JOA - 2026-04-24 - Journal Article
Promising Clinical Outcomes Using Rotational Achilles Autograft for Knee Arthroplasty Terrible Triad.
Montoya KJ, Rainwater RR, Barnes CL, Edwards PK, Tait MA, Bracey JW, Stambough JB, Mears SC, Stronach BM
Topics
Key Takeaway
Rotational gastrocnemius-Achilles flap combined with two-stage revision achieved composite functional success in 8/19 (42%) patients with the knee arthroplasty terrible triad, with a 16% above-knee amputation rate.
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Summary
This study evaluated the rotational gastrocnemius-Achilles flap (GARF) combined with two-stage revision for the knee arthroplasty terrible triad—concurrent PJI, extensor mechanism insufficiency, and soft-tissue defect—in 19 patients. Composite functional success (retained arthroplasty without infection recurrence, ≥90° ROM, ≤15° extensor lag, independent ambulation at one year) was achieved in 42% of patients; 3 required above-knee amputation and 2 underwent knee fusion. KOOS-JR scores improved from 31.8 to 57.5, and 13/19 patients achieved independent ambulation with assistive devices.
Key Limitation
With only 19 patients and no comparative cohort, the claim of superiority over traditional extensor mechanism reconstruction and wound coverage techniques is unsupported by the study's own data.
Original Abstract
BACKGROUND
The knee arthroplasty terrible triad (TT) is a combination of periprosthetic joint infection (PJI), extensor mechanism insufficiency, and soft-tissue defect. The TT is a limb-threatening condition that has historically poor functional results and high probability of amputation or fusion. The rotational gastrocnemius-Achilles flap (GARF) holds promise as native soft-tissue to provide coverage and muscular power to assist with knee extension. We hypothesized that application of the GARF in conjunction with two-stage revision improves functional and limb-salvage outcomes compared to previous rates.
METHODS
A retrospective chart review was performed on 19 patients who had a TT and underwent GARF between January 2020 and December 2024. The primary endpoint was composite functional success, defined as retention of the in situ arthroplasty without infection recurrence, ≥90° knee ROM, ≤15° extensor lag, and independent ambulation at one year. Secondary outcomes included amputation rate, GARF complications, and patient-reported outcomes. The mean age was 66 years (range 51-83) with a mean follow-up of 1.9 years (range 1-4).
RESULTS
Composite functional success was achieved in eight of 19 patients. Two patients underwent knee fusion and three required above-knee amputation. There were 13 patients who were independently ambulatory with assistive devices. Knee injury and Osteoarthritis Outcome Score Joint Replacement scores improved from a mean of 31.8 (range 0-52.5) to 57.5 (range 39.0-71.0). Three patients experienced GARF-related complications, including one who required wound debridement and two who were managed with local wound care.
CONCLUSION
A gastro-Achilles rotational flap is a safe and promising treatment for TT that yields superior early composite functional outcomes and improved limb salvage compared to traditional extensor mechanism reconstruction and wound coverage techniques. Extended follow-up is required to assess sustained treatment success.