Role of staged endoprosthetic revision with flap cover for limb salvage in endoprosthetic failure

Abstract

Endoprosthetic replacement (EPR) is commonly required for limb salvage in bone malignancies. Endoprosthetic failure is a term used to denote mechanical failure or infection usually requiring removal of the prosthesis. Treatment of infection consists of EPR revision with or without placement of a temporary spacer. Flap cover (either local or free) may be required if the overlying soft tissues are of concern. It is claimed that the investment of the endoprosthesis in well-vacularised soft tissue facilitates the eradication of infection. This series included nine patients with endoprosthetic failure due to chronic infection who needed flap cover. These patients underwent revision of the EPR in two stages. The first stage of revision included removal of the endoprosthesis, insertion of a spacer and soft tissue reconstruction. If serial sampling of the periprosthetic space failed to demonstrate microbial growth, the spacer was exchanged for an endoprosthesis.A total of nine patients underwent staged revision of endoprosthesis. In five patients cover was provided by a local pedicled flap and in four by a free flap. Patients undergoing cover by a broad flat musculocutaneous flap (i.e. free/pedicled latissimus dorsi) performed better. This study reports the results of attempted limb salvage in endoprosthetic failure due to infection in nine cases. Initial findings in this small series indicate that staged revision and soft tissue reconstruction in the form of muscle flap investment of the endoprosthesis carries a higher rate of successful limb salvage.Résumé Le remplacement prothètique est fréquemment utilisé pour la chirurgie conservatrice dans les tumeurs osseuses. La faillite de ces prothèses correspond à un échec mécanique ou à une infection qui nécéssite habituellement l'ablation de la prothèse.Le traitement de l'infection consiste en la revision chirurgicale de la prothèse avec ou sans mise en place temporaire d'un espaceur. Une couverture par lambeau (local ou libre) peut être nécessaire selon l'état des parties molles. Il semble que la mise en place de la prothèse au sein de parties molles bien vascularisées facilite l'éradication de l'infection. Présenta-tion d'une étude de 9 patients ayant une faillite de prothèse par infection et ayant besoin d'un lambeau de couverture. La revision a été faite en 2 temps, le second étant realisé si une série de prélévements dans l'espace péri-prothètique ne montraient plus de prolifération microbienne. Dans 5 cas la couverture était réalisée avec un lambeau local et dans 4 cas avec un lambeau libre. Les patients avec un lambeau musculo-cutané libre (grand dorsal) avaient un meilleur résultat. Les résultats précoces de cette petite série montrent que la reprise en 2 temps avec couverture prothètique par un lambeau musculaire donne un taux élevé de réussite dans la préservation des membres.

Deep infection in tumor endoprosthesis around the knee: a multi-institutional study by the Japanese musculoskeletal oncology group

“…In the present study, infection control rate by soft-tissue flap was 42.9%, suggesting that soft tissue coverage without prosthesis removal is not sufficient for infection control. Combination of soft tissue coverage, especially microvascular free flap coverage, and two-stage revision has been reported to yield favorable results, highlighting the importance of both soft tissue and prosthesis management in endoprosthesis infection [18]. We agree that such methods should be employed, especially in patients at high risk of poor infection control, such as those with extraarticular resection or discharge/pus at infection presentation.…”

Management of exposed total knee prostheses with microvascular tissue transfer

“…36,37 Coagulase negative staphylococci (CNS), usually Staphylococcus epidermidis, followed by Staphylococcus aureus are the most commonly recovered organisms. 18,[38][39][40][41] Although it is recommended that antibiotic therapy should initially be broad enough to cover the most common gram-positive and gram-negative bacteria of PJIs, 2 coverage is often incomplete because the wide number of drugs required to treat drug resistant bacteria and the difficulty in determining a cut-off point for what is considered a common PJI organism. 42,43 Furthermore, it is recommended that the coverage should be restricted after culture results reveal the pathogen, 2 but the most common pathogen in PJIs-CNS-often produces false negatives in histology of periprosthetic tissue, considered the gold standard for PJI diagnosis.…”

“…Rao et al found the broad, flat latissimus dorsi flap ideal for prosthesis coverage. 18 Nahabedian's series described complex post-total knee replacement wounds, and included 13 knees with exposed prostheses that were managed successfully with local gastrocnemius or local fasciocutaneous flap coverage. 19,20 We report our experience using free tissue transfer to reconstruct these difficult three-dimensional wounds.…”

Functional outcome of infected endoprosthesis: A 20-year retrospective analysis

“…[31][32][33] Most surgeons currently perform a two-staged revision, as the success rate is higher than a singlestaged revision in controlling the infection. 34,35 The success rate of a two-stage surgery with the usage of antibioticimpregnated cement is 90%. 36 The cases with persistent or repeated infections despite multiple surgical debridements or a two-staged surgery can be offered rotationplasty or amputation, depending on the tumour site.…”