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Infection in a total knee arthroplasty (TKA) is a devastating but rare complication with an incidence of roughly one percent (1). A timely and accurate diagnosis of periprosthetic joint infection (PJI) thorough pre-operative planning and adherence to treatment principles, ideally within a multidisciplinary setting are essential in successful management (2). The decision regarding whether the patient is appropriate for debridement, antibiotics and implant retention (DAIR), single stage or two stage revision is based on many factors including knowledge of the pathogen, component fixation, patient co-morbidities and the surrounding soft-tissue envelope (3). Success rates of a DAIR procedure vary between institutions from 31% to100% when using eradication of infection as the outcome measure (3). Key to the success of any revision procedure for PJI is adequate soft tissue cover and where necessary plastic surgical techniques to facilitate this. Bringing healthy soft tissue into the wound releases tension in the skin around the knee, helps to fill dead space, and adds well-vascularised tissue which is postulated to improve antibiotic delivery to the wound (4). As yet there is no definite evidence that a muscle flap is superior to a skin and fascia flap in the face of infection. The proximity of the gastrocnemius muscle, its convenient anatomy in terms of length and vascular pedicle, and its expendability make it a frequent choice for a flap in this region (5-9). The majority of infected TKAs needing flap cover can be closed with gastrocnemius muscle flaps. In our personal series of forty-six flaps for infected TKA, only two needed flaps other than gastrocnemius: one due to the size of the defect, the second because gastrocnemius had already been used in a previous procedure. Both had free latissimus dorsi reconstructions (unpublished data). It is unusual for the extensor mechanism to be deficient after infection; in our practice this situation more commonly arises after tumour resection from the proximal tibia (4). However, similar reconstructive principles can be applied. Whilst a muscle-alone reconstruction has been described for the patellar tendon using only the fascia around a muscle flap to bridge the tendon gap (10, 11), a common issue with all reconstructive techniques for a failed extensor mechanism in the context of revision arthroplasty or sarcoma is an extensor lag (12, 13). The utilisation of a robust tissue such as a tendon to integrate into the extensor remnant helps to minimise this problem (12, 13). Due to the extensive soft tissue releases associated with revision surgeries often requiring constrained hinged implants, stiffness is not frequently a significant impediment to patient function and outcome (14). Vascularised, autologous tissue is preferable over alloplastic implants in the presence of infection (15). Around the knee, two of the most commonly described vascularised autologous tissue reconstructions are the gastrocnemius muscle with attached Achilles tendon, and a tube of fascia created as part of an anterolateral thigh (ALT) flap. However, any other expendable tendon or dense fascia with a known vascular pedicle can be used. Around the ankle, multiple flaps have been described to reconstruct the Achilles tendon, including local tissue (4) fascia lata (15), adductor magnus tendon Ivyspring

Extensor mechanism reconstruction in the setting of infected total knee arthroplasty