Related Experiment Video
Updated: Apr 28, 2026
Harvesting of Peroneus Longus Tendon Autograft
Published on: September 2, 2025
Promising Clinical Outcomes Using Rotational Achilles Autograft for Knee Arthroplasty Terrible Triad
Katherine J Montoya1, Randall R Rainwater2, C Lowry Barnes3
1Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas.
Background:
The knee arthroplasty terrible triad (TT) is a combination of periprosthetic joint infection, 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 rotational 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 end point was composite functional success, defined as retention of the in situ arthroplasty without infection recurrence, ≥ 90° knee range of motion, ≤ 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 to 83 years) with a mean follow-up of 1.9 years (range one to 4).
Results:
Composite functional success was achieved in eight of 19 patients. There were two patients who 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 to 52.5) to 57.5 (range 39.0 to 71.0). There were three patients who experienced GARF-related complications, including one who required wound debridement and two who were managed with local wound care.
Conclusions:
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.
