Microvascular free flap coverage of complex soft tissue defects after revision total knee arthroplasty: a cross-sectional observation study

Authors

  • Nizar Hamrouni Department of Plastic Surgery and Burns Treatment, Center of Head, Neck and Orthopedics, University Hospital of Copenhagen, Rigshospitalet, Copenhagen https://orcid.org/0000-0003-3202-3568
  • Jens H Højvig Department of Plastic Surgery and Burns Treatment, Center of Head, Neck and Orthopedics, University Hospital of Copenhagen, Rigshospitalet, Copenhagen
  • Ulrik K Knudsen Department of Orthopedic Surgery, Center of Head, Neck and Orthopedics, University Hospital of Copenhagen, Rigshospitalet, Copenhagen
  • Kurt K Skovgaard Department of Orthopedic Surgery, Center of Head, Neck and Orthopedics, University Hospital of Copenhagen, Rigshospitalet, Copenhagen
  • Lisa T Jensen Department of Plastic Surgery and Burns Treatment, Center of Head, Neck and Orthopedics, University Hospital of Copenhagen, Rigshospitalet, Copenhagen
  • Christian T Bonde Department of Plastic Surgery and Burns Treatment, Center of Head, Neck and Orthopedics, University Hospital of Copenhagen, Rigshospitalet, Copenhagen
  • Anders Odgaard Department of Orthopedic Surgery, Center of Head, Neck and Orthopedics, University Hospital of Copenhagen, Rigshospitalet, Copenhagen; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark https://orcid.org/0000-0002-4841-518X

DOI:

https://doi.org/10.2340/17453674.2024.40183

Keywords:

Arthroplasty, Free flap, Implants, Infection, Knee, Microsurgery, Reconstruction

Abstract

Background and purpose: Soft tissue defects after total knee arthroplasties (TKA) represent a major orthopedic challenge with amputation as a feared outcome. Microvascular free flap coverage (FFC) can increase limb salvage rates, but complications related to the procedure are yet to be explored further. We aimed to review a single-center experience with FFC for soft tissue defects related to revision total knee arthroplasty.
Methods: Through a retrospective chart review from 2006 to 2021, we identified all patients who had FFC of a knee with an existing TKA. Typically, patients underwent 2-stage revision arthroplasty. To identify areas of intervention, we divided the entire regimen into 2 phases divided by the free flap surgery (pre- and post-free flap).
Results: We identified 18 patients with a median age at free flap surgery of 69 years (range 39–85), who were followed for a median of 5.1 years (range 2 months to 10.6 years). The median duration from primary TKA to their final operation was 17.5 months (range 19 days to 7 years). Patients underwent a mean of 7.6 surgical procedures on their knee with 3.6 orthopedic revisions prior to the FFC and 0.6 after. Soft tissue coverage was achieved in all patients and no patients underwent amputation. One-third of patients experienced early complications at recipient site after free flap surgery. There were no donor site complications.
Conclusion: Microvascular FFC of complex soft tissue defects after revision total knee arthroplasty proved achievable in all patients with successful limb salvage in all patients.

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References

Odgaard A. Dansk Knaealloplastikregister 2019:144. Available from: https://www.rkkp.dk/kvalitetsdatabaser/databaser/dansk-knaealloplastik-register/resultater/

Postler A, Lützner C, Beyer F, Tille E, Lützner J. Analysis of total knee arthroplasty revision causes. BMC Musculoskelet Disord 2018; 19: 1-6. doi: 10.1186/s12891-018-1977-y.a. DOI: https://doi.org/10.1186/s12891-018-1977-y

Kildow B J, Della-Valle C J, Springer B D. Single vs 2-stage revision for the treatment of periprosthetic joint infection. J Arthroplasty 2020; 35: S24-30. doi: 10.1016/j.arth.2019.10.051. DOI: https://doi.org/10.1016/j.arth.2019.10.051

Pangaud C, Ollivier M, Argenson J N. Outcome of single-stage versus two-stage exchange for revision knee arthroplasty for chronic periprosthetic infection. EFORT Open Rev 2019; 4: 495-502. doi: 10.1302/2058-5241.4.190003. DOI: https://doi.org/10.1302/2058-5241.4.190003

Metcalf R W, Rowe T, Tersteeg M, Dombrowski M E, Odum S, Otero J E. The influence of patient sex on outcomes following one-stage and two-stage revision for periprosthetic joint infection in total joint arthroplasty. Antibiotics 2023; 12(9): 1392. doi: 10.3390/antibiotics12091392. DOI: https://doi.org/10.3390/antibiotics12091392

Lindberg-Larsen M, Jørgensen C C, Bagger J, Schrøder H M, Kehlet H. Revision of infected knee arthroplasties in Denmark. Acta Orthop 2016; 87: 333-8. doi: 10.3109/17453674.2016.1148453. DOI: https://doi.org/10.3109/17453674.2016.1148453

Gottfriedsen T B, Schrøder H M, Odgaard A. Transfemoral amputation after failure of knee arthroplasty. J Bone Joint Surg Am 2016; 98: 1962-9. doi: 10.2106/JBJS.15.01362. DOI: https://doi.org/10.2106/JBJS.15.01362

Gottfriedsen T B, Schrøder H M, Odgaard A. Knee arthrodesis after failure of knee arthroplasty. J Bone Joint Surg Am 2016; 98: 1370-7. doi: 10.2106/jbjs.15.01363. DOI: https://doi.org/10.2106/JBJS.15.01363

Gravvanis A, Kyriakopoulos A, Kateros K, Tsoutsos D. Flap reconstruction of the knee: a review of current concepts and a proposed algorithm. World J Orthop 2014; 5(5): 603-13. doi: 10.5312/wjo.v5.i5.603. DOI: https://doi.org/10.5312/wjo.v5.i5.603

Cetrulo C L, Shiba T, Friel M T, Davis B, Buntic R F, Buncke G M, et al. Management of exposed total knee prostheses with microvascular tissue transfer. Microsurgery 2008; 28(8): 617-22. doi: 10.1002/micr.20578. DOI: https://doi.org/10.1002/micr.20578

Registry AOANJR. Hip, knee & shoulder arthroplasty annual report 2020. Available from: https://aoanjrr.sahmri.com/annual-reports-2020.

Parvizi J, Tan T L, Goswami K, Higuera C, Della Valle C, Chen A F, et al. The 2018 definition of periprosthetic hip and knee infection: an evidence-based and validated criteria. J Arthroplasty 2018; 33: 1309-1314.e2. doi: 10.1016/j.arth.2018.02.078. DOI: https://doi.org/10.1016/j.arth.2018.02.078

Lee G C, Colen D L, Levin L S, Kovach S J. Microvascular free flap coverage for salvage of the infected total knee arthroplasty. Bone Joint J 2020; 102-B: 176-80. doi: 10.1302/0301-620X.102B6.BJJ-2019-1661.R1. DOI: https://doi.org/10.1302/0301-620X.102B6.BJJ-2019-1661.R1

Amin N H, Speirs J N, Simmons M J, Lermen O Z, Cushner F D, Scuderi G R. Total knee arthroplasty wound complication treatment algorithm: current soft tissue coverage options. J Arthroplasty 2019; 34: 735-42. doi: 10.1016/j.arth.2018.12.016. DOI: https://doi.org/10.1016/j.arth.2018.12.016

Manoso M W, Boland P J, Healey J H, Cordeiro P G. Limb salvage of infected knee reconstructions for cancer with staged revision and free tissue transfer. Ann Plast Surg 2006; 56: 532-5. doi: 10.1097/01.sap.0000203990.08414.ad. DOI: https://doi.org/10.1097/01.sap.0000203990.08414.ad

Suda A J, Cieslik A, Grützner PA, Münzberg M, Heppert V. Flaps for closure of soft tissue defects in infected revision knee arthroplasty. Int Orthop 2014; 38: 1387-92. doi: 10.1007/s00264-014-2316-z. DOI: https://doi.org/10.1007/s00264-014-2316-z

Hierner R, Reynders-Frederix P, Bellemans J, Stuyck J, Peeters W. Free myocutaneous latissimus dorsi flap transfer in total knee arthroplasty. J Plast Reconstr Aesthetic Surg 2009; 62: 1692-700. doi: 10.1016/j.bjps.2008.07.038. DOI: https://doi.org/10.1016/j.bjps.2008.07.038

Perrault D, Manrique O J, Lee G, Carre A L, Oakes D A, Wong A K. Complex reconstruction of the knee with a free vertical rectus abdominis flap after periprosthetic soft tissue necrosis. Cureus 2019; 11: 1-6. doi: 10.7759/cureus.3969. DOI: https://doi.org/10.7759/cureus.3969

Browne E Z, Stulberg B N, Sood R. The use of muscle flaps for salvage of failed total knee arthroplasty. Br J Plast Surg 1994; 47: 42-5. doi: 10.1016/0007-1226(94)90116-3. DOI: https://doi.org/10.1016/0007-1226(94)90116-3

Moog P, Tinwald I, Aitzetmueller M, Bauer A-T, Megerle K, Machens H-G, et al. The usage of pedicled or free muscle flaps represents a beneficial approach for periprosthetic infection after knee arthroplasty. Ann Plast Surg 2020; 85(5): 539-45. doi: 10.1097/sap.0000000000002293. DOI: https://doi.org/10.1097/SAP.0000000000002293

Duraes E F R, Schwarz G, Durand P, Moreira-Gonzalez A, Duraes L C, de Sousa J B, et al. Complications following abdominal-based free flap breast reconstruction: is a 30 days complication rate representative? Aesthetic Plast Surg 2015. doi: 10.1007/s00266-015-0534-4. DOI: https://doi.org/10.1007/s00266-015-0534-4

Moon K C, Baek S O, Yoon E S, Lee B Il, Park S H. Predictors affecting complications and aesthetic outcomes in autologous breast reconstruction with free muscle-sparing transverse rectus abdominis myocutaneous flaps. Microsurgery 2020; 40(1): 38-43. doi: 10.1002/micr.30442. DOI: https://doi.org/10.1002/micr.30442

Sanati-Mehrizy P, Massenburg B B, Rozehnal J M, Ingargiola M J, Hernandez Rosa J, Taub P J. Risk factors leading to free flap failure: analysis from the national surgical quality improvement program database. J Craniofac Surg 2016; 27(8): 1956-64. doi: 10.1097/SCS.0000000000003026. DOI: https://doi.org/10.1097/SCS.0000000000003026

Watts C D, Houdek M T, Wagner E R, Taunton M J. Subcutaneous fat thickness is associated with early reoperation and infection after total knee arthroplasty in morbidly obese patients. J Arthroplasty 2016; 31: 1788-91. doi: 10.1016/j.arth.2016.02.008. DOI: https://doi.org/10.1016/j.arth.2016.02.008

Colen D L, Carney M J, Shubinets V, Lanni M A, Liu T B S, Scott Levin L, et al. Soft-tissue reconstruction of the complicated knee arthroplasty: principles and predictors of salvage. Plast Reconstr Surg 2018; 141: 1040-8. doi: 10.1097/PRS.0000000000004255. DOI: https://doi.org/10.1097/PRS.0000000000004255

Højvig J B, Bonde C T. Breast reconstruction using a latissimus dorsi flap after mastectomy. Dan Med J 2015; 62: A5155. PMID: 26621391

Thakrar R R, Horriat S, Kayani B, Haddad F S. Indications for a single-stage exchange arthroplasty for chronic prosthetic joint infection: a systematic review. Bone Joint J 2019; 101B: 19-24. doi: 10.1302/0301-620X.101B1.BJJ-2018-0374.R1. DOI: https://doi.org/10.1302/0301-620X.101B1.BJJ-2018-0374.R1

Højvig J H, Kehlet H, Bonde C T. Enhanced recovery after head and neck cancer reconstruction with a free flap—what is next? J Oral Maxillofac Surg 2020; 78: 10-1. doi: 10.1016/j.joms.2019.07.021. DOI: https://doi.org/10.1016/j.joms.2019.07.021

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Published

2024-04-17

How to Cite

Hamrouni, N., Højvig, J. H., Knudsen, U. K., Skovgaard, K. K., Jensen, L. T., Bonde, C. T., & Odgaard, A. (2024). Microvascular free flap coverage of complex soft tissue defects after revision total knee arthroplasty: a cross-sectional observation study. Acta Orthopaedica, 95, 186–191. https://doi.org/10.2340/17453674.2024.40183

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Vol. 95 (2024): Acta Orthopaedica

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Copyright (c) 2024 Nizar Hamrouni, Jens H Højvig, Ulrik K Knudsen, Kurt K Skovgaard, Lisa T Jensen, Christian T Bonde, Anders Odgaard

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This work is licensed under a Creative Commons Attribution 4.0 International License.

Acta Orthopaedica (Scandinavica) content is available freely online as from volume 1, 1930. The journal owner owns the copyright for all material published until volume 80, 2009. As of June 2009, the journal has however been published fully Open Access, meaning the authors retain copyright to their work. As of June 2009, articles have been published under CC-BY-NC or CC-BY licenses, unless otherwise specified.
 
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