Rotation flaps for coverage after total knee arthroplasty

Risk factors for failure after rotational muscle flap coverage for prosthetic knee infections

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.

A comparison of healing and complication rates between common flaps utilized in total knee arthroplasty: a review of the literature

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.

Short- and Long-Term Complications of Free Anterolateral Thigh Flap Reconstructions: A Single-Centre Experience of 92 Consecutive Cases

Background. The anterolateral thigh (ALT) flap has been amongst the most versatile components of the reconstructive surgeon’s armamentarium. The authors utilise these flaps for a variety of reconstructive procedures including lower limb reconstruction; postsarcoma excision; and open fractures. Few studies have discussed the extent of recipient site morbidity and subsequent revisional procedures. We will report our experience of the ALT flap in 92 consecutive reconstructions with focus on recipient site complications and revisional procedures. Methods. Retrospective data collection was done from 92 patients who underwent ALT flap reconstruction—for various large soft tissue defects—at our unit at the Royal Free Hospital, London. We evaluated primary recipient site complications and the requirements for secondary operations after flap transfer. Results. All flaps survived with the exception of 3 cases (97% survival rate) in which irreversible venous thrombosis was encountered. 16 of 92 patients (17%) required a second recipient site operation for the following: 7 patients experienced major recipient site complications that warranted early return to theatre and 9 patients required a secondary revision thinning procedure(s). 8 of the 16 patients (50%) requiring second operations had construction on their lower leg/ankle/feet (p value = 0.10). Conclusions. Our data demonstrated effective use of the ALT flap in the management of soft tissue reconstructive surgery. Partial flap necrosis was the main complication at the recipient site. In future work, secondary thinning procedures, particularly at the ankle/foot, should be separated from flap-specific complications. Furthermore, we demonstrate tailoring ALT thickness can be performed safely without compromising flap viability.

Total Knee Arthroplasty Wound Complication Treatment Algorithm: Current Soft Tissue Coverage Options

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.

Partial thickness temporalis rotation for alloplastic temporomandibular joint - how I do it

With increasing clinical evidence, the replacement of the temporomandibular joint with alloplastic joints is being increasingly accepted in severe degenerative diseases. There remains a risk of infection and a possibility of a failure of not just these prostheses but any alloplastic joint prosthesis post-operatively. Therefore, an extra precaution and additional coverage to the joint using partial thickness myo-temporalis rotation flap could be a useful option to minimize post-operative joint failure.

Treatment of Periprosthetic Knee Infection With Concurrent Rotational Muscle Flap Coverage Is Associated With High Failure Rates

BACKGROUND

Soft-tissue deficiency is a potentially devastating complication of the infected total knee arthroplasty (TKA). Rotational muscle flaps are commonly used to address these defects. However, reported success rates vary widely.

METHODS

We reviewed 26 consecutive patients who underwent rotational muscle flap surgery for full-thickness anterior soft-tissue defect during treatment of an infected TKA. Twenty-four cases used a medial gastrocnemius rotational flap, 1 used a lateral gastrocnemius flap, and 1 used a rectus femoris-vastus intermedius flap. Implant survival, recurrence of infection, and limb survival were reported. Patient and procedural characteristics were tested for association with failure using χ² and Student t-test. Kaplan-Meier analysis was used to estimate the failure-free survival function.

RESULTS

Mean follow-up time was 3.3 years. Eighteen of 26 patients (69.2%) experienced recurrent infection requiring an average of 5.3 additional operations (range, 1-20). Five (19.2%) required arthrodesis while 6 (23.1%) eventually underwent above-the-knee amputation. Two patients (7.7%) died due to complications of revision surgery or persistent infection. Eleven patients (42.3%) were infection free with a retained prosthesis after treatment at a mean follow-up of 5.3 years (range, 0.7-18.0 years).

CONCLUSION

Rotational muscle flap coverage of soft-tissue defects in the setting of the infected TKA remains a viable salvage option. However, despite adequate tissue coverage, many patients experience recurrent infection requiring additional surgical treatment. Patients and surgeons should be aware of the potential high failure rates observed when treating these complex problems.

Systematic Review and Comparative Meta-Analysis of Outcomes Following Pedicled Muscle versus Fasciocutaneous Flap Coverage for Complex Periprosthetic Wounds in Patients with Total Knee Arthroplasty

Background

In cases of total knee arthroplasty (TKA) threatened by potential hardware exposure, flap-based reconstruction is indicated to provide durable coverage. Historically, muscle flaps were favored as they provide vascular tissue to an infected wound bed. However, data comparing the performance of muscle versus fasciocutaneous flaps are limited and reflect a lack of consensus regarding the optimal management of these wounds. The aim of this study was to compare the outcomes of muscle versus fasciocutaneous flaps following the salvage of compromised TKA.

Methods

A systematic search and meta-analysis were performed to identify patients with TKA who underwent either pedicled muscle or fasciocutaneous flap coverage of periprosthetic knee defects. Studies evaluating implant/limb salvage rates, ambulatory function, complications, and donor-site morbidity were included in the comparative analysis.

Results

A total of 18 articles, corresponding to 172 flaps (119 muscle flaps and 53 fasciocutaneous flaps) were reviewed. Rates of implant salvage (88.8% vs. 90.1%, P=0.05) and limb salvage (89.8% vs. 100%, P=0.14) were comparable in each cohort. While overall complication rates were similar (47.3% vs. 44%, P=0.78), the rates of persistent infection (16.4% vs. 0%, P=0.14) and recurrent infection (9.1% vs. 4%, P=0.94) tended to be higher in the muscle flap cohort. Notably, functional outcomes and ambulation rates were sparingly reported.

Conclusions

Rates of limb and prosthetic salvage were comparable following muscle or fasciocutaneous flap coverage of compromised TKA. The functional morbidity associated with muscle flap harvest, however, may support the use of fasciocutaneous flaps for coverage of these defects, particularly in young patients and/or high-performance athletes.

Proximally Based Anterolateral-Thigh (ALT) Flap for Knee Reconstruction: An Advancement Propeller Perforator Flap

BACKGROUND

Adequate coverage of the knee region is often challenging for plastic and orthopedic surgeons. In the last decade, among several reconstructive techniques, local perforator flaps have become useful reconstructive units. After a wide resection for soft-tissue sarcoma, the knee vascular web may be reasonably damaged and, consequently, perforator flaps based on a local pedicle [such as the distally based anterolateral thigh (ALT) flap] are not reliable. Thus, we harvested a proximally based ALT for knee coverage.

METHODS

A 52-year-old man underwent local radiation therapy and a wide resection of a soft-tissue sarcoma on the anterior-lateral aspect of the left knee, which resulted in a 15 × 10 cm defect. The defect was covered with a proximally based ALT, through an advancement and propeller relocation of its skin paddle.

RESULTS

All margins were tumor free. After 5 days, the donor site was closed primarily because of edema. Neither necrosis of the flap nor dehiscence of the wound was detected. No local relapses were detected at 6-month follow-up.

CONCLUSIONS

In case of soft-tissue defects of the knee region, with likely involvement of the local vascular web, a local perforator solution is the advancement and propeller proximally based ALT flap.

LEVEL OF EVIDENCE V

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Effect of postoperative use of nasal oxygen catheter supplementation in wound healing following total knee arthroplasty

OBJECTIVES

Healing is an event that is fundamental to the success of total knee arthroplasty. The aims of the present study were to compare the rates of complications related to wound healing between two groups of volunteers submitted to total knee arthroplasty and to evaluate the effects of postoperative oxygen supplementation by means of a nasal catheter.

METHOD

A total of 109 patients who underwent total knee arthroplasty were randomized into two groups, namely, groups that did and did not receive postoperative oxygen supplementation via a nasal catheter. The surgical wound was monitored every day during the hospital stay and on the 7th, 14th, 21st, 30th and 42nd postoperative days. Characteristics related to healing were observed, including hyperemia, dehiscence, necrosis, phlyctenules and deep and superficial infection.

RESULTS

There were no cases of deep infection. Hyperemia was statistically correlated with the total number of complications in the groups, with oxygen demonstrated to be a protective factor against hyperemia. Approximately 30% of the patients who exhibited hyperemia had other complications, independent of oxygen supplementation.

CONCLUSION

Oxygen supplementation following total knee arthroplasty was shown to be effective in diminishing hyperemia around the operative wound. The development of hyperemia was a precursor to other complications, irrespective of whether oxygen supplementation was used.