Original Paper

European Journal of Plastic Surgery _ Springer-Verlag 2004 10.1007/s00238-004-0684-0

Original Paper Microvascular soft tissue reconstruction after complicated talocrural arthroplasty E. Tukiainen1 and A. Koski1 (1) Department of Plastic Surgery, Helsinki University Central Hospital, P.O. 266, 00029 Helsinki, Finland A. Koski Email: [email protected] Fax: +358-9-47187570 Received: 25 February 2004 Accepted: 12 August 2004 Published online: 12 October 2004 Abstract Seven patients were referred to our unit during a 17-month period because of soft tissue problems 2_4 weeks after a talocrural arthroplasty (TCA). The infection was superficial in one and deep in six cases. In all patients the area was revised and a microvascular flap reconstruction was performed. In four cases the prosthesis was left in place and in two TC fusions were done. The flap was selected according to size and shape of the defect. Four partial latissimus dorsi flaps (LD), two gracilis free flaps, and one radial forearm flap (RF) were used. Four of the seven TCAs could be salvaged and no amputations were needed. Keywords Talocrural arthroplasty - Infection - Flap - Reconstruction Introduction Talocrural arthroplasty (TCA) is quite a new procedure. The first generation of ankle prostheses were mainly cemented, which has been stated to be associated with a poorer outcome [1, 2]. The second generation of ankle prostheses have now been in use for less than 10 years and so the results of their durability is not yet known [3]. The soft tissue envelope at the ankle is thin and the circulation is often affected by vascular disease or previous surgical scars, causing a high percentage of wound complications after TCA surgery [4]; however, the number of wound complications has diminished with the use of second-generation prostheses [5]. In this study we investigated the possible predisposing factors for wound complications as well as the solutions for wound healing problems after total ankle arthroplasty operations. Materials and methods Seven patients were referred to Helsinki University Central Hospital (HUCH), Department of Plastic Surgery, because of wound healing problems 2_4 weeks after talocrural arthroplasty with Scandinavian Total Ankle Replacement (STAR) ankle prosthesis [6] between 1 September 1999 and 31 January 2002. Patients The indication for TCA was posttraumatic arthritis in four cases, rheumatoid arthritis in two, and secondary arthrosis in one, which was due to post-infectious arthritis of the talocrural (TC) joint. All patients had postoperative skin edge necrosis and wound dehiscence. The patients were referred from four different orthopedic centers in the country. The average age was 54.9 years (range 25_74 years). There were six women and one man. All but one of the patients smoked more that 20 cigarettes per day, four had Diabetes Mellitus, two had arteriosclerosis (both of which were first discovered when complications occurred) and two had a permanent cortisone medication orally for rheumatoid arthritis. Three patients were considered to be overweight (BMI over 28). The vascular status of the extremity was assessed in the vascular laboratory. An angiography was performed in four cases. In one patient an angioplasty was performed and one needed a vascular reconstruction (femorodistal bypass). Deep infection was evident in all cases when the radical wound excision was performed. In six cases there was found to be a connection to the TCA components. In one case the infection affected only the soft tissue and the joint capsule was left untouched; in all others necrotic and infected tissue was removed, the meniscus of the prostheses was temporarily removed, and synovectomy was performed. The revised area was cleaned with jet lavage. Following this, the decision whether to retain or remove the prostheses was made. The components were not removed if the infection had lasted only for a short period, and if the components were firmly in place (four cases). If the prospects for the eradication of infection were assessed to be poor, the components were removed and a TC fusion was performed (two cases). A free muscle flap was selected in six cases. Four partial latissimus dorsi (LD) flaps and two musculus gracilis free flaps were used. In one case, in which the joint was not opened and there was no deep cavity, a radial forearm (RF) flap was used to cover the soft tissue defect. The sizes of the defects and the methods of reconstruction are given in Table 1.

All anastomoses were performed to the tibialis anterior artery (end-to-side if the artery was open to the distal part and end to end if the artery was already damaged). Figure 1a shows the situation of a 65-year-old woman with rheumatoid arthritis 6 weeks after the arthroplasty operation and Fig. 1b shows the situation 2 weeks after the soft tissue reconstruction with a partial LD free flap covered with split thickness skin graft. Table 1 Sizes of the defects and the methods of reconstruction. LD latissimus dorsi flaps Age (years)

Gender

Indication

Size of the defect (height_width, cm)

Smoking Diabetes

Reconstruction

74

F

Rheumatoid arthrosis

Yes

No

5_3

Partial LD free flap

65

F

Rheumatoid arthrosis

Yes

Yes

10_3


25

M

Posttraumatic arthrosis

Yes

No

7_3


57

F

Secondary arthrosis after Yes infection

Yes

1_1


51

F


Yes

Yes

10_5

Radial forearm free flap

71

F


No

Yes

7_4

Musculus gracilis free flap

41

F


Yes

No

1_5

Musculus gracilis free flap

Fig. 1 a A 65-year-old woman with rheumatoid arthritis 6 weeks after the arthroplasty. b Same patient 2 weeks after the soft tissue reconstruction with partial latissimus dorsi free flap covered with split thickness skin graft

Results Of the 7 patients treated at our unit in four cases the TCA could be salvaged. The mean follow-up was 16 months (range 6_33 months); however, due to the demanding immobilization after the reconstruction, all patients had restricted motion in the TC joint. (After the arthroplasty operation, the ankle is always put in a cast to prevent movement in the joint. We did not use a cast after the reconstructions, but did not allow strenuous exercise for 2 weeks). During the follow-up one talocrural arthrodesis was performed 1 year after the primary salvage operation because of persisting pain in the ankle joint. All in all, three arthrodeses were performed which resulted in 2_4 cm shortening of the affected limb. In two cases the wound healing was delayed (1 LD and 1 gracilis). The distal end of the LD was revised and the wound healing problem with the gracilis free flap was treated conservatively. Of the seven infections treated, in four the prosthesis was salvaged. No amputations were needed. Discussion The selection of patients and preoperative assessment of patients for TCA is crucial [1]. Total failure and removal of the prosthesis after a TC arthroplasty leads to a worse eventual result than a TC arthrodesis performed primarily without attempting the arthroplasty. Patients should all be investigated for vascular problems prior to the surgery. It is recommended that at least Doppler and ABI index measurements be performed. If a wound problem and infection is evident, a radical revision and a reconstruction with enough tension free tissue is needed. For soft tissue reconstruction in the ankle area local tissue is often unsuitable, because of scars resulting from previous operations [7]; therefore, a microvascular free flap is needed. In cases where the joint is open a free flap provides good coverage and brings good, well-vascularized tissue to the area [8]. In this group of patients, a partial LD flap was used the most because of the degree arteriosclerosis and obesity would, in our opinion, have made the use of musculus gracilis free flap risky. For the same reason no local turnover flaps were used. If the soft tissues are affected with scars, the soft tissue reconstruction should be performed at the arthroplasty operation simultaneously with the TCA as presented earlier by Heitman and Levin [9].

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s new in foot and ankle surgery. J Bone Joint Surg Am 84-A:504_509

5. Easley ME, Vertullo CJ, Urban WC, Nunley JA (2002) Total ankle arthroplasty. J Am Acad Orthop Surg 10:157_167 6. Coughlin MJ (2002) The Scandinavian total ankle replacement prosthesis. AAOS Instructional course lectures, volume 51 7. Koski A, Tukiainen E, Suominen S, Asko-Seljavaara S (2003) Reconstruction of iatrogenic skin defects of the Achilles tendon region: an analysis of 25 consecutive patients. Eur J Plast Surg 26:298_303 8. Hallock GG (2000) Utility of both muscle and fascia flaps is severe lower extremity trauma. J Trauma 2000:913_917 9. Heitman C, Levin LS (2003) The orthoplastic approach for management of severely traumatized foot and ankle. J Trauma 54:379_390