Soft-Tissue Defects After Total Knee Arthroplasty: Management and Reconstruction

Daniel A. Osei, MD, MSc; Kelsey A. Rebehn, MD; Martin I. Boyer, MD, MS


J Am Acad Orthop Surg. 2016;24(11):769-779. 

In This Article

Risk Factors

Knowledge of the factors that place a patient at higher risk of surgical wound complications can guide management, allowing the surgeon to closely monitor at-risk patients and promptly detect any complications. Factors that increase the risk of wound complications after TKA can be systemic or local. Systemic risk factors include smoking, diabetes mellitus, increasing patient age, obesity, immunocompromised state, preexisting peripheral vascular disease, malnutrition, chronic renal insufficiency, and chemotherapy.[4] Smoking, obesity, and malnutrition are particularly notable because they are associated with increased rates of infection and secondary surgery.[4–7]

Local risk factors include preexisting scars or dystrophic skin, prior surgery on the affected knee, and prior skin irradiation. In the immediate postoperative period, hematoma or superficial skin irradiation can increase the risk of serious wound complications.[4] Existing incisions should be taken into account when the surgical approach is planned. Reusing preexisting longitudinal incisions is preferred. Because perfusion of the skin on the medial aspect of the knee is more robust than on the lateral side of the knee, the use of a lateral incision is recommended to avoid interruption of the primary dermal blood supply, which would place the lateral edges of the skin flap at greater risk of compromise.[8]

Other factors that influence the risk of wound complications include the choice of anticoagulation prophylaxis, the presence of prolonged postoperative wound drainage, early aggressive flexion of the knee, the use of a high-pressure tourniquet, and increased surgical times. Patients on anticoagulation therapy who undergo TKA are often administered higher perioperative doses of warfarin, which has been associated with substantial increases in the duration of wound drainage and the incidence of infection.[9] Factors that influence tissue oxygenation have been linked to postoperative wound healing complications at the surgical site. The use of a high-pressure tourniquet decreases oxygenation and tissue perfusion at the wound site.[10] Similarly, in a series of patients with notable flexion deformity who underwent TKA, an increased risk of necrosis of the skin edge at the incisional site was attributed to the severe ankylosis of the joint, which placed the skin flaps under increased tension when they were approximated over the anterior surface of the prosthesis.[11] This finding emphasizes the importance of adequate, tension-free soft-tissue coverage over the prosthetic knee.