Single midline incision, prevention help avoid problems with previous knee incisions
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WAIKOLOA, Hawaii — Using an appropriate skin incision and the help of a plastic surgeon, as well as performing careful flap dissection, may allow surgeons to avoid trouble in patients with previous knee incisions, according to a speaker.
At Orthopedics Today Hawaii, Douglas A. Dennis, MD, said the number one way to avoid trouble, such as wound complications or infection, in these patients is the skin incision.
“The single, anterior midline incision is probably the best. It’s the least disruptive to the blood supply,” he said, noting any old, small peripatellar incisions from open meniscectomies, for example, can usually be avoided with this approach.
To avoid problems in patients who have two long, previous knee incisions, Dennis said, “It is usually wiser to use the lateral-most incision and you avoid a laterally based flap, and the lateral blood supply is less dominant.”
Patients with multiple previous incisions may benefit from a preoperative consultation with a plastic surgeon, he said.
“Always mark your previous incisions in preop. I think I’ve seen more skin necrosis where the previous surgeons had missed the previous incision by 5 mm,” Dennis said.
He also recommended avoiding the creation of a narrow skin bridge.
“Again, the complex cases, have them see the plastic surgeon,” Dennis said.
The execution of the flap dissection is the next most important way to avoid trouble in these cases, according to Dennis. “You want to avoid excessive tension. You must get meticulous hemostasis.”
Because the prepatellar area of interest lacks muscle and the corresponding intramuscular perforators, “whenever you are dissecting flaps, you must do subfascial dissection, and excessive tension on retraction tears those delicate vessels,” he said.
Should trouble develop with the incision, “the best management is prevention, and sooner is better than later because if you’ve got a wound problem, early intervention is imperative because delay risks deep infection,” according to Dennis.
For wounds that drain for more than 5 days or have a subcutaneous hematoma or hemarthrosis, surgical debridement should be done. Local wound management is a possible treatment for a small superficial necrosis, he said, but larger areas of necrosis may require a soft tissue coverage procedure.
“If you have superficial necrosis, a general principle is necrotic tissue requires debridement,” Dennis said.
“The best treatment is prevention through proper choice of incision, respecting the soft tissues, meticulous hemostasis and avoiding tight wound closure. If you do have persistent drainage or necrosis, early operative intervention is imperative,” he said.
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Dennis DA. Previous incisions: When should you be worried? Methods to avoid trouble. What if there are problems? Presented at: Orthopedics Today Hawaii. Jan. 9-13, 2022; Waikoloa, Hawaii.
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