A Cutaneous Transposition Inversion Flap to Treat Symptomatic Subcutaneous Trochanteric or Soft Tissue Defects After Hip Arthroplasty: A Technical Note

Patients who undergo total hip arthroplasty (THA) strive for pain relief and improvement of quality of life.1 A common complication following THA is persistent greater trochanteric (GT) or lateral trochanteric pain (TP). Symptoms may be similar to end-stage hip osteoarthritis and limit particularly sitting or lying on the affected side.2 The incidence of TP after THA is reported to be between 1% and up to 17%.3,4 Studies regarding the association of TP with the surgical approach remain inconsistent and may be obsolete.4 The etiology of TP is associated with trochanteric bursitis, soft tissue defects over the GT, bone substance defects over the shoulder of the underlying stem, and enlarged femoral offset.3,5 Regarding the management of the abductors there are different surgical techniques described with varying complexity.6,7 Reattachment of the GT also remains challenging despite advanced fixation device systems.8 The postoperative care is often impaired as the patients may not be able to respect weight-bearing limitations. A simple reconstruction with a de-epithelialized cutaneous transposition inversion flap (DCTIF) may relieve TP due to soft tissue defects overlying the implant by providing enough bolstering of the posterolateral hip without requiring relevant postoperative restrictions. We present this surgical technique and discuss its limitations.

MATERIAL AND METHODS

The patient involved provided written informed consent for publication of anonymized data following Institutional Review Board (IRB) policies for publication of a single-patient case study.

A 73-year-old obese (body mass index 33 kg/m2) female patient underwent internal fixation of a trochanteric fracture of her right femur with a short cephalomedullary nail (PFNA, DePuy Synthes, Zuchwil, Switzerland). Because of posttraumatic avascular necrosis of the femoral head and a symptomatic trochanteric nonunion, the nail had to be removed and THA performed. The operation was performed through a transfemoral approach, and reconstruction was performed with a modular, distally fixated, straight, tapered, fluted, uncemented, titanium-alloy stem with a ceramic-on-crosslinked polyethylene bearing in an uncemented cup (Allofit/Durasul/Biolox delta/Revitan straight, Zimmer Biomet, Winterthur, Switzerland) (Fig. 1). Subsequently, typical TP persisted for over a year, despite conservative treatment, with trochanteric tenderness severely limiting sitting and lying on the affected side. The stem’s shoulder was well palpable under the otherwise uneventfully healed skin. Walking was impaired due to pain-induced limping as well as abductor insufficiency. As conservative treatment failed, surgery was performed to attempt reattachment of the GT and to bolster the posterolateral soft tissues, namely the shoulder of the stem, with a DCTIF.

F1FIGURE 1: Anteroposterior radiograph of the pelvis: right hip of a 73-year-old female patient, 1 year after total hip arthroplasty had been performed after failed internal fixation of a trochanteric fracture with a short cephalomedullary nail. Since diaphyseal fixation was necessary, medial metaphyseal support being insufficient, and considering deformity of the trochanteric region, a transfemoral approach9 with reconstruction using a distally fixated, tapered, fluted, and modular stem was chosen. The contours of the left femur were mirrored and projected over the right hip (red line), to illustrate the bone substance defect of the greater trochanter. The subcutaneous protrusion of the shoulder of the stem caused tenderness, limiting sitting or lying on the affected side. Walking was limited due to local pain as well as due to abductor insufficiency.

The patient was placed in a lateral position (Fig. 2). The scar from the preexisting Kocher-Langenbeck approach was excised and cranially extended.9 The fasciae latae presented a defect of the GT, with local bursitis. As expected, the shoulder of the stem was not covered by abductors or bone anymore. Despite mobilization of the scar tissue and the remains of the gluteus medius and minimus muscles, coverage of the stem’s shoulder was impossible. Avoiding overstretching of the abductor muscles, a substance defect of ~15 mm persisted right over the shoulder of the stem even after refixation of the greater trochanter with sutures and a cerclage cable. Thus, the DCTIF was performed to cover the remaining defect (Figs. 3, 4). First, the flap was mobilized from the skin posterior to the incision (Fig. 2). After de-epithelialization, a thin layer of fat tissue was left attached to the gluteal fascia to preserve the epifascial vascular plexus. After mobilization, the posteriorly pediculated flap was inverted and sutured into the defect over the stem’s shoulder. Next, the fasciae latae was closed proximally and distally to the flap’s edges. The subcutaneous tissue was adapted with single resorbable sutures. Thus, tension-free skin closure over the inverted flap could be achieved, leaving no excess volume above the skin level. Preemptive antibiotic therapy (amoxicillin with clavulanic acid) was administered up to 5 days postoperatively. As refixation of the GT was attempted, postoperative care involved partial weight-bearing with hip flexion restrictions for 8 weeks.

F2FIGURE 2:

Overview of the surgical site as illustrated on the right hip: The patient is positioned on the side to be able to access the posterolateral hip. The flap is best mobilized from the posterior edge of the wound, as gluteal tissues usually can easily be mobilized anteriorly, whereas the skin over the iliac crest or in the inguinal region usually is adherent and cannot be extended. The flap is kept posteriorly pediculated at the level of the subcutaneous tissue. After deepithelization, the flap then is inverted as marked by the green arrow. Finally, the skin is adapted over the flap. As the flap fills a subcutaneous tissue defect, no volume increase is to be expected at the level of the skin.

F3FIGURE 3:

Cross-sectional view of the mobilization of the cutaneous transposition inversion flap: first, a skin island broad enough to obliterate the defect is deliminated. The flap remains pediculated posteriorly through the subcutaneous tissue. Only the dermis should be incised along the posterior edge (downward blue arrow), to allow inversion, but preserving as much as possible the subdermal plexus. Then the flap is deepithelialized (upward blue arrows). Next, the deep layers of the subcutaneous tissue are mobilized, leaving a thin layer of epifascial fat tissue attached to the fascia (purple arrows) to preserve the epifascial vascular plexus. After mobilization, the flap is inverted (green arrow) to obliterate the defect of the femur (black tubular structure) or of the abductors (brown structure).

F4FIGURE 4:

Cross-sectional view after mobilization of the cutaneous transposition inversion flap: the posteriorly pediculated, de-epithelialized flap is inverted (green arrow) and sutured into the defect of the femur (black tubular structure) or the abductors (brown structure), as desired. If necessary and if the subcutaneous tissue allows enough mobilization, the flap may be entirely inverted to fill broader defects. The skin then is adapted without tension with single sutures over the inverted flap. Sufficient epifascial mobilization is mandatory to allow skin adaptation. Resorbable subcutaneous sutures may help decrease tension on the skin. As the flap fills a defect, no excess volume above the level of the skin is caused.

RESULTS

The skin healed uneventfully, without any supplemental volume caused by the flap (Fig. 5). As the patient did not comply with the partial weight-bearing requirements, GT fragments redislocated, and an abductor insufficiency persisted. Already 2 months postoperatively, there was no more TP. The patient could walk without pain in a 4-point gait with crutches. Sitting and sleeping on the operated side was also pain free. The shoulder of the stem was not palpable subcutaneously anymore, and the preoperative trochanteric tenderness had resolved. Pain relief could be confirmed up to the annual follow-up examination, as well as improved range of motion, but abductor insufficiency persisted. Crutches to support gait remained necessary.

F5FIGURE 5:

Picture of the lateral right hip of the 73-year-old female patient 8 months after inversion of the cutaneous transposition flap: due to mobilization of the skin, the posteriorly oriented proximal part of the Kocher-Langenbeck approach was straightened. The stem was not palpable anymore, and preoperative trochanteric tenderness resolved. Note the flap caused no increase of volume above the level of the skin.

DISCUSSION

TP following THA is a common complication with an incidence reported between 1% and 17%.3,4 In this case, subcutaneous protrusion of the prosthetic stem due to a posttraumatic defect of both the greater trochanter and of the abductors caused the symptoms (Fig. 1). Simple activities of daily living such as sitting and sleeping were limited, despite conservative treatment for over a year. As classical reconstructions of the abductors or of the GT were poised to fail due to incompliance of our patient, pain relief by bolstering the prosthesis with a DCTIF was simultaneously attempted. This procedure is limited to the skin and the subcutaneous tissue and no complex reconstruction of the proximal femur or of the abductors is required. This was advantageous in this case, with obesity and lack of comprehension resulting in neglect of postoperative restrictions.

Both reconstruction of the GT and repair of the abductor tendons should be attempted to reduce pain and gait dysfunction postoperatively.6,7,10 However, it was not possible in this case as postoperative pain relief can most likely be attributed to the stem’s coverage with the bolstering flap.

Standard covering flaps for defects in the hip region imply dissection of extended neurovascular structures and involve postoperative weight-bearing limits.11,12 The inversion of the DCTIF takes place without extended exposure of neurovascular structures and the underlying muscles, resulting in reduction of donor site morbidity to a minimum. However, the above-mentioned transfers may have been valid treatment options if postoperative compliance would have been expectable.

Two technical aspects should be considered particularly when mobilizing the DCTIF. First, a thin layer of fat should be left attached to the gluteal fascia to preserve the epifascial vascular plexus. Second, the subdermal plexus should be protected and not be overstretched, to ensure perfusion of the flap (Fig. 3). This may however limit inversion, even if technically a full 180 degrees inversion is possible if the subcutaneous tissue is abundant enough (Fig. 4). The main goal is the replacement of the missing fascia with de-epithelialized dermis.

To the best of our knowledge, this is the first description of a cutaneous transposition inversion flap to cover subcutaneous THA protrusion due to deep tissue defects. Similar flaps were described at other sites by other authors but without extending mobilization as far.13–15

Although flap inversion in the present case was simple and effective, our technique does have limitations. First, potential ineffective healing of the epifascial cavity carries the risk of secondary hematoma or seroma formation, which increases the risk of surgical site infection.16 However, a buried de-epithelialized flap may effectively fill this dead space and avoid the formation of fluid collections.13 Second, transposing the de-epithelialized dermis into deeper levels carries the risk of bringing microorganisms from the deep skin layers in close vicinity to the prosthesis, particularly Cutibacterium spp (formerly Propionibacterium) (Fig. 4).17 Viable Cutibacterium acnes persists in the sebaceous glands and hair bulbs of the dermis despite standard surgical skin disinfection and prophylactic antibiotics.18 Thus, inversion of the cutaneous transposition flap could lead to deep seeding of microorganisms, potentially causing a periprosthetic joint infection (PJI).18 However, de-epithelialization generates a well-vascularized surface with numerous intradermal anastomoses, which may be advantageous. Nevertheless, we administered preemptively antibiotics for 5 days, and no PJI developed. The topical application of vancomycin powder may have also been suited for potentially efficient PJI prophylaxis.19 Third, the extension of the incision is necessary for sufficient skin mobilization. It should be possible to implement the technique described in all standard approaches to the hip with enough gluteal skin redundancy for tension-free closure. Closure of the deep fascia may not be possible in all cases, though not strictly necessary.

Generally, there is only poor evidence of the reproducibility of clinical examination for musculoskeletal hip pain and the danger of overinterpretation of the data.20 In the future, larger studies may reveal other intraoperative and postoperative complications.

So far, no satisfactory reconstruction options for bony defects of the GT or soft tissue defects of the abductors are available, which may result in implant protrusion with following TP. This technical note provides a new therapeutical and surgical approach to TP relief. The DCTIF may release TP symptoms by bolstering the subcutaneous implant protrusion due to deep-tissue defects after THA. The simple DCTIF transfer requires no reconstruction of the abductors or the GT and is feasible without extended neurovascular dissection as in more invasive myocutaneous flaps.

Popularizing this technique should not only help gather more experience in the treatment of THA protrusion resulting in TP. It should rather serve as inspiration for future interdisciplinary larger studies revealing more intraoperative and postoperative advantages and disadvantages of this technique.

REFERENCES 1. Stomberg MW, Öman UB. Patients undergoing total hip arthroplasty: a perioperative pain experience. J Clin Nurs. 2006;15:451–458. 2. Fearon AM, Cook JL, Scarvell JM, et al. Greater trochanteric pain syndrome negatively affects work, physical activity and quality of life: a case control study. J Arthroplasty. 2014;29:383–386. 3. Abdulkarim A, Keegan C, Bajwa R, et al. Lateral trochanteric pain following total hip arthroplasty: radiographic assessment of altered biomechanics as a potential aetiology. Ir J Med Sci. 2018;187:663–668. 4. Skibicki HE, Brustein JA, Orozco FR, et al. Lateral trochanteric pain following primary total hip arthroplasty: incidence and success of nonoperative treatment. J Arthroplasty. 2021;36:193–199. 5. Reid D. The management of greater trochanteric pain syndrome: a systematic literature review. J Orthop. 2016;13:15–28. 6. Whiteside LA. Surgical technique: transfer of the anterior portion of the gluteus maximus muscle for abductor deficiency of the hip. Clin Orthop Relat Res. 2012;470:503–510. 7. Whiteside LA. Surgical technique: gluteus maximus and tensor fascia lata transfer for primary deficiency of the abductors of the hip. Clin Orthop Relat Res. 2014;472:645–653. 8. Kim IS, Pansey N, Kansay RK, et al. Greater trochanteric reattachment using the third-generation cable plate system in revision total hip arthroplasty. J Arthroplasty. 2017;32:1965–1969. 9. Wagner M, Wagner H. The transfemoral approach for revision of total hip replacement. Orthop Traumatol. 1999;7:260–276. 10. Whiteside LA, Nayfeh T, Katerberg BJ. Gluteus maximus flap transfer for greater trochanter reconstruction in revision THA. Clin Orthop Relat Res. 2006;453:203–210. 11. Friji MT, Suri MP, Shankhdhar VK, et al. Pedicled anterolateral thigh flap a versatile flap for difficult regional soft tissue reconstruction. Ann Plast Surg. 2010;64:458–461. 12. Koh PK, Tan BK, Hong SW, et al. The gluteus maximus muscle flap for reconstruction of sacral chordoma defects. Ann Plast Surg. 2004;53:44–49. 13. Kim H, Ryu WC, Yoon CS, et al. Keystone-designed buried de-epithelialized flap. Medicine (United States). 2017;96:e7008. 14. Faenza M, Pieretti G, Lamberti R, et al. Limberg fasciocutaneous transposition flap for the coverage of an exposed hip implant in a patient affected by ewing sarcoma. Int J Surg Case Rep. 2017;41:516–519. 15. Mukherjee S, Thakur B, Morris R, et al. Buried island transposition flap for joint Plastic-Neurosurgical management of spinal wound dehiscence–a technical note and single Centre experience. Br J Neurosurg. 2019:1–5. 16. Saleh K, Olson M, Resig S, et al. Predictors of wound infection in hip and knee joint replacement: results from a 20 year surveillance program. J Orthop Res. 2002;20:506–515. 17. Scholz CFP, Kilian M. The natural history of cutaneous propionibacteria, and reclassification of selected species within the genus propionibacterium to the proposed novel genera acidipropionibacterium gen. Nov., cutibacterium gen. nov. and pseudopropionibacterium gen. nov. Int J Syst Evol Microbiol. 2016;66:4422–4432. 18. Phadnis J, Gordon D, Krishnan J, et al. Frequent isolation of Propionibacterium acnes from the shoulder dermis despite skin preparation and prophylactic antibiotics. J Shoulder Elbow Surg. 2016;25:304–310. 19. Baeza J, Cury MB, Fleischman A, et al. General assembly, prevention, local antimicrobials: proceedings of international consensus on orthopedic infections. J Arthroplasty. 2019;34:S75–S84. 20. Martin RRL, Sekiya JK. The interrater reliability of 4 clinical tests used to assess individuals with musculoskeletal hip pain. J Orthop Sports Phys Ther. 2008;38:71–77.

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