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Müller SLC, Kuehl R, Schaefer DJ, Morgenstern M, Clauss M, Osinga R. The myocutaneous gastrocnemius flap for periprosthetic joint infection of the knee. J Exp Orthop 2024; 11:e12089. [PMID: 38974052 PMCID: PMC11227597 DOI: 10.1002/jeo2.12089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2024] [Accepted: 06/03/2024] [Indexed: 07/09/2024] Open
Abstract
Purpose Periprosthetic joint infection (PJI) following total knee arthroplasty (TKA) presents significant challenges, especially in elderly and comorbid patients, often necessitating revision surgeries. We report on a series of patients with confirmed PJI of the knee and concomitant soft-tissue/extensor apparatus defects, treated by using pedicled myocutaneous medial or lateral sural artery perforator (MSAP/LSAP) gastrocnemius flaps. Methods Our retrospective study at the Center for Musculoskeletal Infections, included patients with knee PJI undergoing pedicled myocutaneous MSAP/LSAP gastrocnemius flap reconstruction for combined soft tissue and extensor apparatus defects. The tendinous back of the gastrocnemius muscle was used and, if required, the Achilles tendon for extensor apparatus reconstruction, with the skin island addressing the cutaneous defect. Perioperative complications and postoperative outcomes after 1 year were evaluated, including functional and clinical assessments with the American Knee Society Score (AKSS). Results Eight patients (mean age 73 years; five female) were included, predominantly with Staphylococcus aureus infections. Six patients involved isolated MSAP flaps, two were extended with the Achilles tendon. The median time for wound healing was 9 days. Short-term follow-up showed successful reconstruction in seven patients, with minor wound dehiscence in one patient. One patient required flap revision for a perigenicular haemato-seroma and two patients were diagnosed with new haematogenous PJI infection. Significant improvement in AKSS scores after surgery was observed (functional AKSS: median 33-85; clinical AKSS: median 64-91, p = 0.001). Conclusion Pedicled myocutaneous MSAP/LSAP gastrocnemius flaps offer a safe, reliable and versatile option for reconstructing combined soft tissue and extensor apparatus defects in PJI after TKA. This approach yields excellent functional outcomes with minimal peri- and postoperative complications, which is particularly beneficial in elderly and comorbid patients and feasible in settings without microsurgical availability. Level of evidence Level IV.
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Affiliation(s)
- Seraina L. C. Müller
- Department of PlasticReconstructive, Aesthetic and Hand Surgery, University Hospital BaselBaselSwitzerland
| | - Richard Kuehl
- Center for Musculoskeletal Infections (ZMSI)University Hospital BaselBaselSwitzerland
- Infectious Diseases and Hospital EpidemiologyUniversity Hospital BaselBaselSwitzerland
| | - Dirk J. Schaefer
- Department of PlasticReconstructive, Aesthetic and Hand Surgery, University Hospital BaselBaselSwitzerland
- Center for Musculoskeletal Infections (ZMSI)University Hospital BaselBaselSwitzerland
| | - Mario Morgenstern
- Center for Musculoskeletal Infections (ZMSI)University Hospital BaselBaselSwitzerland
- Department of Orthopaedic and Trauma SurgeryUniversity Hospital BaselBaselSwitzerland
| | - Martin Clauss
- Center for Musculoskeletal Infections (ZMSI)University Hospital BaselBaselSwitzerland
- Department of Orthopaedic and Trauma SurgeryUniversity Hospital BaselBaselSwitzerland
| | - Rik Osinga
- Department of PlasticReconstructive, Aesthetic and Hand Surgery, University Hospital BaselBaselSwitzerland
- Center for Musculoskeletal Infections (ZMSI)University Hospital BaselBaselSwitzerland
- Canniesburn Plastic Surgery UnitGlasgow Royal InfirmaryGlasgowUK
- Praxis beim Merian IselinBaselSwitzerland
- REHAB Basel, Clinic for Neurorehabilitation and ParaplegiologyBaselSwitzerland
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Razii N, Kennedy JW, Shields DW, Hrycaiczuk A, Morgan-Jones R, Meek RMD, Jamal B. Proceedings of the United Kingdom Periprosthetic Joint Infection Meeting 2022: Combined and Arthroplasty Sessions. J Arthroplasty 2024; 39:218-223. [PMID: 37393964 DOI: 10.1016/j.arth.2023.06.039] [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: 03/03/2023] [Revised: 06/15/2023] [Accepted: 06/24/2023] [Indexed: 07/04/2023] Open
Abstract
Considerable variation in practice exists in the prevention, diagnosis, and treatment of periprosthetic joint infection (PJI), which is a devastating complication for patients and surgeons. The consensus principle has been increasingly embraced by the orthopaedic community to help guide practice, especially where high-level evidence remains unavailable. The third United Kingdom Periprosthetic Joint Infection (UK PJI) Meeting was held in Glasgow on April 1, 2022, with more than 180 delegates in attendance, representing orthopaedics, microbiology, infectious diseases, plastic surgery, anesthetics, and allied health professions, including pharmacy and arthroplasty nurses. The meeting comprised a combined session for all delegates, and separate breakout sessions for arthroplasty and fracture-related infection. Consensus questions for each session were prepared in advance by the UK PJI working group, based upon topics that were proposed at previous UK PJI Meetings, and delegates participated in an anonymized electronic voting process. We present the findings of the combined and arthroplasty sessions of the meeting in this article, and each consensus topic is discussed in relation to the contemporary literature.
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Affiliation(s)
- Nima Razii
- Department of Trauma and Orthopaedics, Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | - John W Kennedy
- Department of Trauma and Orthopaedics, Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | - David W Shields
- Department of Trauma and Orthopaedics, Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | - Alex Hrycaiczuk
- Department of Trauma and Orthopaedics, Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | - Rhidian Morgan-Jones
- Cardiff and Vale Orthopaedic Centre, University Hospital Llandough, Cardiff, United Kingdom
| | - R M Dominic Meek
- Department of Trauma and Orthopaedics, Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | - Bilal Jamal
- Department of Trauma and Orthopaedics, Queen Elizabeth University Hospital, Glasgow, United Kingdom
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Schweizer T, Gohritz A, Lo SJ, Schaefer D, Osinga R. [Pedicled myofasciocutaneous medial or lateral sural artery perforator gastrocnemius flap for perigenicular soft tissue reconstruction]. UNFALLCHIRURGIE (HEIDELBERG, GERMANY) 2023; 126:312-315. [PMID: 36912968 PMCID: PMC10060310 DOI: 10.1007/s00113-023-01303-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Accepted: 02/01/2023] [Indexed: 03/14/2023]
Affiliation(s)
- Thierry Schweizer
- Klinik für Plastische, Rekonstruktive, Ästhetische und Handchirurgie, Universitätsspital Basel, Spitalstr. 21, 4031, Basel, Schweiz
| | - Andreas Gohritz
- Klinik für Plastische, Rekonstruktive, Ästhetische und Handchirurgie, Universitätsspital Basel, Spitalstr. 21, 4031, Basel, Schweiz
| | - Steven John Lo
- Canniesburn Plastic Surgery Unit, Glasgow Royal Infirmary, 84 Castle Street, Glasgow, UK
| | - Dirk Schaefer
- Klinik für Plastische, Rekonstruktive, Ästhetische und Handchirurgie, Universitätsspital Basel, Spitalstr. 21, 4031, Basel, Schweiz
- Zentrum für Muskuloskelettale Infektionen (ZMSI), Universitätsspital Basel, Spitalstr. 21, 4031, Basel, Schweiz
| | - Rik Osinga
- Klinik für Plastische, Rekonstruktive, Ästhetische und Handchirurgie, Universitätsspital Basel, Spitalstr. 21, 4031, Basel, Schweiz.
- Canniesburn Plastic Surgery Unit, Glasgow Royal Infirmary, 84 Castle Street, Glasgow, UK.
- Zentrum für Muskuloskelettale Infektionen (ZMSI), Universitätsspital Basel, Spitalstr. 21, 4031, Basel, Schweiz.
- Praxis beim Merian Iselin, Thannerstr. 80, 4054, Basel, Schweiz.
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McCulloch R, Adlan A, Evans S, Parry M, Stevenson J, Jeys L. Outcomes of the gastrocnemius flap performed by orthopaedic surgeons in salvage revision knee arthroplasty. J Bone Jt Infect 2021; 6:425-432. [PMID: 36561206 PMCID: PMC9720735 DOI: 10.5194/jbji-6-425-2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 10/29/2021] [Indexed: 12/25/2022] Open
Abstract
Introduction: The gastrocnemius myofascial flap is used to manage soft-tissue defects over the anterior aspect of the knee in the context of a patient presenting with a sinus and periprosthetic joint infection (PJI) or extensor mechanism failure. The aim of this study was twofold: firstly, to evaluate the outcomes of gastrocnemius flaps performed by appropriately trained orthopaedic surgeons in the context of PJI and, secondly, to evaluate the infection-free survival of this patient group. Patients and methods: We retrospectively reviewed 30 patients who underwent gastrocnemius flap reconstruction during staged revision total knee arthroplasty for prosthetic joint infection (PJI). All flaps were performed by an orthopaedic surgeon with orthoplastics training. Patients had a mean age of 68.9 years (range 50-84) and were followed up for a mean of 50.4 months (range 2-128 months). A total of 29 patients (97 %) were categorized into Musculoskeletal Infection Society (MSIS) local extremity grade 3 (greater than two compromising factors), and 52 % of PJIs were polymicrobial. The primary outcome measure was flap failure, and the secondary outcome measure was recurrent infection. Results: Flap survival was 100 % with no failures or early returns to theatre for flap problems such as necrosis or haematoma. Overall infection-free survival during the study period was 48 % (13 of 27 infected cases). Using limb salvage as the outcome, 77 % (23 of 30 patients) retained the limb. Infection recurrence occurred in 48 % (10 patients) in the type B3 cohort and 67 % (4 patients) in the type C3 cohort ( p = 0.65 ). Conclusions: The surgical technique for a gastrocnemius myofascial flap is reliable and reproducible when performed by appropriately trained orthopaedic surgeons, even in high-risk groups. However, the risks of recurrent infection and amputation remain high within our series due to poor host and extremity factors.
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Affiliation(s)
| | - Amirul Adlan
- Royal Orthopaedic Hospital, Bristol Road South, Northfield,
Birmingham, B31 2AP, UK
| | - Scott Evans
- Royal Orthopaedic Hospital, Bristol Road South, Northfield,
Birmingham, B31 2AP, UK
| | - Michael Parry
- Royal Orthopaedic Hospital, Bristol Road South, Northfield,
Birmingham, B31 2AP, UK
| | - Jonathan Stevenson
- Royal Orthopaedic Hospital, Bristol Road South, Northfield,
Birmingham, B31 2AP, UK
| | - Lee Jeys
- Royal Orthopaedic Hospital, Bristol Road South, Northfield,
Birmingham, B31 2AP, UK,Aston Medical School, Aston University, Birmingham,
UK,School of Life and Health Sciences, Aston University, Birmingham,
UK
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Müller SLC, Morgenstern M, Kuehl R, Muri T, Kalbermatten DF, Clauss M, Schaefer DJ, Sendi P, Osinga R. Soft-tissue reconstruction in lower-leg fracture-related infections: An orthoplastic outcome and risk factor analysis. Injury 2021; 52:3489-3497. [PMID: 34304885 DOI: 10.1016/j.injury.2021.07.022] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Revised: 07/02/2021] [Accepted: 07/13/2021] [Indexed: 02/02/2023]
Abstract
Introduction Fracture-related infection (FRI) is a severe post-traumatic complication which is occasionally accompanied by a deficient or even avital soft-tissue envelope. In these cases, a thoroughly planned orthoplastic approach is imperative as a vital and intact soft-tissue envelope is mandatory to achieve fracture union and infection eradication. The aim of this study was, to analyse if soft-tissue reconstruction (STR) without complications is associated with a better long-term outcome compared to FRI patients with STR complications. In particular, it was investigated if primary flap failure represented a risk factor for compromised fracture union and recurrence of infection. Patients and Methods Patients with a lower leg FRI requiring STR (local, pedicled and free flaps) who were treated from 2010-18 at the University Hospital Basel were included in this retrospective analysis. The main outcome measure was the success rate of STR, further outcome measures were fracture nonunion and recurrence of infection. Results Overall, 145 patients with lower leg FRI were identified, of whom 58 (40%) received STR (muscle flaps: n = 38, fascio-cutaneous flaps: n=19; composite osteo-cutaneous flap: n = 1). In total seven patients required secondary STR due to primary flap failure. All failures and flap-related complications occurred within the first three weeks after surgery. Secondary STR was successful in all cases. A high Charlson Comorbidity Index Score was a significant risk factor for flap failure (p = 0.011). Out of the 43 patients who completed the 9-month follow-up, 11 patients presented with fracture nonunion and 12 patients with a recurrent infection. Polymicrobial infection was a significant risk factor for fracture nonunion (p = 0.002). Primary flap failure was neither a risk factor for compromised fracture consolidation (p = 0.590) nor for recurrence of infection (p = 0.508). Conclusion: A considerable number of patients with lower-leg FRI required STR. This patient subgroup is complex and rich in complications and the long-term composite outcome demonstrated a high rate of compromised fracture consolidation and recurrent infections. It appears that secondary STR should be performed, as primary flap failure was neither a risk factor for compromised fracture consolidation nor for recurrence of infection. We propose to monitor these patients closely for three weeks after STR.
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Affiliation(s)
- Seraina L C Müller
- Center for Musculoskeletal Infections, University Hospital Basel, Spitalstrasse 21, Basel CH-4031 Switzerland; Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital Basel, Switzerland
| | - Mario Morgenstern
- Center for Musculoskeletal Infections, University Hospital Basel, Spitalstrasse 21, Basel CH-4031 Switzerland; Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Switzerland.
| | - Richard Kuehl
- Center for Musculoskeletal Infections, University Hospital Basel, Spitalstrasse 21, Basel CH-4031 Switzerland; Department of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Switzerland
| | - Thaddaeus Muri
- Center for Musculoskeletal Infections, University Hospital Basel, Spitalstrasse 21, Basel CH-4031 Switzerland; Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Switzerland
| | - Daniel F Kalbermatten
- Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital Basel, Switzerland
| | - Martin Clauss
- Center for Musculoskeletal Infections, University Hospital Basel, Spitalstrasse 21, Basel CH-4031 Switzerland; Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Switzerland
| | - Dirk J Schaefer
- Center for Musculoskeletal Infections, University Hospital Basel, Spitalstrasse 21, Basel CH-4031 Switzerland; Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital Basel, Switzerland
| | - Parham Sendi
- Center for Musculoskeletal Infections, University Hospital Basel, Spitalstrasse 21, Basel CH-4031 Switzerland; Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Switzerland; Department of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Switzerland; Institute for Infectious Diseases, University of Bern, Switzerland
| | - Rik Osinga
- Center for Musculoskeletal Infections, University Hospital Basel, Spitalstrasse 21, Basel CH-4031 Switzerland; Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital Basel, Switzerland
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The Proximal Placement of the Knee Joint in the 1-Stage Treatment of Infected Knee Revisions With Large Anterior Soft Tissue Defects. Tech Orthop 2021. [DOI: 10.1097/bto.0000000000000553] [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: 10/21/2022]
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Gohritz A, Osinga R, Haumer A, Schaefer DJ. Microsurgical Reconstruction of the Lower Extremity in the Elderly. Clin Plast Surg 2021; 48:331-340. [PMID: 33674054 DOI: 10.1016/j.cps.2021.01.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Demand has increased for complex lower-extremity reconstruction in the steadily growing elderly patient group in many highly developed countries. Microsurgery is indispensable for soft tissue reconstruction and osseous consolidation salvaging leg function and preventing amputation, with its devastating consequences. Microvascular reconstruction can be performed successfully in specialized centers with low donor-site morbidity, minimal operative time, and comparably low complication rates. However, this requires thorough multidisciplinary planning, preoperative optimization of risk factors, such as diabetes and malnutrition, and individually adapted intraoperative management. Implementing these principles can reliably restore ambulation and mobility, maintaining autonomy in this population.
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Affiliation(s)
- Andreas Gohritz
- Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital Basel, Spitalstrasse 21, Basel CH-4031, Switzerland
| | - Rik Osinga
- Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital Basel, Spitalstrasse 21, Basel CH-4031, Switzerland; Centre for Musculoskeletal Infections, University Hospital Basel, Spitalstrasse 21, Basel CH-4031, Switzerland
| | - Alexander Haumer
- Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital Basel, Spitalstrasse 21, Basel CH-4031, Switzerland
| | - Dirk Johannes Schaefer
- Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital Basel, Spitalstrasse 21, Basel CH-4031, Switzerland; Centre for Musculoskeletal Infections, University Hospital Basel, Spitalstrasse 21, Basel CH-4031, Switzerland.
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Cogswell L, McCulloch R. Extensor mechanism reconstruction in the setting of infected total knee arthroplasty. J Bone Jt Infect 2020; 5:184-186. [PMID: 32670772 PMCID: PMC7358970 DOI: 10.7150/jbji.47622] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 04/03/2020] [Indexed: 11/05/2022] Open
Affiliation(s)
- Lucy Cogswell
- Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Foundation Trust, UK
| | - Rob McCulloch
- Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Foundation Trust, UK
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