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Practical Plastic Surgery 2007

Practical Plastic Surgery 2007

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Mark Sisco and Gregory A. Dumanian

Infected Arterial Bypass Grafts

Vascular graft infections remain challenging clinical problems for the vascular
surgeon, especially when prosthetic material is involved. Traditional approaches,
which until the 1960s consisted of removal of all prosthetic grafts with extra-anatomic
bypass or amputation, has given way to more conservative approaches in patients
whom graft removal is not feasible. These approaches have significantly reduced
mortality and improved limb salvage. Contemporary management consists of an
escalating algorithm of interventions that range from retention of the graft with
healing by secondary intention to graft replacement with muscle flap reconstruction
of the defect. When definitive extra-anatomic bypass is not possible, in situ replace-
ment of infected prosthetic grafts with cadaveric homografts or autogenous tissue is
preferred. The decision to replace the graft is typically made by the vascular surgeon.
This section will focus on reconstructive options in the groin, since it is the most
common site of graft exposure and infection requiring plastic surgical intervention.

Preoperative Considerations

Salvage of an arterial graft may be considered in patients who have patency of
their reconstruction, an intact anastomosis and localized infection. Systemic antibi-
otics should be administered preoperatively. Superficial infections that do not ex-
tend to the graft itself may be managed with debridement alone, followed by local
wound care.

Flap reconstruction is the management of choice for deep infections that involve
the graft. This is due to the its well-established utility in lowering bacterial counts,
improving antibiotic delivery, filling dead space and providing tension-free soft tis-
sue coverage. Patency of donor vessels to the intended flap must be assessed preop-
eratively using MRA or angiography. The reconstructive surgeon must know the
patency status of the graft before commencing the procedure. Staged debridements
may be required prior to reconstruction. Wet-to-dry dressings, hydrogels, or closed
suction drains may be used in the interim.

Operative Considerations

Flap options for coverage of groin wounds are listed in Table 20.1. The most
commonly used flap in the groin is the sartorius. Harvest of the flap involves detach-
ing from the anterior superior iliac spine, transposing it over the graft and suturing
it to the groin musculature and inguinal ligament. Care must be taken not to inter-
rupt more than three perforating vessels to this flap, since its segmental blood sup-
ply from the superficial femoral artery puts it at risk for necrosis.

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Practical Plastic Surgery

20

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.
The 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 suppres-
sive 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

Table 20.1.Options for flap coverage of the groin

Flap

Pedicle

Advantages

Disadvantages

Sartorius

Branches from the

Easy harvest

SFA occlusion common

superficial femoral

Minimal

in vasculopathies

artery (inferior/

donor site

Limited arc of rotation

minor pedicle)

Proximity to infected
tissue

Gracilis

Medial circumflex

Minimal

More difficult harvest

femoral, profunda

donor site

femoris

Rectus

Lateral circumflex

Easy harvest

May weaken extension

femoris

femoral, profunda

Bulky flap

at the knee

femoris

Skin may be
transferred

Rectus

Deep inferior

Wide arc

May develop ventral

abdominis

epigastric,

of rotation

hernia at the donor site

external iliac

DIEA occlusion is
common

113

Infected and Exposed Vascular Grafts

20

grafts are not acutely imperative to life or limb. As in arterial bypass grafts, hemor-
rhage or systemic infection mandates total graft excision. Since such grafts have a
lifespan that averages 2-3 years, simple local flaps are typically used. Flaps such as
the flexor carpi ulnaris and lateral arm flap allow coverage in the proximal forearm.
The radial artery island fasciocutaneous flap, meanwhile, may provide coverage to
the mid and distal forearm. Random pattern flaps should be used with caution, as
they do not provide as reliable coverage. Vascular puncture can usually be continued
during healing.

Pearls and Pitfalls

Patients with infected or exposed vascular grafts are in the highest risk group for
subsequent wound complications. They have already demonstrated wound healing
problems from their initial surgery. Their vascularity and wound healing is compro-
mised due to their underlying peripheral vascular disease. Many of these patients are
also renal failure patients and malnourished.
In considering the coverage procedure, one should expect donor site complica-
tions ahead of time. The donor site should be distant from the graft site and away
from important structures. For example, harvesting a sartorius flap for coverage of a
groin bypass graft may not be wise if the donor site is in close proximity to the
infected wound. In regards to the exposed graft, muscle coverage should be placed
transversely over a longitudinal graft, so that if the coverage breaks down, only a
small area of graft will be exposed. In addition, the graft should be covered in stag-
gered layers by closing the muscle and skin layers separately without the skin inci-
sion lying directly over the muscle incision.

Suggested Reading

1.Morasch MD, Sam IInd AD, Kibbe MR et al. Early results with use of gracilis muscle
flap coverage of infected groin wounds after vascular surgery. J Vasc Surg 2004;
39(6):1277-83.
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.

Chapter 21

Practical Plastic Surgery, edited by Zol B. Kryger and Mark Sisco. ©2007 Landes Bioscience.

Management of Exposed
and Infected Orthopedic Prostheses

Mark Sisco and Michael A. Howard

Background

Wound dehiscence and periprosthetic infections complicating orthopedic im-
plants are a significant source of postoperative morbidity that may be limb, or
life-threatening. While the treatment of superficial wound complications is rela-
tively straightforward, there is less agreement in the literature about the correct course
of action when an implant itself is exposed or infected. Several authors advocate the
traditional approach, which consists of removal of all exposed or infected implants
with delayed flap closure. This approach tends to result in prolonged hospitalization
and significant functional loss. Several recent reports suggest that early debridement
with definitive muscle flap coverage may make it possible to salvage prostheses in
select patients. The plastic surgeon is often consulted after the orthopedic surgeon
has determined that the wound cannot be closed primarily or that the implant is
infected. The cornerstones of prosthesis salvage include:
1.Early identification of infection
2.Aggressive debridement
3.Appropriate antibiotic therapy
4.Prompt soft-tissue coverage
All options in the reconstructive ladder may be needed depending on the size of
the defect and the extent of the exposed structures.

Preoperative Considerations

Orthopedic patients are susceptible to wound complications for several reasons.
Surgery may involve wide undermining of the soft tissues. Postoperative edema may
be significant since joints have relatively poor lymphatic drainage, further compro-
mised by surgery, leading to undue tension of the skin and incision. Prostheses may
be positioned directly underneath the skin incision in an area that is poorly vascular-
ized. Finally, many patients have had prior surgery, the scarring from which contrib-
utes to decreased tissue pliability and blood flow. In sum, the altered blood flow,
increased edema and wound tension result in decreased oxygen delivery to the heal-
ing incision.

Persistent drainage or problematic wound healing has been described in up to
20% of total knee arthroplasty (TKA) patients, with an infection rate of 1-12%.
The total incidence of infection following total hip arthroplasty (THA) is smaller:
about 1%. When evaluating such problems, it is critical to distinguish wound infec-
tion from wound failure, since the treatment algorithms are different. Wound infec-
tion may cause wound failure. Wound failure, meanwhile, may cause implant

21

115

Management of Exposed and Infected Orthopedic Prosthesis

contamination and subsequent infection. The most common symptoms and signs
of infection following TKA and THA are pain, erythema and purulent wound drain-
age. 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 predis-
pose to failure of implant salvage include: previous surgeries, diabetes, adjuvant ra-
diation therapy, connective tissue disease, peripheral vascular disease, tobacco use,
prior steroid treatments and rheumatic disease. Factors that predict successful im-
plant salvage in the setting of infection include: <2 week duration of symptoms;
susceptible gram positive organism (especially Streptococcus); lack of radiologic evi-
dence 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 sal-
vageable, 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-
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 involv-
ing 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

Hip

Knee

Ankle

Vastus lateralis

Medial gastrocnemius

Free flap

Rectus femoris

Lateral gastrocnemius

Tibialis anterior

Rectus abdominis (inferior pedicle)Fasciocutaneous flaps

Medial plantar

Gluteus medius

Free flap

Tensor fascia lata
Free flap

21

116

Practical Plastic Surgery

treated with broad spectrum, anti-staphylococcal antibiotics. Definitive surgical clo-
sure of the wound, often with muscle flaps, may be undertaken when signs of infec-
tion 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. Pa-
tients 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 worsen-
ing picture may develop due to bacterial contamination and subsequent infection.
Hurrying the closure before the wound is clean may result in the subsequent devel-
opment 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.
Clin Orthop Relat Res 1991; (273):105-12.
5.Eckardt JJ, Lesavoy MA, Dubrow TJ et al. Exposed endoprosthesis. Management pro-
tocol 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 in-
fected 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.

Chapter 22

Practical Plastic Surgery, edited by Zol B. Kryger and Mark Sisco. ©2007 Landes Bioscience.

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