Fansa H, Plogmeier K, Schenk K, Schneider W
Klinik für Plastische, Wiederherstellungs- und Handchirurgie, Medizinische Fakultät, Otto-von-Guericke-Universität, Magdeburg.
Chirurg. 1998 Nov;69(11):1238-43. doi: 10.1007/s001040050562.
Total knee arthroplasty has become a routine procedure in surgery. Deep infections have an incidence of 2-5%. Major risk factors are large prostheses, rheumatoid arthritis, diabetes mellitus and postoperative wound-healing complications. In large soft-tissue defects with skin necrosis, local wound care shows poor results, especially if loosening of the prosthesis and necrosis of the patellar ligament are evident. In these cases, no standard surgical therapy has been developed yet. Thus, we consider meticulous débridement with synovialectomy to be mandatory. Exchange of the prosthesis may be necessary. Soft-tissue coverage ought to be performed with a gastrocnemius muscle flap covered with a split-thickness skin graft. In the last three years, 11 patients with large soft-tissue defects and necrosis of the ligament were treated according to this concept. In all cases the muscle flap healed primarily and soft tissue coverage was excellent. Two patients who underwent single-stage removal and reimplantation of the prosthesis showed reinfections of the prosthesis. Reconstruction of the ligament was performed with the flap tendon. The patients with two-stage removal and reimplantation of the prosthesis and those who retained their implants had a good functional outcome. The gastrocnemius muscle flap provides easy and reliable soft-tissue reconstruction in large defects. In our patients a two-stage operation for reimplantation of the prosthesis was superior to a single-stage procedure. The reconstructed ligament should be reinforced with autologous material to prevent a secondary rupture. Early reconstruction with sufficient soft-tissue coverage and reconstruction of the ligament offers the patient the best chances of obtaining a good functional result and prevents arthrodesis or amputation. In addition, reconstructive surgery reduces the length of hospital stay and costs.
全膝关节置换术已成为外科手术中的常规操作。深部感染的发生率为2%至5%。主要危险因素包括大型假体、类风湿性关节炎、糖尿病和术后伤口愈合并发症。在伴有皮肤坏死的大面积软组织缺损中，局部伤口护理效果不佳，尤其是当假体松动和髌韧带坏死明显时。在这些情况下，尚未开发出标准的外科治疗方法。因此，我们认为进行细致的清创术并切除滑膜是必不可少的。可能需要更换假体。软组织覆盖应采用腓肠肌肌瓣加中厚皮片移植。在过去三年中，11例伴有大面积软组织缺损和韧带坏死的患者按照这一理念进行了治疗。在所有病例中，肌瓣均一期愈合，软组织覆盖良好。两名接受假体一期取出和再植入的患者出现了假体再次感染。韧带重建采用肌瓣肌腱进行。接受假体二期取出和再植入的患者以及保留假体的患者功能预后良好。腓肠肌肌瓣为大面积缺损提供了简便可靠的软组织重建方法。在我们的患者中，假体再植入的二期手术优于一期手术。重建的韧带应用自体材料加强，以防止二次断裂。早期进行充分的软组织覆盖和韧带重建，为患者获得良好功能结果提供了最佳机会，并可防止关节融合或截肢。此外，重建手术可缩短住院时间并降低费用。
