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Outcomes of Soft Tissue Coverage in Complex Refractory Periprosthetic Total Knee Arthroplasty
James Economides, MD, Ersilia Anghel, BS, Mark Cinque, BS, Kayvon Golshani, MD, Michael DeFazio, MD, Brian Evans, MD, Mark Zawadsky, MD, Chris Attinger, MD, Karen Evans, MD.
Georgetown University Hospital, Washington, DC, USA.

Wound breakdown following total knee arthroplasty (TKA) may lead to devastating outcomes including prosthesis exposure and limb loss. Despite many options for wound coverage in compromised TKA, there is no consensus on optimal management of these wounds with an aim toward minimizing further morbidity and maximizing function.
A retrospective review of outcomes following surgical management of TKA wounds over 5 years was undertaken. Outcomes were analyzed with Cochran’s Q, Friedman’s, Chi Square, Kruskal-Wallis, and Wilcoxon Signed Rank tests for statistical significance.
Forty­-one patients were identified during the study period with a mean follow-­up of 20 months. Rates of limb salvage (64.7% vs. 75% vs. 75% vs. 0%, p <0.001) and post-operative ambulation (72.7% vs. 86.7% vs. 40% vs. 60%, p= 0.036) were significantly different between patients who had undergone primary closure, local muscle flap coverage, free flap coverage, and above-knee amputation (AKA). The frequency of debridements prior to definitive closure did not significantly influence rates of limb salvage (p=0.21). For each additional debridement prior to definitive closure, however, the odds of ambulating decreased by 25%, with no significant difference between cohorts (p=0.07). Furthermore, delayed time to initial presentation was shown to decrease the likelihood of limb salvage by a factor of 0.99 per day (p=0.043). Pain as measured by visual analog scale (VAS) scores were not significantly different between index closure types (p=0.77). However, pain was significantly reduced for those patients who required fewer than 10 debridements prior to definitive closure (p=0.021). Time to presentation did not significantly influence postoperative pain scores (p=0.68). CONCLUSIONS:Delay in treatment of wound breakdown following TKA may lead to more recalcitrant wounds and an increase in the need for multiple operative debridements, decreased rates of ambulation and decreased rates of limb salvage. Our data suggest that early intervention and aggressive local of free flap coverage by plastic and reconstructive specialists in the management of recalcitrant TKA wounds may lead to more favorable outcomes. These findings may inform practice patterns and surgical treatment of patients presenting with infected TKA.

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