Keystone flaps for the treatment of wound healing complications after knee orthopedic surgery

The anterior midline incision is the most popular approach to the knee among orthopedic surgeons, including in total knee arthroplasty (TKA). Wound breakdown in the anterior knee can rapidly lead to an exposed joint and hardware because of the scarcity of soft tissue padding. Should it happen, expedite reconstitution of the skin envelope is essential to avoid jeopardizing the surgical result. We propose the use of modified advancement-rotation keystone flaps for the effective closure of these defects. The records of patients reconstructed with this technique at our institution between January and July 2021 were reviewed. Four cases were identified and are described, three of which resulted from complications of TKA and one of quadricipital tendon reconstruction. Mean follow-up was 8 months (range 6–12 months). All flaps survived completely. Localized wound dehiscence in one patient was treated successfully with flap readvancement. Other patients recovered uneventfully. Knee flexion was fully regained in two patients and limited only by the underlying osteoarticular condition in the remaining two. Patients with arthroplasty hardware in place could retain it. All patients had remarkably good tactile and pain sensation at the 6-month follow-up. Esthetic results were satisfactory in terms of color, texture, and contour. Orthopedic surgeons continue to struggle to treat and prevent wound dehiscence after knee surgery, especially in peripheral hospitals without plastic surgery consultation. This technique of local tissue redistribution can easily be learned by both plastic and knee surgeons allowing them to solve and potentially prevent this common problem.

Level of evidence: Level V, Therapeutic