Soft tissue flap reconstruction in infected or exposed total knee arthroplasty: A systematic review and network meta-analysis

Background: Total knee arthroplasty (TKA) infection or exposure associated with soft tissue deficiency represents a challenging scenario for the reconstructive surgeon. The aim of the study is to determine the most successful reconstructive option for infected or exposed TKA comparing local muscle flaps (LMF), local fasciocutaneous flaps (LFF), and free muscle flaps (FMF). Methods: A systematic review and single-arm network meta-analysis (PRISMA) was conducted to compare outcomes of complicated TKA requiring soft tissue coverage with either LMF, LFF and FMF. The protocol was registered on PROSPERO (CRD42023388731). PubMed, Embase, Web of Science and Cochrane Library were queried. MINORS criteria were employed for bias assessment. Outcomes included infection recurrence, TKA failure, above-knee amputation, and arthrodesis. Results: A total of 30 studies and 555 flaps were included. Pooled prevalence was 0.18 (95% CI: 0.11-0.26) for infection recurrence, 0.18 (95% CI: 0.11-0.28) for arthroplasty failure, 0.10 (95% CI: 0.08-0.13) for above-knee amputation and 0.10 (95% CI: 0.08-0.13) for arthrodesis. Local fasciocutaneous flaps demonstrated the lowest risk of infection recurrence (LFF = 0.04 ± 0.037, LMF = 0.27 ± 0.043, FMF = 0.26 ± 0.092), arthroplasty failure (LFF = 0.11 ± 0.068, LMF = 0.28 ± 0.045, FMF = 0.22 ± 0.094) and knee arthrodesis (LFF = 0.03 ± 0.027, LMF = 0.14 ± 0.03, FMF = 0.08 ± 0.06) after flap coverage of infected TKA. Free muscle flaps were associated with the lowest risk of above knee amputation (FMF = 0.08 ± 0.07, LFF = 0.10 ± 0.07, LMF = 0.11 ± 0.03). The mean MINORS score was 11.1 (95% CI: 11-12) with major weakness being the lack of prospective enrollment of the patients. Conclusion: Based on the available literature, when appropriate, LFF appear to be the best reconstructive choice for soft tissue reconstruction in complicated TKA.