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This study was conducted to provide anatomical data and surface markers for the safe and efficient exposure of surgical incisions for harvesting gracilis tendons (GT) and semitendinosus tendons (STT) while avoiding technical pitfalls and nerve injury during harvest for ligament reconstruction.Seventy-four Chinese cadaveric lower limbs were dissected to expose the infrapatellar branch of the saphenous nerve (IPBSN) and pes anserinus (PA). Measurements of the borders and accessory bands of the PA tendons were taken. The arrangement of PA tendons and distribution of the IPBSN were assessed.The PA was roughly shaped like a quadrangle, with its superior border at the horizontal plane of the tibial tuberosity (TT). The GT and STT bifurcation point was located on the medial border of the PA. From medial side to lateral side, the sartorius tendons (ST), GT, and STT fused gradually and formed the lateral border of the PA at the distal end. The tendon arrangement of the PA was primarily affected by ST, which commonly covered GT and STT completely. Variant tendons were found in 41.9% of specimens. The insertion of the accessory bands was distal but close to the inferior border of the PA. Accessory bands were observed only in STT and ST, and STT accounted for the most. The width of the first accessory band of STT was similar to the width of the STT. Additionally, most of the IPBSNs were proximal to the horizontal plane of the TT.For clearly exposing the GT and STT, it is crucial to expose the GT and STT bifurcation point on the medial border of the PA, whether directly or indirectly through the incision.The influence of ST insertion and the variability of tendons within the PA must be paid attention to during the operation. To protect IPBSNs highly, the incision should not be higher than the TT level.

Purpose Treatment of total brachial plexus avulsion (TBPA) is a challenge in the clinic, especially the restoration of hand function. The current main surgical order is from proximal to distal joints. The purpose of this study was to demonstrate the outcomes of “distal to proximal” surgical method. Methods Thirty-nine patients underwent contralateral C7 (CC7) nerve transfer to directly repair the lower trunk (CC7-LT) and phrenic nerve transfer to the suprascapular nerve (PN-SSN) during the first stage, followed by free functional gracilis transplantation (FFGT) for elbow flexion and finger extension. Muscle strength of upper limb, degree of shoulder abduction and elbow flexion, and Semmes–Weinstein monofilament test and static two-point discrimination of the hand were examined according to the modified British Medical Research Council (mBMRC) scoring system. Results The results showed that motor recovery reached a level of M3 + or greater in 66.7% of patients for shoulder abduction, 87.2% of patients for elbow flexion, 48.7% of patients for finger extension, and 25.6% of patients for finger flexion. The mean shoulder abduction angle was 45.5° (range 0–90°), and the average elbow flexion angle was 107.2° (range 0–142°), with 2.5 kg average flexion strength (range 0.5–5 kg). In addition, protective sensibility (≥ S2) was found to be achieved in 71.8% of patients. Conclusion In reconstruction of TBPA, CC7 transfer combined with free functional gracilis transplantation is an available treatment method. It could help patients regain shoulder joint stability and the function of elbow flexion and finger extension and, more importantly, provide finger sensation and partial finger flexion function. However, the pick-up function was unsatisfied, which needed additional surgery.

Purpose Reconstruction of the medial patellofemoral ligament (MPFL) is an established procedure to restore patellar stability. Aim of this study is to evaluate the results of a dynamic MPFL reconstruction technique in a large university hospital setting. Methods Two hundred and thirteen consecutive patients with 221 knees were surgically treated for recurrent lateral patellar dislocation. All patients obtained dynamic reconstruction of the MPFL with detachment of the gracilis tendon at the pes anserinus while maintaining the proximal origin at the gracilis muscle. Patellar fixation was performed by oblique transpatellar tunnel transfer. Follow-up data including Kujala and BANFF score, pain level as well as recurrent patella instability were collected at a minimum follow-up of 2 years. Results Follow-up could be obtained from 158 patients (71%). The mean follow-up time was 5.4 years. Mean pain level was 1.9 ± 2.0 on the VAS. Mean Kujala score was 78.4 ± 15.5. Mean BANFF score was 62.4 ± 22.3. MPFL-reconstructions that were performed by surgeons with a routine of more than ten procedures had a significantly shorter surgical time 52.3 ± 17.6 min. Male patients yielded higher satisfaction rates and better clinical scores compared to females. Complications occurred in 27.2% of procedures, 20.9% requiring revision surgery of which were 9.5% related to recurrent patellar instability. 78% of all patients indicated they would undergo the procedure again. Conclusion Dynamic MPFL reconstruction presents a reproducible procedure with increased complication rates, inferior to the results of static reconstruction described in the literature. Despite, it appears to be an efficient procedure to restore patellar stability in a large university hospital setting, without the necessity for intraoperative fluoroscopy. Trial registration The study was registered in ClinicalTrials.gov with the registration number NCT04438109 on June 18th 2020.

Large penoscrotal defects with exposed testis are a challenge to reconstruct. Muscle flaps provide an excellent option to reconstruct such defects. The aim of the article is to present the authors’ experience in using gracilis muscle flap in the reconstruction of penoscrotal defects following Fournier’s gangrene. All patients with Fournier’s gangrene who underwent a soft tissue reconstruction using unilateral gracilis muscle flap from January 2013 to November 2018 were prospectively included in the study. Patients with exposed testis, penoscrotal defects and dead spaces to fill were included, and exclusion criteria were persistent infection, large defects requiring bilateral gracilis or expected shortfall of coverage using unilateral gracilis muscle. Postop aesthetic assessment was done using modified Vancouver Scar Scale (mVSS) after 6 months by an independent reviewer. Fourteen cases of post Fournier’s gangrene defects were reconstructed by using gracilis muscle flap with split skin graft in a tertiary care hospital. All were male patients. Age ranged from 20 to 72 years with mean age 35.5 years. After debridement and regular dressings, operation was done under general or spinal anaesthesia. All flaps survived well and there were no major complications encountered. All the patients had acceptable aesthetic outcomes on mean follow-up of 13.2 months. The pedicled gracilis muscle flap with split skin graft is a good option for large defects involving penis, scrotum and perineum, especially in Fournier gangrene. This flap offers minimal donor site morbidity and minimal major complications with acceptable cosmetic outcomes. Level of evidence: Level IV, therapeutic study.

Summary Background Despite continuous surgical advances, reconstruction of complex lower extremity wounds remains challenging. The indication of local flaps or microsurgical free tissue transfer depends on the anatomical location and size of the defect, as well as the comorbidities and general condition of the patient. In this study, local and free flap reconstruction of distal lower extremity defects was assessed, and postoperative complications and limb salvage were analyzed. Methods A total of 34 patients were included in this retrospective study. Distal lower extremity defects were of traumatic (29%) and non-traumatic (71%) etiologies. Patient characteristics, flap selection, postoperative complications, and limb preservation within the first 12 months were assessed and compared by reconstructive treatment concept. Statistical analysis included parametric and non-parametric tests. The two-sided alpha was set at 5% for all statistical tests. Results While 21 patients were treated with local flaps, 13 patients underwent microsurgical free flap reconstruction. The most common comorbidities were peripheral vascular disease and diabetes. Local flaps included the gastrocnemius muscle flap, soleus flap, sural flap, and plantaris medialis flap. The most commonly used free flaps for soft tissue reconstruction were latissimus dorsi and gracilis muscle flaps. The overall lower extremity preservation rate was 94.1%. There was one case of below-knee amputation 1 month after free flap reconstruction, and one case of first-ray amputation of the foot after local flap coverage. Conclusion Reconstruction of lower extremity defects can be achieved by local or free flap reconstruction. Flap selection is influenced by anatomical location, defect size, and patient factors.

Hamstrings muscle morphology is determinant of muscle function (i.e. strength). Among individuals with ACL reconstruction (ACLR), less cross-sectional area (CSA) and volume in the ACLR-limb are associated with muscle weakness, and may contribute to lower rates of return to preinjury activity level and an increased risk for long-term sequelae. To effectively treat muscular impairments, an accurate understanding of differences in hamstrings morphology following ACLR is needed. A systematic review and meta-analysis were undertaken to describe the morphology of the hamstring muscle complex after ACLR. We searched five databases for studies evaluating the difference between hamstrings size and architecture in individuals with ACLR. Two independent reviewers assessed each paper for inclusion and quality. Means and standard deviations were extracted from each included study to allow fixed-effect size meta-analysis calculations for comparison of results. Twenty-four studies were included for final review. Eight categories of morphological outcomes were identified, and studies were grouped accordingly: (1) volume, (2) cross-sectional area (CSA), (3) muscle length, (4) muscle thickness, (5) fascicle length, (6) pennation angle, (7) fiber area, and (8) fiber type. Meta-analysis demonstrated lower hamstrings volume in the ACLR-limb in both contralateral and control group comparisons, and lower CSA, length, and thickness in the ACLR-limb in contralateral comparisons. The semitendinosus and gracilis were most profoundly impacted. Limited moderate evidence demonstrated greater biceps femoris pennation angle in the ACLR-limb. Individuals with ACLR demonstrated large deficits in semitendinosus and gracilis muscle CSA and volume in the ACLR-limb compared contralaterally, with no differences observed in the biceps femoris or semimembranosus. Clinical implications regarding assessment and treatment of individuals with ACLR are discussed.

Treatment of chronic osteomyelitis (OM) usually comprises surgical excision of infected bone and soft tissue, dead space management, and soft tissue closure. When soft tissue revision results in defects too large for direct closure, assistance from plastic surgeons is needed. This study reports outcomes for patients with OM treated by plastic and orthopedic surgeons in a one-stage operation with an antibiotic-loaded biocomposite (ALB) and a local or free flap. We report a series of 11 consecutive patients with OM treated from February 2017 to September 2019. The treatment protocol included surgical debridement, tissue sampling, dead space management using ALB, stabilization as needed, and soft tissue closure with a local or free flap. Mean age at surgery was 62 years (39–79), mean BMI 28 kg/m2 (23–39). Multiple comorbidities were present. Local flaps were used in six patients, one reverse lateral arm flap, one soleus flap, two gastrocnemius flaps, one latissimus dorsi flap, and one fascia plantaris flap. Free flaps were used in five patients, three gracilis muscle flaps and two antero-lateral thigh (ALT) flaps. Mean follow-up was 28 months (15–42). Nine patients (81.8%) healed uneventfully after the one-stage surgical intervention, while two patients (18.2%) experienced partial or complete flap necrosis and required additional surgery. No patients required amputation, and no mortalities were reported. One-stage treatment of OM using ALB, performed by a multidisciplinary team, led to zero amputations in a highly comorbid population, where amputation would otherwise have been unavoidable. Level of evidence: Level IV, therapeutic study.

To study the effect of age, duration of injury, type of graft and concomitant knee injuries on return to sports after anterior cruciate ligament (ACL) reconstruction.One-hundred and sixteen athletes underwent ACL reconstruction using either bone-patellar tendon-bone graft (BPTB; n = 58) or semitendinosus-gracilis graft (n = 58), depending upon their random number sequences. Five variables were analyzed in terms of their effect on return to sports-age, type of graft, time interval between injury and surgery, chondral damage and meniscal tears.Fifty-three out of 73 (72.6%) athletes aged between 16 and 25 years and 21/43 (49%) athletes aged between 25 and 40 years returned to sports (p = 0.02). The mean time to return to sports was 9.7 ± 2.1 months and 10.8 ± 1.7 months in athletes aged 25 years and 25-40 years, respectively (p = 0.04). ACL reconstruction with BPTB graft (43/58) was associated with higher rate of return to sports as compared to hamstring tendon graft (31/58; p = 0.02). The mean duration of return to sports with BPTB and STGPI graft was 9.7 ± 2.0 months and 10.7 ± 2.0 months, respectively (p = 0.02). 29/36 (80.5%) patients operated between 2 and 6 months, 18/29 (62%) operated in 2 months, and 27/51 (53%) operated after 6 months of injury had returned to sports (p = 0.03). Athletes who were operated within 2 months of the injury were the earliest to return to sports (9.4 ± 2.1 months), followed by those operated within 2-6 months (9.9 ± 1.9 months) and lastly by the ones operated after 6 months of the injury (10.9 ± 2.1 months; p = 0.04).The rate of return to sports was observed to be higher in athletes younger than 25 years as compared to older athletes ( 25 years). ACL reconstruction with BPTB graft was associated with higher and earlier returns to sports as compared to hamstring graft. The rate of return to sports was highest if surgery was performed between 2 and 6 months after the injury.III.

Rectovaginal, pouch-vaginal, and recto-urethral fistulas are very challenging to treat. Gracilis muscle interposition was shown be an effective treatment for these complex fistulas. The aim of this study was to investigate the feasibility and outcomes of redo gracilis interposition for persistent and recurrent complex perineal fistulas. A retrospective analysis of all patients who had redo gracilis muscle interposition for complex perineal fistulas at our institution from 1995 to 2019 was performed. Nine patients (5 males, mean age 55 years) were included for analysis. The types of fistulas were recto-urethral (n = 5), rectovaginal (n = 2) and pouch-vaginal (n = 2). The success rate was 56% with 5 patients achieving complete healing of the fistula. Only 1 patient (11%) experienced a postoperative complication. Redo gracilis muscle interposition is feasible and safe with promising resultsin healing of complex perineal fistula.

To evaluate the optimal graft tension angles in a medial patellofemoral ligament (MPFL) reconstruction with selective bundle tensioning in order to restore patellofemoral contact pressure distributions closest to the native state. Twelve human cadaveric knee specimens were mounted with the femur on a custom-made fixation device allowing free range of motion in the knee joint for testing. Using a sensitive pressure film (Tekscan) patellofemoral contact pressure was measured in 15° intervals during a dynamic flexion movement from 0°–90° in the native state, in cut MPFL and after MPFL-reconstruction with a gracilis tendon. The graft was separated in two bundles and was fixed independently on the patella using two knotless anchors. Two groups were made with either the proximal or distal bundle fixed at the femur at a knee flexion angle of 30° and the corresponding other bundle subsequently fixed at the femur at 15°, 45°, 60°, 75° and 90° of knee flexion using extra-cortical fixation and controlled tension of 2N in both groups. The sequence of the flexion angles at the graft fixation was alternated. Pressure measurements were repeated after every fixation of the graft. Cutting the MPFL resulted in significantly reduced patellofemoral contact pressure at all flexion angles. After MPFL reconstruction the patellofemoral contact pressure remained significantly reduced during dynamic knee flexion in all tested double-bundle combinations (p

The purpose of this study was to map saphenous nerve injuries after gracilis tendon harvest, with the aim of contributing knowledge that makes it possible to prevent these injuries. Twenty-two cadaver limbs were used. Three were dissected to examine fascial structures between the saphenous nerve and the gracilis tendon. In 19 limbs, the gracilis tendon was harvested according to standard operative routine. The saphenous nerve was subsequently exposed by dissection and injuries were recorded. A well-defined sub-sartorial fascial layer separated the saphenous nerve from the gracilis tendon. Incisional injuries involving either a medial cutaneous crural branch or the infrapatellar branch were found in 14 of the 19 cases. Non-incisional injuries affecting the sartorial branch of the saphenous nerve (to conform to most surgical literature, we use the term 'sartorial branch' to denote the continuation of the saphenous nerve after departure of the infrapatellar branch) were found in six cases located 5–8 cm proximal and posterior to the gracilis tendon insertion on tibia. The fascia separating the saphenous nerve from the gracilis tendon had been perforated in relation to all non-incisional injuries. Small subcutaneous branches of the saphenous nerve are at risk of injury from the incision, while the sartorial branch is at risk outside the incision area. Descriptions of the location of non-incisional injuries have not been published before and are of clinical relevance, as they can contribute to the prevention of saphenous nerve injuries during gracilis tendon harvest.

While free tissue transfer has long been established as a reliable microsurgical technique in the adult population, its application in pediatric reconstruction is a relatively recent phenomenon. Despite initial concerns regarding minute vessel diameters, increased propensity for vasospasm, and limited tissue availability, pediatric free tissue transfer is now a widely used technique that has demonstrated an acceptable level of donor and recipient site morbidity in children. Five flaps commonly used in the reconstruction of lower extremity trauma are discussed in this paper: the latissimus dorsi, rectus abdominis, anterolateral thigh, gracilis, and the subscapular and parascapular flaps. The indications, blood supply, advantages, and disadvantages of each are detailed. Incredible progress has been made in the application of microsurgical techniques to the pediatric population over the last several decades. With a healthy understanding of the anatomy and functionality of the donor site, the reconstructive surgeon can repair a variety of complex injuries with an acceptable morbidity and mortality rate.

Background The aim of this study was to evaluate the effectiveness of gracilis muscle transposition (GMT) to treat recurrent anovaginal, rectovaginal, rectourethral, and pouch–vaginal fistulas in patients with inflammatory bowel disease (IBD). Methods A retrospective study was conducted in patients with IBD who had GMT performed by a single surgeon between 2000 and 2018. Follow-up data regarding healing rate, complications, additional procedures, and stoma closure rate was collected. Results A total of 30 women and 2 men had GMT. In all patients fistula was associated with Crohn's disease. In 1 female patient, contralateral gracilis transposition was required after a failed attempt at repair. The primary healing rate was 47% (15/32) and the definitive healing rate (healed by the time of data collection and after secondary procedures) was 71% (23/32). Additional surgical procedures due to fistula persistence or recurrence were performed on 17 patients (53%).At least 7 patients (21%) suffered complications including one wound infection with ischemia of the gracilis muscle. Stoma closure was successful in 18 of 31 cases of patients with stoma (58% of the patients). Conclusions GMT for the treatment of recurrent and complex anorectal fistulas in patients with IBD patient is eventually successful in almost 2/3 of patients.

BACKGROUND: The surgical management of rectovaginal fistulae associated with Crohn's disease is often frustrated by poor results regardless of the different techniques. The outcomes of the gracilis muscle transposition (GMT) for the treatment of recurrent Crohn's-associated fistulae are still debated. The aim of the study is to determine whether the success rate of GMT is similar in Crohn's disease patients and in a control group. MATERIALS AND METHODS: All patients undergoing GMT for rectovaginal or pouch-vaginal fistula were collected from a prospectively maintained database (2005-2016). The primary study outcome was the comparison of the success rate of GMT in Crohn's disease and control group patients. RESULTS: Twenty-one patients with a rectovaginal fistula due to Crohn's disease (8, 38.1%) or other etiologies (13, 61.9%) were included. The groups had similar characteristics and postoperative outcomes. After a median follow-up time of 81 and 57 months (p 0.34), the success rate of GMT was 75% in patients with Crohn's disease and 68.4% in control group (p 0.6). The median time to recurrence was 3.5 months (1-12). The success rate in patients who had more than two previous attempts of repair was lower regardless of the etiology (50 vs 79.4%, p 0.1). CONCLUSION: GMT is associated with a high success rate, especially in Crohn's disease-related rectovaginal fistula. In consideration of the low morbidity rate and the fact that an increasing number of previous local operations might be associated with failure, the procedure should be considered as a first line of treatment for recurrent rectovaginal fistulae.

Medial patellofemoral ligament (MPFL) reconstruction is often performed using gracilis autografts, which may be associated with donor site morbidity and complications. The use of a synthetic material can circumvent a harvest operation and has previously been demonstrated to be effective in other types of reconstructive procedures and may be effective in MPFL reconstruction. This study reports the clinical result with the use of a modern ultra-high molecular weight polyethylene with a braided jacket of polyester tape (FT) in MPFL reconstruction compared to using standard autografts. Data were collected prospectively in 50 MPFL reconstructions. The first 27 underwent reconstruction using gracilis tendon (GT) autograft; the following 23 patients were treated with FT. All patients were clinically and radiologically assessed and underwent pre- and post-operative scoring using the Kujala score, Bartlett score, Tegner activity rating scale, SF-12 score and Lysholm score. Statistical significance was tested between groups using ANOVA with repeated measures. There were no significant differences in the pre-operative scores between the FT and GT groups (n.s.). Both groups showed significant improvements across all scoring modalities between pre- and post-operative periods 12, 24 and 48 months of follow-up (p

The aim of the present study was to investigate the correlation between postoperative tunnel enlargement after ACLR and remnant tissue preservation using the hamstring tendon. One hundred and ninety-two subjects (male, n = 101; female, n = 91; mean age 27.1) who had undergone double-bundle ACL reconstruction were included in the present study. The patients were divided into two groups: the remnant tissue preservation group (Group R) and the non-remnant tissue preservation group (Group N). Computed tomographic scans of the operated knee were obtained at 2 weeks and 6 months after surgery. The area of the tunnel aperture for the anteromedial femoral tunnel (FAMT), posterolateral femoral tunnel (FPLT), anteromedial tibial tunnel (TAMT), and posterolateral tibial tunnel (TPLT) was measured. The area at 2 weeks after ACLR was subtracted from the area at 6 months after ACLR and then divided by the area at 2 weeks after ACLR. The differences in the outcomes and characteristics of the two groups were evaluated. Seventy-seven knees were classified into Group R, and 115 knees were classified into Group N. The age, gender, and body mass index did not differ to a statistically significant extent. The percentages of FAMT and TAMT enlargement in Group R were significantly smaller in comparison with Group N (P = 0.003 and P = 0.03, respectively). The percentage of FPLT and TPLT enlargement in the two groups did not differ to a statistically significant extent. The remnant-preserving technique reduces the amount of bone tunnel enlargement. The present findings indicate the advantages of the remnant-preserving ACLR technique, and therefore the remnant-preserving technique should be recommended. II.

Background Cerebral palsy (CP) is the most common cause of childhood disability, typified by a static encephalopathy with peripheral musculoskeletal manifestations—most commonly related to spasticity—that are progressive with age. Hip displacement is one of the most common manifestations, observed to lead to painful degenerative arthritis over time. Despite the key role that spasticity-related adductor muscle contractures are thought to play in the development of hip displacement in CP, basic science research in this area to date has been limited. This study was initiated to correlate hip adductor muscle changes intrinsic to the sarcomere—specifically, titin isoforms and sarcomere length—to the severity of hip displacement in children with spastic cerebral palsy. Methods Single gracilis muscle biopsies were obtained from children with CP (Gross Motor Function Classification System (GMFCS) III-V; n = 10) who underwent adductor muscle release surgery for the treatment of hip displacement. Gel electrophoresis was used to estimate titin molecular weight. Sarcomere lengths were measured from muscle fascicles using laser diffraction. The severity of hip displacement was determined by measuring by Reimers migration percentage (MP) from anteroposterior pelvic x-rays. Correlation analyses between titin, sarcomere lengths, and MP were performed. Results The mean molecular weight of titin was 3588 kDa. The mean sarcomere length was 3.51 μm. Increased MP was found to be associated with heavier isoforms of titin (R 2 = 0.65, p < 0.05) and with increased sarcomere lengths (R 2 = 0.65, p < 0.05). Heavier isoforms of titin were also associated with increased sarcomere lengths (R 2 = 0.80, p < 0.05). Conclusions Our results suggest that both larger titin isoforms and sarcomere lengths are positively correlated with increased severity of hip displacement and may represent adaptations in response to concomitant increases in spasticity and muscle shortening. Trial registration As this study does not report the results of a health care intervention on human participants, it has not been registered.

A free fascioadipocutaneous flap obtained from the medial thigh is suitable for breast reconstruction in Asian women with a small-to-moderate breast size. In this region, both a medial circumflex femoral artery perforator flap (MCFAp flap) and a posterior medial thigh perforator flap (PMTp flap) are options, based on perforators from the deep femoral vessels. Here, we evaluated the anatomic basis of the medial circumflex femoral artery (MCFA) perforators from the medial circumflex femoral vessels. Between July 2010 and June 2014, 53 patients (55 flaps) underwent breast reconstruction using a fascioadipocutaneous flap from the medial thigh. MCFA perforators larger than or equal to 0.5 mm in this region were investigated. The following parameters were recorded intraoperatively: number of perforators, perforator locations, distance of the perforating point from the proximal thigh crease and anterior border of the gracilis muscle. The total number of perforators was 131, with a mean of 2.4. The number of perforators coursing through the gracilis muscle (gracilis perforators) was the largest, followed by septocutaneous perforator coursing between the adductor longus and gracilis muscle. The average perforating point was located 6.5 cm below the proximal thigh crease and 2.2 cm from the anterior border of the gracilis muscle. Of the 102 procedures performed since 2006, 15 flaps were elevated as MCFAp flaps and there was no major complication. In some cases, MCFA perforators are dominant in this region compared to PMT perforators. A perforator map can be helpful for identifying adequate MCFA perforators intraoperatively.

The growing popularity of elite soccer among female participants has led to increased incidents of anterior cruciate ligament (ACL) ruptures. Many authors underline a positive glide after ACL reconstruction (ACLR), especially in women. In fact, an isolated intra-articular ACLR may be inadequate to control rotational instability after a combined injury of the ACL and the peripheral structures of the knee. Extra-articular procedures are sometimes used in primary cases displaying excessive antero-lateral rotatory instability. The purpose of this case series was to report subjective and objective outcomes after combined ACL and lateral extra-articular tenodesis (LET) with a minimum 4-year follow-up in a selected high-risk population of elite female football players. Between January 2007 and December 2010, 16 elite Italian female football players were included in the study. All patients underwent the same surgical technique: anatomical ACLR with autogenous semitendinosus and gracilis tendons. After the intra-articular reconstruction was performed, an additional extra-articular MacIntosh modified Coker–Arnold procedure was carried out. Patients were assessed pre- and post-operatively with the subjective and objective International Knee Documentation Committee (IKDC) evaluation form, Tegner activity scale (TAS) and Lysholm score. Joint laxity was assessed with KT-1000 by measuring the side-to-side (S/S) differences in displacement at manual maximum (mm) testing. At a mean follow-up of 72.6 ± 8.1 months, two independent examiners reviewed all players. All of the patients had a fully recovered range of motion. Lachman test was negative in all patients (100 %). The evaluation of joint laxity and clinical evaluation showed a statistically significant improvement. No patients experienced complication or a re-rupture. The rationale of combining extra-articular procedures with ACLR is to restrict the internal rotation of the reconstructed knee, taking advantage of its long lever arm and thus providing more stability in the rotational axis and preventing the ACL graft from undergoing further excessive strain. The combination of an LET with ACLR in elite female football players demonstrated excellent results in terms of subjective scales, post-operative residual laxity and re-rupture rate with no complication, and a complete return to sport activity.

To analyse the clinical and radiological outcomes of a quasi-anatomical reconstruction of the medial patellofemoral ligament (MPFL) with a gracilis tendon autograft. Patients with objective recurrent patellar instability that were operated on from 2006 to 2012 were included. A quasi-anatomical surgical technique was performed using a gracilis tendon autograft. It was anatomically attached at the patella, and the adductor magnus tendon was also used as a pulley for femoral fixation (non-anatomical reconstruction). The IKDC, Kujala and Lysholm scores as well as Tegner and VAS for pain were collected preoperatively and at final follow-up. Radiographic measurements of patellar position tilt and signs of osteoarthritis (OA) as well as trochlear dysplasia were also recorded. Thirty-six patients were included. The mean age at surgery was 25.6 years. After a minimum 27 months of follow-up, all functional scores significantly improved (p < 0.001) with respect to the preoperative values. The VAS dropped from 6 (SD 2.48) to 2 (SD 1.58). No recurrence of dislocation was observed in this series. The apprehension sign was still apparent in one patient. The CT scan evaluation showed a significant decrease in patellar tilt (p < 0.001). On the Crosby and Insall grading scale, there were no changes in the radiological signs of OA. This specific MPFL reconstruction gives good clinical results and corrects patellar tilt. It did not affect the patellofemoral surfaces at the short term, as shown by the absence of radiological signs of OA in the CT scan. The procedure has been shown to be safe and suitable for the treatment of chronic patellar instability, including in adolescents with open physis. A new effective, inexpensive and easy-to-perform technique is described to reconstruct MPFL in the daily clinical practice. Therapeutic case series, Level IV.

Background Critical limb ischemia with osteomyelitis is so difficult to treat that even appropriate revascularization and wound therapy cannot achieve limb salvage because of uncontrollable infection. It is still difficult to judge the possibility of limb salvage before revascularization. Case presentation A 73-year-old male complained of a small ulcer on his left toe, which was treated with multiple endovascular therapy. After failed endovascular therapy, he suffered extensive tissue loss with tibial osteomyelitis. We carried out staged surgery that was composed of dual bypass to the sural artery and posterior tibial artery. After intensive debridement and wound care, insertion of a subsequent free gracilis muscle flap to cover the exposed tibial bone was performed, achieving functional limb salvage. Conclusion Even in the threatened limb with extensive tissue loss and osteomyelitis, intensive and multidisciplinary treatment with staged revascularization, muscle transfer, and appropriate wound care achieved functional limb salvage.

The aim of this prospective study was to assess the natural history of the donor hamstrings, compared to the contralateral knee and thigh. In 47 patients who had ACL reconstruction (hamstrings technique), bilateral knees and thighs were investigated using MRI scans, up to 2 years post-operatively. Tendon regeneration below the knee joint line of the semitendinosus occurred in 30/47 (64 %) patients and of the gracilis tendon in 17/47 (36 %) patients. Insertion of both tendons at the “pes anserinus”, with normal anatomic relations, was observed in 5/47 (11 %) patients. Semitendinosus and gracilis donor muscles were found retracted in 41/47 (87 %) patients. In 25/47 (53 %) patients, there was evidence of fatty infiltration of the semitendinosus muscle. All (47/47) (100 %) patients showed semitendinosus muscle atrophy and 41/47 (87 %) patients showed gracilis muscle atrophy, compared to the contralateral limb. High signal intensity on STIR images was observed in the semitendinosus in 22/47 (46 %) patients and in the gracilis muscle in 30/47 (64 %) patients, on MRI examination performed up to 24 months post-operatively. The “regenerated” hamstrings tendons most commonly do not regenerate fully anatomically, so they should not be considered as a first choice for re-harvesting in revision ACL reconstruction. The “donor hamstrings muscles” are found to be shorter, contracted, thinner and with a long-term abnormal MRI signal, features which are considered to be related to reduced muscle performance (knee flexion and internal rotation) post-operatively. II.

The aim of the study was to analyse the patellofemoral alignment in the sagittal plane following tibial fracture surgery with intramedullary nailing and its relationship to parapatellar muscle status.The patellofemoral MRI results of 27 patients (15 males and 12 females) treated with locked intramedullary nailing following tibia shaft fracture were reviewed. The mean age of the patients was 41.8 (±15) years. The patella-patellar tendon angle (P-PT) and the distance between the inferior patellar pole and the tibial tubercle (DP-TT) were evaluated for both the operated extremity and the contralateral normal side. MRI assessment of the infrapatellar fat pad, quadriceps, sartorius, gracilis, semi-membranosus muscles and biceps muscles was also carried out. The correlation between the changes in skeletal muscle mass, the volume of the infrapatellar fat pad and the alterations in the DP-TT distances and P-PT angles were analysed.The quadriceps muscle cross-sectional diameter had a mean of 157.2 mm(2) (115.6/319.5) in the operated extremity, and it was 193 mm(2) (77.6/282.2) in the non-operated normal side (p = 0.001). For the Gracilis muscle, the mean was 84.4 mm(2) (19.7/171) at the operated extremity and 75.7 mm(2) (26.9/238.2) on the normal side (p = 0.05). The cross-sectional areas of the semi-membranosus, sartorius and biceps muscles in the operated and non-operated extremity were not noticeably different (n.s). The P-PT angle was 153° (129.7/156.4) in the operated extremity and 145.7° (137.6/163.4) in the non-operated normal extremity (p 0.05). While DP-TT distance was 11.4 mm (9.4/20.4) in the operated extremity, it was 14.1 mm (7.3/17.1) in the non-operated extremity (p = 0.001). The correlation analyses revealed that the quadriceps hypotrophy negatively correlated (r = -0.4, p = 0.02) with the P-PT angle but positively correlated with the increase in gracilis muscle volume (r = 0.4, p = 0.03).This study revealed that patellofemoral joint kinematics in the operated extremity was diminished in the sagittal plane correlating with the quadriceps muscle volume loss and gracilis muscle hypertrophy. The modalities focused on both preventing and treating the hypotrophy of the quadriceps muscle following the surgical treatment of tibial fracture, which may help to overcome this quite common pathology.

The complete proximal hamstring avulsion is relatively uncommon injury and predominantly occurs in young athletes but causes significant functional impairment. In chronic cases, the muscle mass is so much retracted that primary repair is not possible. A surgical technique for reconstruction of chronic proximal hamstring avulsion using contralateral semitendinosus and gracilis autograft is described in this case report. V.

The pudendal nerves run with internal pudendal vessels, after arising from the ventral primary rami of S2, S3, and S4 bilaterally. They pass through Alcock’s canal, formed by the obturator fascia, and divide into rectal and urogenital terminal branches as neurovascular bundles. The pudendal nerves contain somatic and autonomic nerve fibers. Innervation of the external anal sphincters was mainly provided by the pudendal nerves. Our approach to pudendal nerve exposure and sparing in female patients undergoing transvaginal rectal surgery was as follows. We exposed the pudendal nerves below the levators by using transvaginal access in two female patients: one during ultralow rectal cancer resection and another one with fecal incontinence during sphincteroplasty and gracilis muscle transposition. After the rectovaginal septum was dissected (Fig. 1), the sublevator anal canal sphincter complex was mobilized (Figs. 2, 3). The pudendal nerves were exposed just below the levator muscle level at the posterolateral side of the ischioanal fossa (Fig. 4). Care was taken during surgery to identify the terminal branches of the pudendal nerves which course together with branches of the internal pudendal vessels (Figs. 5, 6).

Because the skin of anteromedial thigh region usually is thinner, pliable, hairless it can be preferred based on the requirements of the recipient site. In this way more information is necessary about the perforators of anteromedial thigh region. The aim of this cadaveric study was described to provide useful knowledge about localizations and number of anteromedial thigh perforators. Study was carried out on 16 lower extremities of 9 cadavers. The area in anteromedial aspect of the thigh searched for perforators was defined between the anterolateral border of sartorius and the posterior border of gracilis. The diameters of the dissected perforators were measured and the locations were documented. A total of 204 perforators were dissected in 16 lower extremities. The majority of musculocutaneous perforators were from gracilis (24 of 37) and there were at most 3 musculocutaneous perforators arising from gracilis muscle. 167 septocutaneous perforators were identified. Origin of all perforators was determined as 52 from deep femoral artery, 25 from proximal part of femoral artery and 127 from distal part of femoral artery and their branches. Perforators with the largest diameter were the ones arising from the intermuscular septa between the adductor (longus and magnus) and sartorius muscles. The mean diameter of the perforators was 0.75 ± 0.11 mm and ranged between 0.61 and 0.96 mm. The septocutaneous perforators of the anteromedial aspect of the thigh are as much important as the musculocutaneous perforators and all they are with adequate to perform anteromedial thigh flap. This study provides numerical overview, useful perception about the localization of the perforators of the anteromedial aspect of the thigh and detailed anatomical basis for anteromedial thigh flap to be an important alternative.

Bupivacaine-induced myotoxicity is associated with mitochondrial bioenergetic alterations. The impact of the duration of bupivacaine treatment on mitochondrial energy production remains undetermined. Here, we assessed, in vivo, the alteration of mitochondrial metabolism following different durations of bupivacaine exposure (40, 56, or 112 hr) that correspond to 5, 7, or 14 repeated injections of 0.25% bupivacaine, respectively.Rats were divided randomly into seven different groups: one control group (no catheter); three groups with normal saline injections (1 mL x kg(-1)) every eight hours via a femoral nerve catheter for 40, 56, and 112 hr, respectively; and three groups with 0.25% bupivacaine injections (1 mL x kg(-1)) every eight hours via a femoral nerve catheter for 40, 56, and 112 hr. Psoas and gracilis muscle samples located within the bupivacaine infusion-diffusion space were investigated. To estimate mitochondrial respiratory capacity, the protein content of the mitochondrial respiratory chain apparatus was evaluated by measuring citrate synthase activity. To measure mitochondrial respiratory function, adenosine diphosphate-stimulated oxygen consumption was measured by polarography in saponin-skinned muscle fibres using glutamate-malate or succinate as energy substrates.In psoas and gracilis muscles, saline solution had no effect on the two mitochondrial parameters. Bupivacaine induced a significant decrease in the citrate synthase activity in psoas (r(2) = 0.74; P0.001) and gracilis muscle (r(2) = 0.52; P0.001), and there was a significant decrease in the adenosine diphosphate-stimulated oxygen consumption using glutamate or succinate as substrates in both muscles (P0.001).The severity of bupivacaine-induced myotoxicity is closely linked to the duration of bupivacaine exposure in the muscle fibres located close to the catheter tip.

Wiederherstellung der aktiven Ellbogenfunktion als Grundvoraussetzung fur die bimanuelle Tatigkeit durch Ersatz einer fehlenden funktionellen Muskeleinheit durch eine freie funktionelle Muskeltransplantation. Der Eingriff stellt eine Therapie der letzten Wahl dar. Ersatzindikation: Komplette Lasionen des Plexus brachialis oder des Nervus musculocutaneus (M0). Augmentationsindikation: Partielle, aber ungenugende Regeneration des Plexus brachialis oder des Nervus musculocutaneus (M1–3). Ersatz der Ellbogenbeuger bei primarem Muskelverlust durch Trauma oder Tumor als „Effektorganersatz“. Gefaslasionen der Arteria axillaris. Ungenugende Moglichkeit der Neurotisation durch inadaquaten Spendernerv. Relativ: Asensibilitat im Unterarm- und Handbereich. Freie funktionelle biartikulare myokutane Musculus-gracilis-Transplantation. Der Musculus gracilis wird mit einem daruberliegenden Hautanteil am Oberschenkel an seinem Gefas-Nerven-Stiel freiprapariert und am Oberarm als Ersatz fur den Musculus biceps verwendet. Proximal wird das Transplantat am Processus coracoideus oder an der lateralen Klavikula befestigt, distal an der distalen Bizepssehne. Die Gefase werden in End-zu-Seit-Technik an die Vasa brachialia angeschlossen. Der Nerv wird mit dem Stumpf des Nervus musculocutaneus koaptiert. Vollstandige Immobilisation fur 6 Wochen. Anlage einer dorsalen Oberarmschiene in 90° Beugung im Ellbogengelenk bis zur ausreichenden Muskelfunktion (12–18 Monate). Nach 6 Wochen intensive Physiotherapie zur Erhaltung der passiven Beweglichkeit. Bei Einsetzen der Muskelkontraktion nach 6–9 Monaten Biofeedbacktraining. Progressiver passiver Bewegungsaufbau („Uben aus der Schiene“) bis zur ausreichenden Muskelkontraktion (M4). Fortfuhrung der physiotherapeutischen Begleittherapie fur 12–18 Monate. Postoperative standardisierte Kompressionstherapie, evtl. kombiniert mit Narbentherapie (Silikonplatte). Funktionell wertvolle Ergebnisse bei 60–75% der Patienten, vor allem bei ungenugender Restfunktion der regenerierten Ellbogenbeuger („Augmentationsindikation“). Die fruhzeitige freie funktionelle Muskeltransplantation bei isolierter muskularer (myogener) Insuffizienz zeigt im Allgemeinen die besten Resultate, da eine ausreichende autochthone Gefas-Nerven-Versorgung vorliegt und meist keine sekundaren Veranderungen wie Gelenksteifen oder Fibrosen bestehen. Die funktionellen Ergebnisse nach freier funktioneller Muskeltransplantation bei kompletter Lasion des Plexus brachialis (neurogene Insuffizienz) und Folgezustand nach Kompartmentsyndrom (gemischte neuromuskulare Insuffizienz) zeigen eine grose Streubreite. Die freie funktionelle Muskeltransplantation stellt oft die einzige noch mogliche Therapie dar. Bei guter Patientenauswahl kann vor allem im Ellbogenbereich mit hoher Wahrscheinlichkeit eine funktionelle Bewegung erreicht werden.

The concept of double free functioning muscle transfer (DFFMT) reconstruction for total arm type brachial plexus injury (BPI) had been successfully reported by Professor Doi from Japan. However, to overcome the weakness of finger/wrist extension after serving two functions by one gracilis muscle as described by Doi, we invented a new method of triple FFMT. This study was aimed to evaluate the clinical effectiveness of triple FFMT for total arm type BPI reconstruction.

In reconstructive techniques, the use of the composite gracilis skin flap may be complicated by a total or partial necrosis of the cutaneous paddle. Our study was aimed to describe the vascular anatomy of the gracilis muscle and the related skin, in order to have a better understanding of the skin’s blood supply, and to help in determining a safer cutaneous paddle during transfer. We performed a detailed anatomical description of the gracilis vessels on 32 human cadavers’ thighs. Selective injections of methylene blue and then colored fluid latex were carried out in the principal pedicle of the gracilis, to color and to measure the perforator vessels and the associated cutaneous paddle. The contour and the anatomical situation of the paddles were digitized in order to have precise data and to try to model a standard theoretical skin paddle. The 32 dissections showed that the principal pedicle of the gracilis originated mainly from the adductor artery (26/32), it penetrated into the muscle 92.8 mm (78–114) below the pubis with a small dispersion of the values that assessed a rather reliable parameter of location. Each muscle had 1–6 perforators (at mean 3.78); 80% of these perforators had their exits from the opposite side to the principal pedicle, included within a 60 mm length of muscle. A skin paddle was quite constantly colored (31/32), located over the proximal half of the muscle with a complex design. Its mean dimensions of length and width were 110 (72–158) and 91.4 mm (65–144), respectively. The computerized surface of the paddle was at a mean of 79.5 cm2 (42.4–139.3), and it was significantly correlated to the number of the perforators from the muscle. Our quantitative values concerning the skin paddle related to the perforator arteries may be of significant interest to the surgeon who aims to harvest a composite musculocutaneous gracilis flap, in order to improve its reliability by reducing the risk of cutaneous necrosis.

applying a vascularized left-sided gracilis muscle flap. Following excision of the excessive perineal skin, the hernial sac was prepared and reposed. The gracilis muscle was mobilized up to its neurovascular bundle and the distal attachment was freed. Through a subcutaneous tunnel, the mobilized muscle was laid and fixed upon the site of the perineal defect (Fig. 1). The patient had an uneventful postoperative period. At the 9-month follow-up, clinical examination and magnetic resonance imaging showed no evidence of recurrence. Careful examination of patients is needed to exclude recurrent tumor prior to repair. Both the abdominal and the perineal approaches, and also a combined abdominoperineal procedure are recommended in the literature [3]. The perineal approach is attractive due to its lower postoperative morbidity rates and more convenient technical aspects; however, detection of a possible abdominal tumor and mobilization of intestinal adhesions are not feasible. In contrast, abdominal exploration carries a much higher risk of unwanted bowel injury, and involves a higher surgical burden. The defect of the levator ani

We present a patient with massive posttraumatic ectopic calcification in the lower extremity. The patient complained of an increasing tender soft tissue mass with signs of acute inflammation and foot dorsiflexion weakness following a tibial fracture for 34 years. A large radiopaque mass was resected and reconstructed using a free functional gracilis muscle transfer, resulting in recovery of stable soft tissue and foot dorsiflexion. The resected material showed highly fibrosed soft tissue with extensive dystrophic calcifications. There were no sign of recurrence at 18-month follow-up.

Background Moebius sequence is a rare congenital absence of the sixth and seventh cranial nerves, although there may be additional congenital cranial neuropathies. Developmental delay, cardiac and musculoskeletal abnormalities may also coexist. Oro-facial manifestations include bilateral facial nerve palsy resulting in a mask like facies, drooling, incomplete eye closure, and strabismus secondary to the extra-ocular muscle imbalance. This condition has multiple implications for anesthetic care.

The objective of this study was to evaluate the possibilities of reinnervation of the gracilis muscle, transposed around the anus, by the pudendal nerve using an end-to-side nerve anastomosis. This study was carried out in 14 cases (7 adult human cadavers bilaterally). The gracilis muscle and its vascular-nervous bundle have been dissected and the nerve innervating the gracilis muscle has been cut at its origin. The gracilis muscle, accompanied by its nerve, has then been transposed around the anus. The pudendal nerve has been dissected from its extrapelvic part. The reinnervation using an end-to-side nerve anastomosis has been considered as feasible when the proximal ending of the nerve of the gracilis was put into a tension-free contact with the extrapelvic part of the pudendal nerve. The extrapelvic part of the pudendal nerve has a common trunk in 12 cases. The width of the extrapelvic part of the pudendal nerve was 2.6+/-0.7 mm, range 1-3.5. The width of the proximal endings of the nerve innervating the gracilis muscle was 2.3+/-0.5 mm, range 2-3. The reinnervation of the gracilis muscle by the pudendal nerve has been possible in 14 cases. An average supplementary length of 17.4+/-15.4 mm was available (range 5-52). These results suggest an eventual practical aspect of this technique for the reconstruction of a functional sphincter using the gracilis muscle transposed around the anus.

A case of a 68-year-old woman who presented with a rapidly enlarging painful right thigh mass is presented. She had a known diagnosis of uterine leiomyosarcoma following a hysterectomy for dysfunctional uterine bleeding. She subsequently developed a single hepatic metastatic deposit that responded well to radiofrequency ablation. Whole-body MRI and MRA revealed a vascular mass in the sartorius muscle and a smaller adjacent mass in the gracilis muscle, proven to represent metastatic leiomyosarcoma of uterine origin. To our knowledge, metastatic uterine leiomyosarcoma to the skeletal muscle has not been described previously in the English medical literature.

Purpose. The technique of dynamic graciloplasty is not yet-completely satisfactory. Its function could be improved by ensuring total wrapping of the neoanus with the muscular part of the gracilis, but this can only be achieved by dividing the main blood vessels, which are considered essential for blood supply to the flap. We devised a vascular delay technique to preserve the flap without these vessels, which we performed first experimentally, then clinically, with promising results. Methods. Seventeen Japanese white rabbits were given graciloplasty after electrical stimulation, vascular ligation, or no preparation. The neoanus was assessed manometrically and histologically 5 days later. The good results seen in the animals encouraged us to start performing enhanced dynamic graciloplasty clinically. Five patients were given electrical stimulation and the vascular delay technique was carried out before dynamic graciloplasty. Results. Vascular delay in the rabbits preserved the muscle flap, but electrical stimulation had a limited effect. In all five patients, the neoanus was successfully wrapped with the muscular part of the flap. There were no ischemic symptoms or perioperative complications. Furthermore, the neoanal pressure increased significantly with electrical stimulation from 23.8 cm H 2 O to 89.2 cm H 2 O. Satisfactory continence was achieved in three of the four patients whom we were able to evaluate. Conclusion. Dissection of the main vessels of the gracilis muscle with vascular delay and long-term electrical stimulation may optimize the gracilis flap in patients requiring dynamic graciloplasty.

The gracilis muscle or myocutaneous flap is a Mathes and Nahai neurovascular flap type II. It can be used either as a pedicled flap, or as a free flap. Since 1983, 21 gracilis muscle flaps were used in 19 patients at this department; 15 were pedicled while six were free flaps. Two pedicled flaps were lost, possibly due to an intraoperative spasm of the feeding artery. The indications for using the gracilis muscle are discussed, and the results with an average follow-up of more than a decade are presented.

Dynamic graciloplasty has recently been developed for reconstruction of anal function in patients who are fecally incontinent in preference to permanent abdominal colostomy. Since the muscular portion of gracilis is wrapped around the neoanus, the length of the gracilis arc influences the functional outcome of graciloplasty. Although dissection of the main pedicle (i.e. the main artery and vein) can facilitate gracilis to have enough muscle arc, it has been unclear whether there are any vessels proximal to the main pedicle or through the origin of the muscle which could support blood flow into the whole of gracilis. In this study, the vascular anatomy of gracilis in both legs of 26 Japanese cadavers was examined. All muscles had a main pedicle, mean maximum diameter 1.08 mm, entering at the proximal one-third of the muscle. However, only 18 muscles (34.6%) had an accessory artery in the proximal portion in addition to the main pedicle. Some arteries always exist at the origin of the muscle, having a mean maximum diameter of 0.34 mm, suggesting that they might be able to support the whole gracilis without supply from the main pedicle.

To investigate the control of cell energetic metabolism, creatine charge, ATP/ADP ratio and oxygen consumption (as indicators of an energetic status, the balance between ATP synthesis and degradation and the aerobic ATP turnover, respectively) were evaluated in the rat gracilis muscle, perfused-superfused in vitro. During the perfusion rate of 70 μl/min the ATP/ADP ratio, as well as the creatine charge are kept at the in vivo level. With the decrease of the rate toward 54 μl/min (of an abundant oxygen delivery), the values of both parameters are lower than levels in vivo. With the increase of the rate up to 100 μl/min, both parameters are kept at the in vivo level, when respiration increases by 125%. The data demonstrate the 'unmatched' control of ATP utilisation and synthesis steady rates during the low perfusion rate; during the increasing steady ATP turnover following the increased perfusion rate, the two fluxes are strikingly 'matched', i.e. precisely balanced.

Free muscle transplantation with motor innervation offers the posibility to add contractile elements to upper extremities with extensive loss of musculature due to direct trauma or untreated compartment syndrome (Volkmann's contracture). The functional cross section area and the mean resting fiber length determine the maximum power and the contracting amplitude of the donor muscle. Although considerably weaker than the finger flexors to be replaced, the gracilis muscle was the preferred donor muscle because of its neurovascular pedicle and the minimal donor site morbidity. In a series of 15 gracilis transplantations, all 13 muscles that survived regained function. Finger motion was dependent on the preoperative condition of tendons and joints. Even after complete loss of the flexor and extensor compartment a useful upper extremity could be restored, which was preferable to the only alternative – amputation.

The reestablishment of anal function by transposition of the gracilis muscle, combined with the implantation of electrodes and a neuromuscular stimulator (dynamic graciloplasty), has recently been developed. With this method, the transposed muscle maintains contraction by electrical stimulation to maintain neoanal pressure without fatigue. It is necessary to convert the fatigue-prone gracilis muscle to fatigue-resistant muscle by long-term electrical stimulation (conditioning). In most patients receiving dynamic graciloplasty, the conditioning is accomplished after the transposition. However, conditioning before graciloplasty should reduce the risk of ischemia in the transposed muscle after the graciloplasty and improve the outcome. This new sequence of procedures is described, in combination with J-pouch construction, in a patient who required abdominoperineal excision of the rectum for lower rectal cancer. The graciloplasty was performed after conditioning of the gracilis muscle in situ; the conditioning did not cause the patient discomfort and resulted in good anal function.

Anal neosphincter formation with electrically stimulated gracilis muscle is used increasingly for the surgical treatment of fecal incontinence. An alternative to gracilis might be of interest if this muscle is not available. 30 semitendinosus muscles and 15 long heads of biceps femoris were investigated on human cadavers. In particular, the nerve and vascular supply of these muscles was studied, both representing basic factors for muscle transposition. The long head of biceps femoris m. was found to receive its dominant vascular supply from the first and second perforating artery and its nerve supply from one motor branch out of the sciatic nerve, both as described in literature. The examination of semitendinosus m., however, revealed new anatomical aspects in its vascular supply. In all cases semitendinosus m. was found to receive dominant vascular pedicles from the medial circumflex femoral artery close to the ischial tuberosity and the second perforating artery. The nerve supply consisted of two motor branches out of the sciatic nerve. Both muscles fulfilled several basic criterias for transposition to the anus. However, regarding these requirements, semitendinosus offered distinct advantages in comparison with the long head of biceps femoris. Due to its vascular and nerve topography, semitendinosus seems suitable to serve as an alternative to gracilis.

Bakken Research Center,Maastricht, The NetherlandsPurpose: To investigate the e•ect of a neurovascularly intact gracilis muscle urethral wrap, to beused to restore urinary continence as a transposed urinary sphincter graft, in patients withneurogenic lower urinary tract dysfunction. Methods: Five neurologically impaired men with adenervated and damaged urinary sphincter mechanisms were treated. The etiology ofsphincteric insu†ciency included sphincter denervation in three patients, external sphincter-otomy in one, and urethral trauma due to a chronic indwelling catheter in one. All patientsunderwent gracilis urethromyoplasty sphincter reconstruction. Two patients also underwentconcomitant ileocystoplasty and one patient ileocystostomy because of poor bladdercompliance and a bladder capacity of 5200 ml. Results: The gracilis urethromyoplastyfunctioned as a new autologous sphincter with follow-ups ranging from 6–35 months. Thesurgery was successful in four patients. Three of the four patients were managed withintermittent catheterization, and one managed by ileocystostomy. The fifth patient continued torequire an indwelling urethral catheter. Conclusion: Gracilis urethromyoplasty achievescompression of the urethra using a neurovascularly intact muscle graft. The functional urethralclosure, obtained from the gracilis muscle wrap, assures dryness, and permits intermittent self-catheterization. It also avoids the risks of infection, erosion, or malfunction associated with theartificical urinary sphincter. The potential exists for electrical stimulation of this muscle graft toallow volitional control of the neo-sphincter mechanism, and voluntary voiding.Keywords: urinary incontinence; tissue transplantation; muscles; electric stimulation;urodynamic; spinal cord injury

Between 1965 and 1994 eight selected patients with faecal incontinence for solid stool (Grade 4) were operated on by the original procedure described by Pickrell (1952), combined with biofeedback training postoperatively. No postoperative complication occurred. All patients were improved by this procedure. Five had normal continence and there were 3 incontinence for flatus. Anal manometry showed an increase in postoperative squeeze pressure (p

Background. To establish the occurrence of regeneration of the semitendinosus and gracilis tendons following their harvesting for anterior cruciate ligament reconstruction, we performed a simulation procedure using 12 lower extremities from six cadavers and studied the length of the muscle stumps that remained distally beyond the knee joint line and recorded their proximity to the popliteal fascia. Results. Six of 12 semitendinosus and gracilis muscles remained beyond the joint line. Nine semitendinosus and eight gracilis muscle stumps were close to the popliteal fascia, while the other stumps were not. The semitendinosus and gracilis muscles that remained beyond the knee joint line and close to the popliteal fascia, even after tendon harvesting, are supposed to increase the likelihood of regeneration of the functional myotendinous junction, compared with muscles not extending to the joint line. Conclusions. We were convinced by these results of regeneration of the semitendinosus and gracilis tendons following tendon harvesting, which had been reported clinically.

The aim of this study was to specify certain anatomic features of the gracilis m. with a view to the use of muscular or myocutaneous flaps. It was based on dissection of 84 gracilis muscles in 42 subjects as well as selective injection of the main pedicle of 20 muscles. This established the following points : 1) The arterial supply is abundant, consisting of several pedicles reaching the muscle on its deep aspect. The main neurovascular pedicle arises from the deep vessels of the thigh, via either the a. of the adductors (73%), the medial circumflex a. (19.2%) or as a double supply from both arteries (7.7%); 2) The cutaneous vascularisation over the gracilis m., derived from the solitary main pedicle, is inconstant. In 20 injections, it was satisfactory in 11 cases, poor in 5 and absent in 4; 3) The distal tendon of the gracilis m. is closely related to the posterior branch of the saphenous n. to the leg, which it crosses in an elongated X; 4) A simple method of calculation based on the distance between the upper border of the pubis and the medial femoral epicondyle allows quite precise determination of the point of entry of the main pedicle into the gracilis m. 5) Complete dissection of the main pedicle adds to the available length of the muscle flap.