Eur J Plast Surg (2004) 27:298–300
E. Tukiainen · A. Koski
Microvascular soft tissue reconstruction
after complicated talocrural arthroplasty
Received: 25 February 2004 / Accepted: 12 August 2004 / Published online: 12 October 2004
Abstract Seven patients were referred to our unit dur-
ing a 17-month period because of soft tissue problems
2–4 weeks after a talocrural arthroplasty (TCA). The in-
fection was superficial in one and deep in six cases. In all
patients the area was revised and a microvascular flap
reconstruction was performed. In four cases the prosthesis
was left in place and in two TC fusions were done. The
flap was selected according to size and shape of the de-
fect. Four partial latissimus dorsi flaps (LD), two gracilis
free flaps, and one radial forearm flap (RF) were used.
Four of the seven TCAs could be salvaged and no am-
putations were needed.
Keywords Talocrural arthroplasty · Infection · Flap ·
Talocrural arthroplasty (TCA) is quite a new procedure.
The first generation of ankle prostheses were mainly ce-
mented, which has been stated to be associated with a
poorer outcome [1, 2].
The second generation of ankle prostheses have now
been in use for less than 10 years and so the results of
their durability is not yet known .
The soft tissue envelope at the ankle is thin and the
circulation is often affected by vascular disease or pre-
vious surgical scars, causing a high percentage of wound
complications after TCA surgery ; however, the num-
ber of wound complications has diminished with the use
of second-generation prostheses .
In this study we investigated the possible predisposing
factors for wound complications as well as the solutions
for wound healing problems after total ankle arthroplasty
Materials and methods
Seven patients were referred to Helsinki University Central Hos-
pital (HUCH), Department of Plastic Surgery, because of wound
healing problems 2–4 weeks after talocrural arthroplasty with
Scandinavian Total Ankle Replacement (STAR) ankle prosthesis
 between 1 September 1999 and 31 January 2002.
The indication for TCA was posttraumatic arthritis in four cases,
rheumatoid arthritis in two, and secondary arthrosis in one, which
was due to post-infectious arthritis of the talocrural (TC) joint. All
patients had postoperative skin edge necrosis and wound dehis-
cence. The patients were referred from four different orthopedic
centers in the country. The average age was 54.9 years (range 25–
74 years). There were six women and one man. All but one of the
patients smoked more that 20 cigarettes per day, four had Diabetes
Mellitus, two had arteriosclerosis (both of which were first dis-
covered when complications occurred) and two had a permanent
cortisone medication orally for rheumatoid arthritis. Three patients
were considered to be overweight (BMI over 28).
The vascular status of the extremity was assessed in the vascular
laboratory. An angiography was performed in four cases. In one
patient an angioplasty was performed and one needed a vascular
reconstruction (femorodistal bypass).
Deep infection was evident in all cases when the radical wound
excision was performed. In six cases there was found to be a
connection to the TCA components. In one case the infection af-
fected only the soft tissue and the joint capsule was left untouched;
in all others necrotic and infected tissue was removed, the meniscus
of the prostheses was temporarily removed, and synovectomy was
performed. The revised area was cleaned with jet lavage. Following
this, the decision whether to retain or remove the prostheses was
The components were not removed if the infection had lasted
only for a short period, and if the components were firmly in place
(four cases). If the prospects for the eradication of infection were
assessed to be poor, the components were removed and a TC fusion
was performed (two cases).
A free muscle flap was selected in six cases. Four partial la-
tissimus dorsi (LD) flaps and two musculus gracilis free flaps were
used. In one case, in which the joint was not opened and there was
no deep cavity, a radial forearm (RF) flap was used to cover the soft
E. Tukiainen · A. Koski (
Department of Plastic Surgery,
Helsinki University Central Hospital,
P.O. 266, 00029 Helsinki, Finland