Gastrocnemius Flap Research Articles

Soft Tissue Reconstruction for Deep Defects over a Complicated Total Knee Arthroplasty: A Systematic Review.

Deep soft tissue defects after complicated primary or revision total knee arthroplasty (TKA) can be devastating to the patient and technically challenging. The purpose of this review was to (1) discuss different methods used to provide coverage for deep defects of the knee following TKA, as well as to (2) report on their success rates. A comprehensive literature search was performed. Reports were only included if they (1) were case series, (2) were level III studies or above (including retrospective cohort studies and meta-analyses), (3) were in English, and (4) discussed the outcome of graft or flap coverage of soft tissue defects after total knee arthroplasty. A total of 28 case series and four retrospective comparative studies were retrieved. In 16 studies, 195 out of 241 patients who received gastrocnemius flaps (81%) experienced successful outcomes. In seven studies including 84 patients that underwent fasciocutaneous flap coverage, over 90% of patients experienced successful outcomes. In the four studies examining 144 patients with delayed versus prophylactic soft tissue reconstruction, up to 81% of patients experienced a successful outcome. Various factors must be taken into consideration when assessing full-thickness defects over a TKA and collaboration between plastic and orthopaedic surgeons is required to select the optimal approach.

Abstract 128: Potential Virulence of MRSA and Enterococcus in Patients Undergoing Free Tissue Transfer for Chronic, Non-healing Lower Extremity Wounds

PURPOSE: Chronic wounds in the lower extremity (LE) often fail to heal, necessitating free tissue transfer (FTT) for limb salvage. Patients in whom microsurgical LE reconstruction is indicated are often highly comorbid and prone to infection. In LE free flap studies, Hashimoto et al.1 and Corten et al.2 reported common wound colonization with Staphylococcus and Enterococcus, findings similar to those within patients of our tertiary-care center. While larger studies have investigated the microsurgical significance of Staphylococcus, few, if any, have investigated Enterococcus. The purpose of this study was to investigate the potential virulence of bacterial colonization on microsurgical limb-salvage outcomes. METHODS: Between April 2011 and May 2018, 140 LE FTT procedures were performed by the corresponding author for reconstruction of chronic wounds. The average patient age was 54.2yrs, the average BMI 29, and 50.3% of patients had diabetes. An average of 2.65 wound-bed debridements were performed per patient prior to FTT. Deep, intra-operative qualitative tissue cultures were obtained. Average follow-up after FTT was 17 months. Using multivariate analysis we studied the implications of wound colonization with Methicillin-resistant Staphylococcus aureus (MRSA) or Enterococcus on microsurgical success and limb-status after closure was attempted via FTT. RESULTS: Overall microsurgical success and limb-salvage rates were 91.4% (128/140) and 85% (119/140), respectively. Flaps contaminated with Enterococcus at the time of surgery were at increased risk for failure (OR6.21, p=0.05). In addition, risk for flap infection was greater in patients with wounds contaminated with Enterococcus during preoperative debridement (OR4.3; 95%CI, 1.518–11.997; p=0.006). Major amputation risk was increased in patients with wounds previously contaminated with MRSA (OR9.08; 95%CI, 2.721–30.320; p=0.0003), patients with positive Enterococcus cultures at the time of surgery (OR6.4; 95%CI, 1.21–34.43; p=0.03), and patients who developed flap infection with Enterococcus (OR19.7; 95%CI, 1.9–199.5; p=0.01). CONCLUSION: FTT can salvage the limb that has otherwise failed all other attempts at wound closure, obviating the need for major amputation. However, the medical demographics of this patient population and technical complexity of FTT make microsurgical outcomes vulnerable to many factors. Thus, part of restoring limb function in these patients is optimizing patient condition by mitigating perioperative risk factors. The negative impact of colonization of chronic wounds with bacteria, including MRSA, has been described. However, studies placing primary focus on individual pathogens in this population are lacking. Our results indicate potential adverse outcomes associated with noninfectious MRSA and Enterococcus colonization of chronic leg wounds. With this information, microsurgeons could stratify patients by infectious etiology for risk of adverse events, potentially allowing for earlier, mitigating treatment in the preoperative course. CITATIONS 1. Hashimoto I, Abe Y, Morimoto A, Kashiwagi K, Goishi K, Nakanishi H. Limb salvage and vascular augmentation by microsurgical free flap transfer for treatment of neuropathic diabetic foot ulcers. J Med Investig. 2014. doi:10.2152/jmi.61.325 2. Corten K, Struelens B, Evans B, Graham E, Bourne RB, MacDonald SJ. Gastrocnemius flap reconstruction of soft-tissue defects following infected total knee replacement. Bone Jt J. 2013. doi:10.1302/0301-620X.95B9

Treatment of postoperative infection of tibial plateau fracture at different stages

Objective To investigate the treatment options for early and delayed postoperative infection of tibial plateau fracture. Methods A retrospective case series study was conducted to analyze 21 patients with postoperative infection of tibial plateau fracture admitted to the Second Affiliated Hospital of Medical College of Zhejiang University from February 2013 to February 2017. There were 16 males and five females, aged 28-68 years, with an average age of 51.9 years. Infection control was achieved in all patients through debridement and local application of antibiotic calcium sulfate or bone cement in all patients and gastrocnemius muscle flap transfer was conducted if necessary. The implants were retained in the 12 patients with early infection through thorough debridement and antibiotic therapy. Of all the nine patients with delayed infection, the implant of one patient was removed after local wound dressing until fracture union and the following debridement closure was performed; two patients with severe damage of knee joint had no chance of reconstruction, with one patient treated with lower femoral amputation and another with replacement of plate by external fixator at stage I and arthrodesis at stage II. The implants were replaced by external fixator followed by debridement and antibiotic therapy in the remaining six patients with delayed infection, among which stage II bone grafting was performed in three patients with bone defect. Infection, bone healing and knee function score of Hospital for Special Surgery (HSS) were evaluated in all patients at regular intervals. Results All patients were followed up for 18-60 months, with an average of 37.4 months. All patients were treated with antibiotic calcium sulfate or bone cement to control infection. Ten patients with infection underwent gastrocnemius muscle flap transfer, and the wounds were healed well with no recurrence of fracture and infection. The implants of 12 patients with early infection were successfully retained, and the fractures were healed. According to HSS scoring criteria, the knee joint function results were excellent in seven patients, good in three, and moderate in two, with an overall excellent and good rate of 83% (10/12). Infection was controlled in nine patients with delayed infection, and fractures or bone defects were healed in seven patients with delayed infection except patients receiving amputation and joint fusion. According to HSS scoring criteria, knee joint function results were excellent in one patient, good in three, moderate in two and poor in one, with an excellent and good rate of 57% (4/7). Conclusions Patients with early postoperative infection of tibial plateau fracture may attempt to retain the implants through early debridement and antibiotic therapy. For patients with delayed infection, although implants may also be retained in stable cases with ongoing fracture healing, removal of implants instead by external fixator is recommended and infection can mostly be controlled by debridement and antibiotic therapy. Meanwhile, gastrocnemius muscle flap transfer and antibiotic calcium sulfate or bone cement contributing to the control of infection can achieve good clinical results. Key words: Tibial fractures; Infection; Treatment

The Medial Sural Artery Perforator Island Flap as a Simpler Alternative for Prophylactic Skin Augmentation Prior to Total Knee Arthroplasty

Total knee arthroplasty is a common orthopaedic procedure of great benefit in restoring unimpeded and pain free ambulation with rare complications [1]. However, subsequent soft tissue compromise and/or joint infection can be disastrous if prosthesis salvage is impossible requiring instead knee fusion or even amputation [1]. The pre-operative presence of tenuous soft tissues, most obvious if a skin graft covers the knee region; or the existence of multiple or problematic scars should be indications for consideration of prophylactic soft tissue replacement with a flap so as to avoid these endpoints [1, 2]. This is a proven and beneficial concept where usually the medial gastrocnemius muscle or distal-based anterolateral thigh flap as a local flap has been selected, or else even a free tissue transfer [1–3]. With the advent of perforator-based cutaneous pedicled flaps, the medial sural artery perforator flap as a local island flap should be considered as another alternative to fulfill this orthoplastic approach for minimizing untoward events [4].

Medial Hemisoleus Muscle Flap in Reconstruction of Soft Tissue Defects of Lower Leg

Background: Reconstruction of lower leg represents a challenge task for plastic surgeons. Although microsurgical flaps have been the golden choice for this reconstruction, many hospitals do not have equipment or microsurgical staff trained for this type of procedure. Aim: The objective of the current study is to evaluate of clinic applicability and functional outcome results of medial hemisoleus muscle as a reconstructive flap modality in lower third leg soft tissue defect. This includes clinical study comparison between two surgical modalities of hemisoleus muscle Hap elevation. Methodology: This study was conducted in Plastic Surgery Department, Aswan University Hospital from May 2017 to August 2018. It was a descriptive study including 30 patients (23 males and 7 females with the age ranging between 29 and 51 years). Results: Our study confirmed this fact as preservation of lateral portion is suitable for planter flexion with gastrocnemius muscle and medial hemisoleus muscle flap showing long arc of rotation especially distally based posterior tibial artery medial hemisoleus muscle flap has long arc of rotation cover up to heal defect. Conclusion: Medial hemisoleus muscle flap is a reliable option for the reconstruction of soft tissue defects of lower leg based on minor pedicle or reversed flow based on posterior tibial artery. Careful flap dissection with preservation of as many perforators as possible is the key to success.

Gastrocnemius flap for the treatment of infections around the knee: A report on 3 cases

Gastrocnemius flap for the treatment of infections around the knee: A report on 3 cases

Application of muscular flap and induced membrane technique in the emergency treatment for limb salvage for Gustilo type III B and III C open fracture of lower leg

Objective To investigate the clinical effectivity of the muscular flap transposition and induced membrane technique in the emergency treatment for the limb salvage of Gustilo type III B/C open fracture of lower leg. Methods From July, 2015 to December, 2017, 10 cases of Gustilo type III B/C fracture of lower leg with bone defects were performed limb salvage surgery. Induced membrane technique was used to fill the bone defects in the emergency room. The gastrocnemius and/or soleus muscular flaps were transposed to cover the bone cement or exposed bone simultaneously in emergence treatment. After the wound healed completely, traditional bone grafting was used to repair the bone defects. There were 4 cases of Gustilo type III B and 6 cases of Gustilo type III C. The average length of bone defect was (5.25±1.70) cm ranging from 3.0 cm to 11.0 cm. The gastrocnemius medial head flaps were performed in 5 cases, the combined application with the gastrocnemius medial head flaps and the medial hemimuscular flaps of soleus were performed in 2 cases, and medial hemimuscular flaps of soleus were transposed in 3 cases. Results The wounds in 6 cases were healed at one stage, but 2 cases healed by dressing because the exudate after skin grafting. In 1 case, the cross-leg flap was used to cover the exposed bone cement due to the necrosis of soleus flap. The other 1 was performed the transposition of the lateral gastrocnemius flaps because the exposure of bone cement after the necrosis of the upper and lateral muscles in lower leg. In the second-stage, the bone defects were reconstructed by traditional bone grafting. The average healed time of bone was 7.2 months ranging from 5 months to 9 months. At the last followed-up time, all patients recovered their function of weight-bearing. The Paley's score of the adjacent joints: excellent in 8 cases and good in 2 cases. Conclusion The combination with induced membrane technique and local muscular flap transposition in emergency surgery is an effective method to limb salvage for the Gustilo type III B/C open fracture of lower leg. Key words: Gustilo type III, Gustilo type; Open fracture of lower leg; Induced membrane technique; Muscular flap; Emergency treatment

Does Patellar Tendon Repair With Gastrocnemius Flap Augmentation Effectively Restore Active Extension After Proximal Tibial Sarcoma Resection?

A rotational gastrocnemius flap is often used for soft tissue reconstruction after proximal tibia sarcoma resection. However, little is known about the frequency and severity of complications and the recovery of extensor function after this procedure. After gastrocnemius flap reconstruction with split-thickness skin grafting (STSG) to augment the extensor mechanism repair after proximal tibial resection for sarcoma, we asked: (1) What ROM was achieved (including extensor lag and active flexion)? (2) How often did complications and reoperations occur and what caused them? Between 1991 and 2014, one surgeon treated 26 patients with proximal tibial resections for primary bone sarcoma. Of these, 18 were reconstructed with the preferred approach: resecting the proximal tibia leaving the patellar tendon in continuity with the tibialis anterior fascia whenever possible (10), cementing a stemmed proximal tibial endoprosthesis, suturing the patellar tendon to the implant, rotating a medial (16) or lateral (two) gastrocnemius flap over the tendon and prosthesis to augment the repair, and covering the flap with STSG. Alternative methods were used when this was technically impossible (one patient), when there was no advantage to secondary soft tissue coverage (two patients), or when the limb could not be salvaged (five patients). Of the 18 treated with gastrocnemius flaps, two were lost to followup or died of disease before the 24-month minimum and excluded; the median followup of the remaining 16 was 6 years (mean, 9.9 years; range, 2.3-21.7 years); three patients died of disease, and four have not been seen within the last 5 years. We reviewed medical records for passive and active extension, maximum flexion achieved, and complications requiring reoperation. ROM in patients with successful limb salvage was graded as excellent (flexion ≥ 110° and no lag), good (flexion 90°-110° and lag ≤ 10°), fair (one function limited: either flexion < 90° or lag > 10°), or poor (both functions limited: flexion < 90° and lag > 10°). At latest followup, three patients had undergone amputation for deep infection. Of those remaining, median active flexion was 110° (mean, 104°; range, 60°-120°) and extensor lag was 0° (mean, 4°; range, 0°-10°). ROM was excellent in nine patients, good in three, fair in one, and poor in none. We observed 18 complications requiring reoperation in 12 patients, including deep infection (four), patellar tendon avulsion/attenuation (three), and flap necrosis (one). Survivorship free from revision or loss of the gastrocnemius flap was 74% (95% confidence interval [CI], 5.6-95.8) at 2, 5, and 10 years. Survivorship free from reoperation for any cause was 74% (95% CI, 52.0-96.0) at 2 years, 52% (95% CI, 25.8-77.8) at 5 years, and 35% (95% CI, 0-61.5) at 10 years using Kaplan-Meier analysis. Although most patients regained functional ROM including active extension, 12 required reoperation for complications including infection and early extensor mechanism failures. Despite the observed risks, we believe the gastrocnemius flap with STSG should be considered a suitable approach to provide active extension and soft tissue coverage given the paucity of good surgical options for extensor mechanism reconstruction in this challenging clinical setting. Level IV, therapeutic study.

Transfer of gastrocnemius muscle flap for postoperative infection with patellar internal fixation

To investigate clinical effect of gastrocnemius muscle flap for repairing postoperative infection of patellar internal fixation. From January 2011 to January 2017, 15 patients with postoperative infection of patellar internal fixation were treated, including 9 males and 6 females ranged from 31 to 66 years old with an average age of (42.5±11.2) years old. The courses of disease ranged from 2 to 8 months with an average of (4.3±1.5) months. All wounds were repaired by gastrocnemius muscle flap after debridement. The coverage of muscle flap was performed by free skin graft and donor site was closed directly. Survival of muscle flap, healing of incision were observed. HUANG Yong-xin clinical criteria and KSS score criteria were used to evaluate knee joint function 9 after operation. All muscle flaps were survived without necrosis. Incision of 13 patients were healed at stageI, and 2 patients had wound dehiscence after operation and healed after symptomatic treatment. All patients were followed up from 9 months to 30 months with an average of(20.6±8.3) months. No recurrence of infection was observed, and texture of muscle flap, skin color, appearance were good. According to HUANG Yong-xin clinical criteria, 13 excellent and 2 moderate. The clinical score of KSS score was 83.3±7.8, and functional score of KSS score was 86.3±10.4. Gastrocnemius muscle flap is an effective method in repairing postoperative infection of patellar internal fixation with stable curative effect and low recurrence rate, which is worthy popularizing.

Distally based anterolateral thigh flap: an underutilized option for peri-patellar wound coverage

Wound coverage in the supra-patellar area presents a significant challenge for orthopaedic and reconstructive surgeons due to the need for preservation of knee joint function but the paucity of regional soft tissue flaps available. While many orthopaedic and reconstructive surgeons make use of the rotational gastrocnemius flap for coverage of peri-patellar defects, this flap has certain limitations. The goal of this study was to report a single-centre experience with the use of the distally based anterolateral thigh flap (ALT) and review the current literature on the use of the ALT for peri-patellar defects. In this report, both a single-centre experience using distally based anterolateral thigh (ALT) island flaps for supra-patellar wound coverage and the existing literature on this topic were reviewed. A systematic literature review was performed to assess the use of the ALT for peri-patellar wounds. Five patients with a mean age of 69 underwent a distally based ALT flap for coverage of peri-patellar defects. Four out of 5 flaps survived at the end of their respective follow-up. Based on this combined experience, the distally based reverse-flow anterolateral thigh island flap represents a useful but relatively underutilized option for appropriately selected supra-patellar wounds due to minimal donor site morbidity, multiple flap components, and predictable pedicle anatomy. The flap’s major weakness is its potentially unreliable venous drainage, requiring delay or secondary venous outflow anastomosis. Given the ALT flap’s favourable profile, the authors recommend consideration for its use when managing a peri-patellar coverage wound issue.

Gastrocnemius Myocutaneous Flaps for Knee Joint Coverage.

The gastrocnemius muscular flap has already proven its efficiency for soft tissue coverage in cases of knee joint exposure. However, it may be too small to cover large defects and has not the same aesthetic and mechanical properties as normal skin. Perforator fasciocutaneous flaps have recently been described in knee joint coverage with good results as they replace skin by skin, but they can be hard to harvest. Gastrocnemius flaps can be easily harvested with a planned skin paddle designed over the chosen muscle. This simple technique combines the advantages of muscular and fasciocutaneous flaps for knee joint area coverage. Perforator fasciocutaneous flap take a growing place in coverage of this localization in recent literature, but very few articles report the results of gastrocnemius myocutaneous flaps (MCFs). All patients who underwent knee joint coverage with the use of a lateral or medial gastrocnemius MCFs between January 2012 and February 2017 in our university institution were included in this retrospective study. Sixteen gastrocnemius MCFs (10 medial and 6 lateral) were performed. The indication was posttraumatic in 5 cases, posttumoral in 5 cases, and after total knee prosthesis exposure in 6 cases. Skin paddles up to 15 cm in width and 18 cm in length were harvested. Complete healing was achieved in 15 days in all cases without suffering or nonunion. Three flaps were secondarily raised to allow total knee prosthesis reimplantation or arthrodesis, and 4 patients were treated with postoperative radiotherapy without complication. In addition to its reliability and very easy harvesting, the gastrocnemius MCF allows a robust joint coverage and good skin resurfacing that makes eventual revision easier and allows early radiotherapy. Furthermore, skin paddle also increases the effective area of the flap. This technique should always be considered with the other classic alternatives.

The Reach of the Gastrocnemius Musculocutaneous Flap: How High Is High?

BACKGROUNDGastrocnemius muscle and musculocutaneous flaps are very versatile and one of the commonly used flaps for lower extremity reconstruction. There is significant literature available on the use of these flaps. However, we feel that the potential of the gastrocnemius musculocutaneous (GMC) flaps has not yet been fully explored in terms of increasing their reach, viability and arc of rotation. An attempt is made to refine the technique of flap harvestation to optimize outcomes of this versatile flap.METHODSSix patients of complex lower limb defects were managed using the GMC flaps. Harvesting of the flap was always initiated from the posterior midline to include the proximal sural pedicle, sural nerve, short saphenous vein and the muscle belly of either the medial or the lateral gastrocnemius muscle along with the cutaneous paddle. All the flaps were islanded and denervated. The origin of the gastrocnemius muscle was detached in all cases to increase the reach of this flap.RESULTSThe flap can reliably and comfortably cover defects from middle third-lower third junction of thigh and the entire posterior aspect of the thigh. Such a local option offers relatively simple but more cost-effective approach to complex clinical problem with tolerable impairment of the donor site. CONCLUSIONThe GMC flap can be considered as a worthwhile alternative to free-tissue transfer for limb salvage.

Tibia Adamantinoma Resection and Reconstruction with a Custom-Made Total Tibia Endoprosthesis: A Case Report with 8-Year Follow-Up

This case study describes a total tibia resection and reconstruction with a custom-made endoprosthetic replacement (EPR) and a long-term, 8-year follow-up. The patient underwent a total tibia adamantinoma resection in 2009. Reconstruction was performed with a custom-made total tibia EPR, where both the knee joint and ankle joint were reconstructed. Two muscle flaps, latissimus dorsi free flap and a pedicled medial gastrocnemius flap, were used for soft tissue reconstruction. The patient returned to normal life as a kindergarten teacher, without complications for eight years. This case demonstrated the importance of successful multidisciplinary teamwork in close collaboration with industry. In our best knowledge, no over 2 years of follow-up of total tibia replacement reports have been published.

Reconstruction of Knee Defects Using Pedicled Gastrocnemius Muscle Flap with Split-Thickness Skin Grafting: A Single Surgeon's Experience with 21 Patients.

Generally, reconstruction of knee defects with exposed bone, joint, tendon, and/or hardware requires a vascularized muscle flap for coverage. Although there are several surgical options for a knee defect reconstruction, the pedicled gastrocnemius muscle still remains the workhorse flap. Although this flap is commonly used for knee defect reconstruction and the technique is described very well, there is an absence of information in the literature detailing the technique of harvesting and insetting of the gastrocnemius flap step by step with illustrations. The purpose of this article is to describe in detail the technique to reconstruct defects of the knee with pedicled gastrocnemius muscle flap as well as to present demographics and surgical results of 21 patients who had knee reconstruction with a pedicled gastrocnemius muscle flap and split-thickness skin grafting.

Treatment of Periprosthetic Knee Infection With Concurrent Rotational Muscle Flap Coverage Is Associated With High Failure Rates

BackgroundSoft-tissue deficiency is a potentially devastating complication of the infected total knee arthroplasty (TKA). Rotational muscle flaps are commonly used to address these defects. However, reported success rates vary widely. MethodsWe reviewed 26 consecutive patients who underwent rotational muscle flap surgery for full-thickness anterior soft-tissue defect during treatment of an infected TKA. Twenty-four cases used a medial gastrocnemius rotational flap, 1 used a lateral gastrocnemius flap, and 1 used a rectus femoris-vastus intermedius flap. Implant survival, recurrence of infection, and limb survival were reported. Patient and procedural characteristics were tested for association with failure using χ2 and Student t-test. Kaplan-Meier analysis was used to estimate the failure-free survival function. ResultsMean follow-up time was 3.3 years. Eighteen of 26 patients (69.2%) experienced recurrent infection requiring an average of 5.3 additional operations (range, 1-20). Five (19.2%) required arthrodesis while 6 (23.1%) eventually underwent above-the-knee amputation. Two patients (7.7%) died due to complications of revision surgery or persistent infection. Eleven patients (42.3%) were infection free with a retained prosthesis after treatment at a mean follow-up of 5.3 years (range, 0.7-18.0 years). ConclusionRotational muscle flap coverage of soft-tissue defects in the setting of the infected TKA remains a viable salvage option. However, despite adequate tissue coverage, many patients experience recurrent infection requiring additional surgical treatment. Patients and surgeons should be aware of the potential high failure rates observed when treating these complex problems.

Reconstruction in Malignant Tumors of the Calf After Tumoral Resection in Children

Abstract Purpose. Evaluation of reconstructive procedures after oncologic resection of malignant bone tumors of the calf in children. Materials and methods. The study contains 4 patients with ages between 5 and 18 years, 2 of the cases being diagnosed with osteosarcoma, respectively 2 with Ewing sarcoma of the tibia. In 3 of the cases, the surgical treatment consisted of en bloc tumoral resection and reconstruction with metal acrylic spacer and, in the 4th case, the tumoral resection was followed by endoprosthetic replacement. In all cases, the surgical treatment was preceded by biopsy and chemotherapy. Results. In 3 of the patients we used a gastrocnemius flap and one patient needed a negative pressure dressing for 11 days after surgery. The follow-up varied between 8 and 17 months after surgery. The patient who underwent endoprosthetic replacement was immobilized in a mobile orthosis and partial weight bearing at 2 weeks PO. The patient who underwent endoprosthetic replacement needed a surgical revision at 10 months PO consisting in the reinsertion of a locking screw of the patellar tendon fixation device. 2 of the presented cases are waiting for replacement of the metal acrylic spacer with a definitive reconstruction procedure, 1 case is proposed for amputation. Conclusions. Malignant bone tumors of the calf in children represent a pathology with high complexity giving the possible complications that can occur, a redoubtable risk being implant loss due to lack of coverage. The discussion remains open regarding the right time for definitive surgical procedure with modular endoprosthesis in children, and other reconstructive techniques available in these cases.

Long-Term Outcomes of Pedicled Gastrocnemius Flaps in Total Knee Arthroplasty.

Deficient soft tissue following total knee arthroplasty (TKA) can jeopardize outcome. The gastrocnemius flap is an important means of providing coverage of a knee with deficient soft tissue. There is a paucity of long-term studies on the use of the gastrocnemius flap in the setting of TKA. The purpose of this study was to review the outcomes after the use of pedicled gastrocnemius flaps for coverage of a soft-tissue defect at the time of TKA. Eighty-three patients in whom a gastrocnemius flap had been used to cover the site of a primary (n = 18) or revision (n = 65) TKA over a 25-year period were identified. There were 48 women (58%) and 35 men (42%) with a mean age and body mass index (BMI) of 65 years and 32.6 kg/m. The mean wound size was 49 cm, and the wound was most commonly located over the anterior aspect of the knee/patellar tendon (n = 33). Patients were followed to the time of implant or flap revision, amputation, or death or for a minimum of 2 years (mean, 8 years). Clinical outcomes were assessed using the Knee Society Score (KSS) for pain and the KSS for function. The Kaplan-Meier method was used to assess revision and amputation-free survival. Risk factors for amputation and revision were identified with Cox regression. The 10-year revision and amputation-free survival rates following gastrocnemius flap coverage were 68% and 79%, respectively. The risk of implant failure was increased by morbid obesity (BMI of ≥40 kg/m) (hazard ratio [HR] = 2.82, 95% confidence interval [CI] = 1.09 to 7.32, p = 0.03) and ≥5 prior surgical procedures on the knee (HR = 2.68, 95% CI = 1.04 to 6.88, p = 0.04). The risk of amputation was increased in patients with ≥5 prior surgical procedures (HR = 10.76, 95% CI = 2.38 to 48.58, p = 0.002), an age of ≥65 years (HR = 4.94, 95% CI = 1.10 to 22.09, p = 0.03), and a wound size of ≥50 cm (HR = 3.29, 95% CI = 1.14 to 9.53, p = 0.02). Preoperatively the mean KSSs for pain and function were 46 and 28, and these scores significantly (p < 0.05) improved to 78 and 43, respectively, at the time of follow-up. The gastrocnemius flap reliably provides coverage of components used in complex knee reconstruction. A history of multiple surgical procedures on the knee and larger soft-tissue defects increase the risk of revision TKA and of amputation. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Two sequential free flaps for coverage of a total knee implant.

Knee revision arthroplasty following peri-prosthetic joint infections is a formidable challenge. Patients are at a high risk of recurrent infection, and the soft tissue over the revised implant is often of questionable quality. Flap reconstruction has improved the salvage rates of infected arthroplasties, and should be considered in all cases of revision arthroplasty. We present a challenging case requiring staged reconstruction with two free latissimus dorsi flaps after the initial use of a medial gastrocnemius flap.

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

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. Therapeutic, III.

Is double-approach surgery and tenodesis without a gastrocnemius flap better for dealing with proximal fibular osteosarcoma?

BackgroundResection of proximal fibular osteosarcoma involving the posteromedial aspect of the fibula is challenging. Reconstruction using a gastrocnemius flap may result in significant lateral instability and abnormal knee movement. Furthermore, postoperative gait may be disturbed by foot drop resulting from scarification of the common peroneal nerve.MethodsBetween January 2011 and December 2013, five patients with proximal fibular osteosarcoma were treated via the double-approach procedure using en bloc resection without a gastrocnemius flap. Simultaneously, all patients received one-stage tenodesis of the anterior tibial and toe extensor tendons. Clinical outcomes, including local tumor recurrence, complications, and functional outcomes, were evaluated.ResultsThe mean follow-up duration was 47.2 months (range 42–52 months). No patients experienced local recurrence. The patients’ Enneking functional scores were excellent (80%) or good (20%) at the final follow-up.ConclusionsIn patients with proximal fibular osteosarcoma, the double-approach procedure allows easier and safer en bloc tumor resection with vessel and nerve protection. One-stage tenodesis without a gastrocnemius flap is associated with good functional outcomes.