The use of muscle flaps in the salvage of infected exposed implants for internal fixation

Abstract

The treatment of infected exposed implants which have been used for internal fixation usually involves debridement and removal of the implant. This can result in an unstable fracture or spinal column. Muscle flaps may be used to salvage these implants since they provide soft-tissue cover and fresh vascularity. However, there have been few reports concerning their use and these have concentrated on the eradication of the infection and successful soft-tissue cover as the endpoint. There is no information on the factors which may influence the successful salvage of the implant using muscle flaps. We studied the results and factors affecting outcome in nine pedicled muscle flaps used in the treatment of exposed metal internal fixation with salvage of the implant as the primary endpoint. This was achieved in four cases. Factors predicting success were age < 30 years, the absence of comorbid conditions and a favourable microbiological profile. The growth of multiple organisms, a history of smoking and the presence of methicillin-resistant Staphylococcus aureus on wound cultures indicated a poor outcome. The use of antibiotic beads, vacuum-assisted closure and dressing, the surgical site, the type of flap performed and the time from primary surgery to flap cover were not predictive of outcome.

What Factors Influence the Success of Medial Gastrocnemius Flaps in the Treatment of Infected TKAs?

“…Patients in our study generally had multiple prior knee procedures (four on average), which may have contributed to poor outcomes overall secondary to decreased blood supply and residual scarring [13], but we were unable to isolate this variable as an independent risk factor for treatment failure. We similarly were unable to substantiate other potential risk factors for failure of salvage muscle flaps, including sex, age, BMI, infecting organism, type of antibiotic spacer, or individual comorbidities (tobacco use [20,31], reflex sympathetic dystrophy syndrome [19], diabetes [19,20], chronic renal failure [20], peripheral vascular disease [20], and steroid use [20]). Despite these no-difference findings, the study may have been underpowered and the optimization of modifiable variables is advised perioperatively, when possible.…”

“…Although some authors [8,19,20,31] have proposed poor prognostic factors based on smaller series, our study is the first, to our knowledge, to statistically evaluate factors associated with flap failure in this setting. There was a trend toward failure when flap coverage was performed at the same time as antibiotic spacer placement but this did not reach statistical significance.…”

“…Despite these no-difference findings, the study may have been underpowered and the optimization of modifiable variables is advised perioperatively, when possible. Although some studies cite superficial culture results as risk factors for poor prognosis [8,31], we recommend against routine microbiologic swabbing of draining wounds owing to the high risk of bacterial contamination [25,32].…”

Complications in ankle fracture surgery

“…The primary goals of successful treatment are anatomic fracture consolidation, a healed soft tissue envelope, and prevention of a chronic infection (Trampuz and Zimmerli 2006). Traditionally, the management has included debridement of all necrotic tissue, a prolonged course of intravenous antibiotics, and likely removal of all infected hardware (Thordarson et al 2000, Calvert et al 2006, Viol et al 2009, Ng and Barnes 2009, Tan et al 2010.…”

“…Since removal of infected hardware prior to fracture union may result in disastrous complications (Calvert et al 2006), wound closure without hardware removal using techniques of soft-tissue reconstruction has been proposed. (Calvert et al 2006, Cavadas and Landin 2006, Cyrochristos et al 2009, Viol et al 2009, Tan et al 2010, Vaienti 2012a, Viaenti 2012b.…”