Refinement of Marionette sutures in gastrocnemius muscle flap to achieve early physiotherapy in coverage of complicated knee joint

Introduction
The gastrocnemius muscle flap forms a cornerstone for knee coverage, which has been cemented in literature as the primary option among many authors. Securing the gastrocnemius muscle flap using conventional polydioxanone suture (PDS) sutures delays passive physiotherapy after 2–3 weeks of surgery and active physiotherapy after 3–4 weeks postoperatively for the fear of dehiscence or separation of the flap.
Patients and methods
In this study, Marionette sutures were used to anchor the gastrocnemius muscle flap to the defect edges aiming at starting early passive and active physiotherapy. Marionette sutures were used to anchor the gastrocnemius muscle flap to the defect, skin surrounding the defect is undermined for 1–2 cm all around, and then PDS United States Pharmacopeia (USP) 1 is used on a round needle tip. Alternatively, anchoring of the gastrocnemius muscle flap to the surrounding structures was performed using the classical technique where PDS sutures were used to anchor the muscle flap to the surrounding subcutaneous tissue of the defect.
Results
A case series of 26 patients was performed in the period from January 2017 to January 2020. In this series of 26 patients, 15 patients had Marionette suturing of the gastrocnemius muscle flap, whereas the conventional method with subcutaneous sutures to fix the flap was used in 11 patients. In the 15 patients who had Marionette suturing fixation of the gastrocnemius muscle flap, 14 patients showed ability to start early passive physiotherapy 2 days postoperatively and early active physiotherapy at 7 days after the surgery.
Conclusion
Gastrocnemius flap is the working horse of knee reconstructive surgery, and it can be refined to encourage early physiotherapy using Marionette suturing technique, which showed effectiveness in reliable flap fixation in its recipient site, which helped patients to start early passive and active physiotherapy and avoid the common complication.