Several surgical factors may prevent wound complications in TKA with previous incisions
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Surgeons may prevent wound complications after total knee arthroplasty in patients with previous incisions with proper skin incision choice, meticulous hemostasis and by avoiding excessive tension, according to a presenter.
When choosing a skin incision, Douglas A. Dennis, MD, noted the anterior midline skin incision is favored as it is the “least disruptive to the vascular architecture of the arteries to the skin.” Surgeons should utilize previous skin incisions whenever possible, according to Dennis. He added it is safe to ignore old, short, peripatellar longitudinal incisions and that transverse incisions may be crossed at a right angle.
“These are the ones you need to be more worried about – the two, long, parallel incisions,” Dennis said in his presentation at the Current Concepts in Joint Replacement Winter Meeting. “It’s usually wise to choose the lateral most incision because you want to avoid a large, laterally based skin flap, because skin oxygenation laterally is inferior.”
If a wound complication does occur, Dennis noted early intervention is imperative to prevent risks of deep infection that can occur with delayed intervention. He added local wound care can be considered for a short time in patients with prolonged serous drainage with no purulence or erythema. However, Dennis noted spontaneous cessation is unlikely in patients with a draining knee wound at 5 days postoperatively and surgical debridement is indicated.
“Should you encounter soft tissue necrosis, the general principle is it requires debridement,” Dennis said. “If it’s small, you can watch it for a while. If it’s greater than 3 cm, many of these require soft tissue transfer procedures, and don’t be fooled, many of these you think are superficial are often deep.”
Dennis noted patients with full-thickness necrosis require immediate debridement. He added secondary closure procedures usually fail in patients with full-thickness necrosis, and vascularized soft tissue transfer is needed either with fasciocutaneous or myocutaneous flaps.
“The medial gastroc flap is the workhorse for vascularized transfer. It is larger, and 2 cm to 3 cm longer, and does not have to transverse the fibula. Therefore, it has a larger arc of rotation and gives excellent coverage in the pretibial, prepatellar area where necrosis is most common,” Dennis said. “Free myocutaneous flaps are rarely needed – only in cases of extensive necrosis, which you can’t cover with rotational flaps.”
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Dennis DA. Previous incisions: When should you be worried? Methods to avoid trouble. What if there are problems? Presented at: Current Concepts in Joint Replacement Winter Meeting; Dec. 8-11, 2021; Orlando (hybrid meeting).
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