AAHS ASPN ASRM - 2013 Annual Meeting - American Association ...

ASRM Concurrent Scientific Paper Presentatons B-2
Long term results in the use muscle flaps for salvage of the infected total knee arthroplasties
Institution where the work was prepared: cleveland clinic, clinic, OH, USA
amardip Bhuller, md1; Wong Moon, MD2; Risal Djohan, MD2; Warren Hammert2; Earl Browne, MD3; (1)clevland clinic foundation, (2)Cleveland Clinic Foundation,
(3)The Cleveland Clinic Foundation
Introduction:
Deep infections occur in 1-5% of all total knee arthroplasties (TKA) and may result in failure of the prosthesis with subsequent amputation. Two stage reimplantation
with a muscle flap is often successful in the salvage of infected total knee arthroplasties. We report a 12 year follow up of group patients successfully
treated with this protocol, and a second group of patients treated with washout and flap coverage.
Methods:
An IRB approved retrospective review of pts from 1990-2005 with infected TKA's was preformed with chart review, questionnaire and telephone call follow up.
Results:
43 patients were found with a range of follow up from 6 months to 12 years. There were two groups of patients treated, 23/43 patients were treated with
explantation of the prosthesis and insertion of an antibiotic spacer with staged reinsertion of the prosthesis and flap coverage (group 1). A second group of
patients had the knee prosthesis washed out and flap coverage was preformed (Group 2) 30% of all cases involved free muscle transfer with or without additional
pedicle muscle rotational flap.
The most common organism found was Staph Aureus 19/43 (MRSA 10/43) followed by, Pseudomonas 6/43, Co-ag neg staph 5/43, Enterococcus 4/43, VRE 2/43
and Group B Strep 2/43ther organisms cultured were Stenotrophomonas (Xanthomonas) maltophilia Proteus mirabilis, , Acinetobacter calcoaceticus-baumannii.
Overall acute Limb salvage was achieved in 97 % patients with a long -term salvage rate of 91%.The acute failure resulted in a failure within one month after
the flap, the other failures occurred because of recurrent infection at six months and at 2years. Group 1 achieved 92 % success rate and group 2 a 90% success
rate. There were two failures in patients treated with free muscle transfer with or without a pedicled flap, and two using pedicled muscle flaps alone.
Overall patients requiring free muscle transfer were a high risk population where a 77% limb salvage rate was achieved. The patients where pedicled muscled
flap was used alone achieved a 94% success rate.
In 32 pats where follow up was obtained 28 patients achieved pain free ambulation.
Conclusion
The use of muscle flaps achieved a 91% long term limb salvage rate in infected total knee arthroplasties. Patients had a good quality of life, and pain free
ambulation was achieved in 28/36 patients. Amputation in infected knee prosthesis can be avoided with the use of muscle flaps adhering to these protocols.
Fasciocutaneous versus Muscle Flaps Following Lower Extremity Trauma: A Pilot Study of Functional Outcomes
Institution where the work was prepared: R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
Rachel Bluebond-Langner, MD1; Navin K. Singh, MD1; Gedge D. Rosson, MD1; Suhail Mithani1; Eduardo D. Rodriguez, DDS, MD2; (1)Johns Hopkins School of Medicine,
(2)R Adams Cowley Shock Trauma Center and the Johns Hopkins School of Medicine
Background:
There has been an increase in the use of free fasciocutaneous flaps versus free muscle flaps for reconstruction of traumatic lower extremity wounds. Functional
outcomes of lower limb salvage compared to amputation have been previously studied. However, there are little data comparing outcomes among different
coverage options. We sought to compare functional outcomes of fasciocutaneous flaps versus muscle flaps with skin grafts.
Methods:
We conducted an IRB approved retrospective review of 120 patients with lower extremity trauma who underwent free tissue transfer between 1998 and 2005
at the R Adams Cowley Shock Trauma Center. The majority of the patients were male (69%) with an average age of 42 years. 29 of these patients agreed to
participate in the study and completed the SF12, SMFA and supplemental questions written by the authors. A physical therapist evaluated five tasks. Sensation
of the donor site was measured using the PSSD machine. The donor sites for the muscle free flaps included the rectus abdominis and gracilis muscles. All fasciocutaneous
flaps were from the anterolateral thigh.
Results:
The mechanism of injury was largely blunt (n=27). 51.7% patients had coverage with a fasciocutaneous flap and 48.3% with a muscle flap. The most common
defect location was the distal third of the leg (n=20), followed by the middle third (n=4), foot (n=3) and proximal third (n=2). 11 patients had contralateral
orthopedic injuries. The average follow up was 18 months in the fasciocutaneous group and 47 months in the muscle group. Functional outcomes (i.e.
physical, emotional, social, societal) measured by the SF 12, SMFA and physical therapist demonstrate equivalence (p >0.05). Satisfaction with cosmetic appearance
was equivalent (p>0.05) with a trend toward women being less satisfied than men overall (p=0.06). 97% of patients would go through the limb salvage
process to avoid amputation. The one patient who would have preferred an amputation had a pain score greater than 2 standard deviations above the mean.
Sensation at the donor site, measured with PSSD, was diminished in all patients however the fasciocutaneous flap donor sites had more significant sensory loss
(p=0.005).
Conclusion:
Both fasciocutaneous and muscle flaps provide vascularized tissue which covers hardware and nourishes the fractured bone however muscle flaps pilfer a full
muscle unit which may not be inconsequential in a trauma patient. The results of this pilot study suggest no functional differences between patients whose
traumatic defects are covered with free fasciocutaneous flaps or muscle flaps.
157