 KNEE

Gastrocnemius flap reconstruction of soft-

tissue defects following infected total knee
replacement

K. Corten, A soft-tissue defect over an infected total knee replacement (TKR) presents a difficult
B. Struelens, technical problem that can be treated with a gastrocnemius flap, which is rotated over the
B. Evans, defect during the first-stage of a revision procedure. This facilitates wound healing and the
E. Graham, safe introduction of a prosthesis at the second stage. We describe the outcome at a mean
R. B. Bourne, follow-up of 4.5 years (1 to 10) in 24 patients with an infected TKR who underwent this
S. J. MacDonald procedure. A total of 22 (92%) eventually obtained a satisfactory result. The mean Knee
Society score improved from 53 pre-operatively to 103 at the latest follow-up (p < 0.001). The
From London Health mean Western Ontario and McMaster Universities osteoarthritis index and Short-Form 12
Sciences Centre, score also improved significantly (p < 0.001).
London, Ontario, This form of treatment can be used reliably and safely to treat many of these complex
Canada cases where control of infection, retention of the components and acceptable functional
recovery are the primary goals.
Cite this article: Bone Joint J 2013;95-B:1217–21.

 K. Corten, MD, Orthopaedic
Surgeon
Ziekenhuis Oost-Limburg
Genk, Schiepse Bos 6, 3600
Genk, Belgium.
 B. Struelens, MD, Resident
University Hospital Pellenberg,
Weligerveld 1, 3212 Pellenberg,
Belgium.
 B. Evans, MD, Plastic
Surgeon
 E. Graham, MD, Orthopaedic
Surgeon
 R. B. Bourne, MD, FRCS(C),
Orthopaedic Surgeon
 S. J. MacDonald, MD,
Orthopaedic Surgeon
London Health Sciences
Centre, University Campus, 339
Windermere Road, London,
Ontario N6A 5A5, Canada.
Correspondence should be sent
to Dr S. MacDonald; e-mail:
steven.macdonald@lhsc.on.ca
©2013 The British Editorial
Society of Bone & Joint
Surgery
doi:10.1302/0301-620X.95B9.
31476 $2.00
Bone Joint J
2013;95-B:1217–21.
Received 31 December 2012;
Accepted after revision 2 April
2013
Wound breakdown with exposure of the com-
ponents following total knee replacement
(TKR) is an uncommon but serious problem
that can potentially lead to above-knee amputa-
tion in 0.1% of the cases.1,2 When necrosis of
the skin does occur in relation to a TKR, recon-
struction of the soft tissues probably provides
the best chance of successfully retaining the
components.1,3-7 Reconstructive techniques
include fasciocutaneous, myocutaneous or free
flap reconstructions.1,3 Gastrocnemius flap
reconstruction, first described by McCraw, Dib-
bell and Carraway,8 is an attractive option
because this rotational myocutaneous flap can
provide sufficient tissue to cover large soft-
tissue defects over a TKR. However, its use in
salvage of an infected TKR with complicated
wound problems has been rarely reported.9,10
Our aim was to report the results and com-
plications associated with the use of a gastroc-
nemius flap during the first part of a two-stage
revision procedure for the treatment of an
infected TKR.
Patients and Methods
After obtaining ethical approval we identified
in our database 24 infected TKRs in
24 patients with a soft-tissue defect that had
required reconstruction with a gastrocnemius
flap between January 1997 and February
2007. There were ten women and 14 men with
a mean age of 66.1 years (50 to 84). In all, ten
procedures followed a primary TKR and
14 followed a previous revision TKR for asep-
tic loosening. The initial indication for primary
TKR in these patients was osteoarthritis in 20,
rheumatoid arthritis in three and gout in one.
Infecting organisms could be identified in 17
patients (Table I). All the patients in this series
were considered infected, even when no infect-
ing organism could be isolated, because the
implant was in direct contact with the skin.
As part of a two-stage revision, the first
stage comprised removal of the components,
extensive debridement of soft tissues and inser-
tion of a cement spacer (created intra-opera-
tively by the operating surgeon) impregnated
with antibiotics (e.g. vancomycin 3 g and gen-
tamicin 3 g). A plastic surgeon then carried out
the gastrocnemius flap reconstruction with the
patient in supine position (Fig. 1). The medial
(n = 22) or lateral (n = 2) vascular pedicle was
identified and the medial or lateral gastroc-
nemius head was released and brought anteri-
orly through a subcutaneous tunnel. The flap
was sutured to the surrounding soft tissues.
The leg was immobilised in a splint for six
weeks. Intravenous antibiotics were given for
six weeks, followed by a six-week antibiotic-
free interval. In patients without a positive cul-
ture, generic broad spectrum antibiotics were
provided (mostly vancomycin and gen-
tamicin). If the C-reactive protein (CRP) and
erythrocyte sedimentation rate (ESR) remained

VOL. 95-B, No. 9, SEPTEMBER 2013 1217

1218 K. CORTEN, B. STRUELENS, B. EVANS, E. GRAHAM, R. B. BOURNE, S. J. MACDONALD
Fig. 1a
Photographs of an infected wound in the presence of an infected right total knee replacement in a 66-year-old male patient at eight weeks after the
initial procedure, a) pre-revision, showing the infected wound with poor-quality soft tissues, and b) during the first-stage revision procedure, show-
ing the resultant defect requiring a lateral gastrocnemius flap reconstruction.
normal at the end of the antibiotic-free interval and the
cultures from an aspiration of the knee produced no
growth, the second stage was performed at a minimum of
three months after the first stage. The skin incision was
made at the margin of the flap that did not contain the vas-
cular pedicle. The knee was extensively debrided and scar
tissue removed together with the cement spacer. Compo-
nent trials were inserted and the knee was tested for stabil-
ity and range of movement. The revision implant was then
inserted and a second trial of stability testing was done. The
final insert was than inserted. The wound was extensively
washed out and closed in layers. The wound could be
closed without tension in all cases. A drain was left in all
cases. Full weight-bearing and full range of movement was
allowed immediate post-operatively.
All patients were assessed for the viability of the flap fol-
lowing the first- and second-stage revisions, for retention of
the components and for any complications. The functional
outcome was assessed using the Knee Society score (KSS;
comprising function and knee subscores and cumulative
total score),11 Short-Form (SF)-12 score12 and Western
Ontario and McMaster Universities osteoarthritis index
(WOMAC).13 In addition, outcome was analysed in rela-
tion to the patient’s age, gender and risk factors for wound
complications, including a history of diabetes mellitus, cor-
ticosteroid use, rheumatoid arthritis, hypothyroidism,
chronic renal failure and peripheral vascular disease. Stand-
ing anteroposterior (AP) and lateral radiographs of the
knee were obtained and assessed by an author (EG) for any
signs of component loosening (such as radiolucent lines
around both components) at six weeks, one year and at
final follow-up.
Statistical analysis. Analyses were performed using SAS
software v9.2 of the SAS System for Windows (SAS Insti-
tute Inc., Cary, North Carolina). Paired Student’s t-tests
Fig. 1b
with a significance level of p < 0.05 were used to compare
the pre- and post-operative functional scores.
Results
The mean follow-up was 4.5 years (1 to 10) following the
second stage. Four patients were lost to follow-up at time of
review with a minimum follow-up of one year. The flaps
healed in 22 of 24 knees (92%), and 22 knees were success-
fully reconstructed (Table I).
The mean range of flexion at the latest review was 99°
(60° to 105°). The total mean KSS improved from 53 pre-
operatively to 103 at latest follow-up and the scores were
graded as good in 16 patients (66.6%), problematical in
five (21%), and a failure in three (12.4%).14 The mean
WOMAC score improved from 43 pre-operatively to 51 at
the final follow-up. The mental and physical components of
the SF-12 score had also improved (Table II).
There were three major complications related to the sur-
gery. The first was in a 78-year-old woman (patient 19 in
Table I) with a history of rheumatoid arthritis, steroid
dependence and smoking. She presented two years after a
primary TKR with a chronic sinus tract. Escherichia coli and
Pseudomonas was identified from the aspiration fluid. The
wound broke down six weeks after the first-stage procedure
with the medial gastrocnemius flap. A quadriceps advance-
ment flap was then carried out by a plastic surgeon, followed
by several debridements. Eventually an arthrodesis was
undertaken, but this went on to a stable fibrous nonunion.
No further intervention is currently planned.
Secondly, a 53-year-old man (patient 7 in Table I) with
insulin-dependent diabetes developed an infection with
Staphylococcus aureus five years after a primary TKR. A
staged revision with a medial gastrocnemius flap was carried
out in 2003. In 2004 there was a further infection with the
same organism, and in 2007 he underwent another staged
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 GASTROCNEMIUS FLAP RECONSTRUCTION OF SOFT-TISSUE DEFECTS FOLLOWING INFECTED TOTAL KNEE REPLACEMENT 1219

Table I. Overview of the patient population

Patient Gender Age (yrs) Follow-up (yrs) Infecting species Flap healing
1 Male 70 7 Pasteurella Yes
2 Female 63 4 - Yes
3 Male 68 4 Staphylococcus No
4 Male 60 4 Staphylococcus No
5 Female 66 2 Staphylococcus Yes
6 Male 84 5 Staphylococcus Yes
7 Male 53 4 Staphylococcus Yes
8 Male 61 3 Enterococcus Yes
9 Male 65 3 Streptococcus Yes
10 Female 52 5 Enterococcus Yes
11 Female 80 9 Staphylococcus Yes
12 Male 73 4 Morganella Yes
13 Female 73 7 - Yes
14 Male 53 10 - Yes
15 Male 58 1 Enterococcus Yes
16 Female 63 7 - Yes
17 Female 63 7 - Yes
18 Male 66 2 Pseudomonas Yes
19 Female 78 1 Pseudomonas and Yes
Escherichia
20 Male 50 8 - Yes
21 Female 79 1 Pseudomonas Yes
22 Male 74 1 - Yes
23 Male 63 5 Staphylococcus Yes
24 Female 71 3 Staphylococcus Yes

Table II. Overview of the mean outcome scores pre-operatively and at final
follow-up (ranges not available)

Evaluation* Pre-operative score Final follow-up p-value†

Knee Society score
Function 20.71 35.0 < 0.001
Knee 31.18 67.53 < 0.001
Total 53.00 102.53 < 0.001
Short-Form 12
Mental 47.69 49.76 < 0.001
Physical 28.24 32.17 < 0.001
WOMAC*
Pain 46.00 56.88 < 0.001
Stiffness 35.00 42.19 < 0.001
Function 43.82 49.45 < 0.001
Total 42.88 51.04 < 0.001
* WOMAC, Western Ontario and McMaster Universities osteoarthritis index
† t-test

revision with a hinged implant. The flap survived all five pro-
cedures and the range of movement was between 0° to 110°.
Thirdly, a 58-year-old man (patient 15 in Table I) was
treated in 2006 with a medial gastrocnemius flap after
many revision operations for recurrent infection of a TKR.
The flap broke down and a latissimus dorsi free flap was
used to close the defect, performed by a plastic surgeon. He
subsequently developed multiple sinuses and is currently
considering having an above-knee amputation.
Discussion
The achievement of adequate soft-tissue cover at revision of
a TKR for infection can be difficult. Our results suggest
that reconstruction using a gastrocnemius flap is a valuable
option. This flap was first described as a rotational myocu-
taneous flap that could be used to cover defects over the
knee joint.8 The entry point of the dominant vascular pedi-
cle determines the mobility of the lateral or medial gastroc-
nemius island flap. The medial gastrocnemius territory
extends to within 5 cm of the medial malleolus. It supplies
the overlying skin, as well as a significant amount distal to
it. The region at the lateral side is smaller. Both heads are
quite reliable as skin-muscle flaps, with the larger medial
head having a wider arc of rotation. The usual size of the
flap is about 8 × 30 cm and its axis of rotation is at the tib-
ial tubercle.15,16 The medial and lateral heads each receive a

VOL. 95-B, No. 9, SEPTEMBER 2013

1220 K. CORTEN, B. STRUELENS, B. EVANS, E. GRAHAM, R. B. BOURNE, S. J. MACDONALD
single vascular branch from the sural arteries, which enter
at the level of the knee joint. The arc of the flap is the upper
half of the calf, the knee, the popliteal fossa and the lower
femur. Sensation in the flap is poor, but the functional loss
and comorbidity are usually minimal because of the com-
pensation provided by the remaining soleus and hemi-gas-
trocnemius muscles.17,18 The medial flap is generally
preferred because of its easy surgical accessibility and
slightly wider range of coverage possibilities. In cases in
which the defect is exclusively lateral, a lateral flap is pre-
ferred – however, this is rarely required. The peroneal nerve
can be jeopardised in case of a lateral flap.
Our results compare favourably with those of other
series of flap reconstructions. Recurrent infection is the
most frequent reason for failure in all series. Menderes et
al4 followed 17 patients treated for a soft-tissue defect for a
mean of 20 months (1 to 61) and found Staph. aureus and
Pseudomonas aeruginosa as the most common organisms
in 12 patients (71%) with a wound infection. In eight
patients a gastrocnemius flap reconstruction was under-
taken for large defects. They concluded that early aggres-
sive debridement and flap coverage were the reasons why
only one implant was revised in this group. Markovic et al5
followed 12 patients, six of whom were treated with a
medial gastrocnemius flap, with successful results in ten
patients (83%) at a mean follow-up of four years. They
described four patients with a prophylactic muscle flap and
another four patients, treated with a free flap because of
chronic infection after total knee arthroplasty. Because of
wound dehiscence, persistent drainage or acute infection in
another four patients, post-operative salvage muscle flaps
with a medial gastrocnemius rotational flap were per-
formed within three weeks after the arthroplasty. In this
group, the mean range of movement was 89°. In all four
patients, prosthesis components were retained. One patient
died 14 months after the procedure. In addition, it was con-
cluded that ‘chronic infection’ was a poor prognostic factor
because two of four chronically infected TKRs had a recur-
rent infection. However, in these cases, a free flap was used.
Nahabedian et al19 evaluated the outcomes of 20 medial
gastrocnemius flaps in 29 knees treated for complex wound
problems following TKR. Deep infection was seen in 12 of
29 knees (41%) of patients. In 11 cases, a medial gastrocne-
mius flap was used, and a free rectus abdominis flap was
transferred in one knee. In seven knees, the result was opti-
mal. Complications occurred in five knees, leading to an
arthrodesis in two knees, two-stage revision arthroplasty in
one case and flap advancement in another patient. The fifth
patient died. Complex wounds were present in 17 knees
(59%) without infection. In 15 knees, (52%), wound dehis-
cence and poor tissue healing occurred. In eight cases a
medial gastrocnemius flap was used, a fasciocutaneous flap
was chosen in four patients, local wound care was sufficient
in two knees and in one case a skin graft was sufficient. The
primary result was excellent in 11 knees (73%), although an
additional intervention was needed in the remaining cases.
Finally, in two knees, haematoma formation resulting in
complex wound dehiscence resulted in a fasciocutaneous
flap in one case and a medial gastrocnemius flap in another.
Overall, deep infection was treated with a gastrocnemius
flap in 11 cases. The final outcome was excellent in eight
cases, although an additional intervention was needed in one
knee. In the remaining knees, ongoing infection ultimately
led to a two-stage re-implantation procedure in one knee and
an arthrodesis in two. The authors recommended irrigation,
debridement and cover using a medial gastrocnemius flap as
the treatment of choice for managing wound problems
around the knee involving exposed bone or prosthesis com-
ponents.19 Superficial wounds larger than 4 cm can be
treated with fasciocutaneous flaps, while smaller wounds
may be managed with local wound care or skingrafts.
Although we agree that the medial flap is useful and to
some extent can provide greater coverage, we think that the
flap should be chosen in relation to the size and position of
the defect. Lateral flaps should only be used in defects lat-
eral to the patellar tendon. Another study reported the
components of the TKR were retained in 19 of 25 patients
(76%) at a mean follow-up of 5.4 years.20 Staphylococcus
species and Pseudomonas were the most common organ-
isms. There was one amputation, and five patients (20%)
required arthrodesis, but ten of 15 patients (66.6%) with
infection healed following a muscle flap. A medial gastroc-
nemius flap was used in 14 knees, with infection healing in
eight. In this study, fasciocutaneous flaps seemed more effi-
cient than muscle flaps. However, the latter are used for
major dehiscence while fasciocutaneous flaps are used in
small defects. Finally, in another study involving nine
infected TKRs treated with a gastrocnemius flap, it was
concluded that older age and steroid therapy were risk fac-
tors for wound breakdown. The authors concluded that the
flap was long enough, versatile and safe.9
The above findings support our conclusion that recur-
rent infection after flap reconstruction has a poor progno-
sis. All our flaps re-vascularised, but patients with larger
defects or those in whom a gastrocnemius reconstruction
has failed might require other reconstructive options, such
as a latissimus dorsi reconstruction. Experience of 16 free
myocutaneous latissimus dorsi transfers in 14 patients with
a large defect has been described.21 These patients had
undergone a mean of ten previous procedures before the
latissimus dorsi transfer. All the flaps survived, but an addi-
tional latissimus dorsi flap was required in two patients
with insufficient soft-tissue coverage. The authors con-
cluded that a free myocutaneous flap should only be used
when a gastrocnemius flap would not cover the defect.21
Hallock6 reported the combined use of a chimeric gastroc-
nemius muscle and sural artery perforator local flap in two
large soft-tissue defects. The technique facilitated oblitera-
tion of the empty space inside the knee cavity, while also
allowing for tension-free skin closure, with each part
retaining an independent blood supply. Another advantage
of such a combined flap is that it can be twisted and
THE BONE & JOINT JOURNAL
 GASTROCNEMIUS FLAP RECONSTRUCTION OF SOFT-TISSUE DEFECTS FOLLOWING INFECTED TOTAL KNEE REPLACEMENT
oriented to close the wound optimally with tension-free
margins and without endangering its vascularity.6,7
In conclusion, early and aggressive debridement in con-
junction with a reconstruction of the soft tissue defect using
a gastrocnemius flap during the first stage revision TKR
allowed a successful second stage to be undertaken in 22
patients (92%) with a previously infected TKR at a mean
follow-up of 4.5 years. The flap reliably re-vascularised and
survived the second stage. Recurrent infection following
flap reconstruction has a poor prognosis for survival of the
arthroplasty.
No benefits in any form have been received or will be received from a commer-
cial party related directly or indirectly to the subject of this article.
This article was primary edited by G. Scott and first-proof edited by D. Rowley.
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