Gastrocnemius Flap Reconstruction in Single-Stage Re-Revision Total Knee Arthroplasty for Infection with Soft-Tissue Defects: A Limb Salvage Approach

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BACKGROUND The infection rate after revision knee arthroplasty due to previous infection is substantially higher than after revision for aseptic reasons or after primary total knee arthroplasty, ranging from 9% to 28% within several years of follow-up. Management becomes more challenging in chronic infections with soft tissue defects. The need for flap coverage is associated with higher rates of recurrent infection, reoperation, and even limb loss. Muscle flaps, particularly the gastrocnemius, play a key role in infection control and stable coverage. Radical debridement supported by methylene blue staining and early soft tissue reconstruction improve outcomes and enable future revision surgeries. CASE REPORT This case report presents an 81-year-old man with recurrent periprosthetic joint infection following total knee arthroplasty, managed successfully with a modified single-stage re-revision arthroplasty combined with soft tissue reconstruction. The procedure included radical debridement guided by methylene blue staining, prosthesis exchange, local antibiotic delivery, and coverage using bilateral gastrocnemius muscle flaps and skin grafts. The reconstruction provided durable, vascularized soft tissue coverage, enabling a safe surgical approach during a subsequent re-re-revision after 18 months. Early results are promising, although extended follow-up is required to confirm long-term success. At 12 months postoperatively, after the second re-re-revision, the patient remained pain-free, with no signs of reinfection and with preserved limb function. CONCLUSIONS A modified single-stage knee re-revision with radical bone and soft tissue debridement, aided by methylene blue staining and immediate reconstruction using gastrocnemius flaps was central to the treatment strategy This approach allows safe future revisions through well-vascularized muscle flaps.

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