Updated: 11/29/2019

TKA Wound Complications

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Introduction
  • Risk factors 
    • systemic factors
      • diabetes mellitus  
      • vascular disease
      • inflammatory arthritides such as rheumatoid arthritis
      • certain medications (immunosuppressives)
      • tobacco use
      • poor nutritional status
      • albumin <3.5g/dL
      • total lymphocyte count <1,500/uL
      • perioperative anemia
      • morbid obesity (BMI >40 kg/m^2)
    • local factors
      • previous incisions
        • skin bridges should be >5-6cm
        • avoid crossing previous skin incisions at an angle <60 degrees
        • use most lateral incision possible
      • knee deformity
      • skin adhesions
      • poor local blood supply
    • technique
      • large subcutaneous skin flaps
      • short incisions requiring vigorous skin traction
      • not preserving subcutaneous fat layer
      • long surgical time
      • long tourniquet time
    • postoperative
      • hematoma
      • infection
      • early (first 4 days) knee flexion beyond 40 degrees in a high risk knee
Presentation
  •   History
    • multiply operated knee
    • prior infection
  • Symptoms
    • persistent knee pain
    • persistent drainage beyond the early postoperative period (7 days)
  • Physical exam  
    • wound breakdown
    • erythema
    • warmth
    • drainage
    • peri-incisional eschar
Imaging
  • Radiographs
    • may help rule-out deep infection. looks for bone resorption
  • Bone scan
    • radionuclide studies if infection suspected but aspiration and serology not confirmatory
  • Angiography
    • if flow through sural arteries in question and gastrocnemius flap planned
Treatment
  • Nonoperative
    • local wound care +/- antibiotics
      • indications
        • may be appropriate for some small superficial wounds
        • patients who are not surgical candidates
  • Operative
    • debridement and coverage with rotational flap 
      • indications
        • full-thickness necrosis
        • medial gastrocnemius rotational flap (medial sural artery): anterior and medial defects
        • lateral gastrocnemius rotational flap (lateral sural artery): lateral defects
 

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(OBQ04.103) A 62-year-old female underwent a primary total knee arthroplasty of the left knee 10 days ago. She presents to clinic with skin necrosis of the midline incision. There is no deep infection present upon aspiration of the knee joint. She undergoes superficial irrigation and debridement and is left with exposed patellar tendon as shown in Figure A. What is the most appropriate next step in management? Review Topic

QID: 1208
FIGURES:
1

Split thickness skin grafting

5%

(85/1641)

2

Twice daily wet-to-dry dressing changes with Dakin's solution until healing by secondary intention

2%

(25/1641)

3

Latissimus dorsi free flap transfer

1%

(21/1641)

4

Vacuum-assisted closure device until healing by secondary intention

7%

(112/1641)

5

Medial gastrocnemius muscle flap transfer and skin grafting

85%

(1393/1641)

L 2

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