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Soft Tissue Reconstruction after Complicated Knee Replacement: Principles and Predictors of Knee Salvage
David L. Colen, M.D.1, Tiffany Liu, BS1, Michael Lanni, BS2, Valeriy Shubinets, MD1, Gwo Lee, MD1, Stephen J. Kovach, MD1.
1University of Pennsylvania, Philadelphia, PA, USA, 2Albany Medical College, Albany, NY, USA.

PURPOSE: The most feared complication of total knee arthroplasty (TKA) is periprosthetic infection (1-5% of cases) which leads to prosthetic failure and may result in knee fusion or even limb loss. The optimal role of a plastic surgeon in salvaging a compromised TKA remains unclear. We sought to elucidate factors associated with TKA salvage and principles of reconstruction that optimize outcomes. METHODS:Retrospective review of all patients requiring soft-tissue reconstruction by the senior-author after TKA over 8y (2008-2016) 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%, most commonly using medial-gastrocnemius flaps. Patients with increased knee surgeries before index reconstructive operation had decreased salvage rates and increased amputation risk. Positive joint cultures significantly decreased knee salvage (gram-negative > gram-positive), particularly at the time of definitive reconstruction, which trended towards increased amputation risk. CONCLUSIONS: We present the largest series of knee reconstructions for compromised TKA, highlighting important concepts for optimal outcomes. In revision TKA, early soft-tissue reconstruction improves salvage rate and there is benefit to involving plastic surgeons earlier in complicated TKAs.
Table 1: Reconstructive Techniques and Overall Outcomes
TechniqueN (%)
Fasciocutaneous flap16 (21.9%)
Medial Gastrocnemius Muscle Flap33 (45.2%)
Free Flap13 (17.8%)
Outcome
Prosthesis Salvage44 (61.1%)
Retained Antibiotic Spacer2 (2.7%)
Knee Fusion8 (11.1%)
Amputation18 (25%)

Table 2: Factors Associated with Salvage and Amputation
FactorEffectp value
Total knee operations prior to definitive reconstructionEach additional knee surgery:Decreased rate of salvage for each additional surgery (OR = 0.68)0.01
Increased risk of amputation (OR = 1.42)0.02
Number of knee washouts prior to definitive reconstructionDecreased rate of salvage for each additional washout (OR = 0.77)0.09
Joint Space ContaminationJoint Space Culture (any)Positive culture: 40% salvage vs. Negative culture: 73.7% salvage0.01
GNR cultureGNR +: 47.1% salvage vs. GNR -: 73.7% salvage0.03
GPC cultureGPC+: 52.7% salvage vs. GPC-: 88.2% salvage0.01
Culture at time of definitive reconstructionPositive culture: 40% salvage vs. Negative culture: 71% salvage0.03
Positive culture: 45% amputation vs. Negative culture: 19% amputation0.06


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