Treatment of major wound necrosis following total knee arthroplasty

The distance between new and previous incisions does not affect skin necrosis in total knee arthroplasty: a parallel-randomized controlled clinical trial

Background

To avoid skin necrosis, an 8 cm distance between the new and previous incision is recommended in patients undergoing total knee arthroplasty (TKA). It was hypothesized that making a new incision less than 8 cm of the prior scar does not increase the risk of skin complications, and the new incision can be made anywhere, regardless of the distance from the previous scar. This study investigated how making a new incision, irrespective of the previous scars, affects skin necrosis.

Methods

In this parallel, randomized clinical trial, by simple randomization method using a random number table, 50 patients with single longitudinal knee scars were randomly assigned to two groups with a 1:1 ratio and 25 participants in each group. Patients with a minimum age of 60 and a single longitudinal previous scar on the knee were included. The exclusion criteria were diabetes mellitus, hypertension, morbid obesity, smoking, vascular disorders, cardiopulmonary disorders, immune deficiencies, dementia, and taking steroids and angiogenesis inhibitors. TKA was performed through an anterior midline incision, regardless of the location of the previous scar in the intervention group. TKA was performed with a new incision at least 8 cm distant from the old incision in the control group. Skin necrosis and scar-related complications were evaluated on the first and second days and first, second, and fourth weeks after the surgery. Knee function was assessed using the Knee Society Score (KSS) six months after the surgery.

Results

The baseline characteristics of the groups did not differ significantly. The average distance from the previous scar was 4.1 ± 3.2 cm in the intervention group and 10.2 ± 2.1 cm in the control group. Only one patient in the control group developed skin necrosis (P-value = 0.31). Other wound-related complications were not observed in both groups. The mean KSS was 83.2 ± 10.2 and 82.9 ± 11.1 in the intervention and control groups, respectively (P-value = 0.33).

Conclusions

It is possible that in TKA patients, the new incision near a previous scar does not increase the risk of skin necrosis and other complications.

A Novel Biofilm-Disrupting Wound Care Technology for the Prevention of Surgical Site Infections Following Total Joint Arthroplasty: A Conceptual Review

Surgical site infections (SSIs) are a major driver for increased costs following lower extremity joint arthroplasty procedures. It has been estimated that these account for over $2 billion in annual costs in the United States. While many of the current strategies for the prevention and treatment of SSIs target planktonic bacteria, 80 to 90% of bacterial pathogens exist in a sessile state. These sessile bacteria can produce extracellular polymeric substance (EPS) as protective barriers from host immune defenses and antimicrobial agents and thus, can be exceedingly difficult to eradicate. A novel wound care gel that disrupts the EPS and destroys the inciting pathogens has been developed for the treatment and prevention of biofilm-related infections. This is achieved by the simultaneous action of four key ingredients: (1) citric acid; (2) sodium citrate; (3) benzalkonium chloride; and (4) polyethylene glycol. Together, these constituents create a high osmolarity, pH-controlled environment that deconstructs and prevents biofilm formation, while destroying pathogens and promoting a moist environment for optimal wound healing. The available clinical evidence demonstrating the efficacy of this technology has been summarized, as well as the economic implications of its implementation and the authors' preferred method of its use. Due to the multifaceted burden associated with biofilm-producing bacteria in arthroplasty patients, this technology may prove to be beneficial for patients who have higher risks for infection, or perhaps, as a prophylactic measure to prevent infections for all patients.

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.

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.

What Factors Influence the Success of Medial Gastrocnemius Flaps in the Treatment of Infected TKAs?

BACKGROUND

Soft tissue defects after TKA are a potentially devastating complication. Medial gastrocnemius flaps occasionally are used to provide soft tissue coverage, most commonly with a periprosthetic joint infection.

QUESTIONS/PURPOSES

We asked: (1) What were the rates of persistent or recurrent infection, implant survivorship, flap-related complications, and reoperation for patients who underwent medial gastrocnemius flap reconstruction for soft tissue coverage after TKA? (2) What were the Knee Society clinical and functional scores for patients who underwent medial gastrocnemius flap reconstruction for soft tissue defects after TKA? (3) What were the risk factors for failure of medial gastrocnemius flap reconstruction after TKA, with failure defined as recurrent or new periprosthetic joint infection or inability to reimplant the TKA prosthesis?

METHODS

Between 2003 and 2011, four surgeons at one institution performed 31 medial gastrocnemius flaps for soft tissue coverage over an infected TKA. Of those, 27 (87%) were available for followup at a minimum of 2 years (mean, 4 years; range, 2-6 years), although patients experiencing complications or treatment failures before two years were included. The study group consisted of 15 men and 12 women with a mean age of 61 years at the time of surgery (range, 36-86 years). The general indication for using a gastrocnemius flap in this setting was full-thickness soft tissue deficiency over the anterior knee during the course of treatment for concomitant deep infection. Six flaps were performed at prosthetic explantation and antibiotic spacer placement, eight at a spacer exchange, eight at second-stage TKA prosthesis reimplantation, and five at débridement with polyethylene exchange. The decision regarding when during staged treatment to place the flap was based solely on when the soft tissues were deemed insufficient, and not based on a belief that placement at one stage versus another was advantageous. Failure was defined as inability to undergo reimplantation of a TKA prosthesis or recurrence of periprosthetic joint infection. Patient and procedural characteristics were tested for association with failure. Survivorship was calculated by Cox proportional hazards modeling. Outcomes scores were drawn from a longitudinal institutional registry.

RESULTS

Fourteen of 27 (52%) patients had a persistent or recurrent infection; survivorship of the TKA prosthesis at 4 years was 48% (95% CI, 31%-66%). Although there were no flap-related complications, 12 patients had a total of 19 reoperations during the study period. Overall, the mean (± SD) Knee Society knee (38 ± 18 vs 65 ± 20; p < 0.001) and function (20 ± 22 vs 37 ± 25; p = 0.002) scores were improved at most recent followup. No factors were identified as associated with failure when a Bonferroni correction was applied.

CONCLUSIONS

Gastrocnemius flaps were used to address difficult soft tissue defects in this series, in the presence of deep infections; the high proportion of patients experiencing persistent or recurrent infections reflects the case complexity and not necessarily a problem with the flaps. However, this series highlights the need to continue to explore alternative approaches to managing this difficult clinical problem. Future studies should aim to establish an evidence-based reconstructive algorithm, focusing on host, wound, and timing characteristics that may maximize outcomes.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Lower extremity reconstruction after limb-sparing sarcoma resection of the proximal tibia in the pediatric population: case series, with algorithm

Limb salvage surgery (LSS) is the current treatment of choice for bone sarcomas in children. These procedures require composite resection and reconstruction, and are subject to high functional demands. Proximal tibia tumours, in particular, pose a significant challenge to treatment and reconstruction. A retrospective review was performed of all patients undergoing resection of proximal tibia bone sarcomas at a single centre over a 12-year period. Twenty-one patients (14 male, seven female) with an average age of 14.4 years (range = 8.3-19.2 years) underwent resection of a proximal tibial sarcoma. Pathology included osteosarcoma (OS) in 16, and Ewing's sarcoma family of tumours (ESFT) in five. Seventeen patients had bone tumour reconstruction with modular endoprsothesis, one patient with allograft, and three patients with an expandable endoprosthesis. One patient had primary closure; 20 patients had combined gastrocnemius and soleus flap reconstruction; three patients required subsequent bipedicled flap reconstruction, and two patients required subsequent sural artery flap reconstruction. No patients required free flap reconstruction. The average length of tibial osteotomy was 15 cm (range = 12.7-22.5 cm). Median soft tissue mass volume resected was 293 cm(3) (range = 211-1141 cm(3)). Median follow-up was 2.8 years (range = 0.5-6.8 years). Two patients died from metastatic disease. Two patients ultimately required amputation. Nineteen patients were ambulatory at last follow-up. This study presents an algorithm for soft-tissue reconstruction after resection of bone sarcomas of the proximal tibia. These techniques minimise complications, and maximise function in the paediatric population.

Reverse gracilis muscle flap: an alternative means of skin coverage for recurrent infection after TKA

PURPOSE

Poor wound-healing and skin necrosis are serious but not unusual complications after total knee arthroplasty, and when skin or soft tissue necrosis occurs, reconstructions in the knee area need thin, pliable, tough skin flaps.

METHODS

A 62-year-old man, who previously underwent multiple TKR operations due to recurrent infection, was transferred from another hospital after a gastrocnemius muscle rotation flap failed. We decided to treat the affected area with a reverse gracilis muscle flap. After confirming that the secondary pedicle was intact by Doppler sonography, muscle dissection was extended to the entry of the secondary pedicle. The proximal tendon of the gracilis muscle was transected, and the muscle was rotated 180° and placed at the recipient site.

RESULTS

The aim is to report a case of reconstruction at the anterior knee using a reverse gracilis muscle flap that achieved an excellent final clinical result.

CONCLUSION

This case suggests that the indications for a reverse gracilis muscle flap could be broadened when other flaps are not available for knee prosthesis coverage.

Wound complications in total knee arthroplasty. Which flap is to be used? With or without retention of prosthesis?

PURPOSE

The aim of our review paper is to present a possible algorithm of treatment of knee periprosthetic soft tissue defects, relative to their extent and depth. Different management of exposed total joints is also proposed, depending on the presence or loss of deep infection and on the timing of infection itself.

METHODS

In accordance with literature and the experience of senior knee surgeon, the incidence and risk factors, and possible treatment options of wound complications following total knee arthroplasty have been throughly analyzed.

RESULTS

There is much controversy regarding the optimal management of wound necrosis around a total knee. Local wound care, debridement, and fasciocutaneous, muscle and perforator flaps have been differently used. Muscle coverage remains the standard to which all other flaps should be compared, especially in infected wounds. Perforator flaps have recently represented a true revolution in the soft tissue reconstruction around the knee, with peculiar advantages due to their low donor morbidity and long pedicles.

CONCLUSION

When wound complications occur, prompt management is mandatory. An algorithm for treatment of wound defects is presented, available for both primary and revision knee replacement.

Extended medial gastrocnemius rotational flap for treatment of chronic knee extensor mechanism deficiency in patients with and without total knee arthroplasty

Nine patients with chronic extensor mechanism disruption were treated with an extended medial gastrocnemius rotational flap reconstruction of the extensor mechanism. Seven patients previously had total knee arthroplasty and two patients had chronic infection of nonreplaced, native knees. Four patients previously had failed Achilles' tendon allograft reconstruction after total knee arthroplasty and two were complicated by infection. Infected arthroplasty patients had a staged procedure with placement of an antibiotic spacer after debridement and extended medial gastrocnemius rotational flap, followed by total knee arthroplasty replant 8 weeks later. The four infected arthroplasty patients had medical comorbidities that included a patient with HIV and hemophilia, and two with diabetes mellitus. Another patient with rheumatoid arthritis was severely malnourished as a result of dumping syndrome. Of the four patients treated by this two-stage procedure, one died in the early postoperative period from chronic medical issues after the second stage and another patient elected to have above-knee amputation after the first stage because of severe reflex sympathetic dystrophy. The final group of seven patients was studied at a mean followup of 21 months (range, 7-31 months), the average extensor lag was 13.5 degrees (range, 0-50 degrees ), and the average range of motion was 2 degrees to 93 degrees . The two patients with nonreplaced, native knees had extensor lags of 30 degrees and 10 degrees . All patients were able to regain sufficient extensor mechanism strength to return to independent ambulation, and all infections resolved after treatment. Two patients were able to ascend stairs foot over foot without support. In addition to the patient who had amputation, the other complication involved a wound breakdown that required a free flap at 13 months in a patient who had a failed Achilles' tendon allograft reconstruction after takedown of a knee fusion. Medial gastrocnemius flap reconstruction can provide successful salvage of a failed extensor mechanism allograft or an alternative to allograft reconstruction in patients with poor soft tissue coverage, previous infection, or a compromised immune system.

Operative management and outcome of complex wounds following total knee arthroplasty

This study describes the treatment protocol for and the outcome of the management of complex wounds around total knee replacements. An analysis of 28 patients (29 knees) with complex defects who had surgery between January 1, 1986, and July 30, 1996, was performed. A specific management protocol was applied to each knee on the basis of the size and depth of the wound, the presence of infection, and the quality of soft tissue. Primary treatment included local wound care, debridement, and skin grafting or coverage with a fasciocutaneous flap, pedicled muscle flap, or free muscle transfer. Postoperatively, knees were evaluated using the Knee Society objective score. Successful salvage of the lower extremity was obtained in 28 knees (97 percent) and of the knee prosthesis in 24 of 29 knees (83 percent). Secondary plastic surgery procedures were necessary in five knees (17 percent), and secondary orthopedic procedures were necessary in four knees (14 percent). Successful salvage of total knee arthroplasty in the presence of a complex wound requires early identification of infection, aggressive irrigation and debridement, and early appropriate soft-tissue coverage. The use of our proposed algorithm will facilitate management of these complex wounds.

Salvage procedures for complex soft tissue defects of the knee

The management options for complex soft tissue defects about the knee are varied. Limb threatening conditions such as exposure of joint prosthesis or bone requires stable coverage to avoid amputation. A study was conducted to review the authors' management protocol and experience with complex defects about the knee. A retrospective analysis from 1986 to 1996 of 35 patients with complex defects about the knee was performed. Treatment options were based on the nature, size, location, and depth of the wound. A specific management protocol was applied for each patient. Treatments included local wound care, debridement and skin graft, fasciocutaneous flap, pedicled muscle flap, and free muscle transfer. Postoperatively, patients were evaluated using Knee Society objective and functional scores and other instruments to measure outcome. Successful salvage of the lower extremity was obtained in 34 (97%) patients. Salvage of the total knee prosthesis was obtained in 24 of 29 (83%) patients. Secondary plastic surgery procedures were necessary in eight (23%) patients. Secondary orthopaedic procedures were necessary in five (15%) patients. No patient required an amputation.

Wound complications in total knee arthroplasty

Wound problems are a dreaded complication following TKA and ideally are avoided. Preventative measures include proper choice of the skin incision, gentle handling of the soft tissues, meticulous hemostasis, and wound closure without excessive tension. Should persistent wound drainage or soft-tissue necrosis occur, early intervention is imperative as delay risks deep infection and failure of the TKA. Cases associated with full-thickness soft-tissue necrosis often require transfer of well-vascularized tissue such as a medial gastrocnemius myocutaneous flap reconstruction.

The use of muscle flaps for salvage of failed total knee arthroplasty

Deep infections occur in 1-5% of all patients undergoing total knee arthroplasty, and may result in failure of the prosthesis and subsequent arthrodesis. Two-stage reimplantation is often successful, but depends upon the presence of good soft tissue coverage. We have treated 9 patients in whom chronic infection developed which required removal of the prosthesis, debridement, and implantation of antibiotic impregnated spacers for control. These patients all had poor quality soft tissue cover precluding prosthesis reimplantation. The use of muscle flaps resulted in 7 of the 9 patients having successful reimplantation of a prosthesis and remaining free of infection in a follow-up ranging from 1-5 years.