Philadelphia, Pa.
From the Division of Plastic Surgery, Department of Surgery, and the Department of Orthopaedic Surgery, University of Pennsylvania.
Plast Reconstr Surg. 2018 Apr;141(4):1040-1048. doi: 10.1097/PRS.0000000000004255.
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.
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.
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.
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.
全膝关节置换术是美国常见的骨科手术，但术后并发症可能会带来严重后果。软组织损伤或关节感染可能导致假体失效，需要行膝关节融合或截肢。对于需要优化软组织覆盖的病例，整形外科医生在全膝关节置换术中起着至关重要的作用。本研究旨在阐明与并发症后全膝关节置换术挽救相关的因素，并阐明重建原则以优化结果。
对 8 年来由资深作者行全膝关节置换术后软组织重建的患者进行回顾性研究。采用逻辑回归和 Fisher 确切检验确定与主要结局（假体挽救与膝关节融合或截肢）相关的因素。
71 例患者的 73 膝需要行软组织重建（平均随访 1.8 年），挽救率为 61.1%，主要采用内侧腓肠肌皮瓣。与仅在本系统内治疗的患者相比，转至我院治疗的伴有复杂假体周围伤口的患者更有可能失去膝关节假体。在确定性软组织重建之前有多次膝关节手术的患者，假体挽救率显著降低，截肢风险增加。关节培养阳性（革兰阴性菌大于革兰阳性菌）和在确定性重建时，膝关节挽救率显著降低，截肢风险也呈增加趋势。
在翻修全膝关节置换术中，及时进行软组织重建可提高成功率，而延长手术过程和污染会增加失败和截肢的风险。作者表明，在全膝关节置换术并发症发生的早期让整形外科医生参与，优化膝关节的软组织，可以带来获益。
临床问题/证据水平：治疗性，III 级。
