Review Article

Pedicled Rotational Medial and

Lateral Gastrocnemius Flaps:
Surgical Technique

Abstract
Zeke Walton, MD Gastrocnemius flaps have been used for decades to reconstruct defects
Milton Armstrong, MD, FACS of the proximal tibia and knee. They have proven to be useful in the soft-
tissue reconstruction of defects caused by trauma, tumors, and infections
Sophia Traven, MD
about the knee, and the reconstruction of extensor mechanism
Lee Leddy, MD discontinuity with and without total joint arthroplasty. The flaps have low
failure rates and a distinct proximally based blood supply that allows them
to be elevated and rotated up to 15 cm above the level of the knee joint.
The vascular anatomy is reproducible because rotational flaps do not
require microvascular anastomosis. An understanding of the applied
surgical anatomy, approaches, and utility of the gastrocnemius flap
makes the technique a useful tool for the orthopaedic surgeon when
plastic surgery assistance is not readily available.

W hen discussing lower extremity

From the Department of Orthopaedic
Surgery (Dr. Walton, Dr. Traven, and
Dr. Leddy) and the Division of Plastic
and Reconstructive Surgery
(Dr. Armstrong), Medical University of
South Carolina, Charleston, SC.
Dr. Leddy or an immediate family
member has received research or
institutional support from KCI and
serves as a board member, owner,
officer, or committee member of the
American Academy of Orthopaedic
Surgeons and the Musculoskeletal
Tumor Society. None of the following
authors or any immediate family
member has received anything of
value from or has stock or stock
options held in a commercial company
or institution related directly or
indirectly to the subject of this article:
Dr. Walton, Dr. Armstrong, and
Dr. Traven.
J Am Acad Orthop Surg 2017;25:
744-751
DOI: 10.5435/JAAOS-D-15-00722
Copyright 2017 by the American
Academy of Orthopaedic Surgeons.
reconstruction, the leg is
divided into upper, middle, and lower
thirds. The gastrocnemius flap is the
primary muscle flap used in the
reconstruction of the upper third of
the leg. Rotational pedicled gastroc-
nemius flaps have been used for
decades for various reconstruction
needs about the knee. The flaps are
robust muscle and have a unique
blood supply that enables the recon-
struction of defects located up to 15
cm away from the knee joint. The
medial gastrocnemius muscle, lateral
gastrocnemius, or both can be har-
vested. The medial gastrocnemius
muscle is most commonly used
because it is larger. The lateral gas-
trocnemius does not reach defects on
the medial leg because of anatomic
constraints and size differences.
Orthopaedic surgeons have used gas-
trocnemius flaps for reconstruction of
many types of defects, including
defects after tumor resection, soft-
tissue defects resulting from trau-
matic events, and extensor mechanism
defects in native knees and total knee
arthroplasties. In addition, gastrocne-
mius flaps allow for the performance
of soft-tissue reconstruction around
a megaprosthesis, in the setting of
chronic osteomyelitis, around an in-
fected knee prosthesis, and after total
arthrectomy1-15 (Figures 1 and 2).
One gastrocnemius muscle flap or a
combination of muscle flaps allows
the surgeon to cover most anterior
leg wounds about the knee. An
understanding of the anatomy of the
gastrocnemius muscle and the appli-
cation of flaps enables orthopaedic
surgeons to create these flaps in a safe,
reliable manner without the assistance
of plastic surgeons. Moreover, few
problematic functional effects are
encountered when a gastrocnemius
flap is performed correctly.
Anatomy
The medial and lateral gastrocnemius
muscles are located in the superficial

744 Journal of the American Academy of Orthopaedic Surgeons

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
 Zeke Walton, MD, et al

posterior compartment of the leg. Figure 1

They originate from the posterior
medial and lateral femoral condyles,
respectively. The muscles become
confluent with the soleus tendon dis-
tally to comprise the Achilles tendon,
which inserts on the posterior
calcaneus. The muscular portion of
the medial gastrocnemius tends to be
longer than that of the lateral head.
The medial portion extends down to 5
cm above the distal level of the medial
malleolus, and the lateral portion
extends 10 cm above the distal level of
the lateral malleolus.
Two clear independent heads can
be seen proximally in the leg. The A, Intraoperative photograph showing coverage of a 15 cm · 10 cm defect
overlying the medial knee with a medial gastrocnemius flap. B, Clinical photograph
medial sural cutaneous nerve, a showing the medial gastrocnemius flap and the split-thickness skin graft at 3-month
branch of the tibial nerve, exits the follow-up. Changes can be seen on the skin resulting from external beam radiation.
popliteal fossa between these two
heads. It can be used as an anatomic
reference point to identify the mid- to distinguish from each other ocutaneous flap. Each head of the
line superficially. The deep portion distally. gastrocnemius muscle is supplied by an
of the muscle bellies are covered Feldman et al16 described the blood independent branch of the popliteal
with fascia and can be more difficult supply of the gastrocnemius my- artery. The medial sural artery supplies

Figure 2

A, Intraoperative photograph showing the exposed endoprosthesis during tibial resection and reconstruction with a medial
gastrocnemius flap. B, Intraoperative photograph showing coverage of the proximal tibial endoprosthesis with a medial
gastrocnemius flap (black arrow), the use of the tendon for patellar tendon repair, and extensor mechanism reconstruction
with advancement of the anterior compartment to the soleus (white arrow). C, Clinical photograph showing primary closure
of the incision over the drains.

November 2017, Vol 25, No 11 745

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Pedicled Rotational Medial and Lateral Gastrocnemius Flaps: Surgical Technique

Table 1 Imaging
Indications and Contraindications for Gastrocnemius Flaps In the setting of a tumor, a pre-
operative MRI can provide useful
Indications
information about the anatomy of
Soft-tissue defect around the knee or proximal one third of the tibia with exposed
bone, cartilage, or knee capsule that cannot be covered by local advancement flap the tumor and the potential need for
Chronic extensor mechanism disruption with or without total knee prosthesis reconstruction with a gastrocnemius
Exposed, infected total knee prosthesis rotational flap. We do not recom-
Extensor mechanism reconstruction and soft-tissue repair after knee tumor
mend the routine use of preoperative
resection CT angiography for pedicled, rota-
Exposed hardware of the proximal tibia tional gastrocnemius flaps without
Contraindications cause. If the patient previously sus-
Active purulent infection tained an insult to the vascular net-
Soft-tissue defect .15 cm away from the knee joint work of the surgical extremity,
Patient with serious malnutrition resulting in inability to heal surgical insult
preoperative evaluation with CT
angiography may be useful to obtain
more information about the status of
the medial and lateral sural arteries.
the medial head of the gastrocnemius, knee that is not amenable to simpler
and the lateral sural artery supplies the forms of tissue rearrangement or
lateral gastrocnemius muscle belly. simple skin grafting. Rotational Technique
These arteries are 2 to 3 mm in gastrocnemius flaps are most useful
diameter and are accompanied by one for soft-tissue defects over the Medial Gastrocnemius
or two large veins that are 3 to 5 mm in proximal one third of the tibia or When harvesting a medial gastrocne-
diameter. This blood supply originates about the knee joint itself. Indica- mius flap, an incision is made from the
in the popliteal fossa at the level of the tions and contraindications for the medial tibia just posterior to the pes
knee joint, enters the proximal muscle use of gastrocnemius flaps are noted anserine tendons and carried along the
belly, and propagates distally through in Table 1. superficial posterior compartment to
the muscle, providing most of the within 10 cm above the ankle18 (Figure
blood supply to the gastrocnemius, 3, A). The fascia of the superficial
making a flap from this area a Mathes Preoperative posterior compartment is entered and
and Nahai type 1 muscle flap.17 This Considerations released throughout the length of the
unique blood supply enables the compartment (Figure 3, B). The gas-
gastrocnemius muscle to be detached Nutrition trocnemius is separated from the soleus
distally, rotated on the proximal Preoperative assessment of nutri- muscle and freed superficially and
vascular pedicle, and positioned into tional status should be performed deep. This step usually can be com-
place for the reconstruction of defects. before any flap reconstruction with pleted with minimal blunt dissection.
Both bellies of the gastrocnemius or without skin graft. If concern The two heads of the gastrocnemius
are innervated by branches from the exists that the patient is not prepared muscle are readily identified proxi-
tibial nerve in the popliteal fossa. nutritionally for proper healing mally as distinct structures. The sur-
Rotational gastrocnemius flaps can to occur, it may be worthwhile to geon should take care to avoid
be elevated up to 15 cm away from delay the surgery to improve the vigorous dissection centrally between
the knee joint. Compared with a nutritional status of the patient. the two heads of the gastrocnemius
lateral gastrocnemius flap, a medial Simple nutritional laboratory tests, proximally to minimize the risk of
flap typically can reach defects far- such as prealbumin and albumin injury to the artery and vein. It is
ther distal to the knee joint because levels, can used to evaluate the important to be cognizant of the sural
of its longer length and lack of soft- patient’s nutritional status. We con- nerve during this dissection proxi-
tissue interpositions. sider a prealbumin level .17 mg/dL mally because it runs superficially
to be optimal. If the patient is between the medial and lateral heads
Indications nutritionally deplete, a high-protein of the gastrocnemius muscle.
diet can be implemented to restore Distally, the deep fascia of the medial
Gastrocnemius flaps are indicated the patient to normal nutritional and lateral gastrocnemius become
for soft-tissue coverage about the levels before surgery. confluent, which can make them

746 Journal of the American Academy of Orthopaedic Surgeons

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
 Zeke Walton, MD, et al

Figure 3

Illustrations showing the technique used for the harvest of a medial gastrocnemius flap. A, The planned incision begins just
posterior to the pes anserine tendons and is carried along the superficial posterior compartment. B, Superficial dissection
reveals the saphenous vein and nerve. The fascia overlying the superficial posterior compartment is split throughout its
course (dotted line). C, The plane between the gastrocnemius and soleus is developed. The medial gastrocnemius muscle
belly is harvested on its neurovascular pedicle, shown proximally. D, The flap is rotated into the defect over the knee. It can
be tunneled under the skin bridge if necessary. Care is taken to avoid placing the neurovascular bundle under too much
tension. E, The incision is closed over closed suction drains. The muscle belly is covered with a meshed, split-thickness skin
graft, which is covered with a bolster dressing or vacuum dressing.

difficult to distinguish from each other.
However, a close inspection can help
identify the raphe that displays a dif-
ferent orientation of the fascia fibers.
The raphe is released longitudinally
sharply or with electrocautery, begin-
ning at the proximal muscle belly and
carried down to the level of the inser-
tion distally. The flap is then released
distally from the underlying soleus fas-
cia where the gastrocnemius and soleus
become confluent at the proximal edge
of the Achilles tendon (Figure 3, C).
If needed, a hemisection of the
Achilles tendon can be harvested with
the flap to aid in reconstruction. If
additional length is needed, dissec-
tion can be carried proximally along
the muscle belly; the gastrocnemius
flap is then released from the origin
on the femoral condyles, in essence
creating an island flap, thus increas-
ing its arc of rotation and adding 5 cm
of length. Great care must be taken
when releasing the proximal edge of
the muscle to avoid overtensioning
the neurovascular bundle. Other
techniques for increasing flap length
include pie crusting the gastrocne-
mius fascia or removing the fascia
altogether. The remaining attached
distal fascia or Achilles tendon auto-
graft can be used to repair directly
into the overlying capsule or extensor
mechanism (Figure 3, D). The medial
incision is closed primarily over a
drain, and the muscle belly is covered
with a split-thickness skin graft
(Figure 3, E).
Lateral Gastrocnemius
Harvest of a lateral gastrocnemius
flap begins with an incision 2 cm
posterior to and parallel to the fibula,

November 2017, Vol 25, No 11 747

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Pedicled Rotational Medial and Lateral Gastrocnemius Flaps: Surgical Technique
beginning at the level of the fibular
head. This incision is carried distally
to approximately 10 cm above the
distal fibula. Typically, the lateral
head is approximately 3 to 4 cm
shorter than the medial gastrocne-
mius muscle belly. The superficial
posterior compartment is identified,
and the fascia is opened throughout
the length of the compartment. Care
must be taken to identify and protect
the superficial peroneal nerve, which
can be followed proximally to the
common peroneal nerve, which
should be identified early in the dis-
section and protected.
Blunt dissection between the gas-
trocnemius and the soleus and
between the fascia and the lateral
gastrocnemius allows identification
of the lateral gastrocnemius muscle.
Careful blunt dissection is carried
out between the medial and lateral
gastrocnemius muscle bellies prox-
imally. The vessels and sural nerve
are protected similarly to those in
the medial gastrocnemius flap. The
midline raphe is identified, and the
lateral gastrocnemius is released
from the medial gastrocnemius
from proximal to distal. The flap is
released distally from the underly-
ing soleus fascia, where the gas-
trocnemius and soleus become
confluent at the proximal edge of
the Achilles tendon. If needed, a
hemisection of the Achilles tendon
can be harvested with the flap to aid
in reconstruction. The flap can be
rotated superficial to the fibula and
common peroneal nerve. However,
the lateral flap cannot reach to the
same extent as that of the medial flap
because of the restraints of the fibula
(if intact) and the shorter anatomy of
the muscle belly of the lateral
gastrocnemius. If needed, the origin
from the lateral femoral condyle can
be released to increase the length of
the flap. The lateral incision is closed
over a drain, and the muscle belly is
covered with a split-thickness skin
graft.
748
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Postoperative Care
Postoperative care varies, depend-
ing on the patient and the indication
for a gastrocnemius flap. If a skin
graft is present, it can be covered
with a bolster dressing or vacuum
dressing postoperatively. The bol-
ster or vacuum dressing typically is
removed 5 to 7 days postoperatively
for evaluation of the skin graft. If
the graft is adherent and remains
viable, it is coated with antibiotic
ointment and covered with a non-
adherent gauze and tape. This pro-
cess is repeated once per day at
home. We usually immobilize the
patient in a postoperative short leg
splint for 1 to 2 weeks to minimize
shear stress on the skin graft, espe-
cially if the patient has a skin graft
overlying the muscle belly. Weekly
follow-up is typical for patients
with a skin graft to ensure that re-
epithelialization is occurring. Typi-
cally, touch-down weight bearing is
ordered until the flap and/or skin
graft has completely healed. After
healing, physical therapy typically is
implemented to promote progressive
weight bearing and range of motion
(ROM) of the patient’s knee and ankle.
The underlying pathology and the
reason for reconstruction will help
guide this process. For example, in
patients undergoing an extensor
mechanism reconstruction, we typi-
cally use a cylinder cast post-
operatively for 6 to 8 weeks to allow
for complete consolidation of the graft
before physical therapy.
Outcomes
Using a medial gastrocnemius flap for
soft-tissue reconstruction about the
knee is a common way of achieving
coverage for several different types
of defects. Outcomes of these
local rotational muscle flaps are
generally good, especially in complex
skeletal and soft-tissue reconstruc-
Journal of the American Academy of Orthopaedic Surgeons
tion. Reports of outcomes for this
flap are limited in the literature, and
studies often are small series or case
reports. Most series are organized
around the indication for the flap.
Functional Donor Site
Morbidity
Kramers-de Quervain et al19 examined
five patients who had undergone a
gastrocnemius flap procedure to
determine what functional deficits were
present following recovery. Gait anal-
ysis revealed no donor site morbidity,
indicated by normal gait patterns at a
free, patient-selected walking speed. At
higher walking speeds, a decrease in
push-off strength by a mean of 7.3%
was noted. During uphill walking,
patients had a shorter stride on the
contralateral side to reduce the demand
on the posterior calf muscles on the
surgical side. This reduction in stride
length measured approximately 5%.
Overall, the authors of the study con-
cluded that the functional donor site
morbidity after harvest of one head of
the triceps surae is mild in patients who
have recovered completely from their
injuries. They also noted that normal
level gait is possible.
Total Knee Arthroplasty
Several small case series report the
outcomes of local rotational gastroc-
nemius flaps for soft-tissue complica-
tions associated with total knee
arthroplasty (TKA). The clinical
scenario is often an infected TKA
or extensor mechanism disruption.
Gerwin et al5 studied 12 patients
with exposed or infected total
knee implants. All patients had medial
gastrocnemius flaps. Half of the
patients had the implants removed,
and half retained the implants with the
use of intravenous antibiotics. Of 12
patients, 11 had an excellent outcome
and no flap failures. One patient went
on to amputation because of persistent
drainage. McPherson et al8 reported
on a relatively large series of 21

patients with late, chronic infection
of their TKAs who underwent a two-
stage reimplantation with a gastroc-
nemius flap. Of 21 patients, 20 were
immunocompromised hosts. The
authors obtained good clearance of the
infection, with 20 patients having no
further infection at final follow-up.
A medial gastrocnemius flap readily
can be used to reconstruct the knee
extensor mechanism. Jaureguito et al1
examined seven patients with good
functional outcomes. They reported
substantial improvement in Knee
Society Scoring System scores
(from 16 to 82) and ROM (from
70 to 100). Extensor lag declined
from 53 to 24. All patients experi-
enced decreased need for an assistive
walking device. Busfield et al3
described outcomes in nine patients
with gastrocnemius flaps used for
extensor mechanism reconstruction.
Seven patients underwent follow-up
and two did not undergo arthro-
plasty. The postreconstruction exten-
sor lag was 13.5, and the average
ROM was 2 to 93. All patients had
sufficient extensor function for inde-
pendent ambulation.
Reconstruction After Tumor
Resection
A frequent indication for a
gastrocnemius flap is a large
oncologic resection around the knee,
particularly at the proximal tibia,
where the extensor mechanism of the
knee inserts and where little soft-tissue
coverage exists on the anterior medial
border of the extremity. The proximal
tibia is one of the more difficult sites for
orthopaedic surgical oncologists to
reconstruct because of the lack of soft-
tissue coverage present after large
oncologic resections. Grimer et al11
demonstrated a reduction in the
infection rate after proximal tibia
resection and endoprosthetic recon-
struction with a medial gastrocnemius
flap. In 151 patients who underwent
endoprosthetic reconstruction after
November 2017, Vol 25, No 11
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tumor resection, the authors reported
a decrease in infection rates from
36% to 12% after using a medial
gastrocnemius flap. The risk of revi-
sion surgery was 70% at 10 years.
Anract et al12 reported that nine
patients who underwent extra-
articular resection of skeletal sarco-
mas around the knee had a medial
gastrocnemius flap to aid in soft-
tissue coverage. The mean Musculo-
skeletal Tumor Society (MSTS) score
was 61%. Knee flexion averaged 62,
and mean extensor lag was 12. The
authors noted poorer outcomes if the
proximal tibia was resected.
Jentzsch et al20 reported on 16
patients who underwent proximal
tibial reconstructions with gastrocne-
mius flaps. The patients were followed
for at least 2 years, with 14 patients
remaining at the time of the study.
Patella alta developed postoperatively
in 11 patients, and they were more
likely to have an extensor lag and
lower MSTS scores.
Buchner et al7 reported the midterm
results of 25 patients who underwent
proximal tibia resections with endo-
prosthetic reconstruction combined
with a medial gastrocnemius flap. The
mean MSTS score was 75%. None of
the patients had severe pain, and only
two patients had moderate pain. The
mean extensor lag was 6, and four
patients had an extensor lag .20.
Complications
Gastrocnemius rotational flaps often
are used in high-risk, complicated
surgical reconstructions about the
knee. The complications can vary,
depending on the surgical indication.
Commonly, this flap is used in several
scenarios: to reconstruct extensor
mechanism defects, in traumatic
soft-tissue defects with or without
fracture, following bone sarcoma
resection (commonly of the tibia), or
to provide soft-tissue coverage over
a previously infected TKA. The
Zeke Walton, MD, et al
definitions and the severity of com-
plications can vary. Major complica-
tions often are defined as complete or
partial flap loss. Minor complications
often are associated with repeat
procedures, such as débridements
or repeat skin grafts. Reported com-
plications associated with
gastrocnemius rotational flaps are
summarized in Table 2.
Complications Associated
With Traumatic Defects and
Total Knee Arthroplasty
Reports of complications associated
with medial or lateral gastrocnemius
flaps are more common for soft-tissue
defects associated with a fracture.15
In a report of patients with 30 medial
gastrocnemius flaps, 7 flaps had
necrosis (5 complete loss and 2
partial loss).15
Common indications for
gastrocnemius flaps include coverage
for an infected TKA or for use as an
aid in extensor mechanism recon-
struction. Jaureguito et al1 reported on
seven patients in whom the flap was
used to reconstruct the extensor
mechanism after TKA. They reported
two complications, including the need
for manipulation under anesthesia and
one partial flap necrosis that was
managed with débridement and a
revision skin graft. Gerwin et al5 used
a medial gastrocnemius flap for
exposed or infected TKAs in 12
patients. They reported no failures of
the graft or the need for revision. One
patient required amputation for per-
sistent infection. McPherson et al8 re-
ported the results of a series of 21
patients undergoing two-stage re-
implantation for infected TKAs with
medial gastrocnemius flaps. They
observed 25 complications in 13
patients; 8 patients had no complica-
tions. Complication rates were higher
in patients with a history of reflex
sympathetic dystrophy and diabetes
mellitus. Busfield et al3 reported on
medial gastrocnemius flaps used for
749
Pedicled Rotational Medial and Lateral Gastrocnemius Flaps: Surgical Technique

Table 2
Reported Complications of Gastrocnemius Rotational Flaps
No. of Mean Flexion Mean Extensor Functional
Study Patients Complications (degrees) Lag (degrees) Score (MSTS)

Buchner 25 1 graft necrosis 60 6 75%

et al7
Chim et al21 10 3 minor wound healing problems NR NR NR
Anract et al12 9 2 infections, 1 extensor 62 12 61%
mechanism failure
Grimer 151 26 amputations, 28 infections 104 30 77%
et al11
Busfield 9 1 amputation, 1 failure, 1 revision 93 13.5 NR
et al3 for instability, 1 wound
breakdown

MSTS = Musculoskeletal Tumor Society Score, NR = not reported

extensor mechanism reconstruction in
nine patients, seven with TKAs and
two without. The authors reported
one death in the postoperative period
and one patient who required a
transfemoral amputation for refrac-
tory reflex sympathetic dystrophy. In
the remaining seven patients, the
average ROM was 2 to 93, and the
average extensor lag was 13.5. They
also observed one wound breakdown,
one failed extensor mechanism
reconstruction requiring another flap,
and the development of flexion insta-
bility requiring conversion to a con-
strained prosthesis in one patient.
Complications Associated
With Reconstruction After
Tumor Resection
Massive prostheses often are used for
skeletal reconstruction after tumor
resection about the knee. A medial
gastrocnemius flap commonly is used
to provide vascularized soft tissue
and to assist in extensor mechanism
repair, particularly after proximal
tibia resection. Anract et al12 exam-
ined nine patients with muscle flap
reconstruction after extra-articular
resection about the knee. Compli-
cations included two deep infections
and one extensor mechanism rup-
ture. Buchner et al7 reported on 25
patients who underwent surgery for
proximal tibia malignant bone
tumors and received a medial
gastrocnemius flap. One patient had
a deep infection and flap necrosis of
the transposed gastrocnemius flap
10 days postoperatively. This flap
was revised with additional muscle
transfer. One other deep infection
was reported, but the flap was not
compromised.
Summary
Gastrocnemius flaps are useful,
robust flaps for reconstructing many
types of defects about the knee. These
flaps have good functional results in
many settings but can have compli-
cations. In the absence of readily
available plastic surgery assistance,
simple rotational flaps are fairly
straightforward and can be per-
formed safely and reliably. When a
revision flap is required or creation of
a flap is not straightforward, plastic
surgical consultation should be ob-
tained to aid in reconstructive surgi-
cal planning and execution.
References
Evidence-based Medicine: Levels of
evidence are described in the table of
contents. In this article, references 6,
9, and 14 are level III studies. Ref-
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19-21 are level IV studies. References
2, 10, and 16-18 are level V expert
opinion.
References printed in bold type are
those published within the past 5
years.
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