Pedicled gastrocnemius muscle flap re-elevation in complex knee periprosthetic joint infection: Outcomes and an orthoplastic treatment algorithm.

Abstract

Repeat operative access is common in complex knee periprosthetic joint infection; however, outcomes that are specifically associated with muscle flap re-elevation in this setting are poorly described. We performed a retrospective single-institution review (2010-2024) of patients knee with periprosthetic joint infection (PJI) who underwent muscle flap coverage and subsequent flap re-elevation for repeat knee/periprosthetic access. Re-elevations were analyzed at the event level and outcomes at the patient level. Additionally, we present an institutional orthoplastic treatment algorithm for complex knee PJI incorporating anticipated repeat operative access. Twenty-three patients underwent 39 flap re-elevation events (mean 1.69 per patient; range 1-5). Flaps were viable at re-entry in 38/39 events (97.6%) and were re-inset in all cases. Procedure-level wound complications included superficial dehiscence (7.7%), delayed wound healing (7.7%), draining ulceration (5.1%), and deep dehiscence (2.6%). No cases of partial or total flap loss occurred. At the last follow-up, 15 patients (65.2%) achieved functional joint preservation, and recurrent PJI occurred in 11 patients (39.1%). In complex knee PJI, repeat operative access through a previously inset flap should be anticipated as a routine feature of staged revision care. Muscle flap re-elevation is technically reliable with low flap-specific morbidity. Nonetheless, successful re-elevation does not ensure infection cure or joint preservation, and the outcomes remain strongly shaped by host biology, microbiology, and the ability to achieve durable infection control.