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Intraoperative angiography provides objective assessment of skin perfusion in complex knee reconstruction.

ABSTRACT: Wound necrosis is a potentially devastating complication of complex knee reconstruction. Laser-assisted indocyanine green angiography (LA-ICGA) is a technology that has been described in the plastic surgery literature to provide an objective assessment of skin perfusion in the operating room. This novel technology uses a plasma protein bound dye (ICG) and a camera unit that is calibrated to view the frequency emitted by the dye. The intention of this technology is to offer real-time visualization of blood flow to skin and soft tissue in a way that might help surgeons make decisions about closure or coverage of a surgical site based on blood flow, potentially avoiding soft tissue reconstruction while preventing skin necrosis or wound breakdown after primary closures, but its efficacy is untested in the setting of complex TKA.The purpose of this study was to evaluate perfusion borders and tension ischemia in a series of complex knee reconstructions to guide optimal wound management.Beginning in mid-2011, an LA-ICGA system was used to evaluate soft tissue viability in knee reconstruction procedures that were considered high risk for wound complications. Seven patients undergoing complex primary or revision TKA from 2011 to 2013 were included. These patients were chosen as a convenience sample of knee reconstruction procedures for which we obtained consultation with the plastic surgery service. The perfusion of skin and soft tissue coverage was evaluated intraoperatively for all patients with the LA-ICGA system, and the information was used to guide wound management. Followup was at a mean of 9 months (range, 6-17 months), no patients were lost to followup, and the main study endpoint was uneventful healing of the surgical incision.All seven closures went on to heal without necrosis. One patient, however, was subsequently revised for a deep periprosthetic infection 4 months after their knee reconstruction and underwent flap coverage at the time of that revision.Implementation of LA-ICGA provides an objective intraoperative assessment of soft tissue perfusion. This technology may help guide the surgeon's decisions about wound closure in real-time to accommodate the perfusion challenges unique to each patient. Specifically, patients with medical risk factors for poor perfusion or wound healing (such as diabetes, peripheral vascular disease, tobacco use, corticosteroid therapy, infection) or anatomical/surgical risk factors (ie, previous surgery about the reconstruction site, trauma wounds, or reconstruction of severe deformity) may benefit from objective intraoperative information regarding perfusion of the wound site. Furthermore, LA-ICGA could be used to prospectively evaluate the physiologic impact of different wound closure techniques.Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

SUBMITTER: Wyles CC

PROVIDER: S-EPMC4390910 | biostudies-literature |

REPOSITORIES: biostudies-literature

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Project description:Background: Reconstruction with the use of perforator flaps makes it possible to make the skin surface resistant to the influence of mechanical factors and as similar to the lost skin cover as possible. However, while planning any flap, along with the design of the required shape and size, its blood supply should be taken into account to ensure optimal viability. Therefore, the task to precisely determine the topographic-anatomical relationships suitable for the formation of a pedicle of perforators is still relevant. The aim of this study was to increase the efficiency of surgical reconstruction of wound defects by transposition of locoregional perforator flaps. Methods: The authors conducted a retrospective analysis of 72 cases of reconstruction by means of locoregional perforator flaps with vascular pedicle detachment to determine the efficiency of preoperative diagnostic preparation with the help of multidetector-row computed tomographic angiography (MDCT) in the process of reconstruction. Thirty-seven individual cases of surgical interventions were chosen using a case-controlled study from the study group when MDCT with angiography was used for preoperative planning of perforator flaps, as well as 35 control cases similar in terms of important predictive peculiarities with the reconstruction at the same level of difficulty. The patient groups were precisely matched by gender (P = .950), age (P = .804), flap area (P = .192), and type of reconstruction that was performed. Results: In all cases, the location of the perforator with a diameter greater than 1.0 mm was marked. All perforators determined during MDCT scanning were faultlessly localized intraoperatively. The distance between the intraoperative position of the perforator and the position obtained in the result of the examination did not exceed 1 cm. There was no need to change the planned design of the flap intraoperatively. In all cases where MDCT was performed, the duration of the surgical procedure varied from 60 to 150 minutes (average: 120.77 [18.90] minutes) and was reduced by 49.40 minutes (95% CI: 39.17-59.63) compared with the patients who did not undergo preoperative visualization of perforators where the average duration of the operation was 170.17 (19.19) minutes (from 140 to 220 minutes). Among the patients examined by MDCT, surgical complications were noted in 5 cases (13.51%) compared to 14 cases (40.00%) in the control group. Conclusions: The preoperative MDCT for the locoregional perforator flap reconstruction makes it possible to increase the efficiency of patient treatment given the reduction in surgery duration by 49.40 minutes (95% CI: 39.17-59.63) on average and the reduction in the level of postsurgery complications from 40% to 13.5% compared with the group of patients in whom presurgical visualization was not performed (P = .031).

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Intraoperative angiography provides objective assessment of skin perfusion in complex knee reconstruction.

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