The salvage of knee-exposed prosthesis using neurofasciocutaneous sural flap

Prosthetic exposure is a severe complication of total knee arthroplasty. Many factors are responsible for failed wound healing, and successful salvage of total knee arthroplasty requires early identification of infection, antecedent events related with wound healing failure, aggressive surgical debridement and early appropriate soft-tissue coverage with local skin, fasciocutaneous, muscle, neurocutaneous or perforator flaps. In this report, we present 15 cases of exposed knee prosthesis treated with island sural neurocutaneous flap. Follow-up showed favorable clinical outcomes: all flaps survived and only two cases of hematoma and one of aseptic phystula occurred. According to our results, the island neurofasciocutaneous sural flap represents a sensate reconstructive alternative for providing fine and dependable soft tissue for covering skin defects around the knee.     

Treatment of the exposed knee prosthesis

Ten knees with early tissue breakdown after knee arthroplasty resulting in exposed prostheses were treated with different plastic surgical techniques. Six knees were successfully covered: four using a gastrocnemius musculocutaneous flap, one using a fasciocutaneous flap, and one using split-skin grafts. Four knees failed: two using local skin flaps and two using split-skin grafts. A gastrocnemius musculocutaneous flap seems to provide a reliable coverage of the exposed knee joint.     

Management of wounds of exposed or infected knee prostheses.

Skin damage after total knee arthroplasty may jeopardise the functional benefit of the prosthesis. In such cases standard treatment is aimed at avoiding arthrodesis, sometimes replacing the implant and, in exceptional cases, amputation. In most cases early and adequate coverage of the soft tissue defect may make it possible to salvage the prosthesis. Ten patients with skin damage after total knee arthroplasty were treated by debridement of the wound, which was then covered with a pedicled gastrocnemius muscle flap. This was supported by local irrigation and systemic antibiotics. Seven patients were reviewed after a mean follow-up of 28 months (range 14-59). Six patients kept their prostheses and one had a relapse caused by infection at 22 months, which required removal of the prosthesis and secondary arthrodesis. The gastrocnemius muscle flap provides good quality coverage, permits early mobilisation and fast rehabilitation, and reduces the rate of arthrodesis after failure of total knee arthroplasty.     

Treatment of the exposed knee prosthesis

Ten knees with early tissue breakdown after knee arthroplasty resulting in exposed prostheses were treated with different plastic surgical techniques. Six knees were successfully covered: four using a gastrocnemius musculocutaneous flap, one using a fasciocutaneous flap, and one using split-skin grafts. Four knees failed: two using local skin flaps and two using split-skin grafts.

A gastrocnemius musculocutaneous flap seems to provide a reliable coverage of the exposed knee joint.     

Management strategies for complex wounds following total knee arthroplasty

Complex wounds following total knee arthroplasty can result in loss of the prosthesis or limb. We report our experience with 32 patients (33 knees) with complex wounds following total knee arthroplasty. Wound assessment includes size, location, depth, presence of infection, quality of tissue, and exposure of bone or prosthetic components. Management options include debridement and closure, local wound care, skin graft, fasciocutaneous flap, local muscle flap, and free tissue transfer. Postoperative outcome is based on complications and clinical evaluation using the Knee Society Score. Successful salvage of the total knee prosthesis was obtained in 28 of 33 knees (85%). Secondary procedures were necessary in ten knees and consisted of soft tissue revision in six knees, removal of prosthetic components in three knees, and both soft tissue revision and removal of prosthetic components in one knee. Our algorithm for management includes early plastic surgery consultation, control of infection, aggressive debridement, and early soft tissue coverage. Received: 25 May 1999 / Accepted: 13 July 1999     

全膝关节置换术后皮肤坏死的处理

目的探讨应用真空负压引流术（VSD）、内侧腓肠肌皮瓣转移术治疗全膝关节置换（TKA）术后皮肤坏死,挽救TKA的疗效。方法2007年至2009年本组共有4例患者采用内侧腓肠肌皮瓣转移术治疗TKA术后伤口皮肤坏死,平均随访19个月（12—32个月）,采用KSS膝关节评分系统进行功能评价,在最后随访时对患者的感染消除情况进行临床评价,测量患者活动度。结果根据KSS膝关节评分系统,4例患者结果优良。所有患者均有良好的股四头肌力量。患者不需要助步器行走,所有皮瓣一期愈合,无感染复发。结论内侧腓肠肌皮瓣能提供良好的覆盖,允许早期活动和快速康复,可以降低TKA术失败后关节僵硬的发生率。     

The distally pedicled gracilis flap for salvage of complex knee wounds

IntroductionSoft tissue defects around the knee joint resulting from trauma or because of wound breakdown after total knee arthroplasty present a challenge in a group of patients that often suffer from other co-morbidities. A pedicled gastrocnemius muscle flap remains a workhorse for this kind of wound. However, where the defect lies in the supero-lateral aspect of the proximal knee area, an alternative solution is required. The distally based pedicled gracilis flap has been described as an option for these cases where free-tissue transfer may not be an option and the pedicled gastrocnemius is not sufficient or has already been used. The purpose of this review is to evaluate the usefulness of this flap in the nine cases in which we have utilized it in our unit.MethodsNine patients underwent reconstruction of complex proximal knee wound defects with a distally based pedicled gracilis muscle flap. The mean age was 62 years (range 23–83). Five patients had wound breakdown following total-knee arthroplasty (TKR) and four patients had wound complications after road traffic accidents (RTA). Three of the nine flaps were delayed.ResultsEight of the nine patients had successful salvage of the knee with the use of the distally based gracilis flap. Although four of the flaps suffered partial loss, this did not compromise the joint salvage. The patients were moderately satisfied with the reconstruction and achieved a mean range of movement of 75° (±12°).ConclusionThe distally based pedicled gracilis flap can be a salvage solution for complex soft tissue defects with exposed knee joint, patella or proximal part of knee or exposed knee prosthesis in cases where a pedicled gastrocnemius muscle is inadequate or the patient is not suitable for a free flap.Evidence Level IV.     

Gastrocnemius pedicled muscle flap for knee and upper tibia soft tissue reconstruction. A useful tool for the orthopaedic surgeon

Soft tissue defect coverage has always been a challenge for the orthopaedic surgeon. Over the last decades the surgery of flaps has completely changed the prognosis for large defects. The purpose of this study is to retrospectively review our experience with the gastrocnemius muscle as pedicled local flaps for reconstruction of knee and upper third of the tibia soft tissue defects.Twenty-seven patients underwent reconstruction of soft tissue defects around the knee using pedicled gastrocnemius muscle flaps. There were eighteen men and nine women ranged in with a mean age of 50.3 years. Medial gastrocnemius was used in 21 cases, and lateral gastrocnemius in 5 cases. In one patient, soleus and medial gastrocnemius were transferred simultaneously. All but one had at the same time split thickness skin graft for coverage of the muscle.All muscle flaps transferred were successful. There were no complications and all flaps survived completely without vascular compromise, satisfactory coverage of the defect, and good primary wound healing. There has been no recurrence of osteomyelitis. The donor sites healed perfectly with no remarkable resultant functional disability. A mean follow-up of 4.4 years revealed acceptable cosmetic results with high patient satisfaction.Our results indicate that the gastrocnemius muscle transfer is a useful technique for coverage of soft tissue defects in the upper tibia and around the knee in our orthopaedic practice. It is a reliable option for the coverage of exposed bone, the filling up of deep cavities and the treatment of bone infection. The principal advantage of a muscle flap is to bring a real blood supply to the recipient site and to improve the trophicity of the surrounding tissues. The pedicled muscle flap is our preference for the management of soft tissue defects around the knee, when no other procedure, apart from free flap is suitable. The pedicle flap is easier, quicker and with less complications than a free flap. Orthopaedic surgery has gained much from the use of island flap, however, it requires knowledge of the vascular anatomy and its variations promoted through cadaveric dissections and flap dissection courses.     

Reconsidering the soleus muscle flap for coverage of wounds of the distal third of the leg

Traditionally, cross-leg flaps and microsurgical flaps have been used to reconstruct defects of the distal third of the leg. In the authors' experience, the soleus muscle has also provided suitable tissue for coverage of these lesions in a notable number of cases. During a 2-year period, the authors treated 28 patients who required flap coverage of defects of the lower third of the leg. In this group, the soleus muscle was used successfully in 8 patients. All of these procedures resulted in healed wounds. The remaining patients underwent reconstruction with microsurgical flaps, fasciocutaneous local flaps, and a gastrocnemius muscle flap. Their experience has demonstrated that the soleus muscle is a valuable tool and should be included in the treatment algorithm for reconstructing lesions of the distal third of the lower extremity.     

Managing skin necrosis and prosthesis subluxation after total knee arthroplasty

Skin necrosis and prosthetic subluxation are dreaded complications after total knee arthroplasty. It can result in deep infection with subsequent failure of prosthesis. The incidence of infection in patients with rheumatoid arthritis who undergo knee arthroplasty is high when compared to patients with primary osteoarthritis. The gastrocnemius muscle flap has been described for cover of proximal tibia and tendon loss because of malignancy and has been used as a bridge graft in trauma patients with patellar tendon loss. We describe a patient with total knee arthroplasty with anterior knee skin necrosis and prosthesis subluxation because of attenuation and loss of continuity of patellar tendon. This was managed by using gastrocnemius bridge grafting. Here, the gastrocnemius bridge graft was used as a soft tissue cover as well as a dynamic anterior stabilizer for the prosthesis.     

Die Musculus-gastrocnemius-Lappenplastiken

OBJECTIVE: Defect reconstruction by transposition of well-vascularized muscle (muscle flap) or muscle/skin tissue (myocutaneous flap). Reconstruction of missing muscle unit by free functional muscle transplantation. INDICATIONS: Treatment of first choice for defect coverage at the distal thigh, knee (including exposed and infected total knee prosthesis), and proximal lower leg. CONTRAINDICATIONS: Lesions of the popliteal artery. Concomitant lesion of the soleus muscle (impaired plantar flexion). SURGICAL TECHNIQUE: Proximally pedicled flap: the distal tendinous insertion of the medial and/or lateral gastrocnemius muscle at the Achilles tendon is cut. Vascularization is assured by the medial and lateral sural artery, respectively. - Muscle flaps (medial gastrocnemius, lateral gastrocnemius). - Muscle-skin (myocutaneous) flaps. Distally pedicled flap: the proximal tendinous origin of the medial or lateral gastrocnemius muscle is cut. Vascularization is assured by vascular anastomoses between the two muscles crossing the midline. Because of its unpredictable vascularization, especially after trauma, this technique is rarely used today. To improve arterial inflow, the cut sural artery can be anastomosed in microsurgical technique with an adequate arterial blood vessel at the recipient site. POSTOPERATIVE MANAGEMENT: Complete immobilization for 5-7 days (knee and ankle joints). Progressive increase of range of motion after 1 week (30 degrees /45 degrees /60 degrees /90 degrees ). Postoperative standardized compression therapy, combined with scar therapy (silicone sheet). RESULTS: Reliable, excellent functional and aesthetic results.     

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.     

Soft tissue reconstruction following total knee arthroplasty: treatment possibilities and retrospective analysis of plastic surgery therapy treatment possibilities

AIM: We performed a retrospective analysis of patients with soft tissue defects following total knee arthroplasty and therapy. Furthermore, we described the possibilities of covering soft tissue defects following knee arthroplasty. METHOD: In 5 patients, soft tissue defects following knee arthroplasty were covered with medial M. gastrocneminus flaps. Localisation and size of the defect, microbiology, risk factors, and interval between arthroplasty and the occurrence of the soft tissue defect were retrospectively analysed. RESULTS: On average, defects occurred 9 weeks after prosthesis implantation. In all cases, the soft tissue defect developed in the area of the incision. In 3 cases, wound infection was diagnosed. Four patients exhibited factors associated with wound-healing failure. No prosthesis was lost. CONCLUSION: The gastrocneminus muscle flap provides good quality coverage with small donor site defect, permits early mobilisation, and allows for fast rehabilitation. The risk of flap loss is minimal. Early and adequate defect coverage can reduce both prosthesis loss and amputation rates.     

Reconstruction of severe uncontained bone defects in revision total knee arthroplasty in a patient with rheumatoid arthritis

We report on a 54-year-old rheumatoid arthritic female patient with uncontained type-III tibial and femoral bone defects at the time of revision total knee arthroplasty (TKA). The knee was reconstructed using a structural distal femoral allograft and a stemmed, semi-constrained knee prosthesis. We achieved the re-alignment of a severe preoperative valgus deformity of 40 degrees. Due to postoperative wound complications we had to perform a gastrocnemius muscle flap. At two-year follow-up the patient was free of pain and the Knee Society Score improved from 18 to 156 (p < 0.01). Radiographs revealed no loosening of the prosthetic components and progressive incorporation of the graft. Reconstruction of extensive uncontained bone defects in revision of TKA in rheumatoid arthritis can be managed by structural allografts; however, wound complications in those patients might necessitate soft tissue techniques.     

The gastrocnemius with soleus bi-muscle flap.

The gastrocnemius muscle flap is often insufficient in volume and arc of rotation for coverage of a large soft tissue defect of the knee and the upper third of the leg. Therefore we developed a new concept of the flap which combines soleus and gastrocnemius muscles, named the 'gastrocnemius with soleus bi-muscle flap'. In 16 cadavers we studied the location and number of perforators, which penetrate the gastrocnemius muscle through the soleus muscle. In all cases perforators were found in the distal half of the gastrocnemius muscle. Angiography in one fresh cadaver confirmed that the soleus muscle could receive the reversed flow from the gastrocnemius muscle perforators. We subsequently treated a patient with exposed proximal tibia with this flap. This flap is useful to cover a large soft tissue defect of the knee and the upper third of the leg.     

Local knee random fasciocutaneous flaps

Extensive wounds of the knee region have previously mandated utilization of a local muscle or free flap to achieve healing. The recent successes of fasciocutaneous flaps in the lower leg region have been extrapolated for use of local, randomly oriented anteromedial or anterolateral knee flaps in addition to previously described posterior calf flaps; results have been equally acceptable as the standard established by muscle flaps for knee coverage. For small- or moderate-sized noncontaminated parapatellar wounds, less morbidity has been observed using instead these simple local knee fasciocutaneous flaps.     

Gastrocnemius perforating artery flap including vascularized sural nerve

A degree of communication was found between the superficial sural artery (the concomitant vessel of the sural nerve) and the muscle perforators from the gastrocnemius muscle, together with the cutaneous branches of the peroneal artery. A fasciocutaneous flap designed in the posterior calf region, including the vascularized sural nerve, was elevated based on the perforating artery of the gastrocnemius. This compound flap was used to reconstruct facial nerves and soft-tissue defects created by resection of malignant tumors in three patients. The results were satisfactory, and facial animation returned in two patients, who were followed-up for more than 6 months. This compound flap offers several advantages, such as a long vascular pedicle with a sufficient diameter and a rich blood supply for the sural nerve and fasciocutaneous flap. This new technique should become another choice for vascularized sural nerve grafts, when the superficial sural artery or the cutaneous branches of the peroneal artery are not adequate for flap elevation or microsurgical anastomoses.     

Total knee arthroplasty covered with pedicle peroneal flap

Three cases of total knee arthroplasty (TKA) covered with pedicle peroneal flaps are reported. One peroneal flap was performed after TKA to correct post-TKA skin necrosis. Two peroneal flaps were performed before TKA to replace previous traumatic scar formed around the knee. All three TKAs were successful after the procedure. The thickness, elasticity, appearance, and durability of the peroneal flaps were more suitable for the skin around the knee than the gastrocnemius muscle flap or the local fasciocutaneous flap. As the peroneal flap was elevated as a pedicle flap, freedom of transfer was good, microanastomosis was not necessary, and no donor sites were needed from the contralateral limb. Scar tissue around the knee can be effectively replaced by the pedicle peroneal flap before TKA.     

Lower-Extremity Local Flaps

Some soft-tissue defects of the lower extremities can be covered reliably with local flaps. Five such flaps--the tensor fascia lata, gastrocnemius, soleus, posterior tibial artery fasciocutaneous, and dorsalis pedis flaps--are described. If the indications for each flap are understood and the vascular pedicle is carefully preserved, these flaps can be used to provide relatively simple and reliable coverage of selected soft-tissue defects on the lower extremities. However, the indications must not be overextended in an attempt to avoid a free-tissue transfer. The gastrocnemius flap is most often used. It reliably covers common defects about the knee and the proximal tibia. A skin graft is required for the gastrocnemius flap, as well as the soleus flap, which covers the midportion of the tibia. The soleus requires deeper dissection of the calf for elevation. The tensor fascia lata flap and the more recently described posterior tibial artery fasciocutaneous flap are relatively easy to raise, but there are fewer orthopaedic indications for their use. The dorsalis pedis cutaneous flap is technically more demanding, but it can be used to cover difficult defects around the ankle.     

Fasciocutaneous flap closure of a grade III lower third tibial fracture: an alternative to free flap coverage

We present a patient who sustained a close-range shotgun wound resulting in a grade III fracture of the lower tibia. The wound was debrided on several occasions and, on day 4, was closed with a flexor digitorum muscle and pedicled fasciocutaneous flap. Grades III and IV lower one-third tibial fractures generally require a free flap to accomplish stable soft-tissue coverage. Free-tissue transfer, however, remains a tedious and lengthy procedure. Occasionally a fasciocutaneous flap may be available to facilitate wound closure and spare the patient a lengthy procedure and distant donor site. The established principles of compound tibial coverage must be adhered to when choosing a local fasciocutaneous flap.