Systematic Review and Comparative Meta-Analysis of Outcomes Following Pedicled Muscle versus Fasciocutaneous Flap Coverage for Complex Periprosthetic Wounds in Patients with Total Knee Arthroplasty

James M Economides, Michael V DeFazio, Kayvon Golshani, Mark Cinque, Ersilia L Anghel, Christopher E Attinger, Karen Kim Evans, James M Economides, Michael V DeFazio, Kayvon Golshani, Mark Cinque, Ersilia L Anghel, Christopher E Attinger, Karen Kim Evans

Abstract

Background: In cases of total knee arthroplasty (TKA) threatened by potential hardware exposure, flap-based reconstruction is indicated to provide durable coverage. Historically, muscle flaps were favored as they provide vascular tissue to an infected wound bed. However, data comparing the performance of muscle versus fasciocutaneous flaps are limited and reflect a lack of consensus regarding the optimal management of these wounds. The aim of this study was to compare the outcomes of muscle versus fasciocutaneous flaps following the salvage of compromised TKA.

Methods: A systematic search and meta-analysis were performed to identify patients with TKA who underwent either pedicled muscle or fasciocutaneous flap coverage of periprosthetic knee defects. Studies evaluating implant/limb salvage rates, ambulatory function, complications, and donor-site morbidity were included in the comparative analysis.

Results: A total of 18 articles, corresponding to 172 flaps (119 muscle flaps and 53 fasciocutaneous flaps) were reviewed. Rates of implant salvage (88.8% vs. 90.1%, P=0.05) and limb salvage (89.8% vs. 100%, P=0.14) were comparable in each cohort. While overall complication rates were similar (47.3% vs. 44%, P=0.78), the rates of persistent infection (16.4% vs. 0%, P=0.14) and recurrent infection (9.1% vs. 4%, P=0.94) tended to be higher in the muscle flap cohort. Notably, functional outcomes and ambulation rates were sparingly reported.

Conclusions: Rates of limb and prosthetic salvage were comparable following muscle or fasciocutaneous flap coverage of compromised TKA. The functional morbidity associated with muscle flap harvest, however, may support the use of fasciocutaneous flaps for coverage of these defects, particularly in young patients and/or high-performance athletes.

Keywords: Arthroplasty, replacement, knee; Knee prosthesis; Surgical flaps.

Conflict of interest statement

No potential conflict of interest relevant to this article was reported.

Figures

Fig. 1. Forest plot of limb salvage
Fig. 1. Forest plot of limb salvage
Pooled rates of limb salvage across all studies (Cochran Q=40, df=17, P2=57.5). df, degrees of freedom; LCL, lower confidence limits; UCL, upper confidence limits; WGHT, weight.
Fig. 2. Forest plot of device salvage
Fig. 2. Forest plot of device salvage
Pooled rates of device salvage across all studies (Cochran Q=18, df=13, P=0.16; I2=62.5). df, degrees of freedom; LCL, lower confidence limits; UCL, upper confidence limits; WGHT, weight.
Fig. 3. Forest plot of ambulation rates
Fig. 3. Forest plot of ambulation rates
Pooled rates of postoperative ambulation across all studies (Cochran Q=4, df=11, P=0.46; I2=1.75). df, degrees of freedom; LCL, lower confidence limits; UCL, upper confidence limits; WGHT, weight.
Fig. 4. Funnel plot of limb salvage
Fig. 4. Funnel plot of limb salvage
Funnel plot representation of publication bias in the reporting of rates of limb salvage. SD, standard deviation.
Fig. 5. Funnel plot of device salvage
Fig. 5. Funnel plot of device salvage
Funnel plot representation of publication bias in the reporting of rates of device salvage. SD, standard deviation.
Fig. 6. Funnel plot of ambulation rates
Fig. 6. Funnel plot of ambulation rates
Funnel plot representation of publication bias in the reporting of rates of postoperative ambulation. SD, standard deviation.
Fig. 7. Study attrition diagram
Fig. 7. Study attrition diagram
Diagram showing the study selection process and attrition.

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