Lappenplastiken bei Weichteildefekten nach endoprothetischem Kniegelenkersatz^[*]

 

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Zusammenfassung

Aufgrund des geringen periartikulären Weichteilmantels und des hohen Risikos einer begleitenden Weichteil- bzw. Protheseninfektion stellen Weichteildefekte im Bereich der kniegelenksnahen Region nach endoprothetischem Kniegelenksersatz immer ein relevantes chirurgisches Problem dar und verlangen ein suffizientes Komplikationsmanagement. Neben der Berücksichtigung von patientenspezifischen, intra- und postoperativen Risikofaktoren muss den Deckungskonzepten für die einzelnen Defektstadien häufig ein dezidiertes Infektionsmanagement vorangehen, das bei fortgeschrittenen Defekten den Ausbau der Prothese mit sekundär geplantem Wiederaufbau beinhalten kann. Es werden insgesamt 4 Stadien unterschieden (Typ A–D), welchen als Unterscheidungskriterien die allgemeine Weichteildeckung, die Exposition bzw. Nekrose des Streckapparats, der Erhalt oder die Eröffnung der Gelenkkapsel und/oder die begleitende septische Lockerung des freiliegenden Implantats zugrunde liegen. Das Konzept der plastischen Deckung folgt einem stadiengerechten Algorithmus und führt über einen sekundären Wundverschluss oder eine Spalthauttransplantation bei einfachen Defekten, über fasziokutane Verschiebelappen bei mittleren Defekten, bis hin zu gestielten oder freien Muskellappenplastiken bei tiefgreifenden Defektsituationen mit begleitender intrakapsulärer Ausbreitung. Maßgeblich entscheidend für eine erfolgreiche Therapie ist, neben einer soliden Infektbekämpfung, das frühe Erkennen und die korrekte Analyse der Defektcharakteristika, die sorgfältige Vorbereitung des Wundbetts mit seriellen Débridements und die saubere Durchführung der Lappendeckung durch rechtzeitige/frühe Konsultation plastisch-chirurgischer Expertise.

Abstract

Due to the marginal periarticular soft tissue envelope and the high risk of concomitant soft tissue or periprosthetic infection with the presence of exposed metal or bone, soft tissue defects after total knee arthroplasty are always a relevant surgical problem. Specific patient-related, intra- and postoperative risk factors have been identified and need to be considered during the course of treatment. Often a profound management of underlying infection must accompany the staged defect treatment which could require a prosthesis explantation with secondary revision in the case of a deep infection and involvement of the prosthesis. Four stages of soft tissue defects have been introduced (types A–D) and criteria for differentiation are the overall soft tissue coverage, the exposure, respectively, necrosis of the extensor mechanism, preservation or involvement of the joint capsule and/or an accompanying septic loosening of the prosthesis. The concept of plastic coverage follows a stage-adapted algorithm and includes secondary wound healing and mesh coverage for superficial defects, fasciocutaneous flaps for moderate defects and pedicled or free muscle flaps for deep defect situations with extension into the joint capsule. Crucial factors for a successful therapy include the early identification and precise analysis of defect characteristics, the careful preparation of the wound bed with serial debridements and the diligent flap coverage with early consultation of plastic-surgical expertise.

^* Nach einem Vortrag vom Sektionstag der Arbeitsgemeinschaft für Endoprothetik DKOU 2012.

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