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This chapter describes a technique for reconstruction of the knee extensor mechanism disruption after total knee replacement (TKR). Disruption of the knee extensor mechanism is an infrequent but serious complication. The options for treatment include observation, bracing, fixation with sutures or staples, autologous-tissue augmentation with use of the semitendinosus or gracilis tendon, turndown of the quadriceps tendon and reconstruction with an intercalary allograft. These options have been associated with a high risk of complications and have not addressed the associated problems of contracted devascularized skin flaps or deficient patellar bone stock. The medial gastrocnemius flap has been shown to be suitable for providing soft-tissue coverage of the proximal aspect of the tibia, knee, and distal aspect of the femur. Historically the technique for reconstruction of the extensor mechanism was described for limb salvage after resection of proximal aspect of the tibia for malignant tumors. This described technique is an adaptation of such previously accepted techniques for disruption of the extensor mechanism after total knee arthroplasty (TKA). The use of a medial or an extended medial gastrocnemius flap appears to be a reliable option for reconstruction of a ruptured extensor mechanism after TKA.