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Soft-Tissue Reconstruction of the Complicated Knee Arthroplasty: Principles and Predictors of Salvage

Colen, David L., M.D.; Carney, Martin J., B.S.; Shubinets, Valeriy, M.D.; Lanni, Michael A., M.D.; Liu, Tiffany, B.S.; Levin, L. Scott, M.D.; Lee, Gwo-Chin, M.D.; Kovach, Stephen J., M.D.

Plastic and Reconstructive Surgery: April 2018 - Volume 141 - Issue 4 - p 1040-1048
doi: 10.1097/PRS.0000000000004255
Reconstructive: Lower Extremity: Original Article
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Coding Perspective

Background: Total knee arthroplasty is a common orthopedic procedure in the United States and complications can be devastating. Soft-tissue compromise or joint infection may cause failure of prosthesis requiring knee fusion or amputation. The role of a plastic surgeon in total knee arthroplasty is critical for cases requiring optimization of the soft-tissue envelope. The purpose of this study was to elucidate factors associated with total knee arthroplasty salvage following complications and clarify principles of reconstruction to optimize outcomes.

Methods: A retrospective review of patients requiring soft-tissue reconstruction performed by the senior author after total knee arthroplasty over 8 years was completed. Logistic regression and Fisher’s exact tests determined factors associated with the primary outcome, prosthesis salvage versus knee fusion or amputation.

Results: Seventy-three knees in 71 patients required soft-tissue reconstruction (mean follow-up, 1.8 years), with a salvage rate of 61.1 percent, mostly using medial gastrocnemius flaps. Patients referred to our institution with complicated periprosthetic wounds were significantly more likely to lose their knee prosthesis than patients treated only within our system. Patients with multiple prior knee operations before definitive soft-tissue reconstruction had significantly decreased rates of prosthesis salvage and an increased risk of amputation. Knee salvage significantly decreased with positive joint cultures (Gram-negative greater than Gram-positive organisms) and particularly at the time of definitive reconstruction, which also trended toward an increased risk of amputation.

Conclusions: In revision total knee arthroplasty, prompt soft-tissue reconstruction improves the likelihood of success, and protracted surgical courses and contamination increase failure and amputations. The authors show a benefit to involving plastic surgeons early in the course of total knee arthroplasty complications to optimize genicular soft tissues.

CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Coding Perspective for this Article is on Page 1046.

Philadelphia, Pa.

From the Division of Plastic Surgery, Department of Surgery, and the Department of Orthopaedic Surgery, University of Pennsylvania.

Received for publication June 9, 2017; accepted October 24, 2017.

Disclosure:Dr. Kovach is a paid consultant for Bard-Davol. The authors have no other financial disclosures to report.

Stephen J. Kovach, M.D., Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Perelman Center for Advanced Medicine, South Pavilion, 7th Floor, 3400 Civic Center Boulevard, Philadelphia, Pa. 19104, stephen.kovach@uphs.upenn.edu

Copyright © 2017 by the American Society of Plastic Surgeons