The role of the gastrocnemius flap in implant retention strategies for acute periprosthetic joint infection following total knee arthroplasty: a systematic review

Acute periprosthetic joint infection (PJI) represents a major cause of early failure following total knee arthroplasty (TKA). In selected cases, implant retention strategies such as debridement, antibiotics, and implant retention (DAIR), including modified techniques such as debridement, antibiotic pearls, and retention of the implant (DAPRI), may be considered. However, the success of these approaches is strongly influenced by the condition of the surrounding soft tissues. In the presence of compromised or tenuous wound conditions, soft tissue reconstruction may play a critical adjunctive role. This review aims to evaluate the role of the gastrocnemius flap as an adjunct to implant retention strategies in the management of acute PJI following TKA. A systematic review was conducted in accordance with PRISMA guidelines. After screening 27 studies, five retrospective case series met the inclusion criteria, comprising a total of 73 patients with a mean follow-up of 48.7 months. The medial gastrocnemius flap was the most used technique, accounting for approximately 70% of cases. Infection clearance rates ranged from 66% to 77%, while prosthesis retention was achieved in nearly 79% of patients. Gastrocnemius flap coverage was applied in conjunction with different PJI treatment strategies, including staged revision procedures and implant retention approaches. Early flap application, particularly when combined with debridement and implant retention in the presence of compromised soft tissues, was associated with improved wound healing and limb salvage, although the level of evidence remains limited. Gastrocnemius flap reconstruction appears to be a useful adjunct in selected patients undergoing implant retention strategies for acute PJI following TKA, particularly in the presence of compromised soft tissue conditions. Nevertheless, the current evidence is based on low-level, non-comparative studies, and definitive conclusions regarding its routine or preventive use cannot be drawn. Further prospective and comparative studies are required to better define indications, timing, and expected outcomes.