliation(s)
- Arman J Fijany
- Plastic Surgery, Vanderbilt University Medical Center, Nashville, USA
| | - Sofia E Olsson
- Plastic Surgery, Anne Burnett Marion School of Medicine, Texas Christian University, Fort Worth, USA
| | | | - Ilana Zago
- Plastic Surgery, Anne Burnett Marion School of Medicine, Texas Christian University, Fort Worth, USA
| | - Anthony E Bishay
- Neurosurgery, Vanderbilt University School of Medicine, Nashville, USA
| | - Thomas Troia
- Plastic Surgery, Anne Burnett Marion School of Medicine, Texas Christian University, Fort Worth, USA
| | - Trevor S Page
- Plastic Surgery, Rosalind Franklin University of Medicine and Science, North Chicago, USA
| | | | - Michael W Downey
- Trauma and Reconstructive Surgery, Precision Orthopedics and Sports Medicine, Fort Worth, USA
| | - Maxim Pekarev
- Plastic Surgery, Anne Burnett Marion School of Medicine, Texas Christian University, Fort Worth, USA
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4
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Wiberg R, Mukka C, Backman O, Stålhult G, Edmundsson D, Mukka S. Outcome following soft tissue coverage with a medial gastrocnemius flap of an exposed or infected total knee arthroplasty. Scand J Surg 2023; 112:173-179. [PMID: 37264639 DOI: 10.1177/14574969231175562] [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] [Indexed: 06/03/2023]
Abstract
BACKGROUND Soft tissue defects or periprosthetic infections after total knee arthroplasty (TKA) are severe complications that may lead to loss of the arthroplasty or the limb. Reconstructions with medial gastrocnemius flaps (MGF) are occasionally used to provide soft tissue coverage around the knee. AIMS The study aimed to establish the rate of implant survivorship after MGF reconstruction for soft tissue coverage in the treatment of exposed or infected TKA and to establish functional outcome. METHODS A retrospective analysis was performed on all patients who received soft tissue coverage with an MGF of an exposed or infected TKA between 2000 and 2017 at the Department of Hand and Plastic Surgery at Umeå University Hospital. The outcomes were implant survivorship and patient-reported outcome measures (PROMs) using the five-level EQ-5D version and The Knee Injury and Osteoarthritis Outcome Score. RESULTS Forty-seven patients (mean age = 67 years, 30 women) were included. The mean time between flap coverage and follow-up was 6.7 (±3.4) years. Implant survivorship was observed in 28 of 47 (59.6%) patients at follow-up. Flap failure was rare, with only 3 of 47 (6.4%) cases. Of the 20 patients who answered the PROMs, 10 of 20 experienced moderate to severe pain or discomfort. CONCLUSIONS Due to unfavorable underlying conditions, MGF reconstruction after TKA is often associated with a compromised functional outcome. Because donor site morbidity is limited and flap failure is unusual, the procedure can be considered prophylactically in a small subset of patients with risk factors to prevent soft tissue defects and periprosthetic joint infection.
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Affiliation(s)
- Rebecca Wiberg
- Hand and Plastic surgery Department of Surgical and Perioperative SciencesUmeå University Umeå SE-901 87 Sweden
| | - Camilla Mukka
- Hand and Plastic Surgery, Department of Surgical and Perioperative Sciences, Umeå University, Umeå, Sweden
| | - Olof Backman
- Hand and Plastic Surgery, Department of Surgical and Perioperative Sciences, Umeå University, Umeå, Sweden
| | - Göran Stålhult
- Hand and Plastic Surgery, Department of Surgical and Perioperative Sciences, Umeå University, Umeå, Sweden
| | - David Edmundsson
- Orthopedics, Department of Surgical and Perioperative Sciences, Umeå University, Sweden
| | - Sebastian Mukka
- Orthopedics, Department of Surgical and Perioperative Sciences, Umeå University, Sweden
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Keystone flaps for the treatment of wound healing complications after knee orthopedic surgery. EUROPEAN JOURNAL OF PLASTIC SURGERY 2022. [DOI: 10.1007/s00238-022-01992-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
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Sheridan GA, Lennox PA, Masri BA. Soft Tissue Procedures in the Multiply Operated on Knee Replacement Patient. Orthop Clin North Am 2022; 53:267-276. [PMID: 35725035 DOI: 10.1016/j.ocl.2022.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- Gerard A Sheridan
- Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada.
| | - Peter A Lennox
- Department of Surgery, Division of Plastic and Reconstructive Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Bassam A Masri
- Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada
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Cepas A, Tammela I, Nieminen J, Laitinen M, Karppelin M, Kaartinen I, Kiiski J. Surgical and patient-reported outcomes after total knee arthroplasty requiring soft-tissue flap reconstruction - 12-year experience from high volume arthroplasty hospital. J Plast Reconstr Aesthet Surg 2022; 75:3732-3742. [DOI: 10.1016/j.bjps.2022.06.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Revised: 03/06/2022] [Accepted: 06/05/2022] [Indexed: 10/18/2022]
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8
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CAI YC, ZHANG GY, LIAN J, SHI WJ, CAI YQ, FENG QY, ZHU L. Pre-expanded Muscle-Sparing Latissimus Dorsi Free Flap: An Ideal Option for the Reconstruction of Extensive Anterior Knee Contractures. J Plast Reconstr Aesthet Surg 2022; 75:3743-3750. [DOI: 10.1016/j.bjps.2022.06.074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Revised: 05/19/2022] [Accepted: 06/07/2022] [Indexed: 11/29/2022]
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Abstract
BACKGROUND Free flap coverage in the setting of a total knee arthroplasty is rare. The purpose of the current study was to evaluate the outcome of patients who underwent a free flap to assist with soft-tissue coverage following a complex total knee arthroplasty. METHODS The authors used their institutional total joint registry to retrospectively review patients undergoing a free soft-tissue flap in the setting of complex primary and revision total knee arthroplasty. Among 29,069 primary and 6433 revision total knee arthroplasties from 1994 to 2017, eight (0.02 percent) required a free flap for wound coverage. This included three primary total knee arthroplasties (0.01 percent) for posttraumatic arthritis and five revision total knee arthroplasties (0.07 percent) in the setting of infection. Median follow-up was 4 years. RESULTS Free flaps included vertical rectus abdominis (n = 3), anterior lateral thigh (n = 2), latissimus (n = 2), and transverse rectus abdominis (n = 1). There were no total flap losses; however, one patient required additional skin grafting. Reoperation occurred in six patients, of which four were revisions of the total knee arthroplasty for infection (n = 2) and tibial component loosening (n = 2). One patient ultimately underwent transfemoral amputation for persistent infection. Following reconstruction, there was improvement in the median Knee Society Score (49 versus 82; p = 0.03) and total range of motion between preoperative and postoperative assessments (70 degrees versus 85 degrees; p = 0.14). CONCLUSION Free flap coverage in the setting of total knee arthroplasty was associated with a high rate of reoperation; however, the limb was able to be preserved in the majority of patients, with a reasonable functional outcome. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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10
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Soft tissue coverage options around the knee. ANN CHIR PLAST ESTH 2020; 65:517-523. [PMID: 32718770 DOI: 10.1016/j.anplas.2020.07.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Accepted: 07/01/2020] [Indexed: 11/21/2022]
Abstract
Defects around the knee exhibit various etiologies and pose challenges to both orthopedists and plastic surgeons. While a number of reconstructive coverage options are available, flaps are almost always required for complex defects. Many local flaps are easily placed, including muscle and perforator flaps sourced from the thigh to the leg. As the recipient vessels lie deep, free tissue transfers are challenging. Good postoperative management and efficient collaboration between orthopedic and reconstructive surgeons are the keys to successful knee reconstruction, restoring an esthetic contour and preserving joint function.
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11
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Early Plastic Surgery Involvement Improves Outcomes in Total Joint Arthroplasty Patients With Soft Tissue Complications. Tech Orthop 2020. [DOI: 10.1097/bto.0000000000000476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Azoury SC, Stranix JT, Piper M, Kovach SJ, Hallock GG. Attributes of Perforator Flaps for Prophylatic Soft Tissue Augmentation Prior to Definitive Total Knee Arthroplasty. J Reconstr Microsurg 2019; 37:51-58. [PMID: 31877565 DOI: 10.1055/s-0039-3401847] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND As our population ages, the demand for total knee arthroplasty (TKA) will dramatically increase to ensure an independent lifestyle with unimpeded and pain-free ambulation. Complications will be inevitable, especially in that patient with preexisting soft tissue deficits or extensive scarring in the knee region. Under these circumstances, prophylactic soft tissue augmentation should be strongly considered and be extremely beneficial. METHODS A retrospective review of all TKA procedures at our institutions over the past two decades revealed seven patients who specifically had soft tissue augmentation prior to their definitive TKA. Each had a single perforator flap used to achieve this. In no cases was a muscle flap used for this purpose. Excluded were all patients who had a flap of any kind for coverage of an exposed prosthesis or to accomplish wound healing after the TKA. RESULTS Seven perforator flaps were utilized in seven patients for soft tissue replacement prior to the ultimate TKA. For smaller defects in three patients, a local island medial sural artery perforator flap was used. For larger defects in four patients, an anterolateral thigh perforator free flap was necessary. All flaps were successful. The only complication was an implant infection after one anterolateral thigh free flap that required a revision arthroplasty that eventually allowed salvage. Unrestricted ambulation was possible in all patients except for one who had a preexisting contralateral below-knee amputation. CONCLUSION As the number of TKA procedures in the near future increases, prevention of the absolute number of complications becomes even more important. An awareness that any knee region suboptimal soft tissue base can lead to wound breakdown and then periprosthetic infection should alert all involved that prevention of this sequela can be best achieved by prior soft tissue augmentation. Preferably, this may be possible by capturing the assets of local and free perforator flaps.
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Affiliation(s)
- Saïd C Azoury
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Perelman Center for Advanced Medicine, Philadelphia, Pennsylvania
| | - John T Stranix
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Perelman Center for Advanced Medicine, Philadelphia, Pennsylvania
| | - Merisa Piper
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Perelman Center for Advanced Medicine, Philadelphia, Pennsylvania
| | - Stephen J Kovach
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Perelman Center for Advanced Medicine, Philadelphia, Pennsylvania
| | - Geoffrey G Hallock
- Division of Plastic Surgery, St. Luke's Hospital, Sacred Heart Division, Allentown, Pennsylvania
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13
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Soft Tissue Issues and Considerations in Total Knee Arthroplasty. Tech Orthop 2019. [DOI: 10.1097/bto.0000000000000380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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14
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Hallock GG. The Medial Sural Artery Perforator Island Flap as a Simpler Alternative for Prophylactic Skin Augmentation Prior to Total Knee Arthroplasty. ACTA ACUST UNITED AC 2019. [DOI: 10.29337/ijops.26] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Soft-Tissue Reconstruction of the Complicated Knee Arthroplasty: Principles and Predictors of Salvage. Plast Reconstr Surg 2018; 141:1040-1048. [PMID: 29596192 DOI: 10.1097/prs.0000000000004255] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Total knee arthroplasty is a common orthopedic procedure in the United States and complications can be devastating. Soft-tissue compromise or joint infection may cause failure of prosthesis requiring knee fusion or amputation. The role of a plastic surgeon in total knee arthroplasty is critical for cases requiring optimization of the soft-tissue envelope. The purpose of this study was to elucidate factors associated with total knee arthroplasty salvage following complications and clarify principles of reconstruction to optimize outcomes. METHODS A retrospective review of patients requiring soft-tissue reconstruction performed by the senior author after total knee arthroplasty over 8 years was completed. Logistic regression and Fisher's exact tests determined factors associated with the primary outcome, prosthesis salvage versus knee fusion or amputation. RESULTS Seventy-three knees in 71 patients required soft-tissue reconstruction (mean follow-up, 1.8 years), with a salvage rate of 61.1 percent, mostly using medial gastrocnemius flaps. Patients referred to our institution with complicated periprosthetic wounds were significantly more likely to lose their knee prosthesis than patients treated only within our system. Patients with multiple prior knee operations before definitive soft-tissue reconstruction had significantly decreased rates of prosthesis salvage and an increased risk of amputation. Knee salvage significantly decreased with positive joint cultures (Gram-negative greater than Gram-positive organisms) and particularly at the time of definitive reconstruction, which also trended toward an increased risk of amputation. CONCLUSIONS In revision total knee arthroplasty, prompt soft-tissue reconstruction improves the likelihood of success, and protracted surgical courses and contamination increase failure and amputations. The authors show a benefit to involving plastic surgeons early in the course of total knee arthroplasty complications to optimize genicular soft tissues. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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16
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Houdek MT, Wagner ER, Wyles CC, Harmsen WS, Hanssen AD, Taunton MJ, Moran SL. Long-Term Outcomes of Pedicled Gastrocnemius Flaps in Total Knee Arthroplasty. J Bone Joint Surg Am 2018; 100:850-856. [PMID: 29762280 DOI: 10.2106/jbjs.17.00156] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Deficient soft tissue following total knee arthroplasty (TKA) can jeopardize outcome. The gastrocnemius flap is an important means of providing coverage of a knee with deficient soft tissue. There is a paucity of long-term studies on the use of the gastrocnemius flap in the setting of TKA. The purpose of this study was to review the outcomes after the use of pedicled gastrocnemius flaps for coverage of a soft-tissue defect at the time of TKA. METHODS Eighty-three patients in whom a gastrocnemius flap had been used to cover the site of a primary (n = 18) or revision (n = 65) TKA over a 25-year period were identified. There were 48 women (58%) and 35 men (42%) with a mean age and body mass index (BMI) of 65 years and 32.6 kg/m. The mean wound size was 49 cm, and the wound was most commonly located over the anterior aspect of the knee/patellar tendon (n = 33). Patients were followed to the time of implant or flap revision, amputation, or death or for a minimum of 2 years (mean, 8 years). Clinical outcomes were assessed using the Knee Society Score (KSS) for pain and the KSS for function. The Kaplan-Meier method was used to assess revision and amputation-free survival. Risk factors for amputation and revision were identified with Cox regression. RESULTS The 10-year revision and amputation-free survival rates following gastrocnemius flap coverage were 68% and 79%, respectively. The risk of implant failure was increased by morbid obesity (BMI of ≥40 kg/m) (hazard ratio [HR] = 2.82, 95% confidence interval [CI] = 1.09 to 7.32, p = 0.03) and ≥5 prior surgical procedures on the knee (HR = 2.68, 95% CI = 1.04 to 6.88, p = 0.04). The risk of amputation was increased in patients with ≥5 prior surgical procedures (HR = 10.76, 95% CI = 2.38 to 48.58, p = 0.002), an age of ≥65 years (HR = 4.94, 95% CI = 1.10 to 22.09, p = 0.03), and a wound size of ≥50 cm (HR = 3.29, 95% CI = 1.14 to 9.53, p = 0.02). Preoperatively the mean KSSs for pain and function were 46 and 28, and these scores significantly (p < 0.05) improved to 78 and 43, respectively, at the time of follow-up. CONCLUSIONS The gastrocnemius flap reliably provides coverage of components used in complex knee reconstruction. A history of multiple surgical procedures on the knee and larger soft-tissue defects increase the risk of revision TKA and of amputation. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Matthew T Houdek
- Departments of Orthopedic Surgery (M.T.H., E.R.W., C.C.W., A.D.H., M.J.T., and S.L.M.) and Biostatistics and Health Sciences Research (W.S.H.) and Division of Plastic and Reconstructive Surgery (S.L.M.), Mayo Clinic, Rochester, Minnesota
| | - Eric R Wagner
- Departments of Orthopedic Surgery (M.T.H., E.R.W., C.C.W., A.D.H., M.J.T., and S.L.M.) and Biostatistics and Health Sciences Research (W.S.H.) and Division of Plastic and Reconstructive Surgery (S.L.M.), Mayo Clinic, Rochester, Minnesota
| | - Cody C Wyles
- Departments of Orthopedic Surgery (M.T.H., E.R.W., C.C.W., A.D.H., M.J.T., and S.L.M.) and Biostatistics and Health Sciences Research (W.S.H.) and Division of Plastic and Reconstructive Surgery (S.L.M.), Mayo Clinic, Rochester, Minnesota
| | - William S Harmsen
- Departments of Orthopedic Surgery (M.T.H., E.R.W., C.C.W., A.D.H., M.J.T., and S.L.M.) and Biostatistics and Health Sciences Research (W.S.H.) and Division of Plastic and Reconstructive Surgery (S.L.M.), Mayo Clinic, Rochester, Minnesota
| | - Arlen D Hanssen
- Departments of Orthopedic Surgery (M.T.H., E.R.W., C.C.W., A.D.H., M.J.T., and S.L.M.) and Biostatistics and Health Sciences Research (W.S.H.) and Division of Plastic and Reconstructive Surgery (S.L.M.), Mayo Clinic, Rochester, Minnesota
| | - Michael J Taunton
- Departments of Orthopedic Surgery (M.T.H., E.R.W., C.C.W., A.D.H., M.J.T., and S.L.M.) and Biostatistics and Health Sciences Research (W.S.H.) and Division of Plastic and Reconstructive Surgery (S.L.M.), Mayo Clinic, Rochester, Minnesota
| | - Steven L Moran
- Departments of Orthopedic Surgery (M.T.H., E.R.W., C.C.W., A.D.H., M.J.T., and S.L.M.) and Biostatistics and Health Sciences Research (W.S.H.) and Division of Plastic and Reconstructive Surgery (S.L.M.), Mayo Clinic, Rochester, Minnesota
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Kim HJ, Kim JY, Kee YM, Rhee YG. Total elbow arthroplasty under unfavourable soft tissue conditions. INTERNATIONAL ORTHOPAEDICS 2017; 42:367-374. [PMID: 29209741 DOI: 10.1007/s00264-017-3704-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Accepted: 11/21/2017] [Indexed: 11/25/2022]
Abstract
PURPOSE To evaluate the clinical and radiographic outcomes of patients with total elbow arthroplasty (TEA) and soft tissue reconstruction. METHODS We investigated six patients who underwent TEA and soft tissue reconstruction (two elbows with 1-stage surgery and four elbows with 2-stage surgery). The mean patient age at the time of the surgical procedure was 43.2 years; the mean follow-up duration was 88.2 months. RESULTS The mean pain visual analogue scale (VAS) during motion was improved from 6.3 pre-operatively to 0.7 at the last follow-up. The mean Mayo Elbow Performance Score (MEPS) improved from 26.7 pre-operatively to 81.7 at the last follow-up. The mean flexion-extension arcs of the 1- and 2-stage surgery groups increased from 12.5° and 13.8° pre-operatively to 72.5° and 100° at the last follow-up, respectively. The mean MEPS of the one and two stage surgery groups were 75 and 85, respectively, at the last follow-up. One of the six elbows had loosening on the simple radiograph at the last follow-up, and there were no cases with bushing wear. Three elbows needed additional skin debridement owing to wound complications (2/2 elbows in the 1-stage surgery group and 1/4 elbows in the 2-stage surgery group). CONCLUSIONS Under unfavorable soft tissue conditions, performing soft tissue reconstruction with TEA provides satisfactory functional improvement and pain relief. The two stage surgery provided a lower rate of wound complication and better elbow function than the one stage surgery, which led to high patient satisfaction post-operatively. LEVEL OF EVIDENCE Therapeutic Level IV.
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Affiliation(s)
- Hwan Jin Kim
- Shoulder & Elbow Clinic, Department of Orthopaedic Surgery, College of Medicine, Kyung Hee University, 1 Hoegi-dong, Dongdaemun-gu, Seoul, 130-702, Korea
| | - Jung Youn Kim
- Department of Orthopaedic Surgery, Hangang Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea
| | - Young Moon Kee
- Shoulder & Elbow Clinic, Department of Orthopaedic Surgery, College of Medicine, Kyung Hee University, 1 Hoegi-dong, Dongdaemun-gu, Seoul, 130-702, Korea
| | - Yong Girl Rhee
- Shoulder & Elbow Clinic, Department of Orthopaedic Surgery, College of Medicine, Kyung Hee University, 1 Hoegi-dong, Dongdaemun-gu, Seoul, 130-702, Korea.
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Abstract
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.
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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: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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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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Patnaik S, Nayak B, Mishra L, Sahoo AK. Complex Primary Total Knee Replacement (TKR) Using Prophylactic Gastrocnemius Flap and Rotating-Hinge Knee in Post-traumatic, Infective Arthritis of the Knee - A Case Report. J Orthop Case Rep 2016; 5:40-3. [PMID: 27299096 PMCID: PMC4845454 DOI: 10.13107/jocr.2250-0685.342] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Prophylactic gastrocnemius flap with primary rotating hinge knee is technically demanding in a case of neglected post-traumatic, infective arthritis of the knee, with challenges of compromised skin and soft tissues, articular bone defect, limb mal-alignment, gross instability, retained hardware and a contracted extensor mechanism with the patella fixed in the lateral gutter all in combination, is rarely reported. We report such a complex case in this study. CASE REPORT We report a 48 year male patient with a history of fracture lateral femoral condyle of right knee due to road traffic accident 10 years back, for which he got operated with open reduction and internal fixation with cancellous screws, which subsequently got infected. Primary procedure undertaken was removal of implants, debridement, placement of antibiotic-cement spacer followed by prophylactic medial gastrocnemius flap and a temporary joint spanning external fixator. Definitive procedure undertaken, after clearance of infection in 12 weeks was conversion to a rotating hinge TKR using a lateral para-patellar arthrotomy & tibial tubercle osteotomy to address the challenges of fixed patella in the lateral gutter and contracted ligamentum patellae. At one year follow up, the knee was painless, stable, with satisfactory range of motion and improved function without any infection or aseptic lysis. CONCLUSION Prophylactic Gastrocnemius flap cover along with rotating hinge knee arthroplasty using a lateral para-patellar approach and tibial tubercle osteotomy in a case of neglected post-traumatic, infective arthritis of knee with the complexities of limb mal-alignment, compromised skin and soft tissue, articular bone loss and ligamentous instability is a satisfactory bail out option in such a highly complex joint scenario.
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Affiliation(s)
- Sanjeev Patnaik
- Department of Orthopaedics, Apollo Hospital, Unit-15, Bhubaneswar, Odisha, India
| | - Biswaranjan Nayak
- Department of Neurosurgery, Apollo Hospital, Bhubaneswar, Odisha, India
| | - Laxmikanta Mishra
- Department of Orthopaedics, Apollo Hospital, Unit-15, Bhubaneswar, Odisha, India
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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: 21] [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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Baldini A, Castellani L, Traverso F, Balatri A, Balato G, Franceschini V. The difficult primary total knee arthroplasty: a review. Bone Joint J 2015; 97-B:30-9. [PMID: 26430084 DOI: 10.1302/0301-620x.97b10.36920] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Primary total knee arthroplasty (TKA) is a reliable procedure with reproducible long-term results. Nevertheless, there are conditions related to the type of patient or local conditions of the knee that can make it a difficult procedure. The most common scenarios that make it difficult are discussed in this review. These include patients with many previous operations and incisions, and those with severe coronal deformities, genu recurvatum, a stiff knee, extra-articular deformities and those who have previously undergone osteotomy around the knee and those with chronic dislocation of the patella. Each condition is analysed according to the characteristics of the patient, the pre-operative planning and the reported outcomes. When approaching the difficult primary TKA surgeons should use a systematic approach, which begins with the review of the existing literature for each specific clinical situation.
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Affiliation(s)
- A Baldini
- IFCA Institute, via del Pergolino 4, Florence 50139, Italy
| | - L Castellani
- IFCA Institute, via del Pergolino 4, Florence 50139, Italy
| | - F Traverso
- Humanitas Clinical and Research Center, via Manzoni 56 Rozzano, Milan, Italy
| | - A Balatri
- IFCA Institute, via del Pergolino 4, Florence 50139, Italy
| | - G Balato
- IFCA Institute, via del Pergolino 4, Florence 50139, Italy
| | - V Franceschini
- "Sapienza" University of Rome, via F. Faggiana 1668 Latina, Italy
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Kwiecien G, Lamaris G, Gharb BB, Murray T, Hendrickson MF, Zins JE, Isakov R. Long Term Outcomes of Total Knee Arthroplasty Following Soft Tissue Defect Reconstruction with Flaps. Plast Reconstr Surg 2015. [DOI: 10.1097/01.prs.0000472291.16708.84] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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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: 0.9] [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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Hansen DC, Moon WK, Kusuma SK. Prophylactic Free Flap for Chronic Lower-Extremity Soft-Tissue Defect Prior to Total Knee Arthroplasty: A Case Report. JBJS Case Connect 2013; 3:e75. [PMID: 29252614 DOI: 10.2106/jbjs.cc.m.00005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Dane C Hansen
- Department of Orthopaedic Surgery, Doctors Hospital Medical Education, 5100 West Broad Street, Columbus, OH 43228.
| | - Wong K Moon
- Department of Plastic Surgery (W.K.M.), Department of Orthopaedic Surgery (S.K.K.), Grant Medical Center, 393 East Town Street, Columbus, OH 43215
| | - Sharat K Kusuma
- Department of Plastic Surgery (W.K.M.), Department of Orthopaedic Surgery (S.K.K.), Grant Medical Center, 393 East Town Street, Columbus, OH 43215
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Tikhilov RM, Kornilov NN, Kulyaba TA, Saraev AV, Ignatenko VL. MODERN TRENDS IN ORTHOPEDICS: THE KNEE ARTHROPLASTY. TRAUMATOLOGY AND ORTHOPEDICS OF RUSSIA 2012. [DOI: 10.21823/2311-2905-2012--2-5-15] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/11/2023]
Abstract
Using PubMed the authors analyzed publications dedicated to knee arthroplasty that were published in 2011. The modern trends of knee joint replacement include improvement of implants and instruments; partial knee replacement as alternative to TKA; reducing of surgical trauma due to less-invasive approaches; achieving of deep flexion after TKA; using of computer navigation and individual cutting blocks to make surgery more precise; optimization of rehabilitation process in pre-, intra-and postoperative period; including multimodal pain control; development of complex strategies for prevention of intra- and postoperative complications. In this review the attention was attracted to the most discussed in 2011 subjects: development of new designs and materials of knee implants; navigation, robotics and individualized resection blocks; partial knee replacement; infection, blood loss and venous thromboembolism after TKA; influence of different factors on arthroplasty outcomes, especially components and leg alignment, patella resurfacing, PCL retention or substitution, uncemented fixation, mobility of PE insert, severe pre-op deformities or stiffness, previous intra-articular fractures and tibia or femur osteotomies, soft tissue deficit etc.
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Fischer JP, Nelson JA, Mirzabeigi MN, Wang GJ, Foley PJ, Wu LC, Woo EY, Kanchwala S. Prophylactic muscle flaps in vascular surgery. J Vasc Surg 2012; 55:1081-6. [DOI: 10.1016/j.jvs.2011.10.110] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2011] [Revised: 10/12/2011] [Accepted: 10/19/2011] [Indexed: 10/14/2022]
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