Systemic factors play an important role in predictable soft-tissue healing. Smoking, obesity, and malnutrition are primary drivers toward poor outcomes. Additionally, poorly controlled diabetes mellitus, peripheral vascular disease, kidney failure, bleeding dyscrasias, and rheumatologic disorders all potentially contribute to poor anterior tissue quality and reliable soft-tissue coverage for the infected total knee replacement.

Further, the use of suction drains in the postoperative period and the need to evacuate postoperative blood and fluid accumulations collectively serve to decompress the anterior soft tissue to afford a more tension-free closure. Postoperative hematoma applies untoward tension to the suture line and deprives the healing surgical site of much needed microvascular blood supply. The diminished oxygen tension at the incision can predictably result in areas of wound necrosis and require surgical débridement.

The surgeon must appreciate the patient factors described above and the end goal of robust, durable soft-tissue coverage over an infected or replanted knee arthroplasty. The process of identifying the myriad factors contributing to the coverage problem, in combination with choosing the appropriate closure modality, is patient specific but should be as thoughtful and as algorithmic as possible.

Generally, this simplest closure is often the best. If a patient’s soft tissues can be approximated and healed primarily, this should be the optimal choice. When patients cannot be closed primarily a methodical approach toward closure should be undertaken-taking into consideration the balance between surgical morbidity and a durable result. The approach to durable soft-tissue coverage in infected total knee arthroplasties lies in a balance between the simplest and the most complicated of methods as deemed most appropriate, given the state of the patient and the character of the wound, surrounding soft tissues, and defect.

Primary closure remains the workhorse and preferred choice among surgeons when faced with a wound that can be closed without undue tension along the suture line. The choice of skin staples versus nondissolvable monofilament suture has yet to be determined. Both are viable options for primary closure. If the wound edges cannot be opposed tension-free or if after primary sutures have been placed, wound ischemia is observed (white edges along the suture line) a second-line option is necessary. In other surgical scenarios, healing by secondary intention (allowing for granulation tissue to populate a defect) is an acceptable option. However, in the setting of joint replacement surgery especially involving the knee, prolonged exposure of the fascia to dressing changes persists as an ongoing vulnerability that may undermine the sterility of the joint and increase the risk of deep infection. For this reason, healing by secondary intention is not advisable.