Medial Gastrocnemius Flap in the Course of Treatment for an Infection at the Site of a Total Knee Arthroplasty

[Introduction][1] The pedicled medial gastrocnemius flap provides a robust coverage option for most soft-tissue deficiencies over the distal anterior aspect of the knee encountered in the setting of an infection after total knee arthroplasty. [Indications & Contraindications][2] [Step 1: Patient Positioning][3] Position the patient supine with an ipsilateral sterile thigh tourniquet to allow room for harvest of a split-thickness skin graft as needed. [Step 2: Revision Arthroplasty for Infection][4] Perform the arthroplasty to address the underlying deep infection (e.g., irrigation and debridement with exchange of modular components, component removal with antibiotic spacer placement, antibiotic spacer exchange, or second-stage reimplantation) prior to the medial gastrocnemius flap that is utilized for soft-tissue coverage. [Step 3: Incision and Approach for the Medial Gastrocnemius Flap][5] Use one of two different surgical approaches for the exposure and elevation of the medial gastrocnemius muscle and the identification of its vascular pedicle: the medial approach or the posterior midline approach. [Step 4: Elevation of the Medial Gastrocnemius Flap][6] Protect the sural artery pedicle in the popliteal fossa because it is key to raising a viable medial gastrocnemius flap. [Step 5: Transposition and Insetting of the Flap Over the Defect][7] Rotate the flap and transpose it anteriorly over the defect either through a subcutaneous tunnel or by dividing the intervening skin bridge. [Step 6: Closure, Skin-Grafting, and Dressing Application][8] Complete the layered skin closure and place a split-thickness skin graft over the remaining exposed muscle flap and a nonadherent compressive bolster dressing or negative-pressure device over the skin graft to prevent hematoma under the skin graft. [Step 7: Postoperative Care][9] Progress range of motion of the knee once the flap and graft show evidence of survival, while an appropriate antibiotic regimen is completed. [Results][10] We recently reported the largest English-language series, to our knowledge, of medial gastrocnemius flaps performed for soft-tissue coverage in the course of treatment for infection after total knee arthroplasty[13][11]. [Pitfalls & Challenges][12] [Introduction][1] The pedicled medial gastrocnemius flap provides a robust coverage option for most soft-tissue deficiencies over the distal anterior aspect of the knee encountered in the setting of an infection after total knee arthroplasty. [Indications & Contraindications][2] [Step 1: Patient Positioning][3] Position the patient supine with an ipsilateral sterile thigh tourniquet to allow room for harvest of a split-thickness skin graft as needed. [Step 2: Revision Arthroplasty for Infection][4] Perform the arthroplasty to address the underlying deep infection (e.g., irrigation and debridement with exchange of modular components, component removal with antibiotic spacer placement, antibiotic spacer exchange, or second-stage reimplantation) prior to the medial gastrocnemius flap that is utilized for soft-tissue coverage. [Step 3: Incision and Approach for the Medial Gastrocnemius Flap][5] Use one of two different surgical approaches for the exposure and elevation of the medial gastrocnemius muscle and the identification of its vascular pedicle: the medial approach or the posterior midline approach. [Step 4: Elevation of the Medial Gastrocnemius Flap][6] Protect the sural artery pedicle in the popliteal fossa because it is key to raising a viable medial gastrocnemius flap. [Step 5: Transposition and Insetting of the Flap Over the Defect][7] Rotate the flap and transpose it anteriorly over the defect either through a subcutaneous tunnel or by dividing the intervening skin bridge. [Step 6: Closure, Skin-Grafting, and Dressing Application][8] Complete the layered skin closure and place a split-thickness skin graft over the remaining exposed muscle flap and a nonadherent compressive bolster dressing or negative-pressure device over the skin graft to prevent hematoma under the skin graft. [Step 7: Postoperative Care][9] Progress range of motion of the knee once the flap and graft show evidence of survival, while an appropriate antibiotic regimen is completed. [Results][10] We recently reported the largest English-language series, to our knowledge, of medial gastrocnemius flaps performed for soft-tissue coverage in the course of treatment for infection after total knee arthroplasty[13][11]. [Pitfalls & Challenges][12] [1]: #sec-13 [2]: #sec-14 [3]: #sec-17 [4]: #sec-18 [5]: #sec-19 [6]: #sec-20 [7]: #sec-21 [8]: #sec-22 [9]: #sec-23 [10]: #sec-24 [11]: #ref-13 [12]: #sec-25