title: Soft Tissue Reconstruction After Total Ankle Arthroplasty.
abstract: BACKGROUND
  Wound complications following total ankle replacement (TAR) may potentially lead to devastating consequences. Soft tissue coverage of the prosthesis and tendons with a flap potentially prevent a catastrophic cascade leading to infection and implant failure. The aim of this study was to investigate the success and complications of flaps following soft tissue defects as a result of total ankle arthroplasty.
  
  
  METHODS
  We retrospectively identified a consecutive series of 1001 primary TARs performed between January 1998 and December 2014 whose data were prospectively collected. We then identified patients who required a secondary surgery to treat soft tissue defects that were not amenable to split-thickness skin grafting. Clinical outcomes including secondary procedures, wound healing failure, complications, and implant failure rate were recorded. Nineteen patients had a total of 44 operative procedures to treat wound issues (1.9% of all prostheses). The follow-up time from the flap procedure is 24.1 months.
  
  
  RESULTS
  More than two-thirds (13/19) of patients had 1 or more previous surgeries on the ankle, for an average of 1.2 procedures. The mean time to the flap procedure was 13.1 weeks after the index TAR. The most common reason for flap coverage was a non-healing anterior wound. Thirteen of 19 patients (68.4%) underwent formal operative wound exploration and debridement prior to their definitive flap coverage. The average size of the wound was 5.4 × 3.8 cm with an average area of 24.9 cm(2). The most common type of flap performed was a sural pedicle flap followed by a propeller flap. There were 4 flap failures (21.1%), with 2 subsequent below-the-knee amputations. No TAR patients developed a deep infection following a flap unless they had a preexisting infection. In patients who had a successful flap, there were significant improvements in their American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot, visual analog scale (VAS), and Short Musculoskeletal Function Assessment bother index, but not their Short Form-36 scores.
  
  
  CONCLUSIONS
  Ankle wounds that occur after TAR can result in a devastating outcome, but management with a coordinated effort with surgeons with microvascular experience can help achieve salvage of the prosthesis. A variety of flap reconstruction options are available and should be employed to improve the rate of implant survival and retention.
  
  
  METHODS
  Level IV, case series.
authors.affiliation: Department of Orthopaedics, Medical University of South Carolina, Charleston, SC, USA cgross144@gmail.com.
authors.forename: Christopher E
authors.initials: CE
authors.lastname: Gross
authors.affiliation: Department of Plastic Surgery, Duke University Medical Center, Durham, NC, USA.
authors.forename: Ryan
authors.initials: R
authors.lastname: Garcia
authors.affiliation: Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA.
authors.forename: Samuel B
authors.initials: SB
authors.lastname: Adams
authors.affiliation: Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA.
authors.forename: James K
authors.initials: JK
authors.lastname: DeOrio
authors.affiliation: Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA.
authors.forename: Mark E
authors.initials: ME
authors.lastname: Easley
authors.affiliation: Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA.
authors.forename: James A
authors.initials: JA
authors.lastname: Nunley
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000671:Amputation, Surgical; D058737:Arthroplasty, Replacement, Ankle / Q000009:adverse effects* / Q000379:methods; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000601:surgery*; D019651:Plastic Surgery Procedures / Q000379:methods*; D012189:Retrospective Studies; D016038:Skin Transplantation; D013524:Surgical Flaps / Q000098:blood supply; D017211:Treatment Failure; D014945:Wound Healing
keywords: flaps; total ankle arthroplasty; wound management