Aim

In the context of total knee arthroplasty (TKA), trauma with perigenicular fracture fixation or oncological surgical treatment, soft tissue defects can expose critical structures such as the extensor apparatus, the knee joint, bone or implants. This work compares soft tissue reconstruction (STR) between a classical pedicled gastrocnemius (GC) muscle flap and a pedicled chimeric sural artery perforator (SAP) musculocutaneous GC flap in complex orthoplastic scenarios.

Aims

Fungal periprosthetic joint infections (fPJIs) are rare complications, constituting only 1% of all PJIs. Neither a uniform definition for fPJI has been established, nor a standardized treatment regimen. Compared to bacterial PJI, there is little evidence for fPJI in the literature with divergent results. Hence, we implemented a novel treatment algorithm based on three-stage revision arthroplasty, with local and systemic antifungal therapy to optimize treatment for fPJI.

Aim. A number of orthopaedic strategies have been described for limb salvage following periprosethic joint infection (PJI). However, this is often only possible with concomitant soft tissue reconstruction in the form of flap coverage. The purpose of this study was to determine the long-term clinical outcome of patients who underwent pedicled gastrocnemius flap coverage as part of their treatment for knee PJI. Method. We performed a retrospective review of all patients undergoing gastrocnemius muscle transfer with split thickness skin grafting as part of their treatment for knee PJI at a tertiary referral centre between 1994 and 2015. Data recorded included patient characteristics, orthopaedic procedure, microbiology result and antimicrobial management. Outcome measures included flap failure, infection recurrence, amputation, functional outcome (Oxford knee score; OKS) and mortality. Results. In total, 115 consecutive patients (39% female) with a mean age of 74.4 years (range 44–100) were followed up for an average of 5.5 years (range 119 days – 19.7 years). There were no reported cases of flap failure. Gastrocnemius flaps were most commonly performed at the time of the first stage of a two-stage revision (41%), or during debridement and implant retention (DAIR) (27%). 10% were performed at the second stage of a two-stage procedure and 4% were performed during a single stage revision. Of 96 positive deep specimen cultures, 43 (45%) showed mixed growth and 47 (49%) grew coagulase-negative staphylococcus (with or without other microorganisms). The infection recurrence rate was 32%. Limb salvage was achieved in 88% of cases. 12% of patients required life-long suppressive antibiotic therapy. 55 knees were followed up for five years or more, with a survival (not deceased, not amputated) of 64%. 37 knees were followed up for 10 years or more, with a survival of 32%. In living patients who did not have an amputation, the mean OKS was 25.8 (n=36; range 7–47). Conclusion. This study represents the largest series to date of infected knee prostheses treated with gastrocnemius flap coverage. A multidisciplinary approach to complex PJI surgery is recommended, involving infectious disease physicians and the orthoplastic team. We also recommend a low threshold for requesting plastic surgery input. In our experience, this technique is safe, with no flap failure, and has enabled limb salvage for the majority (88%) of patients with infected knee prostheses and insufficient soft tissue envelope

Aims

The use of a noninvasive growing endoprosthesis in the management of primary bone tumours in children is well established. However, the efficacy of such a prosthesis in those requiring a revision procedure has yet to be established. The aim of this series was to present our results using extendable prostheses for the revision of previous endoprostheses.

We evaluated the clinical results and complications after extra-articular resection of the distal femur and/or proximal tibia and reconstruction with a tumour endoprosthesis (MUTARS) in 59 patients (mean age 33 years (11 to 74)) with malignant bone or soft-tissue tumours. According to a Kaplan–Meier analysis, limb survival was 76% (95% confidence interval (CI) 64.1 to 88.5) after a mean follow-up of 4.7 years (one month to 17 years). Peri-prosthetic infection was the most common indication for subsequent amputation (eight patients). Survival of the prosthesis without revision was 48% (95% CI 34.8 to 62.0) at two years and 25% (95% CI 11.1 to 39.9) at five years post-operatively. Failure of the prosthesis was due to deep infection in 22 patients (37%), aseptic loosening in ten patients (17%), and peri-prosthetic fracture in six patients (10%). Wear of the bearings made a minor revision necessary in 12 patients (20%). The mean Musculoskeletal Tumor Society score was 23 (10 to 29). An extensor lag > 10° was noted in ten patients (17%).

These results suggest that limb salvage after extra-articular resection with a tumour prosthesis can achieve good functional results in most patients, although the rates of complications and subsequent amputation are higher than in patients treated with intra-articular resection.

Cite this article: Bone Joint J 2013;95-B:1425–31.

A soft-tissue defect over an infected total knee replacement (TKR) presents a difficult technical problem that can be treated with a gastrocnemius flap, which is rotated over the defect during the first-stage of a revision procedure. This facilitates wound healing and the safe introduction of a prosthesis at the second stage. We describe the outcome at a mean follow-up of 4.5 years (1 to 10) in 24 patients with an infected TKR who underwent this procedure. A total of 22 (92%) eventually obtained a satisfactory result. The mean Knee Society score improved from 53 pre-operatively to 103 at the latest follow-up (p < 0.001). The mean Western Ontario and McMaster Universities osteoarthritis index and Short-Form 12 score also improved significantly (p < 0.001).

This form of treatment can be used reliably and safely to treat many of these complex cases where control of infection, retention of the components and acceptable functional recovery are the primary goals.

Cite this article: Bone Joint J 2013;95-B:1217–21.

The purpose of this study was to assess the outcome of 15 patients (mean age 13.6 years (7 to 25)) with a primary sarcoma of the tibial diaphysis who had undergone excision of the affected segment that was then irradiated (90 Gy) and reimplanted with an ipsilateral vascularised fibular graft within it.

The mean follow-up was 57 months (22 to 99). The mean time to full weight-bearing was 23 weeks (9 to 57) and to complete radiological union 42.1 weeks (33 to 55). Of the 15 patients, seven required a further operation, four to obtain skin cover. The mean Musculoskeletal Society Tumor Society functional score at final follow-up was 27 out of 30 once union was complete. The functional results were comparable with those of allograft reconstruction and had a similar rate of complication.

We believe this to be a satisfactory method of biological reconstruction of the tibial diaphysis in selected patients.

Vascularised soft tissue transfer may be helpful in the salvage of severe sepsis involving avascular tissues hosting joint replacements or other metal work. Transferred tissue covers the exposed implants and delivers intravenous antibiotics. Twenty-one cases for the knee, elbow and shoulder are presented. Gastrocnemius flaps were used for seven knee replacements and 10 knee fractures. Antegrade radial artery flaps were used for two elbow replacements. Pectoralis major or minor flaps were used for two shoulder replacements. All procedures were performed by an orthopaedic surgeon with supplementary plastics training. Synchronous bony surgery included revision arthroplasty in seven cases, conversion to fusion in one case and preservation of existing hardware in the remainder. Sepsis was eliminated in the longterm in 9 of 10 knee fracture fixation cases, 5 out of 7 knee replacements and both elbow replacements. Both shoulder replacements remained septic despite multiple repeat procedures. Complications included necrosis of two gastrocnemius flaps, one from pre-existing partial compartment syndrome and one when combined with fusion of the knee. One other knee replacement developed further sepsis three years post procedure. No limb required amputation. These procedures are well within the remit of orthopaedic surgeons, the non reliance on plastics surgeons allowed prompt treatment combined with bony procedures. Results were good for the knee and elbow but disappointing for the shoulder—this, probably related to the natural mobility of the joint

We reviewed 25 patients who had undergone resection of a primary bone sarcoma which extended to within 5 cm of the knee with reconstruction by a combination of a free vascularised fibular graft and a massive allograft bone shell. The distal femur was affected in four patients and the proximal tibia in 21. Their mean age at the time of operation was 19.7 years (5 to 52) and the mean follow-up period 140 months (28 to 213). Three vascularised transfers failed. The mean time to union of the fibula was 5.6 months (3 to 10) and of the allograft 19.6 months (10 to 34). Full weight-bearing was allowed at a mean of 21.4 months (14 to 36). The mean functional score at final follow-up was 27.4 (18 to 30) using a modfied 30-point Musculoskeletal Tumour Society rating system. The overall limb-salvage rate was 88%. The results of our study suggest that the combined use of a vascularised fibular graft and allograft is of value as a limb-salvage procedure for intercalary reconstruction after resection of bone tumours around the knee, especially in skeletally immature patients.

Nonunion of the tibia associated with bone loss, previous infection, obliteration of the intramedullary canal or located in the distal metaphysis poses a challenge to the surgeon and significant morbidity to patients. We retrospectively reviewed the records of 24 patients who were treated by central bone grafting and compared them to those of 20 who were treated with a traditional posterolateral graft. Central bone grafting entails a lateral approach, anterior to the fibula and interosseous membrane which is used to create a central space filled with cancellous iliac crest autograft. Upon consolidation, a tibiofibular synostosis is formed that is strong enough for weight-bearing. This procedure has advantages over other methods of treatment for selected nonunions.

Of the 24 patients with central bone grafting, 23 went on to radiographic and clinical union without further intervention. All healed within a mean of 20 weeks (10 to 48). No further bone grafts were required, and few complications were encountered. These results were comparable to those of the 20 patients who underwent posterolateral bone grafting who united at a mean of 31.3 weeks (16 to 60) but one of whom required below-knee amputation for intractable sepsis.

Central bone grafting is a safe and effective treatment for difficult nonunions of the tibia.

Purpose: To describe the technique and outcomes of patients requiring Lateral Gastrocnemius flaps for soft tissue coverage of the lateral side of the knee after sarcoma. Methods: Four patients with sarcomas on the lateral knee capsule were identified. 1 patient had an Osteosarcoma of the proximal tibia resected, requiring reconstruction. 2 patients had Malignant fibrous hystiocytoma proximal to the lateral knee joint and 1 patient had a leiomyosar-coma who presented after 6 failed local resections. The length of follow up is from 13 months to 5 years, average 3.25 years. There were no graft failures. The average surface area of the resection was 118 cm2. There were two sarcoma recurrences requiring excision and radiation. There was one death due to metastases. The technique involves the releasing the gastroc flap down to the aponeurosis and then the careful dissection of the peroneal nerve with delivery of the muscle up behind the peroneal nerve to the lateral aspect of the knee. The flap is rotated fibrous layer down and the muscle readily accepts a meshed skin graft taken locally, giving this technique the advantage of reconstructing a capsule and creating a superior bed for accepting skin grafts. Results: Average time to healing was 3.8 weeks. There have been no nerve injuries, no graft loss and all had a function range of motion. The functional results have been very reliable. Using the musculoskeletal tumour society score (MSTS) and the Toronto Extremity Salvage Scoring (TESS) system we had an average MSTS score of 21.5 with a percent of 71.5 and a TESS score of 44.5 for the living patients. These correlate to very good outcomes. Conclusions: The lateral gastrocs flap has a reputation of being technically complex. Meller et al.(1997) report peroneal nerve injuries in 8 of 27 cases. This institution has no complications with this flap and recommends it for soft tissue defects that extend to the midline on the lateral aspect of the knee joint