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Knee Reconstruction, Soft Tissue Workup

  • Author: Steven L Bernard, MD; Chief Editor: Jorge I de la Torre, MD, FACS  more...
 
Updated: Sep 04, 2015
 

Laboratory Studies

See the list below:

  • Routine preoperative screening of healthy people undergoing elective surgery is not recommended.
  • A serum creatinine level should be ordered for patients older than 40 years.
  • Blood coagulation studies should be performed in all patients currently on anticoagulants.
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Imaging Studies

See the list below:

  • Order a chest radiograph in patients older than 60 years.
  • All patients with suspected vascular injury should undergo arteriograms of the affected leg.
  • Patients in whom free tissue transfer is considered as an option in the reconstruction should undergo arteriogram of the leg.
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Other Tests

See the list below:

  • Order an ECG in patients older than 40 years.
  • If the patient has a significant history of cardiopulmonary disease, further testing may be indicated (eg, echocardiography, pulmonary function tests).
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Diagnostic Procedures

See the list below:

  • For those patients being treated for infected TKA, wound tissue cultures and bone cultures should all be negative and the patient should have completed his or her course of long-term antibiotics prior to replacing an antibiotic knee joint spacer with a new TKA.
  • The procedure can be stage by first proving adequate soft tissue vascularized coverage and later replacing the TKA.
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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 Society of Plastic Surgeons, Ohio Valley Society of Plastic Surgeons

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Jorge I de la Torre, MD, FACS Professor of Surgery and Physical Medicine and Rehabilitation, Chief, Division of Plastic Surgery, Residency Program Director, University of Alabama at Birmingham School of Medicine; Director, Center for Advanced Surgical Aesthetics

Jorge I de la Torre, MD, FACS is a member of the following medical societies: American Burn Association, American College of Surgeons, American Medical Association, American Society for Laser Medicine and Surgery, American Society of Maxillofacial Surgeons, American Society of Plastic Surgeons, American Society for Reconstructive Microsurgery, Association for Academic Surgery, Medical Association of the State of Alabama

Disclosure: Nothing to disclose.

Additional Contributors

Christian E Paletta, MD, FACS Clinical Professor of Surgery and Instructor of Surgery, Department of Surgery, Dartmouth-Hitchcock Medical Center, Geisel School of Medicine at Dartmouth; Clinical Professor of Surgery and Instructor in Surgery, Rwanda Human Resources for Health, Rwanda Ministry of Health and Clinton Health Access Initiative

Christian E Paletta, MD, FACS is a member of the following medical societies: American Society of Plastic Surgeons, Plastic Surgery Research Council, American Council of Academic Plastic Surgeons, American College of Surgeons, American Medical Association

Disclosure: Nothing to disclose.

Acknowledgements

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.

Robert Rodrigues, MD Staff Physician, Department of Surgery, Division of Plastic Surgery, University of Michigan Health System

Disclosure: Nothing to disclose.

References
  1. Manoso MW, Boland PJ, Healey JH, Cordeiro PG. Limb salvage of infected knee reconstructions for cancer with staged revision and free tissue transfer. Ann Plast Surg. 2006. 56(5):532-5. [Medline].

  2. Chowdri NA, Darzi MA. Z-lengthening and gastrocnemius muscle flap in the management of severe postburn flexion contractures of the knee. J Trauma. 1998 Jul. 45(1):127-32. [Medline].

  3. 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 Joint J. 2013 Sep. 95-B(9):1217-21. [Medline].

  4. Gravvanis A, Kyriakopoulos A, Kateros K, Tsoutsos D. Flap reconstruction of the knee: a review of current concepts and a proposed algorithm. World J Orthop. 2014 Nov 18. 5 (5):603-13. [Medline].

  5. Pontén B. The fasciocutaneous flap: its use in soft tissue defects of the lower leg. Br J Plast Surg. 1981 Apr. 34(2):215-20. [Medline].

  6. Veber M, Vaz G, Braye F, Carret JP, Saint-Cyr M, Rohrich RJ, et al. Anatomical study of the medial gastrocnemius muscle flap: a quantitative assessment of the arc of rotation. Plast Reconstr Surg. 2011 Jul. 128(1):181-7. [Medline].

  7. Mitsala G, Varey AH, O'Neill JK, Chapman TW, Khan U. The distally pedicled gracilis flap for salvage of complex knee wounds. Injury. 2014 Nov. 45 (11):1776-81. [Medline].

  8. Satoh K, Fukuya F, Matsui A, Onizuka T. Lower leg reconstruction using a sural fasciocutaneous flap. Ann Plast Surg. 1989 Aug. 23(2):97-103. [Medline].

  9. Gill NA, Hameed A. The Sural Compendium: Reconstruction of Complex Soft-Tissue Defects of Leg and Foot by Utilizing the Posterior Calf Tissue. Ann Plast Surg. 2011 Jul 5. [Medline].

  10. Wiedner M, Koch H, Scharnagl E. The superior lateral genicular artery flap for soft-tissue reconstruction around the knee: clinical experience and review of the literature. Ann Plast Surg. 2011 Apr. 66(4):388-92. [Medline].

  11. Song SH, Choi S, Kim YM, Lee SR, Choi YW, Oh SH. The composite anterolateral thigh flap for knee extensor and skin reconstruction. Arch Orthop Trauma Surg. 2013 Nov. 133(11):1517-20. [Medline].

  12. Erba P, Raffoul W, Bauquis O. Safe dissection of the distally based anterolateral thigh flap. J Reconstr Microsurg. 2012 Jul. 28(6):405-11. [Medline].

  13. Seo SW, Kim KN, Yoon CS. Extended Scope of the Use of the Peroneal Perforator Flap in Lower Limb Reconstruction. J Reconstr Microsurg. 2015 Jul 28. [Medline].

  14. Pant R, Younge D. Turn-up bone flap for lengthening the below-knee amputation stump. J Bone Joint Surg Br. 2003 Mar. 85(2):171-3. [Medline].

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This photograph shows a complex degloving wound of the left knee.
With the skin retracted, open fracture and fixation hardware is evident in the wound.
The medial (top) and lateral (bottom) gastrocnemius muscles are elevated and ready for inset and wound coverage. Access to the muscles was through a midline posterior incision (the incision is not seen in this photograph, which is of the anterior leg).
The medial and lateral muscles are sutured to each other and inset over the wound.
The knee wound is healed.
This is an illustration of the adipofascial flap. The drawing shows the flap elevated and ready to be flipped on itself for inset over the wound of the knee.
This photograph shows a leg that cannot be salvaged, even with a standard below-the-knee amputation, because of the extent of damage to both the knee and calf. The foot, however, is in good shape and can be used for a filet of foot flap.
The foot has been isolated on the posterior tibial vessels and tibial nerve. The phalanges and metatarsal bone have all been removed. Of the tarsal bones, only the calcaneus is saved. The intervening tibia and fibula have been removed, as well.
The foot is now rotated 180 degrees and rigidly fixed to the remaining stump of the tibia.
As can be seen in this photograph, the end of the amputation stump now has the excellent and tough coverage of the sole of the foot and heel.
Mobility is preserved in the knee.
The good coverage allows for prosthesis fitting.
The salvage of the knee in this patient allows for greatly improved function over an above-the-knee amputation.
Large wound with extensive damage to the femur and tibia and exposed hardware.
Radiograph of the leg.
Latissimus dorsi muscle free flap is inset into the wound and covered with a split-thickness skin graft.
Healed wound of the knee.
 
 
 
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