Practical Plastic Surgery

112 Practical Plastic Surgery

Table 20.1. Options for flap coverage of the groin

The senior author has described an extended approach to the gracilis, which can also be used successfully. It is approached through an overlying medial thigh incision. If a recent saphenectomy has been performed, this incision may be used. After medial reflection of the adductor longus, the gracilis is identified by the absence of nerves around the muscle, the lack of attachments deep and superficial to the muscle, and tapering of the muscle as it dissection proceeds down the thigh.

20The dominant pedicle is identified on the deep medial aspect of the muscle. The insertion of the gracilis to the femur is divided distally, and the minor segmental pedicles are ligated, as are small vessels from the dominant pedicle that supply the overlying adductor longus. The origin of the gracilis at the pubic symphysis is then divided and the muscle is tunneled beneath the adductor into the femoral triangle. Drains are placed in the donor site and beneath the flap if possible.

The use of the rectus femoris is another option. This flap is reached through a midline thigh incision. The tendon is divided 4 cm from the patella. The distal minor pedicle is ligated, and the flap can be folded up into the wound. The rectus abdominis has also been used successfully in this setting. Finally, the ipsilateral or contralateral rectus muscle can be used for coverage of the groin when the profunda femoris vascular pedicle is compromised. Intraoperatively, blood flow to the flap should be confirmed with a handheld Doppler, before it is elevated.

Postoperative Considerations

Intravenous antibiotics should be administered based on intraoperative culture results. Some authors have suggested that therapy be continued for six weeks in the case of autogenous grafts and up to one year for prosthetic grafts. Lifelong suppressive doses of oral antibiotics should be considered in the latter group.

Infected Prosthetic Hemodialysis Grafts

Although exposed dialysis grafts have traditionally been removed, the paucity of vascular access sites in long-term hemodialysis patients has led to several successful strategies to salvage them. In contrast to the bypass grafts described above, dialysis

2.Alkon JD, Smith A, Losee JE et al. Management of complex groin wounds: Preferred use of the rectus femoris muscle flap. Plast Reconstr Surg 2005; 115(3):776-83.

contamination and subsequent infection. The most common symptoms and signs of infection following TKA and THA are pain, erythema and purulent wound drainage. Additional laboratory tests such as a CBC, ESR, C-reactive protein and joint aspiration may also help to establish the diagnosis.

It is also important to consider the patient’s comorbidities. Factors that predispose to failure of implant salvage include: previous surgeries, diabetes, adjuvant radiation therapy, connective tissue disease, peripheral vascular disease, tobacco use, prior steroid treatments and rheumatic disease. Factors that predict successful implant salvage in the setting of infection include: <2 week duration of symptoms; susceptible gram positive organism (especially Streptococcus); lack of radiologic evidence of infection or loosening of the prosthesis; and absence of a sinus tract.

Operative and Postoperative Considerations

Open Wounds without Evidence of Infection

In the absence of infection, prostheses underlying open wounds are often salvageable, even when exposed. Immediate closure may be considered, provided that there are no signs of infection and well-vascularized tissue exists. Primary closure may be especially difficult due to the lack of mobile soft tissue adjacent to the wound. Wounds that do not involve exposed tendon, bone or joint may be treated with local wound care, negative pressure wound therapy followed by skin grafts, or fasciocutaneous flaps-depending on the size of the defect. Wounds in which the tendon, bone or joint are exposed should be treated with debridement, irrigation and flap reconstruction. Some of the more commonly used flaps are listed in Table 21.1.

Infections

The keys to initial management of wound infections are: identification of the anatomic extent of infection, aggressive debridement of devascularized tissue, thor- 21 ough irrigation, and culture-specific systemic antibiotic therapy. Thereafter, superfi-

cial infections may be managed with local wound care, skin grafts or fasciocutaneous flaps. Medium-depth infections, which extend to the joint capsule without involving the bone or joint structures, may be treated with skin grafts, fasciocutaneous flaps or muscle flaps depending on the size of the defect and, in the case of the knee, whether tendon is involved.

Deep infections that involve the bone or joint structures require more aggressive management. Acutely infected wounds should be thoroughly debrided, irrigated and

Table 21.1. A hierarchical list of flaps useful for treatment of exposed and infected artificial joints

treated with broad spectrum, anti-staphylococcal antibiotics. Definitive surgical closure of the wound, often with muscle flaps, may be undertaken when signs of infection have abated, preferably within 7 days. Chronic infections (greater than 4 weeks) often require implant removal and placement of an antibiotic-impregnated spacer, followed by second-stage reimplantation after long-term IV antibiotic therapy. Patients who require implant removal are at increased risk of wound failure following prosthesis reimplantation due to inadequate local tissues and patient compromise. As such, a low threshold should be used for muscle flap coverage at the second stage.

Pearls and Pitfalls

Successful salvage of a threatened or exposed implant requires a good working relationship with the orthopedic surgeon and prompt evaluation and treatment of the patient. Serial debridements may be needed until the site is clean and all tissues are deemed viable. Final closure should proceed in an expeditious manner when the wound is deemed ready. The major pitfalls to success lie in both delaying treatment and conversely, rushing closure. If one adopts the “wait and see” attitude, a worsening picture may develop due to bacterial contamination and subsequent infection. Hurrying the closure before the wound is clean may result in the subsequent development of osteomyelitis.

Suggested Reading

1.Adam RF, Watson SB, Jarratt JW et al. Outcome after flap cover for exposed total knee arthroplasties. A report of 25 cases. J Bone Joint Surg Br 1994; 76(5):750-3.

2.Attinger CE, Ducic I, Cooper P et al. The role of intrinsic muscle flaps of the foot for bone coverage in foot and ankle defects in diabetic and nondiabetic patients. Plast Reconstr Surg 2002; 110(4):1047-54.

3.Browne Jr EZ, Stulberg BN, Sood R. The use of muscle flaps for salvage of failed total knee arthroplasty. Br J Plast Surg 1994; 47(1):42-5.

4.Burger RR, Basch T, Hopson CN. Implant salvage in infected total knee arthroplasty.

21Clin Orthop Relat Res 1991; (273):105-12.

5.Eckardt JJ, Lesavoy MA, Dubrow TJ et al. Exposed endoprosthesis. Management protocol using muscle and myocutaneous flap coverage. Clin Orthop Relat Res 1990; (251):220-9.

6.Gusenoff JA, Hungerford DS, Orlando JC et al. Outcome and management of infected wounds after total hip arthroplasty. Ann Plast Surg 2002; 49(6):587-92.

7.Jones NF, Eadie P, Johnson PC et al. Treatment of chronic infected hip arthroplasty wounds by radical debridement and obliteration with pedicled and free muscle flaps. Plast Reconstr Surg 1991; 88(1):95-101.

8.Markovich GD, Dorr LD, Klein NE et al. Muscle flaps in total knee arthroplasty. Clin Orthop Relat Res 1995; (321):122-30.

9.Nahabedian MY, Mont MA, Orlando JC et al. Operative management and outcome of complex wounds following total knee arthroplasty. Plast Reconstr Surg 1999; 104(6):1688-97.

10.Nahabedian MY, Orlando JC, Delanois RE et al. Salvage procedures for complex soft tissue defects of the knee. Clin Orthop Relat Res 1998; (356):119-24.

wound complications (e.g., infection or delayed healing). In such cases, excision should be accompanied by a measure to decrease tension. Splinting of the incision is most effectively accomplished by intradermal sutures left in place for 6 weeks to 6 months, depending on the degree of tension. Z-plasties and other techniques of reorienting the direction of tension can be used as well.

Silicone Gel Sheeting

This modality has become standard of care for the treatment of hypertrophic scars. It should be used as a first-line agent for linear hypertrophic scars. Numerous randomized, double-blind studies have shown that it is efficacious for treating hypertrophic scars and small keloids. The benefits of silicone sheeting have not been demonstrated with other types of semior total occlusive dressings. Since this treatment is painless, it is an excellent option for children or adults unwilling to tolerate more painful options. For prophylaxis in those at risk for hypertrophic scarring, treatment should begin a few days postoperatively. Silicone sheeting should be worn a minimum of 12 hours a day, and preferably the entire day. It should be continued for several weeks postoperatively.

Corticosteroid Injections

Years of clinical experience and many randomized, prospective trials have shown that triamcinolone injected into the scar is efficacious at decreasing scarring. Response rates range from 50-100%, with a recurrence rate of 10-50%. It should be the first-line therapy for keloids and second-line for hypertrophic scars. In combination with other therapies such as surgery and cryotherapy, corticosteroid injections can be even more effective. Side effects are common and include skin atrophy, telengiectasias and pigment changes. The exact mechanism by which steroids diminish scarring is still largely unknown. What has been shown is that topical steroids are not effective in reducing scarring.

22 Pressure Therapy

Compression is the first-line treatment for post-burn, widespread hypertrophic scars. In order to be effective, pressure must be maintained between 24-30 mm Hg for at least 6 months duration. The longer the treatment, the more efficacious pressure therapy has been shown to be.

Steri-Strips®

Adhesive microporous paper tape applied to fresh incisions for several weeks postoperatively is moderately useful in preventing hypertrophic scaring. The mechanism is not entirely clear. It is likely a combination of occlusion and splinting of the incision.

Radiation Therapy

Radiotherapy should be reserved for adults with keloids resistant to other treatment modalities. Monotherapy is controversial, and most authors recommend using it following surgical excision. Response rates range from 10-90% for radiotherapy alone, and in combination with surgery it is more likely to be effective. Recurrence is very common, ranging from 50-100%.

Table 22.1. Recommended treatment modality for various types of pathologic scars

Suggested Reading

1.Chang P, Laubenthal KN, Lewis IInd RW et al. Prospective, randomized study of the efficacy of pressure garment therapy in patients with burns. J Burn Care Rehabil 1995; 16:473.

2.Gold MH. A controlled clinical trial of topical silicone gel sheeting in the treatment of hypertrophic scars and keloids. J Am Acad Dermatol 1994; 30:506.

3.Mustoe TA, Cooter RD, Gold MH et al. International clinical recommendations on scar management. Plast Reconstr Surg 2002; 110:560.

4.Poston J. The use of silicone gel sheeting in the management of hypertrophic and keloid scars. J Wound Care 2000; 9:10.

5.Rockwell WB, Cohen IK, Ehrlich HP. Keloids and hypertrophic scars: A comprehensive review. Plast Reconstr Surg 1989; 84:827.

6.Tang YW. Intraand postoperative steroid injections for keloids and hypertrophic scars. Br J Plast Surg 1992; 45:371

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