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Background The gracilis flap is rarely used in colorectal surgery and requires a multidisciplinary surgical team including plastic surgeons. There is a paucity of data on the outcome of the gracilis flap when performed by colorectal surgeons. Methods A retrospective review was performed of all consecutive patients who underwent the gracilis flap at a single institution. Data collected included patient-related characteristics, indications for surgery, postoperative outcomes, and healing rates. Results Eighteen patients underwent a total of 19 flaps. The median age was 60 years. Thirteen patients (72.2%) had prior radiation therapy. The most common indication for radiation was prostate carcinoma (38.9%) and rectal or anal carcinoma (33.3%). Indications for operation were complex fistulas in 14 patients (77.8%) or wound defect closure in four patients (22.2%). Six out of 14 patients (42.9%) had failed prior fistula repair. All patients had existing stoma or underwent stoma placement at the time of the gracilis flap. Median length of stay was 5 days. Post-operative complications occurred in three patients (16.7%), and the readmission rate was 11%. Flap failure was noted in three patients (16.6%). Both patients with rectourethral fistulas healed after additional intervention. During a median follow-up time of 24 months, 11 out of the 12 temporary stomas were closed, and one was converted to a permanent colostomy. Conclusions The gracilis flap can be successfully used for complex pelvic fistulas and perineal wounds. This study demonstrates that a colorectal surgeon with interest and expertise in this technique can perform this operation with excellent outcomes.

Background Despite advances in neoadjuvant therapies and surgical techniques, abdominoperineal excision of the rectum (APER) is still necessary in a considerable number of cases, often requiring the creation of a permanent colostomy, which can significantly impact a patient’s quality of life (QOL). Total anorectal reconstruction (TAR) with dynamic graciloplasty has emerged as a reconstructive option for patients undergoing APER, aiming to restore continence by avoiding a permanent abdominal colostomy and improving quality of life. However, this approach presents several challenges, including technical complexity and variable long-term outcomes. Case report We present the case of a 34-year-old female patient who underwent APER with extended resection (rectum and vaginal wall) due to low rectal adenocarcinoma infiltrating the posterior vaginal wall. Following a prolonged postoperative course and the decision against living with an abdominal colostomy, the patient underwent secondary TAR with reconstruction of the posterior vaginal wall and dynamic graciloplasty in 2001. The procedure included creating a neorectum using a myocutaneous flap for vaginal reconstruction and a gracilis muscle wrap with neurostimulation as a neosphincter. Despite early postoperative complications, the patient achieved satisfactory continence with regular transanal irrigation and lived with the reconstruction for over 20 years. In 2024, the patient returned for management due to the obsolescence of her neurostimulator, which was subsequently removed without deterioration in her continence function. Conclusion This case highlights the complex and prolonged management challenges associated with TAR and dynamic graciloplasty for patients with severe anorectal dysfunction following APER. While dynamic graciloplasty has been shown to offer some level of continence in patients with faecal incontinence, the need for additional interventions, such as regular irrigation, is often required to maintain quality of life after TAR following APER. The durability of this reconstructive approach and the patient’s long-term satisfaction underline its potential as a viable, though technically demanding, alternative to conventional colostomy in selected patients. However, the role of electrically induced muscle fiber transformation (“dynamic graciloplasty”) needs to be discussed.

Purpose: Gracilis muscle flaps are useful to cover defects of the hand. However, there are currently no studies describing outcome measurements after covering soft tissue defects using free flaps in the hand. Aim: To analyze mid-term results of gracilis muscle flap coverage for defects on the hand, with regard to functional and esthetic integrity. Methods: 16 patients aged 44.3 (range 20–70) years were re-examined after a mean follow-up of 23.6 (range 2–77) months. Mean defect size was 124 (range 52–300) cm 2 located palmar ( n  = 9), dorsal ( n  = 6), or radial ( n  = 1). All flaps were performed as microvascular muscle flaps, covered by split thickness skin graft. Results: Flaps survived in 15 patients. 6 patients required reoperations. Reasons for revisions were venous anastomosis failure with total flap loss ( n  = 1) requiring a second gracilis muscle flap; necrosis at the tip of the flap ( n  = 1) with renewed split thickness skin cover. A surplus of the flap ( n  = 2) required flap thinning and scar corrections were performed in 2 patients. Mean grip strength was 25% (range 33.3–96.4%) compared to the contralateral side and mean patient-reported satisfaction 1.4 (range 1–3) (1 = excellent; 4 = poor). Conclusions: Gracilis muscle flaps showed a survival rate of 94%. Patients showed good clinical outcomes with acceptable wrist movements and grip strength as well as high reported satisfaction rates. Compared to fasciocutaneous free flaps, pliability and thinness especially on the palmar aspect of the hand are advantageous. Hence, covering large defects of the hand with a gracilis muscle flap can be a very satisfactory procedure. Level of evidence: IV observational.

Purpose To biomechanically evaluate MPTL reconstruction and compare it with two techniques for MPFL reconstruction in regard to changes in patellofemoral contact pressures and restoration of patellar stability. Methods This is an experimental laboratory study in eight human cadaveric knees. None had patellofemoral cartilage lesions or trochlear dysplasia as evaluated by conventional radiographs and MRI examinations. The specimens were secured in a testing apparatus, and the quadriceps was tensioned in line with the femoral shaft. Contact pressures were measured using the TekScan sensor at 30°, 60° and 90°. The sensor was placed in the patellofemoral joint through a proximal approach between femoral shaft and quadriceps tendon to not violate the medial and lateral patellofemoral complex. TekScan data were analysed to determine mean contact pressures on the medial and lateral patellar facets. Patellar lateral displacement was evaluated with the knee positioned at 30° of flexion and 9 N of quadriceps load, then a lateral force of 22 N was applied. The same protocol was used for each condition: native, medial patellofemoral complex lesion, medial patellofemoral ligament reconstruction (MPFL-R) using gracilis tendon, MPFL-R using quadriceps tendon transfer, and medial patellotibial ligament reconstruction (MPTL-R) using patellar tendon transfer. Results No statistical differences were found for mean and peak contact pressures, medial or lateral, among all three techniques. However, while both techniques of MPFL-R were able to restore the medial restraint, MPTL-R failed to restore resistance to lateral patellar translation to the native state (mean lateralization of the patella [mm]: native: 9.4; lesion: 22; gracilis MPFL-R: 8.1; quadriceps MPFL-R: 11.3; MPTL-R: 23.4 ( p  < 0.001). Conclusion MPTL-R and both techniques for MPFL-R did not increase patellofemoral contact pressures; however, MPTL-R failed to provide a sufficient restraint against lateral patellar translation lateral translation in 30° of flexion. It, therefore, cannot be recommended as an isolated procedure for the treatment of patellar instability.

Background/Objectives: Free gracilis (GM) and latissimus dorsi muscle (LDM) flaps are reliable options for complex defect coverage, but long-term sensory outcomes remain underexplored. Sensory impairment, especially the loss of protective cutaneous sensation, increases the risk of injury, thermal damage, and ulceration in reconstructed areas. This study aimed to systematically assess multidimensional sensory recovery after free muscle flap (FMF) reconstruction. Methods: In a prospective single-center study, 94 patients (49 GM, 45 LDM) underwent standardized sensory testing following FMF transfer. Five modalities were evaluated: pressure detection (Semmes-Weinstein monofilaments), vibration perception, two-point discrimination (2PD), sharp–dull differentiation, and temperature differentiation. Measurements were compared to contralateral healthy skin (CHS). Subgroup analyses were performed by anatomical region (head, trunk, extremities). Results: All sensory modalities were significantly impaired in FMF compared to CHS (p < 0.0001). Mean pressure thresholds were markedly higher in FMF (248.8 g) versus CHS (46.8 g). Vibration perception scores were reduced (FMF 3.97 vs. CHS 5.31), and 2PD was significantly poorer (11.6 cm vs. 4.7 cm). Sharp–dull and thermal discrimination were largely absent in FMF (positivity rates < 20%), with 58.5% of patients demonstrating only deep pressure sensation (≥300 g). No significant differences were found between GM and LDM in most modalities, except for worse 2PD in GM. Subgroup analyses confirmed uniform deficits across all anatomical regions. Conclusions: FMFs without neurotization result in profound, persistent sensory deficits, particularly the loss of protective sensation. Clinically, fascio-cutaneous flaps with nerve coaptation should be considered in functionally critical regions. Future strategies should focus on neurotization techniques to enhance sensory recovery.

Purpose Rectovaginal fistulas are difficult to treat completely, especially when patients present with a history of multiple surgeries and radiation therapy. We aimed to evaluate the efficacy of gracilis muscle flap transposition to treat rectovaginal fistula. Methods We performed a retrospective chart review of all gracilis muscle transposition cases and other procedures between January 2009 and July 2016. Results Total 53 cases were reviewed. A total of 11 patients underwent gracilis muscle flap transposition for rectovaginal fistula repair, with 8 patients showing good results without recurrence (total success rate, 72.7%). Comparison of this patient group with patients who had undergone other surgical procedures for rectovaginal fistula repair showed that those who received a gracilis transposition flap had significantly higher average number of previous surgeries (2.18 ± 1.17 vs. 1.1 ± 1.25) and had previously undergone radiotherapy at a significantly higher rate (63.6 vs. 26.2%). Furthermore, none of our patients complained of donor site discomfort. Conclusions Based on these results, we recommend using the gracilis muscle flap for rectovaginal fistula repair in cases where there is a history of radiotherapy and had surgical failure more than twice.

Purpose 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. Method 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. Results 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). Conclusions 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. Level of evidence III.

Purpose To analyse the clinical and radiological outcomes of a quasi-anatomical reconstruction of the medial patellofemoral ligament (MPFL) with a gracilis tendon autograft. Methods 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. Results 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. Conclusion 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. Level of evidence Therapeutic case series, Level IV.

Purpose Graft diameter ≥ 8 mm reduces the risk of failure after anterior cruciate ligament reconstruction (ALCR) with hamstring tendon autograft. Pre-operative measurement of gracilis (GT) and semitendinosus (ST) cross-sectional area using MRI has been utilized but the optimal location for measurement is unknown. The main purpose of this study was to examine the cross-sectional areas of GT + ST at different locations and develop a model to predict whether a doubled hamstring graft of GT + ST will be of sufficient cross-sectional area for ACLR. Methods A retrospective review was performed of 154 patients who underwent primary ACLR using doubled hamstring autograft. Cross-sectional area measurements of GT + ST on pre-operative MRI axial images were made at three locations: medial epicondyle (ME), tibiofemoral joint line (TJL), and tibial physeal scar (TPS) and calculated the correlation of intra-operative graft size for each location using the Pearson’s correlation coefficient. A receiver operating characteristic (ROC) established a threshold that would predict graft diameter ≥ 8 mm. Results Measurement of GT + ST at the ME had a stronger correlation ( r  = 0.389) to intra-operative graft diameter than measurements at the TJL ( r  = 0.256) or TPS ( r  = 0.240). The ROC indicated good predictive value for hamstring graft diameter ≥ 8 mm based on MRI measurement at the ME with the optimal threshold with the highest sensitivity and specificity as 18 mm 2 . Conclusion Cross-sectional area measurement of GT + ST at the ME correlated most closely to intra-operative diameter of a doubled hamstring autograft compared to measurements at the TJL or the TPS. As graft diameter < 8 mm is correlated with higher failure rates of ACL surgery, the ability to pre-operatively predict graft diameter is clinically useful. Level of evidence Level III, prognostic study.

Purpose To evaluate the knee kinematics of the intact, MPFL-ruptured and MPFL-reconstructed knee and, moreover, to compare dynamic patellofemoral contact pressure of the gracilis tendon and the fascia lata as an alternative graft option for reconstruction of the MPFL. Methods Eight paired human cadaveric knees were fixed in a custom-made fixation device. Patellofemoral contact pressure was assessed during a dynamic flexion movement at 15°–30°–45°–60°–75° and 90° using a pressure-sensitive film (Tekscan). The medial patellofemoral ligament was cut, and measurements were repeated. Finally, reconstruction of the MPFL was performed using the gracilis tendon (group I) or a fascia lata graft (group II). Tunnel localization was performed under fluoroscopic control. Grafts were fixed at 30° of flexion, and pressure measurements were repeated. Results Incision of the medial patellofemoral ligament significantly reduced patellofemoral contact pressure at 15°, 30° and 45° of knee flexion compared to the intact knee ( p  < 0.05), whereas reconstruction of the MPFL using either gracilis tendon of the fascia lata was able to restore pressure distributions at 15° and 30° of knee flexion. However, in the hamstring group, reconstruction of the MPFL revealed a significantly reduced contact pressure at 45° of flexion ( p  = 0.038) compared to the intact knee. In the fascia lata group, a significant reduction in patellofemoral contact pressure was observed after MPFL reconstruction at 45°, 60°, 75° and 90° of knee flexion ( p  < 0.05). Conclusions Anatomic reconstruction of the MPFL with either a gracilis or a fascia lata graft showed comparable patellofemoral pressure distributions which were closely restored compared to the native knee. Therefore, the fascia lata has shown to be a viable alternative to the gracilis tendon for reconstruction of the MPFL. However, anatomic reconstruction of the MPFL may lead to persistently altered patellofemoral contact pressure during knee flexion compared to the native knee independent of the tested graft.