eMedicine Specialties > Plastic Surgery > Lower Extremity Reconstruction

Lower Extremity Reconstruction, Knee

Author: Steven L Bernard, MD, Department of Plastic Surgery, Cleveland Clinic Foundation, Assistant Professor of Surgery, Case Western Reserve University School of Medicine
Contributor Information and Disclosures

Updated: Jan 27, 2009

Introduction

Soft tissue defects of the knee that require reconstructive surgery occur after trauma or following a surgical procedure. A common procedure that may require reconstructive surgery to achieve adequate soft tissue coverage of the knee is total knee arthroplasty (TKA). Wound breakdown with exposure of the prosthesis is rare and is a challenge for both plastic and orthopedic surgeons. Previously, recommended management has been implant removal followed by arthrodesis and, at times, has required above-knee amputation (AKA). More recently, the goals are to preserve the prosthetic components and the function of the knee.1 Knee coverage to avoid arthrodesis or AKA results in a more normal gait and greatly reduces the energy required for the patient to ambulate.

Reconstruction must be designed so that the desired functional and aesthetic results can be achieved using the simplest method available and with minimal donor tissue or donor-site morbidity. Early aseptic closure is of paramount importance to the preservation of the function of the knee joint. Soft tissue reconstruction can reestablish mobility and joint function, provide dynamic stabilization of the joint, provide soft tissue coverage of the prosthesis, and fill the dead space. Good, healthy, well-vascularized soft tissue coverage leads to positive local effects, provides dead space obliteration, and improves the host’s defenses by increasing vascularity, which results in the proper delivery of oxygen, antibiotics, and humeral defense factors to the wound bed.

Another cause of soft tissue deficit results from the release of burn contractures involving the knee.2 In burn injuries of the knee, contractures left untreated for prolonged periods result in permanent shortening of the flexor tendons, nerves, and vessels. Patients with contracted burned extremities also present multiple problems for nurses, one of which is the maintenance of perineal hygiene. Adequate release of these contractures is possible only after lengthening the shortened tendons. Release of the contracture leaves large skin defects and exposes bow-stringed hamstring tendons and major vessels and nerves in the popliteal fossa, requiring soft tissue coverage.

For excellent patient education resources, visit eMedicine's Foot, Ankle, Knee, and Hip Center and Arthritis Center. Also, see eMedicine's patient education article Knee Joint Replacement.

Etiology

Risks

As many as 17-20% of patients with arthroplasties have complications that result in healing difficulties, ranging from superficial skin loss to more severe areas of skin and subcutaneous tissue necrosis and implant exposure. Exposure can then go on to infection of the prosthesis. Prostheses in the knee are particularly at risk because of their superficial location as well as the location of the surgical access wounds. The need for early motion may interfere with wound healing, jeopardizing the prosthesis. Often, patients who require a knee replacement have insensate and unstable skin around the knee joint secondary to trauma, post–knee arthroplasty wound breakdown, or persistent synovial fistula following an arthroscopy.

Patients requiring a TKA often have a long history of degenerative joint disease, rheumatoid arthritis, or systemic lupus erythematosus. Most patients with these diseases are female. Subsequently, they may be on long-term steroid therapy, which adversely affects wound healing.

After excision of malignant tumors, some patients receive radiation and chemotherapy, which impairs wound healing. This requires continual surveillance because infection or open wounds can happen early or as many as 1-3 years after surgery. Other factors that negatively affect wound healing include a history of smoking prior to surgery, long-term steroid treatment, diabetes mellitus, hypoproteinemia, and hypothyroidism. Ultimately, the knee may be exposed as a result of impaired healing, poor vascular supply, or simple mechanical erosion.

The most common cause of failure is infection. The knee can become infected by early postoperative cellulitis, abscess, or delayed hematogenous seeding. Wound complications increase the risk of infection and implant loss. Soft tissue defects occur at the central-to-distal third of the incision. True dehiscence is a more severe postoperative complication, is more likely to have bacterial contamination requiring more rapid action, and may have a poorer outcome.

Differentiating wound infection leading to wound breakdown from failed wound healing leading to contamination is important because different clinical outcomes are expected. If contaminated, the knee can be irrigated thoroughly and closed with a flap; however, if it is infected, the prosthesis should be removed, the flap should be closed, and antibiotics should be administered for 6 weeks. Wound contamination occurring outside the United States is mainly by staphylococci; in the United States, pseudomonads are observed. Chronic infections that occur 3 months or more after arthroplasty can also involve staphylococci or pseudomonads.

Relevant Anatomy

See Surgical therapy for anatomic details of specific flaps.

Contraindications

Judging the potential for meaningful postsurgical rehabilitation is the first consideration when evaluating a patient in need of soft tissue reconstruction over the knee. Consider whether the patient is reluctant to participate in a complex rehabilitation. Many procedures are performed in conjunction with an orthopedic procedure (eg, TKA, tumor resection) that requires complex rehabilitation. Also consider whether significant neurologic deficit (eg, paralysis, myopathies) will limit the patient's mobility. Moreover, consider whether the knee contracture has significantly limited the range of motion of the knee.

Another issue to consider before surgery is that patients must undergo routine preoperative clearance. Identify characteristics that place patients at higher risk for complications. Cardiac disease (eg, a history of myocardial infarction, angina, hypertension, diabetes, peripheral vascular disease, congestive heart failure) is a risk factor. Another is pulmonary disease (eg, emphysema, chronic obstructive pulmonary disease). Also consider a history of embolus or deep vein thrombosis, obesity, age (>70 y), drug use (eg, ethanol, tobacco), and gastrointestinal reflux disease as pertinent surgical risk factors.

If the patient is deemed a moderate risk to receive general anesthesia, many of the procedures outlined in this article may be performed with the patient under spinal anesthesia.

More on Lower Extremity Reconstruction, Knee

Overview: Lower Extremity Reconstruction, Knee
Workup: Lower Extremity Reconstruction, Knee
Treatment: Lower Extremity Reconstruction, Knee
Follow-up: Lower Extremity Reconstruction, Knee
Multimedia: Lower Extremity Reconstruction, Knee
References
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References

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Further Reading

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Keywords

lower extremity reconstruction, total knee arthroplasty, TKA, soft tissue knee defects, knee reconstruction, knee prosthesis, arthrodesis, knee prosthesis, knee replacement, above-the-knee amputation, AKA, below-the-knee amputation, BKA, burn contracture, burn contracture repair, contracture release, arthroplasties, arthroplasty, impaired wound healing, total knee replacement, long-term steroid therapy, long-term steroids, steroids, chronic steroids, wound dehiscence, wound contamination, muscle flap, muscle-skin flap, musculocutaneous flap, fasciocutaneous flap

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Contributor Information and Disclosures

Author

Steven L Bernard, MD, Department of Plastic Surgery, Cleveland Clinic Foundation, Assistant Professor of Surgery, Case Western Reserve University School of Medicine
Steven L Bernard, MD is a member of the following medical societies: American Association of Plastic Surgeons, American Society of Plastic Surgeons, and Ohio Valley Society of Plastic Surgeons
Disclosure: Nothing to disclose.

Medical Editor

Christian Paletta, MD, FACS, Professor, Division Chief and Program Director, Department of Plastic and Reconstructive Surgery, St Louis University School of Medicine
Christian Paletta, MD, FACS is a member of the following medical societies: Alpha Omega Alpha, American Association of Plastic Surgeons, American Burn Association, American Cleft Palate/Craniofacial Association, American College of Surgeons, American Medical Association, and Missouri State Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

B Sekhar Chandrasekhar, MD, Associate Professor, Department of Surgery, Division of Plastic and Reconstructive Surgery, University of Southern California
B Sekhar Chandrasekhar, MD is a member of the following medical societies: American Association of Plastic Surgeons, American College of Surgeons, American Society for Reconstructive Microsurgery, and California Medical Association
Disclosure: Nothing to disclose.

CME Editor

Nicolas (Nick) G Slenkovich, MD, Director, Colorado Plastic Surgery Center
Nicolas (Nick) G Slenkovich, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, American Society of Aesthetic Plastic Surgery, American Society of Plastic Surgeons, and Colorado Medical Society
Disclosure: Nothing to disclose.

Chief Editor

Jorge I de la Torre, MD, FACS, Professor of Surgery and Physical Medicine and Rehabilitation, Residency Program Director, Division of Plastic Surgery, University of Alabama at Birmingham; Director, Center for Advanced Surgical Aesthetics
Jorge I de la Torre, MD, FACS is a member of the following medical societies: American Association of Plastic Surgeons, American Burn Association, American College of Surgeons, American Medical Association, American Society for Laser Medicine and Surgery, American Society for Reconstructive Microsurgery, American Society of Maxillofacial Surgeons, American Society of Plastic Surgeons, Association for Academic Surgery, and Medical Association of the State of Alabama
Disclosure: Nothing to disclose.

 
 
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