Orthoplastics in Periprosthetic Joint Infection of the Knee: Treatment Concept for Composite Soft-tissue Defect with Extensor Apparatus Deficiency

Abstract

Abstract. Introduction: Reconstruction of composite soft-tissue defects with extensor apparatus deficiency in patients with periprosthetic joint infection (PJI) of the knee is challenging. We present a single-centre multidisciplinary orthoplastic treatment concept based on a retrospective outcome analysis over 20 years.Methods and Results: One-hundred sixty patients had PJI after total knee arthroplasty. Plastic surgical reconstruction of a concomitant perigenicular soft-tissue defect was indicated in 47 patients. Of these, six presented with extensor apparatus deficiency. One patient underwent primary arthrodesis and five patients underwent reconstruction of the extensor apparatus. The principle to reconstruct missing tissue 'like with like' was thereby favoured: Two patients with a wide soft-tissue defect received a free anterolateral thigh flap with fascia lata; one patient with a smaller soft-tissue defect received a free sensate, extended lateral arm flap with triceps tendon; and two patients who did not qualify for free flap surgery received a pedicled medial sural artery perforator gastrocnemius flap. Despite good functional results 1 year later, long-term follow-up revealed that two patients had to undergo arthrodesis because of recurrent infection and one patient was lost to follow-up.Conclusion: These results show that PJI of the knee and extensor apparatus deficiency is a dreaded combination with a poor long-term outcome. Standardization of surgical techniques for a defined PJI problem and consensus on study variables may facilitate interinstitutional comparisons of outcome data, and hence, improvement of treatment concepts.

Soft-tissue reconstruction in lower-leg fracture-related infections: An orthoplastic outcome and risk factor analysis

“…The reconstruction method depended upon the preoperative three-dimensional analysis of the size and components of the composite defect, the vascular status and the comorbidities of the patient [9] . In general, the principle to replace tissue 'like with like' was favoured to achieve the best functional and aesthetic outcome [10] . For example, if the damaged structures consisted of cutaneous, subcutaneous and tendineous tissue reconstruction was performed with a free fascio-tendino-cutaneous antero-lateral thigh (ALT) flap (under the precondition that patient's vascular status and comorbidities allow free flap reconstruction) ( Fig.…”

The Proximal Placement of the Knee Joint in the 1-Stage Treatment of Infected Knee Revisions With Large Anterior Soft Tissue Defects

“…37 In addition, large free flaps have been found to fail more than smaller local flaps or soft tissue transfers. 37 This is why we chose to study the proximal placement technique which can preserve the extensor mechanism and potentially eliminate the need for a flap.…”

“…36 Preservation of the knee extensor mechanism in patients requiring extensive debridement is integral to maintaining biomechanical functionality of the knee. 37 In addition, large free flaps have been found to fail more than smaller local flaps or soft tissue transfers. 37 This is why we chose to study the proximal placement technique which can preserve the extensor mechanism and potentially eliminate the need for a flap.…”

Extensor mechanism reconstruction in the setting of infected total knee arthroplasty

“…In our practice, we rarely need to use free flaps to replace lost skin in infected total knee arthroplasty, and therefore gastrocnemius-based flaps form the majority of extensor mechanism reconstructions. Equally, on the rare cases when we do encounter a larger skin defect, it is important that as surgeons working in the field of infected TKA, plastic surgeons have the flexibility to reconstruct all defects, as the case series of Osinga et al (20) so beautifully illustrates.…”