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http://dx.doi.org/10.5999/aps.2017.44.2.124

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  

Economides, James M. (Department of Plastic Surgery, Georgetown University Hospital)
DeFazio, Michael V. (Department of Plastic Surgery, Georgetown University Hospital)
Golshani, Kayvon (Department of Orthopaedic Surgery, Georgetown University Hospital)
Cinque, Mark (Department of Plastic Surgery, Georgetown University Hospital)
Anghel, Ersilia L. (Department of Plastic Surgery, Georgetown University Hospital)
Attinger, Christopher E. (Department of Plastic Surgery, Georgetown University Hospital)
Evans, Karen Kim (Department of Plastic Surgery, Georgetown University Hospital)
Publication Information
Archives of Plastic Surgery / v.44, no.2, 2017 , pp. 124-135 More about this Journal
Abstract
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.
Keywords
Arthroplasty, replacement, knee; Knee prosthesis; Surgical flaps;
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1 Johnson DP. The effect of continuous passive motion on wound-healing and joint mobility after knee arthroplasty. J Bone Joint Surg Am 1990;72:421-6.   DOI
2 Patella V, Speciale D, Patella S, et al. Wound necrosis after total knee arthroplasty. Orthopedics 2008;31:807.
3 Lian G, Cracchiolo A 3rd, Lesavoy M. Treatment of major wound necrosis following total knee arthroplasty. J Arthroplasty 1989;4 Suppl:S23-32.   DOI
4 Vince K, Chivas D, Droll KP. Wound complications after total knee arthroplasty. J Arthroplasty 2007;22:39-44.
5 Dennis DA. Wound complications in total knee arthroplasty. Instr Course Lect 1997;46:165-9.
6 Galat DD, McGovern SC, Larson DR, et al. Surgical treatment of early wound complications following primary total knee arthroplasty. J Bone Joint Surg Am 2009;91:48-54.   DOI
7 Peersman G, Laskin R, Davis J, et al. Infection in total knee replacement: a retrospective review of 6489 total knee replacements. Clin Orthop Relat Res 2001;(392):15-23.
8 Panni AS, Vasso M, Cerciello S, et al. Wound complications in total knee arthroplasty. Which flap is to be used? With or without retention of prosthesis? Knee Surg Sports Traumatol Arthrosc 2011;19:1060-8.   DOI
9 Nahabedian MY, Orlando JC, Delanois RE, et al. Salvage procedures for complex soft tissue defects of the knee. Clin Orthop Relat Res 1998;(356):119-24.
10 Adam RF, Watson SB, Jarratt JW, et al. Outcome after flap cover for exposed total knee arthroplasties: a report of 25 cases. J Bone Joint Surg Br 1994;76:750-3.
11 Andres LA, Casey WJ, Clarke HD. Techniques in soft tissue coverage around the knee. Tech Knee Surg 2009;8:199-25.
12 Tiengo C, Macchi V, Vigato E, et al. Reversed gracilis pedicle flap for coverage of a total knee prosthesis. J Bone Joint Surg Am 2010;92:1640-6.   DOI
13 Jung JA, Kim YW, Cheon YW. Reverse gracilis muscle flap: an alternative means of skin coverage for recurrent infection after TKA. Knee Surg Sports Traumatol Arthrosc 2013;21: 2779-83.   DOI
14 Demirseren ME, Efendioglu K, Demiralp CO, et al. Clinical experience with a reverse-flow anterolateral thigh perforator flap for the reconstruction of soft-tissue defects of the knee and proximal lower leg. J Plast Reconstr Aesthet Surg 2011; 64:1613-20.   DOI
15 Moscatiello F, Masia J, Carrera A, et al. The ‘propeller' distal anteromedial thigh perforator flap: anatomic study and clinical applications. J Plast Reconstr Aesthet Surg 2007;60: 1323-30.   DOI
16 Busfield BT, Huffman GR, Nahai F, et al. Extended medial gastrocnemius rotational flap for treatment of chronic knee extensor mechanism deficiency in patients with and without total knee arthroplasty. Clin Orthop Relat Res 2004;(428): 190-7.
17 Insall JN, Dorr LD, Scott RD, et al. Rationale of the Knee Society clinical rating system. Clin Orthop Relat Res 1989;(248):13-4.
18 Slim K, Nini E, Forestier D, et al. Methodological index for non-randomized studies (minors): development and validation of a new instrument. ANZ J Surg 2003;73:712-6.   DOI
19 Clopper CJ, Pearson ES. The Use of Confidence or Fiducial Limits Illustrated in the Case of the Binomial. Biometrika 1934;26:404-13.   DOI
20 Newcombe RG. Two-sided confidence intervals for the single proportion: comparison of seven methods. Stat Med 1998;17:857-72.   DOI
21 Agresti A, Coull BA. Approximate is better than “exact” for interval estimation of binomial proportions. Am Stat 1998; 52:119-26.
22 Akhtar MS, Khan AH, Khurram MF, et al. Inferiorly based thigh flap for reconstruction of defects around the knee joint. Indian J Plast Surg 2014;47:221-6.   DOI
23 Chim H, Tan BK, Tan MH, et al. Optimizing the use of local muscle flaps for knee megaprosthesis coverage. Ann Plast Surg 2007;59:398-403.   DOI
24 Kim JS, Lee HS, Jang PY, et al. 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 2010;30:32-6.
25 Corten K, Struelens B, Evans B, et al. Gastrocnemius flap reconstruction of soft-tissue defects following infected total knee replacement. Bone Joint J 2013;95B:1217-21.
26 Gerwin M, Rothaus KO, Windsor RE, et al. Gastrocnemius muscle flap coverage of exposed or infected knee prostheses. Clin Orthop Relat Res 1993;(286):64-70.
27 Gravvanis AI, Iconomou TG, Panayotou PN, et al. Medial gastrocnemius muscle flap versus distally based anterolateral thigh flap: conservative or modern approach to the exposed knee joint? Plast Reconstr Surg 2005;116:932-4.   DOI
28 Greenberg B, LaRossa D, Lotke PA, et al. Salvage of jeopardized total-knee prosthesis: the role of the gastrocnemius muscle flap. Plast Reconstr Surg 1989;83:85-9.   DOI
29 Hallock GG. Chimeric gastrocnemius muscle and sural artery perforator local flap. Ann Plast Surg 2008;61:306-9.   DOI
30 Han SE, Lee KT, Mun GH. Muscle-chimaeric medial sural artery perforator flap: a new design for complex three-dimensional knee defect. J Plast Reconstr Aesthet Surg 2014; 67:571-4.   DOI
31 Markovich GD, Dorr LD, Klein NE, et al. Muscle flaps in total knee arthroplasty. Clin Orthop Relat Res 1995;(321): 122-30.
32 McPherson EJ, Patzakis MJ, Gross JE, et al. Infected total knee arthroplasty. Two-stage reimplantation with a gastrocnemius rotational flap. Clin Orthop Relat Res 1997;(341): 73-81.
33 Misra A, Niranjan NS. Fasciocutaneous flaps based on fascial feeder and perforator vessels for defects in the patellar and peripatellar regions. Plast Reconstr Surg 2005;115: 1625-32.   DOI
34 Papp A, Kettunen J, Miettinen H. Pedicled gastrocnemius flap in complicated total knee arthroplasty. Scand J Surg 2003;92:156-9.   DOI
35 Pozzobon LR, Helito CP, Guimaraes TM, et al. Rotation flaps for coverage after total knee arthroplasty. Acta Ortop Bras 2013;21:219-22.   DOI
36 Ries MD. Skin necrosis after total knee arthroplasty. J Arthroplasty 2002;17:74-7.   DOI
37 Siim E, Jakobsen IE, Medgyesi S. Soft-tissue procedures for the exposed knee arthroplasty. 18 cases followed for 7 (1-17) years. Acta Orthop Scand 1991;62:312-4.   DOI
38 Taniguchi Y, Kitano T, Shimoe T, et al. Superior lateral genicular artery flap for coverage of a soft tissue defect after total knee arthroplasty. J Reconstr Microsurg 2009;25:479-82.   DOI
39 Vaienti L, Menozzi A, Lonigro J, et al. The salvage of knee-exposed prosthesis using neurofasciocutaneous sural flap. Musculoskelet Surg 2010;94:33-40.   DOI
40 Alexiades M, Sands A, Craig SM, et al. Management of selected problems in revision knee arthroplasty. Orthop Clin North Am 1989;20:211-9.
41 Lidwell OM, Lowbury EJ, Whyte W, et al. Infection and sepsis after operations for total hip or knee-joint replacement: influence of ultraclean air, prophylactic antibiotics and other factors. J Hyg (Lond) 1984;93:505-29.   DOI
42 Vince KG, Abdeen A. Wound problems in total knee arthroplasty. Clin Orthop Relat Res 2006;452:88-90.   DOI
43 Casanova D, Hulard O, Zalta R, et al. Management of wounds of exposed or infected knee prostheses. Scand J Plast Reconstr Surg Hand Surg 2001;35:71-7.   DOI
44 Menderes A, Demirdover C, Yilmaz M, et al. Reconstruction of soft tissue defects following total knee arthroplasty. Knee 2002;9:215-9.   DOI
45 Moller AM, Pedersen T, Villebro N, et al. Effect of smoking on early complications after elective orthopaedic surgery. J Bone Joint Surg Br 2003;85:178-81.
46 Gosain A, Chang N, Mathes S, et al. A study of the relationship between blood flow and bacterial inoculation in musculocutaneous and fasciocutaneous flaps. Plast Reconstr Surg 1990;86:1152-62.   DOI
47 Harry LE, Sandison A, Pearse MF, et al. Comparison of the vascularity of fasciocutaneous tissue and muscle for coverage of open tibial fractures. Plast Reconstr Surg 2009;124:1211-9.   DOI
48 Salgado CJ, Mardini S, Jamali AA, et al. Muscle versus nonmuscle flaps in the reconstruction of chronic osteomyelitis defects. Plast Reconstr Surg 2006;118:1401-11.   DOI
49 Rodriguez ED, Bluebond-Langner R, Copeland C, et al. Functional outcomes of posttraumatic lower limb salvage: a pilot study of anterolateral thigh perforator flaps versus muscle flaps. J Trauma 2009;66:1311-4.   DOI
50 Yazar S, Lin CH, Lin YT, et al. Outcome comparison between free muscle and free fasciocutaneous flaps for reconstruction of distal third and ankle traumatic open tibial fractures. Plast Reconstr Surg 2006;117:2468-75.   DOI
51 Knopp W, Buchholz J, Muhr G, et al. Negative effects of local tibial muscle flap repair on foot function. Unfallchirurg 1993;96:229-34.
52 Kramers-de Quervain IA, Lauffer JM, Kach K, et al. Functional donor-site morbidity during level and uphill gait after a gastrocnemius or soleus muscle-flap procedure. J Bone Joint Surg Am 2001;83:239-46.   DOI
53 Daigeler A, Drucke D, Tatar K, et al. The pedicled gastrocnemius muscle flap: a review of 218 cases. Plast Reconstr Surg 2009;123:250-7.   DOI
54 Hanasono MM, Skoracki RJ, Yu P. A prospective study of donor-site morbidity after anterolateral thigh fasciocutaneous and myocutaneous free flap harvest in 220 patients. Plast Reconstr Surg 2010;125:209-14.   DOI
55 Nahabedian MY, Mont MA, Orlando JC, et al. Operative management and outcome of complex wounds following total knee arthroplasty. Plast Reconstr Surg 1999;104:1688-97.   DOI
56 Jones RE. Wound healing in total joint arthroplasty. Orthopedics 2010;33:660.