Soft Tissue Reconstruction of the Complicated Knee Arthroplasty: Principles and Predictors of Salvage

Purpose: Total-knee-arthroplasty (TKA) is a common orthopedic procedure in the US 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 TKA is critical for cases requiring optimization of the soft tissue envelope. The purpose of this study is to elucidate factors associated with TKA salvage following complications and clarify principles of reconstruction to optimize outcomes. Methods: A retrospective review of patients requiring soft-tissue reconstruction by the senior author after TKA 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. Results: Seventy-three knees in 71 patients required soft-tissue reconstruction (mean follow-up 1.8y) with salvage rate of 61.1%, 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 only treated within our system. Patients with multiple prior knee surgeries before definitive soft-tissue reconstructive had significantly decreased rates of prosthesis salvage and increased risk of amputation. Knee salvage significantly decreased with positive joint cultures (gram-negative > gram-positive) and particularly at the time of definitive reconstruction, which also trended towards increased the risk of amputation. Conclusions: In revision TKA, prompt soft tissue reconstruction improves likelihood of success and protracted surgical courses and contamination increase failure and amputations. We show a benefit to involving plastic surgeon early in the course of TKR complications to optimize genicular soft tissues. Financial Disclosures: Dr. Stephen J. Kovach is a paid consultant for Bard-Davol. The authors have no other disclosures. Corresponding Author: Stephen J. Kovach, Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Perelman Center for Advanced Medicine, South Pavilion 7th floor, 3400 Civic Center Boulevard, Philadelphia, PA 19104; Phone: 215-662-2520; Fax: 215-615-0474; Email: stephen.kovach@uphs.upenn.edu ©2017American Society of Plastic Surgeons