Download PDF
CC BY-NC 4.0 · Arch Plast Surg 2017; 44(02): 124-135
DOI: 10.5999/aps.2017.44.2.124
Original Article

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

James M. Economides
Department of Plastic Surgery, Georgetown University Hospital, Washington, DC, USA
,
Michael V. DeFazio
Department of Plastic Surgery, Georgetown University Hospital, Washington, DC, USA
,
Kayvon Golshani
Department of Orthopaedic Surgery, Georgetown University Hospital, Washington, DC, USA
,
Mark Cinque
Department of Plastic Surgery, Georgetown University Hospital, Washington, DC, USA
,
Ersilia L. Anghel
Department of Plastic Surgery, Georgetown University Hospital, Washington, DC, USA
,
Christopher E. Attinger
Department of Plastic Surgery, Georgetown University Hospital, Washington, DC, USA
,
Karen Kim Evans
Department of Plastic Surgery, Georgetown University Hospital, Washington, DC, USA
› Author Affiliations
› Further Information
   Permissions and Reprints

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


Publication History

Received: 12 August 2016

Accepted: 12 January 2017

Article published online:
20 April 2022

© 2017. The Korean Society of Plastic and Reconstructive Surgeons. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonCommercial License, permitting unrestricted noncommercial use, distribution, and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes. (https://creativecommons.org/licenses/by-nc/4.0/)

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 

  • REFERENCES

  • 1 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
    CrossrefPubMedSearch in Google Scholar
  • 2 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
    PubMedSearch in Google Scholar
  • 3 Nahabedian MY, Mont MA, Orlando JC. et al. Operative management and outcome of complex wounds following total knee arthroplasty. Plast Reconstr Surg 1999; 104: 1688-1697
    CrossrefPubMedSearch in Google Scholar
  • 4 Jones RE. Wound healing in total joint arthroplasty. Orthopedics 2010; 33: 660
    PubMedSearch in Google Scholar
  • 5 Johnson DP. The effect of continuous passive motion on wound-healing and joint mobility after knee arthroplasty. J Bone Joint Surg Am 1990; 72: 421-426
    CrossrefPubMedSearch in Google Scholar
  • 6 Patella V, Speciale D, Patella S. et al. Wound necrosis after total knee arthroplasty. Orthopedics 2008; 31: 807
    PubMedSearch in Google Scholar
  • 7 Lian G, Cracchiolo 3rd A, Lesavoy M. Treatment of major wound necrosis following total knee arthroplasty. J Arthroplasty 1989; 4: S23-S32
    CrossrefPubMedSearch in Google Scholar
  • 8 Vince K, Chivas D, Droll KP. Wound complications after total knee arthroplasty. J Arthroplasty 2007; 22: 39-44
    PubMedSearch in Google Scholar
  • 9 Dennis DA. Wound complications in total knee arthroplasty. Instr Course Lect 1997; 46: 165-169
    PubMedSearch in Google Scholar
  • 10 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: 1060-1068
    CrossrefPubMedSearch in Google Scholar
  • 11 Nahabedian MY, Orlando JC, Delanois RE. et al. Salvage procedures for complex soft tissue defects of the knee. Clin Orthop Relat Res 1998; (356) 119-124
    PubMedSearch in Google Scholar
  • 12 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: 750-753
    PubMedSearch in Google Scholar
  • 13 Andres LA, Casey WJ, Clarke HD. Techniques in soft tissue coverage around the knee. Tech Knee Surg 2009; 8: 119-125
    CrossrefSearch in Google Scholar
  • 14 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: 1640-1646
    CrossrefPubMedSearch in Google Scholar
  • 15 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: 2779-2783
    CrossrefPubMedSearch in Google Scholar
  • 16 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: 1613-1620
    CrossrefPubMedSearch in Google Scholar
  • 17 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: 1323-1330
    CrossrefPubMedSearch in Google Scholar
  • 18 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: 32-36
    CrossrefPubMedSearch in Google Scholar
  • 19 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) 190-197
    PubMedSearch in Google Scholar
  • 20 Insall JN, Dorr LD, Scott RD. et al. Rationale of the Knee Society clinical rating system. Clin Orthop Relat Res 1989; (248) 13-14
    PubMedSearch in Google Scholar
  • 21 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: 712-716
    CrossrefPubMedSearch in Google Scholar
  • 22 Clopper CJ, Pearson ES. The Use of Confidence or Fiducial Limits Illustrated in the Case of the Binomial. Biometrika 1934; 26: 404-413
    CrossrefSearch in Google Scholar
  • 23 Newcombe RG. Two-sided confidence intervals for the single proportion: comparison of seven methods. Stat Med 1998; 17: 857-872
    CrossrefPubMedSearch in Google Scholar
  • 24 Agresti A, Coull BA. Approximate is better than “exact” for interval estimation of binomial proportions. Am Stat 1998; 52: 119-126
    Search in Google Scholar
  • 25 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: 221-226
    PubMedSearch in Google Scholar
  • 26 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
    CrossrefPubMedSearch in Google Scholar
  • 27 Corten K, Struelens B, Evans B. et al. Gastrocnemius flap reconstruction of soft-tissue defects following infected total knee replacement. Bone Joint J 2013; 95-B: 1217-1221
    CrossrefPubMedSearch in Google Scholar
  • 28 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
    PubMedSearch in Google Scholar
  • 29 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: 932-934
    CrossrefPubMedSearch in Google Scholar
  • 30 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: 85-89
    CrossrefPubMedSearch in Google Scholar
  • 31 Hallock GG. Chimeric gastrocnemius muscle and sural artery perforator local flap. Ann Plast Surg 2008; 61: 306-309
    CrossrefPubMedSearch in Google Scholar
  • 32 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: 571-574
    CrossrefPubMedSearch in Google Scholar
  • 33 Markovich GD, Dorr LD, Klein NE. et al. Muscle flaps in total knee arthroplasty. Clin Orthop Relat Res 1995; (321) 122-130
    PubMedSearch in Google Scholar
  • 34 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
    PubMedSearch in Google Scholar
  • 35 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: 1625-1632
    CrossrefPubMedSearch in Google Scholar
  • 36 Papp A, Kettunen J, Miettinen H. Pedicled gastrocnemius flap in complicated total knee arthroplasty. Scand J Surg 2003; 92: 156-159
    CrossrefPubMedSearch in Google Scholar
  • 37 Pozzobon LR, Helito CP, Guimaraes TM. et al. Rotation flaps for coverage after total knee arthroplasty. Acta Ortop Bras 2013; 21: 219-222
    CrossrefPubMedSearch in Google Scholar
  • 38 Ries MD. Skin necrosis after total knee arthroplasty. J Arthroplasty 2002; 17: 74-77
    CrossrefPubMedSearch in Google Scholar
  • 39 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: 312-314
    CrossrefPubMedSearch in Google Scholar
  • 40 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: 479-482
    Thieme ConnectPubMedSearch in Google Scholar
  • 41 Vaienti L, Menozzi A, Lonigro J. et al. The salvage of knee-exposed prosthesis using neurofasciocutaneous sural flap. Musculoskelet Surg 2010; 94: 33-40
    CrossrefPubMedSearch in Google Scholar
  • 42 Alexiades M, Sands A, Craig SM. et al. Management of selected problems in revision knee arthroplasty. Orthop Clin North Am 1989; 20: 211-219
    PubMedSearch in Google Scholar
  • 43 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: 505-529
    CrossrefPubMedSearch in Google Scholar
  • 44 Vince KG, Abdeen A. Wound problems in total knee arthroplasty. Clin Orthop Relat Res 2006; 452: 88-90
    CrossrefPubMedSearch in Google Scholar
  • 45 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: 71-77
    CrossrefPubMedSearch in Google Scholar
  • 46 Menderes A, Demirdover C, Yilmaz M. et al. Reconstruction of soft tissue defects following total knee arthroplasty. Knee 2002; 9: 215-219
    CrossrefPubMedSearch in Google Scholar
  • 47 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: 178-181
    PubMedSearch in Google Scholar
  • 48 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: 1152-1162
    CrossrefPubMedSearch in Google Scholar
  • 49 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: 1211-1219
    CrossrefPubMedSearch in Google Scholar
  • 50 Salgado CJ, Mardini S, Jamali AA. et al. Muscle versus nonmuscle flaps in the reconstruction of chronic osteomyelitis defects. Plast Reconstr Surg 2006; 118: 1401-1411
    CrossrefPubMedSearch in Google Scholar
  • 51 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: 1311-1314
    CrossrefPubMedSearch in Google Scholar
  • 52 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: 2468-2475
    CrossrefPubMedSearch in Google Scholar
  • 53 Knopp W, Buchholz J, Muhr G. et al. Negative effects of local tibial muscle flap repair on foot function. Unfallchirurg 1993; 96: 229-234
    PubMedSearch in Google Scholar
  • 54 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: 239-246
    CrossrefPubMedSearch in Google Scholar
  • 55 Daigeler A, Drucke D, Tatar K. et al. The pedicled gastrocnemius muscle flap: a review of 218 cases. Plast Reconstr Surg 2009; 123: 250-257
    CrossrefPubMedSearch in Google Scholar
  • 56 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: 209-214
    CrossrefPubMedSearch in Google Scholar