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

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

Disclosures

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

In This Article

Assessment

In patients who have undergone TKA, prompt identification of delayed healing or infection is crucial to allow retention of the prosthesis. Consensus on standardization of periprosthetic wound evaluation has not been reached in the orthopaedic literature. Laing et al[12] proposed a graded wound classification system; however, their system does not capture the complexity of soft-tissue defects after TKA because it does not address the presence of infection, the size of the wound, or characteristics of the tissue loss. Postoperative evaluation of patients who have undergone TKA should include serial assessments of the wound. If a delay in wound healing is observed, the surgeon should assess the area of soft-tissue loss and the depth of the wound, noting the presence and/or exposure of any bone, prosthesis, or cement in the wound. The surgeon should also note the presence or absence of erythema, purulent drainage, and a sinus tract.

Early identification of a periprosthetic infection is important and may influence the choice of initial treatment. Surface wound swabs of drainage are usually discouraged because they have high rates of contamination with skin microbiota and little correlation with deep infection.[13] Joint aspiration around the prosthesis offers a better indication of deep infection than surface wound swabs provide. In the 6-week postoperative period, synovial white blood cell counts >27,800 cells/μL should raise a high index of suspicion for infection. In one study, the use of this parameter instead of the standard threshold of 3,000 cells/μL was associated with a positive predictive value of 94% and negative predictive value of 98%, resulting in a reduction in the number of surgical interventions that would have been performed in noninfected knees.[14]

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