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Published in: Knee Surgery, Sports Traumatology, Arthroscopy 7/2011

01-07-2011 | Knee

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

Authors: Alfredo Schiavone Panni, Michele Vasso, Simone Cerciello, Marzia Salgarello

Published in: Knee Surgery, Sports Traumatology, Arthroscopy | Issue 7/2011

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Abstract

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.
Literature
1.
go back to reference Abdel-Salam A, Eyres KS (1995) Effects of tourniquet during total knee arthroplasty: a prospective randomised study. J Bone Joint Surg Br 77:250–253PubMed Abdel-Salam A, Eyres KS (1995) Effects of tourniquet during total knee arthroplasty: a prospective randomised study. J Bone Joint Surg Br 77:250–253PubMed
2.
go back to reference Adam RF, Watson SB, Jarratt JW, Noble J, Watson JS (1994) Outcome after flap cover for exposed total knee arthroplasties: a report of 25 cases. J Bone Joint Surg Br 76B:750–753 Adam RF, Watson SB, Jarratt JW, Noble J, Watson JS (1994) Outcome after flap cover for exposed total knee arthroplasties: a report of 25 cases. J Bone Joint Surg Br 76B:750–753
3.
go back to reference Alexiades M, Sands A, Craig SM, Scott WN (1989) Management of selected problems in revision knee arthroplasty. Orthop Clin North Am 20:211–219PubMed Alexiades M, Sands A, Craig SM, Scott WN (1989) Management of selected problems in revision knee arthroplasty. Orthop Clin North Am 20:211–219PubMed
4.
go back to reference Anderson DR, Brill-Edwards P, Walker I (1992) Warfarin-induced skin necrosis in 2 patients with protein S deficiency: successful reinstatement of warfarin therapy. Haemostasis 22:124–128PubMed Anderson DR, Brill-Edwards P, Walker I (1992) Warfarin-induced skin necrosis in 2 patients with protein S deficiency: successful reinstatement of warfarin therapy. Haemostasis 22:124–128PubMed
5.
go back to reference Andres LA, Casey WJ, Clarke HD (2009) Techniques in soft tissue coverage around the knee. Tech Knee Surg 8:119–125CrossRef Andres LA, Casey WJ, Clarke HD (2009) Techniques in soft tissue coverage around the knee. Tech Knee Surg 8:119–125CrossRef
6.
go back to reference Bal BS, Gurba DM (1991) Coumadin-induced necrosis of the skin after total knee replacement. A case report. J Bone Joint Surg Am 73:129–130PubMed Bal BS, Gurba DM (1991) Coumadin-induced necrosis of the skin after total knee replacement. A case report. J Bone Joint Surg Am 73:129–130PubMed
7.
go back to reference Balestra B (1995) Skin necrosis: a paradoxical complication of anticoagulation. Schweiz Med Wochenschr 125:361–364PubMed Balestra B (1995) Skin necrosis: a paradoxical complication of anticoagulation. Schweiz Med Wochenschr 125:361–364PubMed
8.
go back to reference Blondeel PN, Morris SF, Hallock GG, Neligan PC (2006) Perforator flaps. Anatomy, technique and clinical applications. Quality Medical Publishing Inc., St.Louis, Missouri Blondeel PN, Morris SF, Hallock GG, Neligan PC (2006) Perforator flaps. Anatomy, technique and clinical applications. Quality Medical Publishing Inc., St.Louis, Missouri
9.
go back to reference Busfield BT, Huffman GR, Nahai F, Hoffman W, Ries MD (2004) Extended medial gastrocnemius rotational flap for treatment of chronic knee extensor mechanism deficiency in patients with or without total knee arthroplasty. Clin Orthop Relat Res 428:190–197PubMedCrossRef Busfield BT, Huffman GR, Nahai F, Hoffman W, Ries MD (2004) Extended medial gastrocnemius rotational flap for treatment of chronic knee extensor mechanism deficiency in patients with or without total knee arthroplasty. Clin Orthop Relat Res 428:190–197PubMedCrossRef
10.
go back to reference Callam MJ, Harper DR, Dale JJ, Ruckley CV (1985) Chronic ulceration of the leg: extent of the problem and provision of care. Br Med J (Clin Res Ed) 290:1855–1856CrossRef Callam MJ, Harper DR, Dale JJ, Ruckley CV (1985) Chronic ulceration of the leg: extent of the problem and provision of care. Br Med J (Clin Res Ed) 290:1855–1856CrossRef
11.
go back to reference Casanova D, Hulard O, Zalta R, Bardot J, Magalon G (2001) Management of wounds of exposed or infected knee prostheses. Scand J Plast Reconstr Surg Hand Surg 35:71–77PubMedCrossRef Casanova D, Hulard O, Zalta R, Bardot J, Magalon G (2001) Management of wounds of exposed or infected knee prostheses. Scand J Plast Reconstr Surg Hand Surg 35:71–77PubMedCrossRef
12.
go back to reference Chandrasekhar B, Brien W (1993) Coverage strategies in total joint replacement. Orthop Clin North Am 24:523–529PubMed Chandrasekhar B, Brien W (1993) Coverage strategies in total joint replacement. Orthop Clin North Am 24:523–529PubMed
13.
go back to reference Clarke MT, Longstaff L, Edwards D, Rushton N (2001) Tourniquet-induced wound hypoxia after total knee replacement. J Bone Joint Surg Br 83:40–44PubMedCrossRef Clarke MT, Longstaff L, Edwards D, Rushton N (2001) Tourniquet-induced wound hypoxia after total knee replacement. J Bone Joint Surg Br 83:40–44PubMedCrossRef
14.
go back to reference Dennis DA (1997) Wound complications in total knee arthroplasty. Instr Course Lect 46:165–169PubMed Dennis DA (1997) Wound complications in total knee arthroplasty. Instr Course Lect 46:165–169PubMed
15.
go back to reference Fitzgerald RH Jr (1995) Infected total hip arthroplasty: diagnosis and treatment. J Am Acad Orthop Surg 3:249–262PubMed Fitzgerald RH Jr (1995) Infected total hip arthroplasty: diagnosis and treatment. J Am Acad Orthop Surg 3:249–262PubMed
16.
go back to reference Gaine WJ, Ramamohan NA, Hussein NA, Hullin MG, McCreath SW (2000) Wound infection in hip and knee arthroplasty. J Bone Joint Surg Br 82B:561–565CrossRef Gaine WJ, Ramamohan NA, Hussein NA, Hullin MG, McCreath SW (2000) Wound infection in hip and knee arthroplasty. J Bone Joint Surg Br 82B:561–565CrossRef
17.
go back to reference Galat DD, McGovern SC, Larson DR, Harrington JR, Hansenn AD, Clarke HD (2009) Surgical treatment of early wound complications following primary total knee arthroplasty. J Bone Joint Surg Am 91:48–54PubMedCrossRef Galat DD, McGovern SC, Larson DR, Harrington JR, Hansenn AD, Clarke HD (2009) Surgical treatment of early wound complications following primary total knee arthroplasty. J Bone Joint Surg Am 91:48–54PubMedCrossRef
18.
go back to reference Gerwin M, Rothaus KO, Windsor RE, Brause BD, Insall JN (1993) Gastrocnemius muscle flap coverage of exposed or infected knee prostheses. Clin Orthop Relat Res 286:64–70PubMed Gerwin M, Rothaus KO, Windsor RE, Brause BD, Insall JN (1993) Gastrocnemius muscle flap coverage of exposed or infected knee prostheses. Clin Orthop Relat Res 286:64–70PubMed
19.
go back to reference Hansson C, Andersson E, Swanbeck G (1988) Leg ulceration epidemiology in Gothenburg. Acta Chir Scand Suppl 544:12–16PubMed Hansson C, Andersson E, Swanbeck G (1988) Leg ulceration epidemiology in Gothenburg. Acta Chir Scand Suppl 544:12–16PubMed
20.
go back to reference Hierner R, Reynders-Frederix P, Bellemans J, Stuyck J, Peeters W (2009) Free myocutaneous latissimus dorsi flap transfer in total knee arthroplasty. J Plast Reconstr Aesthet Surg 62:1692–1700PubMedCrossRef Hierner R, Reynders-Frederix P, Bellemans J, Stuyck J, Peeters W (2009) Free myocutaneous latissimus dorsi flap transfer in total knee arthroplasty. J Plast Reconstr Aesthet Surg 62:1692–1700PubMedCrossRef
21.
go back to reference Johnson DP (1990) The effect of continuous passive motion on wound-healing and joint mobility after knee arthroplasty. J Bone Joint Surg Am 72:421–426PubMed Johnson DP (1990) The effect of continuous passive motion on wound-healing and joint mobility after knee arthroplasty. J Bone Joint Surg Am 72:421–426PubMed
22.
go back to reference Jones RE (2010) Wound healing in total joint arthroplasty. Orthopedics 33(9) Jones RE (2010) Wound healing in total joint arthroplasty. Orthopedics 33(9)
23.
go back to reference Kim JS, Lee HS, Jang PY, Choi TH, Lee KS, Kim NG (2010) Use of the descending branch of lateral circumflex femoral artery as a recipient pedicle for coverage of a knee defect with free flap: anatomical and clinical study. Microsurgery 30:32–36PubMed Kim JS, Lee HS, Jang PY, Choi TH, Lee KS, Kim NG (2010) Use of the descending branch of lateral circumflex femoral artery as a recipient pedicle for coverage of a knee defect with free flap: anatomical and clinical study. Microsurgery 30:32–36PubMed
24.
go back to reference Kim YH, Cho SH, Kim JS (1999) Total knee arthroplasty in bony ankylosis in gross flexion. J Bone Joint Surg Br 81B:296–300CrossRef Kim YH, Cho SH, Kim JS (1999) Total knee arthroplasty in bony ankylosis in gross flexion. J Bone Joint Surg Br 81B:296–300CrossRef
25.
go back to reference Klayman MH, Trowbridge CC, Stammers AH, Wolfgang GL, Zijerdi DA, Bitterly TJ (2006) Autologous platelet concentrate and vacuum-assisted closure device use in a nonhealing total knee replacement. J Extra Corpor Technol 38:44–47PubMed Klayman MH, Trowbridge CC, Stammers AH, Wolfgang GL, Zijerdi DA, Bitterly TJ (2006) Autologous platelet concentrate and vacuum-assisted closure device use in a nonhealing total knee replacement. J Extra Corpor Technol 38:44–47PubMed
26.
go back to reference Lian G, Cracchiolo A, Lesavoy M (1989) Treatment of major wound necrosis following total knee arthroplasty. J Arthroplasty 4(Suppl):S23–S32PubMedCrossRef Lian G, Cracchiolo A, Lesavoy M (1989) Treatment of major wound necrosis following total knee arthroplasty. J Arthroplasty 4(Suppl):S23–S32PubMedCrossRef
27.
go back to reference Lidwell OM, Lowbury EJL, Whyte W, Blowers R, Stanley SJ, Lowe D (1984) Infection and sepsis after operations for total hip or knee-joint replacement: influence of ultraclean air, prophylactic antibiotics and other factors. J Hyg 93:505–529CrossRef Lidwell OM, Lowbury EJL, Whyte W, Blowers R, Stanley SJ, Lowe D (1984) Infection and sepsis after operations for total hip or knee-joint replacement: influence of ultraclean air, prophylactic antibiotics and other factors. J Hyg 93:505–529CrossRef
28.
go back to reference Manoso MW, Boland PJ, Healey JH, Cordeiro PG (2006) Limb salvage of infected knee reconstructions for cancer with stage revision and free tissue transfer. Ann Plast Surg 56:532–535PubMedCrossRef Manoso MW, Boland PJ, Healey JH, Cordeiro PG (2006) Limb salvage of infected knee reconstructions for cancer with stage revision and free tissue transfer. Ann Plast Surg 56:532–535PubMedCrossRef
29.
go back to reference Meller I, Ariche A, Sagi A (1997) The role of the gastrocnemius muscle flap in limb-sparing surgery for bone sarcomas of the distal femur: a proposed classification of muscle transfers. Plast Reconstr Surg 99:751–756PubMedCrossRef Meller I, Ariche A, Sagi A (1997) The role of the gastrocnemius muscle flap in limb-sparing surgery for bone sarcomas of the distal femur: a proposed classification of muscle transfers. Plast Reconstr Surg 99:751–756PubMedCrossRef
30.
go back to reference Menderes A, Demirdover C, Yilmaz M, Vayvada H, Barutcu A (2002) Reconstruction of soft tissue defects following total knee arthroplasty. Knee 9:215–219PubMedCrossRef Menderes A, Demirdover C, Yilmaz M, Vayvada H, Barutcu A (2002) Reconstruction of soft tissue defects following total knee arthroplasty. Knee 9:215–219PubMedCrossRef
31.
go back to reference Moller AM, Pedersen T, Villebro N, Munksgaard A (2003) Effect of smoking on early complications after elective orthopaedic surgery. J Bone Joint Surg Br 85:178–181PubMedCrossRef Moller AM, Pedersen T, Villebro N, Munksgaard A (2003) Effect of smoking on early complications after elective orthopaedic surgery. J Bone Joint Surg Br 85:178–181PubMedCrossRef
32.
go back to reference Moscatiello F, Masia J, Carrera A, Clavero JA, Larrañaga JR, Pons G (2007) The ‘propeller’ distal anteromedial thigh perforator flap. Anatomic study and clinical applications. J Plast Reconstr Aesthet Surg 60:1323–1330PubMedCrossRef Moscatiello F, Masia J, Carrera A, Clavero JA, Larrañaga JR, Pons G (2007) The ‘propeller’ distal anteromedial thigh perforator flap. Anatomic study and clinical applications. J Plast Reconstr Aesthet Surg 60:1323–1330PubMedCrossRef
33.
go back to reference Munjal S, Phillips MJ, Krackow KA (2001) Revision total knee arthroplasty: planning, controversies, and management infection. In: Sim FH (ed) AAOS instructional course lectures, vol 50. C.V. Mosby, St. Louis, p 367 Munjal S, Phillips MJ, Krackow KA (2001) Revision total knee arthroplasty: planning, controversies, and management infection. In: Sim FH (ed) AAOS instructional course lectures, vol 50. C.V. Mosby, St. Louis, p 367
34.
go back to reference Nahabedian MY, Orlando JC, Delanois RE, Mont MA, Hungerford DS (1998) Salvage procedures for complex soft tissue defects of the knee. Clin Orthop Relat Res 356:119–124PubMedCrossRef Nahabedian MY, Orlando JC, Delanois RE, Mont MA, Hungerford DS (1998) Salvage procedures for complex soft tissue defects of the knee. Clin Orthop Relat Res 356:119–124PubMedCrossRef
35.
go back to reference Papagelopoulos PJ, Mavrogenis AF, Giannitsioti E, Kikilas A, Kanellakopoulou K, Soucacos PN (2007) Management of a multidrug-resistant Pseudomonas Aeruginosa infected total knee arthroplasty using colistin. A case report and review of the literature. J Arthroplasty 22:457–463PubMedCrossRef Papagelopoulos PJ, Mavrogenis AF, Giannitsioti E, Kikilas A, Kanellakopoulou K, Soucacos PN (2007) Management of a multidrug-resistant Pseudomonas Aeruginosa infected total knee arthroplasty using colistin. A case report and review of the literature. J Arthroplasty 22:457–463PubMedCrossRef
36.
go back to reference Patel NS, Ibrahim DT, Finn HA (2002) Knee extensor mechanism reconstruction with medial gastrocnemius flap. Clin Orthop Relat Res 398:176–181PubMedCrossRef Patel NS, Ibrahim DT, Finn HA (2002) Knee extensor mechanism reconstruction with medial gastrocnemius flap. Clin Orthop Relat Res 398:176–181PubMedCrossRef
37.
go back to reference Patel VP, Walsh M, Sehgal B, Preston C, DeWal H, Di Cesare PE (2007) Factors associated with prolonged wound drainage after primary total hip and knee arthroplasty. J Bone Joint Surg Am 89A:33–38CrossRef Patel VP, Walsh M, Sehgal B, Preston C, DeWal H, Di Cesare PE (2007) Factors associated with prolonged wound drainage after primary total hip and knee arthroplasty. J Bone Joint Surg Am 89A:33–38CrossRef
38.
go back to reference Patella V, Speciale D, Patella S, Moretti B, Pesce V, Spinarelli A (2008) Wound necrosis after total knee arthroplasty. Orthopedics 31:807PubMedCrossRef Patella V, Speciale D, Patella S, Moretti B, Pesce V, Spinarelli A (2008) Wound necrosis after total knee arthroplasty. Orthopedics 31:807PubMedCrossRef
39.
go back to reference Rhomberg M, Schwabegger AH, Ninkovic M, Bauer T, Ninkovic M (2002) Gastrocnemius myotendinous flap for patellar or quadriceps tendon repair, or both. Clin Orthop Relat Res 377:152–160CrossRef Rhomberg M, Schwabegger AH, Ninkovic M, Bauer T, Ninkovic M (2002) Gastrocnemius myotendinous flap for patellar or quadriceps tendon repair, or both. Clin Orthop Relat Res 377:152–160CrossRef
40.
41.
go back to reference Ries MD, Bozic KJ (2006) Medial gastrocnemius flap coverage for treatment of skin necrosis after total knee arthroplasty. Clin Orthop Relat Res 446:186–192PubMedCrossRef Ries MD, Bozic KJ (2006) Medial gastrocnemius flap coverage for treatment of skin necrosis after total knee arthroplasty. Clin Orthop Relat Res 446:186–192PubMedCrossRef
42.
go back to reference Saleh K, Olson M, Resig S, Bershadsky B, Kuskowski M, Gioe T, Robinson H, Schmidt R, McElfresh E (2002) Predictors of wound infection in hip and knee joint replacement: results from a 20 year surveillance program. J Orthop Res 20:506–515PubMedCrossRef Saleh K, Olson M, Resig S, Bershadsky B, Kuskowski M, Gioe T, Robinson H, Schmidt R, McElfresh E (2002) Predictors of wound infection in hip and knee joint replacement: results from a 20 year surveillance program. J Orthop Res 20:506–515PubMedCrossRef
43.
go back to reference Scott WN (2006) Insall & Scott’s surgery of the knee, vol 1, 4th edn. Churchill Livingstone Elsevier, Philadelphia Scott WN (2006) Insall & Scott’s surgery of the knee, vol 1, 4th edn. Churchill Livingstone Elsevier, Philadelphia
44.
go back to reference Sierra RJ, Trousdale RT, Pagnano MW (2003) Above-the-knee amputation after a total knee arthroplasty. Prevalence, etiology, and functional outcome. J Bone Joint Surg Am 85A:1000–1004 Sierra RJ, Trousdale RT, Pagnano MW (2003) Above-the-knee amputation after a total knee arthroplasty. Prevalence, etiology, and functional outcome. J Bone Joint Surg Am 85A:1000–1004
45.
go back to reference Tiengo C, Macchi V, Vigato E, Porzionato A, Stecco C, Azzena B, Morra A, De Caro R (2010) Reversed gracilis pedicle flap for coverage of a total knee prosthesis. J Bone Joint Surg Am 92:1640–1646PubMedCrossRef Tiengo C, Macchi V, Vigato E, Porzionato A, Stecco C, Azzena B, Morra A, De Caro R (2010) Reversed gracilis pedicle flap for coverage of a total knee prosthesis. J Bone Joint Surg Am 92:1640–1646PubMedCrossRef
46.
go back to reference Vince KG, Abdeen A (2006) Wound problems in total knee arthroplasty. Clin Orthop Relat Res 452:88–90PubMedCrossRef Vince KG, Abdeen A (2006) Wound problems in total knee arthroplasty. Clin Orthop Relat Res 452:88–90PubMedCrossRef
47.
go back to reference Weber AB, Worland RL, Jessup DE, Van Bowen J, Keenan J (2003) The consequences of lateral release in total knee replacement: a review of over 1,000 knees with follow up between 5 and 11 years. Knee 10:187–191PubMedCrossRef Weber AB, Worland RL, Jessup DE, Van Bowen J, Keenan J (2003) The consequences of lateral release in total knee replacement: a review of over 1,000 knees with follow up between 5 and 11 years. Knee 10:187–191PubMedCrossRef
Metadata
Title
Wound complications in total knee arthroplasty. Which flap is to be used? With or without retention of prosthesis?
Authors
Alfredo Schiavone Panni
Michele Vasso
Simone Cerciello
Marzia Salgarello
Publication date
01-07-2011
Publisher
Springer-Verlag
Published in
Knee Surgery, Sports Traumatology, Arthroscopy / Issue 7/2011
Print ISSN: 0942-2056
Electronic ISSN: 1433-7347
DOI
https://doi.org/10.1007/s00167-010-1328-5

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