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

Initial Intervention

After diagnosis of a wound healing complication, early and thorough débridement of any infected or devitalized tissue is crucial; all nonviable tissue must be excised. In patients with infection, the colonized soft tissue should be débrided in a similar manner. In patients with symptoms of infection, treatment consisting of irrigation, débridement, systemic antibiotic therapy, and immediate soft-tissue coverage has been associated with high rates of retention of the prosthesis.[15–18] In patients with chronic deep periprosthetic infections, implant revision with long-term antibiotic therapy is recommended. Debate exists as to whether a single-stage revision or a two-stage revision with delayed reimplantation and the use of an antibiotic spacer or cement during the interval between stages leads to improved results.[15] If a single-stage revision is chosen, flap coverage can be performed during the same procedure to augment blood flow to the region, increase local antibiotic delivery, and decrease bacterial proliferation. If a two-stage approach is chosen, flap coverage can be performed at the time of implant removal or can be delayed.[19] Regardless of whether a single-stage or two-stage approach is chosen, coverage of the prosthesis depends on the often tenuous condition of the soft-tissue envelope after the wound has been débrided to healthy, bleeding tissue.

In patients who are at especially high risk of wound healing complications, prophylactic flap coverage has shown excellent outcomes in limited retrospective studies. Casey et al[20] studied 23 patients who had prohibitive soft-tissue envelopes after TKA because of multiple scars, prior wound complications, or prior infections. These high-risk patients were treated with prophylactic flaps and were compared with 18 patients (19 knees) who underwent salvage flap procedures for infection, wound eschar, or wound dehiscence. All prostheses were retained in the group of patients who underwent prophylactic flap coverage, whereas 10 of the 19 prostheses in the salvage group required removal. Furthermore, 2 of the 19 limbs treated with salvage flap coverage ultimately required above-knee amputation.