Skip to main content
SpringerLink
Log in

Skin Exposure Issues

  • Chapter
  • First Online:
Revision Total Knee Arthroplasty

  • 1361 Accesses

Abstract

Primary wound healing is critical for the success of any total knee arthroplasty (TKA). Wound healing problems following TKA are infrequent but can be a harbinger of devastating results. Delays in wound healing risk infection and implant failure and can ultimately result in amputation. Wound problems are minimized by proper selection of skin incisions, understanding cutaneous blood supply and patient risk factors, and using operative techniques that protect the soft tissues. When wound complications do arise, prompt management is imperative.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution
Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 109.00
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 139.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info
Hardcover Book
USD 199.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

References

  1. Cross MB, Yi PH, Thomas CF, Garcia J, Della Valle CJ. Evaluation of malnutrition in orthopaedic surgery. J Am Acad Orthop Surg. 2014;22(3):193–9.

    Article  PubMed  Google Scholar 

  2. Greene KA, Wilde AH, Stulberg BN. Preoperative nutritional status of total joint patients. Relationship to postoperative wound complications. J Arthroplast. 1991;6(4):321–5.

    Article  CAS  Google Scholar 

  3. Jaberi FM, Parvizi J, Haytmanek CT, Joshi A, Purtill J. Procrastination of wound drainage and malnutrition affect the outcome of joint arthroplasty. Clin Orthop Relat Res. Jun 2008;466(6):1368–71.

    Article  PubMed  PubMed Central  Google Scholar 

  4. Seibert DJ. Pathophysiology of surgical site infection in total hip arthroplasty. Am J Infect Control. 1999;27(6):536–42.

    Article  CAS  PubMed  Google Scholar 

  5. Jones RE, Russell RD, Huo MH. Wound healing in total joint replacement. Bone Joint J. 2013;95-B(11_Supple_A):144–7.

    Article  CAS  PubMed  Google Scholar 

  6. Zorrilla P, Gomez LA, Salido JA, Silva A, Lopez-Alonso A. Low serum zinc level as a predictive factor of delayed wound healing in total hip replacement. Wound Repair Regen. 2006;14(2):119–22.

    Article  PubMed  Google Scholar 

  7. Wilson MG, Kelley K, Thornhill TS. Infection as a complication of total knee-replacement arthroplasty. Risk factors and treatment in sixty-seven cases. J Bone Joint Surg Am. 1990;72(6):878–83.

    Article  CAS  PubMed  Google Scholar 

  8. Cruse PJ, Foord R. A five-year prospective study of 23,649 surgical wounds. Arch Surg. 1973;107(2):206–10.

    Article  CAS  PubMed  Google Scholar 

  9. Goodman SM, Figgie M. Lower extremity arthroplasty in patients with inflammatory arthritis: preoperative and perioperative management. J Am Acad Orthop Surg. 2013;21(6):355–63.

    PubMed  Google Scholar 

  10. Johnson BK, Goodman SM, Alexiades MM, Figgie MP, Demmer RT, Mandl LA. Patterns and associated risk of perioperative use of anti-tumor necrosis factor in patients with rheumatoid arthritis undergoing total knee replacement. J Rheumatol. 2013;40(5):617–23.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  11. Loza E, Martinez-Lopez JA, Carmona L. A systematic review on the optimum management of the use of methotrexate in rheumatoid arthritis patients in the perioperative period to minimize perioperative morbidity and maintain disease control. Clin Exp Rheumatol. 2009;27(5):856–62.

    CAS  PubMed  Google Scholar 

  12. Morrison TA, Figgie M, Miller AO, Goodman SM. Periprosthetic joint infection in patients with inflammatory joint disease: a review of risk factors and current approaches to diagnosis and management. HSS J. 2013;9(2):183–94.

    Article  PubMed  PubMed Central  Google Scholar 

  13. Klein NECC. Wound problems in total knee arthroplasty, vol. 2. Baltimore: Williams & Wilkins; 1994.

    Google Scholar 

  14. D’Apuzzo MR, Novicoff WM, Browne JA. The John Insall award: morbid obesity independently impacts complications, mortality, and resource use after TKA. Clin Orthop Relat Res. 2014.

    Google Scholar 

  15. Kulkarni A, Jameson SS, James P, Woodcock S, Muller S, Reed MR. Does bariatric surgery prior to lower limb joint replacement reduce complications? Surgeon. 2011;9(1):18–21.

    Article  CAS  PubMed  Google Scholar 

  16. Green JP. Steroid therapy and wound healing in surgical patients. Br J Surg. 1965;52:523–5.

    Article  CAS  PubMed  Google Scholar 

  17. Wahl LM. Hormonal regulation of macrophage collagenase activity. Biochem Biophys Res Commun. 1977;74(2):838–45.

    Article  CAS  PubMed  Google Scholar 

  18. Werb Z. Biochemical actions of glucocorticoids on macrophages in culture. Specific inhibition of elastase, collagenase, and plasminogen activator secretion and effects on other metabolic functions. J Exp Med. 1978;147(6):1695–712.

    Article  CAS  PubMed  Google Scholar 

  19. Krause ML. Matteson EL. Perioperative management of the patient with rheumatoid arthritis. World. J Orthop. 2014;5(3):283–91.

    Google Scholar 

  20. Goh L, Jewell T, Laversuch C, Samanta A. Should anti-TNF therapy be discontinued in rheumatoid arthritis patients undergoing elective orthopaedic surgery? A systematic review of the evidence. Rheumatol Int. 2012;32(1):5–13.

    Article  CAS  PubMed  Google Scholar 

  21. Saag KG, Teng GG, Patkar NM, et al. American College of Rheumatology 2008 recommendations for the use of nonbiologic and biologic disease-modifying antirheumatic drugs in rheumatoid arthritis. Arthritis Rheum. 2008;59(6):762–84.

    Article  CAS  PubMed  Google Scholar 

  22. Arredondo J, Hall LL, Ndoye A, et al. Central role of fibroblast alpha3 nicotinic acetylcholine receptor in mediating cutaneous effects of nicotine. Lab Investig. 2003;83(2):207–25.

    Article  CAS  PubMed  Google Scholar 

  23. Benowitz NL, Kuyt F, Jacob P III. Influence of nicotine on cardiovascular and hormonal effects of cigarette smoking. Clin Pharmacol Ther. 1984;36(1):74–81.

    Article  CAS  PubMed  Google Scholar 

  24. Craig S, Rees TD. The effects of smoking on experimental skin flaps in hamsters. Plast Reconstr Surg. 1985;75(6):842–6.

    Article  CAS  PubMed  Google Scholar 

  25. Kaufman T, Eichenlaub EH, Levin M, Hurwitz DJ, Klain M. Tobacco smoking: impairment of experimental flap survival. Ann Plast Surg. 1984;13(6):468–72.

    Article  CAS  PubMed  Google Scholar 

  26. Moller AM, Pedersen T, Villebro N, Munksgaard A. Effect of smoking on early complications after elective orthopaedic surgery. J Bone Joint Surg Br. 2003;85(2):178–81.

    Article  PubMed  Google Scholar 

  27. Rees TD, Liverett DM, Guy CL. The effect of cigarette smoking on skin-flap survival in the face lift patient. Plast Reconstr Surg. 1984;73(6):911–5.

    Article  CAS  PubMed  Google Scholar 

  28. Moller AM, Villebro N, Pedersen T, Tonnesen H. Effect of preoperative smoking intervention on postoperative complications: a randomised clinical trial. Lancet. 2002;359(9301):114–7.

    Article  PubMed  Google Scholar 

  29. Lindstrom D, Sadr Azodi O, Wladis A, et al. Effects of a perioperative smoking cessation intervention on postoperative complications: a randomized trial. Ann Surg. 2008;248(5):739–45.

    Article  PubMed  Google Scholar 

  30. Singh JA. Smoking and outcomes after knee and hip arthroplasty: a systematic review. J Rheumatol. 2011;38(9):1824–34.

    Article  PubMed  PubMed Central  Google Scholar 

  31. Parvizi J, Ghanem E, Joshi A, Sharkey PF, Hozack WJ, Rothman RH. Does “excessive” anticoagulation predispose to periprosthetic infection? J Arthroplast. 2007;22(6 Suppl 2):24–8.

    Article  Google Scholar 

  32. Stryker LS, Abdel MP, Morrey ME, Morrow MM, Kor DJ, Morrey BF. Elevated postoperative blood glucose and preoperative hemoglobin A1C are associated with increased wound complications following total joint arthroplasty. J Bone Joint Surg Am. 2013;95(9):808–14. S801-802.

    Article  PubMed  Google Scholar 

  33. Goletz TH, Henry JH. Continuous passive motion after total knee arthroplasty. South Med J. 1986;79(9):1116–20.

    Article  CAS  PubMed  Google Scholar 

  34. Johnson DP. The effect of continuous passive motion on wound-healing and joint mobility after knee arthroplasty. J Bone Joint Surg Am. 1990;72(3):421–6.

    Article  CAS  PubMed  Google Scholar 

  35. Bjorkstrom S, Goldie IF. A study of the arterial supply of the patella in the normal state, in chondromalacia patellae and in osteoarthrosis. Acta Orthop Scand. 1980;51(1-6):63–70.

    Article  CAS  PubMed  Google Scholar 

  36. Scapinelli R. Studies on the vasculature of the human knee joint. Acta Anat (Basel). 1968;70(3):305–31.

    Article  CAS  Google Scholar 

  37. Waisbrod H, Treiman N. Intra-osseous venography in patellofemoral disorders. A preliminary report. J Bone Joint Surg Br. 1980;62-B(4):454–6.

    CAS  PubMed  Google Scholar 

  38. Johnson DP. Midline or parapatellar incision for knee arthroplasty. A comparative study of wound viability. J Bone Joint Surg Br. 1988;70(4):656–8.

    CAS  PubMed  Google Scholar 

  39. Johnson DP, Houghton TA, Radford P. Anterior midline or medial parapatellar incision for arthroplasty of the knee. A comparative study. J Bone Joint Surg Br. 1986;68(5):812–4.

    CAS  PubMed  Google Scholar 

  40. Windsor RE, Insall JN, Vince KG. Technical considerations of total knee arthroplasty after proximal tibial osteotomy. J Bone Joint Surg Am. 1988;70(4):547–55.

    Article  CAS  PubMed  Google Scholar 

  41. Argenta LC, Marks MW, Pasyk KA. Advances in tissue expansion. Clin Plast Surg. 1985;12(2):159–71.

    CAS  PubMed  Google Scholar 

  42. Mahomed N, McKee N, Solomon P, Lahoda L, Gross AE. Soft-tissue expansion before total knee arthroplasty in arthrodesed joints. A report of two cases. J Bone Joint Surg Br. 1994;76(1):88–90.

    Article  CAS  PubMed  Google Scholar 

  43. Manders EK, Oaks TE, VK A, et al. Soft-tissue expansion in the lower extremities. Plast Reconstr Surg. 1988;81(2):208–17.

    Article  CAS  PubMed  Google Scholar 

  44. Manders EK, Schenden MJ, Furrey JA, Hetzler PT, Davis TS, Graham WP III. Soft-tissue expansion: concepts and complications. Plast Reconstr Surg. 1984;74(4):493–507.

    Article  CAS  PubMed  Google Scholar 

  45. Manifold SG, Cushner FD, Craig-Scott S, Scott WN. Long-term results of total knee arthroplasty after the use of soft tissue expanders. Clin Orthop Relat Res. 2000;380:133–9.

    Article  Google Scholar 

  46. Radovan C. Tissue expansion in soft-tissue reconstruction. Plast Reconstr Surg. 1984;74(4):482–90.

    Article  CAS  PubMed  Google Scholar 

  47. Namba RS, Diao E. Tissue expansion for staged reimplantation of infected total knee arthroplasty. J Arthroplast. 1997;12(4):471–4.

    Article  CAS  Google Scholar 

  48. Rand JA, Ries MD, Landis GH, Rosenberg AG, Haas S. Intraoperative assessment in revision total knee arthroplasty. J Bone Joint Surg Am. 2003;85-A(Suppl 1):S26–37.

    Article  Google Scholar 

  49. Santore RF, Kaufman D, Robbins AJ, Dabezies EJ Jr. Tissue expansion prior to revision total knee arthroplasty. J Arthroplast. 1997;12(4):475–8.

    Article  CAS  Google Scholar 

  50. Long WJ, Wilson CH, Scott SM, Cushner FD, Scott WN. 15-year experience with soft tissue expansion in total knee arthroplasty. J Arthroplast. 2012;27(3):362–7.

    Article  Google Scholar 

  51. Clayton ML, Thirupathi R. Patellar complications after total condylar arthroplasty. Clin Orthop Relat Res. 1982;170:152–5.

    Google Scholar 

  52. Kayler DE, Lyttle D. Surgical interruption of patellar blood supply by total knee arthroplasty. Clin Orthop Relat Res. 1988;229:221–7.

    Google Scholar 

  53. Scuderi G, Scharf SC, Meltzer LP, Scott WN. The relationship of lateral releases to patella viability in total knee arthroplasty. J Arthroplast. 1987;2(3):209–14.

    Article  CAS  Google Scholar 

  54. Johnson DP, Eastwood DM. Lateral patellar release in knee arthroplasty. Effect on wound healing. J Arthroplast. 1992;7(Suppl):427–31.

    Article  Google Scholar 

  55. Brem MH, Bail HJ, Biber R. Value of incisional negative pressure wound therapy in orthopaedic surgery. Int Wound J. 2014;11(s1):3–5.

    Article  PubMed  Google Scholar 

  56. Karlakki S, Brem M, Giannini S, Khanduja V, Stannard J, Martin R. Negative pressure wound therapy for managementof the surgical incision in orthopaedic surgery: a review of evidence and mechanisms for an emerging indication. Bone Joint Res. 2013;2(12):276–84.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  57. Stannard JP, Gabriel A, Lehner B. Use of negative pressure wound therapy over clean, closed surgical incisions. Int Wound J. 2012;9(Suppl 1):32–9.

    Article  PubMed  Google Scholar 

  58. Webb LX. New techniques in wound management: vacuum-assisted wound closure. J Am Acad Orthop Surg. 2002;10(5):303–11.

    Article  PubMed  Google Scholar 

  59. Bengston S, Knutson K, Lidgren L. Treatment of infected knee arthroplasty. Clin Orthop Relat Res. 1989;245:173–8.

    Google Scholar 

  60. Weiss AP, Krackow KA. Persistent wound drainage after primary total knee arthroplasty. J Arthroplast. 1993;8(3):285–9.

    Article  CAS  Google Scholar 

  61. Hallock GG. Salvage of total knee arthroplasty with local fasciocutaneous flaps. J Bone Joint Surg Am. 1990;72(8):1236–9.

    Article  CAS  PubMed  Google Scholar 

  62. Lewis VL Jr, Mossie RD, Stulberg DS, Bailey MH, Griffith BH. The fasciocutaneous flap: a conservative approach to the exposed knee joint. Plast Reconstr Surg. 1990;85(2):252–7.

    Article  PubMed  Google Scholar 

  63. Ries MD. Skin necrosis after total knee arthroplasty. J Arthroplast. 2002;17(4):74–7.

    Article  Google Scholar 

  64. Joseph EHC, Berman S, et al. A prospective randomized trial of vacuum assisted closure versus standard therapy of chronic nonhealing wounds. Wounds. 2000;12:60–7.

    Google Scholar 

  65. Lian G, Cracchiolo A 3rd, Lesavoy M. Treatment of major wound necrosis following total knee arthroplasty. J Arthroplast. 1989;4(Suppl):S23–32.

    Article  Google Scholar 

  66. Bengtson S, Carlsson A, Relander M, Knutson K, Lidgren L. Treatment of the exposed knee prosthesis. Acta Orthop Scand. 1987;58(6):662–5.

    Article  CAS  PubMed  Google Scholar 

  67. Eckardt JJ, Lesavoy MA, Dubrow TJ, Wackym PA. Exposed endoprosthesis. Management protocol using muscle and myocutaneous flap coverage. Clin Orthop Relat Res. 1990;251:220–9.

    Google Scholar 

  68. Greenberg B, LaRossa D, Lotke PA, Murphy JB, Noone RB. Salvage of jeopardized total-knee prosthesis: the role of the gastrocnemius muscle flap. Plast Reconstr Surg. 1989;83(1):85–9. 97-89

    Article  CAS  PubMed  Google Scholar 

  69. Hemphill ES, Ebert FR, Muench AG. The medial gastrocnemius muscle flap in the treatment of wound complications following total knee arthroplasty. Orthopedics. 1992;15(4):477–80.

    CAS  PubMed  Google Scholar 

  70. Salibian AH, Anzel SH. Salvage of an infected total knee prosthesis with medial and lateral gastrocnemius muscle flaps. A case report. J Bone Joint Surg Am. 1983;65(5):681–4.

    Article  CAS  PubMed  Google Scholar 

  71. Sanders R, O’Neill T. The gastrocnemius myocutaneous flap used as a over for the exposed knee prosthesis. J Bone Joint Surg Br. 1981;63-B(3):383–6.

    CAS  PubMed  Google Scholar 

  72. Rhomberg M, Schwabegger AH, Ninkovic M, Bauer T. Gastrocnemius myotendinous flap for patellar or quadriceps tendon repair, or both. Clin Orthop Relat Res. 2000;377:152–60.

    Article  Google Scholar 

  73. Gerwin M, Rothaus KO, Windsor RE, Brause BD, Insall JN. Gastrocnemius muscle flap coverage of exposed or infected knee prostheses. Clin Orthop Relat Res. 1993;286:64–70.

    Google Scholar 

  74. Nahabedian MY, Orlando JC, Delanois RE, Mont MA, Hungerford DS. Salvage procedures for complex soft tissue defects of the knee. Clin Orthop Relat Res. 1998;356:119–24.

    Article  Google Scholar 

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

    CAS  PubMed  Google Scholar 

  76. Bedair H, Ting N, Jacovides C, et al. The mark Coventry award: diagnosis of early postoperative TKA infection using synovial fluid analysis. Clin Orthop Relat Res. 2011;469(1):34–40.

    Article  PubMed  Google Scholar 

  77. Insall J, Scott WN, Ranawat CS. The total condylar knee prosthesis. A report of two hundred and twenty cases. J Bone Joint Surg Am. 1979;61(2):173–80.

    Article  CAS  PubMed  Google Scholar 

  78. Tetreault MW, Wetters NG, Aggarwal VK, et al. Should draining wounds and sinuses associated with hip and knee arthroplasties be cultured? J Arthroplast. 2013;28(8):133–6.

    Article  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Colorado Joint Replacement, 2535 S. Downing St., Suite 100, Denver, CO, 80210, USA

    Jason M. Jennings M.D. & Douglas A. Dennis M.D.

Authors
  1. Jason M. Jennings M.D.
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Douglas A. Dennis M.D.
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Douglas A. Dennis M.D. .

Editor information

Editors and Affiliations

  1. Clinical Professor of Orthopedic Surgery, Tufts University School of Medicine, Boston, Massachusetts, USA

    James V. Bono

  2. Professor of Orthopaedic Surgery, Emeritus, Harvard Medical School, Boston, Massachusetts, USA

    Richard D. Scott

Rights and permissions

Reprints and permissions

Copyright information

© 2018 Springer International Publishing AG

About this chapter

Check for updates. Verify currency and authenticity via CrossMark

Cite this chapter

Jennings, J.M., Dennis, D.A. (2018). Skin Exposure Issues. In: Bono, J., Scott, R. (eds) Revision Total Knee Arthroplasty. Springer, Cham. https://doi.org/10.1007/978-3-319-67344-8_5

Download citation

  • DOI: https://doi.org/10.1007/978-3-319-67344-8_5

  • Published:

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-319-67342-4

  • Online ISBN: 978-3-319-67344-8

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation