Mid-term Clinical Outcome of Microvascular Gracilis Muscle Flaps for Defects of the Hand.

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) cm2 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.

[Effects of free gracilis muscle flap combined with sural nerve transfer for reconstruction of digital flexion and sensory function of hand in patient with wrist electric burn].

Objective: To explore the effects of free gracilis muscle flap combined with sural nerve transfer for reconstruction of digital flexion and sensory function of hand in patient with severe wrist electric burn. Methods: A retrospective observational study was conducted. From January 2017 to December 2020, 4 patients with wrist high-voltage electric burn admitted to the Department of Burns of the First People's Hospital of Zhengzhou and 4 patients with wrist high-voltage electric burn admitted to the Department of Hand Surgery of Beijing Jishuitan Hospital met the inclusion criteria, including 6 males and 2 females, aged 12 to 52 years. They were all classified as type Ⅱ wrist high-voltage electric burns with median nerve defect. In the first stage, the wounds were repaired with free anterolateral thigh femoral myocutaneous flap. In the second stage, the free gracilis muscle flap combined with sural nerve transplantation was used to reconstruct the digital flexion and sensory function of the affected hand in 3 to 6 months after wound healing. The cut lengths of muscle flap and nerve were 32 to 38 and 28 to 36 cm, respectively. The muscle flap donor area and nerve donor area were both closed and sutured. The survival condition of gracilis muscle flap and sural nerve, the wound healing time of recipient area on forearm, the healing time of suture in muscle flap donor area and nerve donor area were observed and recorded after operation, and the recovery of donor and recipient areas was followed up. In 2 years after operation, the muscle strength of thumb and digital flexion and finger sensory function after the hand function reconstruction were evaluated with the evaluation criteria of the hand tendon and nerve repair in the trial standard for the evaluation of functions of upper limbs of Hand Surgery Society of Chinese Medical Association. Results: All the gracilis muscle flap and sural nerve survived successfully after operation. The wound healing time of recipient area on forearm was 10 to 14 days after operation, and the healing time of suture in muscle flap donor area and nerve donor area was 12 to 15 days after operation. The donor and recipient areas recovered well. In the follow-up of 2 years after operation, the muscle strength of thumb and digital flexion was evaluated as follows: 4 cases of grade 5, 3 cases of grade 4, and 1 case of grade 2; the finger sensory function was evaluated as follows: 4 cases of grade S3+, 2 cases of grade S3, and 2 cases of grade S2. Conclusions: For patients with hand dysfunction caused by severe wrist electric burn, free gracilis muscle flap combined with sural nerve transplantation can be used to reconstruct the digital flexion and sensory function of the affected hand. It is a good repair method, which does not cause great damage to thigh muscle flap donor area or calf nerve donor area.

Functional reconstruction of the masseter muscle by microvascular free gracilis muscle transfer: technique and outcome.

Microvascular reconstruction of the cheek is most often performed using fasciocutaneous flaps and without functional reconstruction of the masseter muscle. This article reports a technique of masseter muscle resection, dissection of the masseteric nerve, and masseter muscle reconstruction with a functional gracilis muscle flap. The technique was applied in a 38-year-old man with recurrent intramuscular lipoma of the right masseter muscle. The flap was highly stable in form and showed good function. Bite force, electromyography results, and the radiological appearance of the gracilis muscle were similar to those of the contralateral masseter muscle at 12 months after surgery. In conclusion, full rehabilitation of masseter muscle function and good facial aesthetics were achieved by functional gracilis muscle reconstruction of the masseter muscle in a case of total resection.

Microvascular Gracilis Free Flap: Single and Double Innervation.

Facial paralysis (FP) is a devastating condition that can lead to significant aesthetic, social, and emotional morbidities for patients. For some patients with FP, free gracilis muscle transfer (FGMT) is the best option for smile restoration. Masseteric-driven FGMT produces a reliable voluntary smile. Cross-face nerve graft-driven FGMT can produce a spontaneous smile, but this technique has higher failure rates. Early studies suggest dual-innervation FGMT can produce a spontaneous smile while maintaining the reliability of masseteric-driven procedures. Great care should be taken during FGMT surgery to minimize facial bulk and place medial inset sutures that create a natural-appearing smile.

Long-term follow-up of bilateral gracilis reconstruction following extra-levator abdominoperineal excision.

INTRODUCTION: Colorectal operations such as an extra-levator abdominoperineal (elAPE) excision for locally advanced or recurrent cancer create a significant perineal tissue deficit. Options for perineal reconstruction include bilateral pedicled gracilis muscle flaps (BPGMF). Fashioning the gracili into a 'weave' creates a muscular sling that supports pelvic contents and is a novel technique. Our series reports the outcomes of the BPGMF in 50 patients undergoing surgery for pelvic cancer. METHOD: This is a retrospective, single-centre study of patients undergoing reconstruction of perineal defects using BPGMF. All surgeries took place between January 2008 and February 2021. The primary outcome measured was perineal wound healing. The secondary outcomes measured were complications of surgical sites and length of hospital stay (short term), flap integrity on follow-up imaging and functional outcomes (long term). RESULTS: Fifty patients underwent perineal reconstruction using BPGMF (26 males). The median age was 62 years. The 30-day mortality was 2% (n = 1). The average follow-up period was 2 years. Complete perineal wound healing was 86% (42/49) at outpatient follow-up. Complication rates for the donor site and reconstructed site were 14% and 22%, respectively. Complications included infection (2% donor site, 12% perineum), haematoma (4% donor site), dehiscence (2% donor site, 4% perineum) and seroma (3% donor site, 2% perineum). CONCLUSION: BPGMF offers a reliable and technically simple muscle flap to reconstruct large perineal defects. The muscle flap integrity appears maintained on follow-up imaging despite a lack of flap monitoring tools. This cohort had minimal functional impairment following BPGMF.

The Split Hypoglossal Nerve and Cross-Face Nerve Graft for Dual Innervation of the Functional Muscle Transfer in Facial Reanimation.

Facial paralysis is a disabling deformity. The affected individual is seriously affected both esthetically and functionally. Free functional muscle transfer is currently the corner stone in the management of long-standing facial nerve paralysis. Several nerve options are available to supply the free muscle transfer. These nerves can be used alone or in combination. The aim of this work is to study the possibility and results of dually innervating the free functioning muscle transfer. The dual innervation is done using the split hypoglossal nerve and cross-face nerve graft (CFNG) both sutured in an end-to-end manner to the nerve to gracilis. Twenty-nine patients with unilateral long-standing facial nerve paralysis (more than 1 y) were treated using free gracilis muscle transfer dually supplied by the split hypoglossal nerve and CFNG, both sutured in an end-to-end manner. The gained excursion after the free gracilis transfer was 9 to 29 mm (mean: 17.24 mm). A statistically significant increase ( P -value=0.0001) in the distance from where the midline crosses the lower vermilion border to commissure occurred from preoperative (mean: 16.55 mm) to postoperative setting (mean: 33.79 mm). Spontaneity was achieved in 26 patients (89.6%). In conclusion, dual innervation of the free muscle transfer using both the split hypoglossal nerve and CFNG (both sutured in an end-to-end manner to the nerve to gracilis) is a good possible option to treat long-standing cases of facial nerve paralysis. It yields adequate muscle excursion with acceptable spontaneity.

Facial Reanimation Using Free Functional Muscle Transfer: Lessons Learnt From a Long Term Experience Comparing Innervation With Cross Facial Nerve Graft and Masseter Nerve.

BACKGROUND: Facial palsy is a complex problem and goal of reanimation is to achieve symmetric face at rest and spontaneous smile. in our study the authors performed facial reanimation in long standing cases of facial palsy (more than 1 year), gracilis muscle was used as a free functioning muscle transfer. Two motor donor nerves were used: cross-face nerve graft and masseter nerve. MATERIALS AND METHODS: A total of 205 cases of unilateral facial reanimation with free functional muscle transfer (FFMT) were performed between 1998 and 2019. Out of 205 patients, 184 patients were operated by cross facial nerve graft-gracilis, and 21 by masseter nerve-gracilis. Quantitative assessment for outcome was done by measuring the excursion on follow up. Oral competence outcome and satisfaction score calculation was done by questionnaire. Results of spontaneous smile were divided into positive and negative groups. RESULTS: A 2 stage cross facial nerve graft-gracilis FFMT achieved most natural and spontaneous smile when longer observation period (≥2 years) was followed. Masseter nerve-gracilis provided satisfactory results in the shortest rehabilitation period, had more excursion but never obtained spontaneous smile. CONCLUSIONS: The cross facial nerve graft-gracilis FFMT can achieve natural and spontaneous smile and remains our first choice for facial reanimation. Masseter nerve-gracilis can be used if cross facial nerve graft-gracilis fails, patient desires a single stage surgery and in some specific conditions, such as bilateral mobius syndrome.

[Bilateral pedicled gracilis muscle flap and bilateral gluteus muscle flap for multiple-stage reconstruction of vagina, pelvis and perineal region]. / Bilaterale gestielte M. gracilis-Lappenplastik und bilaterale M. gluteus-Rotationslappenplastik zur mehrzeitigen Rekonstruktion der Vagina, des kleinen Beckens sowie der Perinealregion.

Plastic reconstructions of oncological anorectal defects often prove to be very difficult and lead to prolonged hospitalisation due to severe bacterial contamination, neoadjuvant radiotherapy and chemotherapy and difficult anatomical conditions. There is no common standard for plastic reconstruction in such cases. We present a patient diagnosed with distal rectal cancer with infiltration of the anus and vagina, who underwent radical tumour resection of the rectum and anus as well as partial resection of the vagina. A severe necrotising infection occurred post-surgery, which resulted in an extensive defect of the pelvis and perineal region. This article provides a retrospective clinical evaluation and photographic documentation of the reconstruction of the vagina, pelvis and perineal region with a bilateral gracilis and gluteus muscle flap.

Dynamic Reconstruction of the Lower Lip With Free Functioning Gracilis Muscle Transfer.

ABSTRACT: The restoration of large full-thickness lip defects still remains a formidable challenge for the reconstructive surgeons. Traumatic injuries, infections and tumors (primarily squamous cell carcinoma) are the most common source of the lip defects. Lower lips are more important in providing oral competence, unfortunately throughout the life-time they are significantly more exposed to ultraviolet radiation and thus are the most common site for the lip cancers (89%). This type of defect requires a complex reconstruction of an adequate sphincter function, defined vermilion, proper oral lining and sufficient mouth opening. To maintain the oral competence, it is of paramount importance to restore the function of orbicularis oris, which principally composes the body of the lip. Currently, the dynamic reconstructions are gaining considerable interest. They enables not only improvement of appearance but also a restoration of function and preservation of health-related quality of life. The use of the free gracilis muscle transfer to reconstruct the lower lip and its dynamic character in contrast to other, static reconstructions can provide the sufficient movement of the lower lip, which does not depend on function of other mimic muscles as it becomes an independent motor unit with its own neurotization. In our opinion the free functioning gracilis muscle flap, due to its anatomic and functional features as well as low-rate donor-site morbidity is the worth considering option for a lower lip reconstruction.

Seminal Studies in Facial Reanimation Surgery: Consensus and Controversies in the Top 50 Most Cited Articles.

ABSTRACT: Facial paralysis can impair one's ability to form facial expressions that are congruent with internal emotion. This hinders communication and the cognitive processing of emotional experience. Facial reanimation surgery, which aims to restore full facial expressivity is a relatively recent undertaking which is still evolving. Due in large part to published techniques, refinements, and clinical outcomes in the scientific literature, consensus on best practice is gradually emerging, whereas controversies still exist.Taking stock of how the discipline reached its current state can help delineate areas of agreement and debate, and more clearly reveal a path forward. To do this, the authors have analyzed the 50 seminal publications pertaining to facial reanimation surgery. In longstanding cases, the free gracilis transfer emerges as a clear muscle of choice but the nerve selection remains controversial with prevailing philosophies advocating cross facial nerve grafts (with or without the support of an ipsilateral motor donor) or an ipsilateral motor donor only, of which the hypoglossal and nerve to masseter predominate. The alternative orthodoxy has refined the approach popularized by Gillies in 1934 and does not require the deployment of microsurgical principles. Although this citation analysis does not tell the whole story, surgeons with an interest in facial reanimation will find that this is a good place to start.

Unilateral breast reconstruction using double transverse upper gracilis (TUG) flaps.

INTRODUCTION: When the deep inferior epigastric perforator (DIEP) flap is unavailable, autologous reconstruction of a moderate-to-large breast presents a surgical challenge. We retrospectively review our experience of unilateral breast reconstruction using double transverse upper gracilis (TUG) flaps and highlight specific technical considerations. METHODS: Thirty-four patients underwent double TUG flaps for unilateral breast reconstruction between 2012 and 2020. The average patient age was 50 years and the average body mass index (BMI) was 23.1 kg/m2. In all cases, the indication for surgery was breast cancer: 31 patients had immediate reconstruction, 11 had simultaneous axillary surgery and eight had primary contralateral symmetrising surgery. RESULTS: Of the 68 TUG flaps, 67 (98.5%) were successful. The mean operative time was 5 h 50 min (195-460 min) and the mean combined flap weight was 551 g (279-916 g). Eight patients returned to the operating theatre in the early post-operative period and five patients underwent secondary lipofilling to address contour deformities. Most commonly (n = 22), the flaps were oriented horizontally/obliquely, with one flap anastomosed medially to the internal mammary axis and the other anastomosed lateral to the subscapular system. The internal mammary artery perforators and serratus anterior artery provided the best vessel calibre match with the TUG vessels. CONCLUSIONS: Double TUG reconstruction is a safe and reliable option for unilateral breast reconstruction and is an important option when the DIEP flap is unavailable.

Video-Endoscopic Mobilization of the Gracilis Muscle for Rectourinary Fistula Repair.

INTRODUCTION: Transposition of the gracilis has been used in a large number of reconstructive procedures. Its advantage is its proximity to these defects and a good blood supply. Traditionally, the gracilis mobilization is performed by open surgery with one or more incisions. We describe our initial experience with the video-endoscopic mobilization of gracilis. METHOD: We described a retrospective review of all patients who underwent gracilis muscle mobilization for treatment of rectourethral fistula, performed by video-endoscopy, between March 2013 and September 2017, for treatment of rectourethral fistula. Also, our surgical technique is described in detail. RESULTS: Three patients, with a mean age of 66.6 years, underwent the procedures. The mean time for mobilization of the gracilis was 107 min (range 60-145). There was no case of donor area infection, no change in the sensitivity of the medial aspect of the thigh or chronic pain. Conversion to open surgery was not necessary in any case. The hospital discharge occurred in average after 4 days. The bladder catheter was removed after 4 weeks after cystography was performed without evidence of leakage. One patient had a recurrence of the fistula. DISCUSSION: The gracilis is an excellent choice of tissue to be interposed in reconstructive procedures of the perineal region, especially in the treatment of rectourinary fistulas. However, endoscopic harvest of the gracilis muscle has not yet found its way into everyday practice. The results in the treatment of rectourinary fistulas are excellent, with a success rate of 87.7%. Our rate of 67% is below, probably due to the small number of cases. In open surgery, complications are uncommon; however, approximately half of the patients expressed concern about the painful scar, which can be reduced by minimally invasive access. CONCLUSION: Video-endoscopic mobilization of gracilis muscle for the treatment of rectourethral fistula is feasible and safe. Studies comparing this technique with the conventional mobilization are required.

The combined use of pedicled profunda artery perforator and bilateral gracilis flaps for pelvic reconstruction: A cohort study.

The result of an extra-levator abdominoperineal excision of the rectum (ELAPE) is a composite three-dimensional defect. This is performed for locally advanced anorectal cancer, and may involve partial excision of the vagina. The aim of reconstruction is to achieve wound healing, restore the pelvic floor and to allow micturition and sexual function. We aim to evaluate the concurrent use of profunda artery perforator (PAP) and bilateral gracilis flaps for vaginal and pelvic floor reconstruction. We performed a retrospective case note review of patients undergoing pelvo-perineal reconstruction with combined gracilis and PAP flaps between July 2018 and December 2019. Eighteen pedicled flaps were performed on six patients with anal or vulval malignancies. All underwent pre-operative radiotherapy. Four patients had extended abdominoperineal tumour resections, while two patients underwent total pelvic exenteration. The median age was 57 (range 47-74) years, inpatient stay was 22 (11-47) days and the follow-up was 10 (5-21) months. Four patients developed partial perineal wound dehiscence, of which one was re-sutured. One patient had a post-operative bleed requiring radiological embolisation of an internal iliac branch and had subsequent 1cm PAP flap loss. All other flaps survived completely. Median time to heal was 4 (1-6) months. This is the first series reporting combined bilateral gracilis and PAP flaps for pelvic reconstruction. The wound dehiscence rate and healing times were expected in the context of irradiation and radical pelvic tumour resection. This is a reliable technique for perineal and vaginal reconstruction with minimal donor site morbidity.

Gracilis Muscle Interposition for Treatment of Complex Anal Fistula: Experience With 119 Consecutive Patients.

BACKGROUND: Treatment of complex anal fistula is challenging, often mandating multiple procedures. The gracilis muscle has been used to treat perineal fistulas and to repair perineal defects. OBJECTIVE: This study aims to report the results of gracilis muscle interposition for complex anal fistula, including prognostic factors for success. DESIGN: This is a retrospective analysis of a prospective database for patients who underwent gracilis muscle interposition for complex anal fistula from 2000 to 2018. SETTING: Patient demographics, operative data, and postoperative outcome were obtained from medical records. Office visits were used for follow-up. PATIENTS: All patients who underwent gracilis muscle interposition for complex anal fistula were included. Patients who underwent gracilis muscle interposition for reasons other than complex anal fistula were excluded. MAIN OUTCOME MEASURES: The primary outcome measured was the healing of complex anal fistula following gracilis muscle interposition and following additional procedures, when needed. RESULTS: A total of 119 patients (60 men, 59 women; median age: 56 (21-85) years) were included. The initial success rate of gracilis muscle interposition was 42%; the final success rate if additional procedures were undertaken was 92%. Overall success rate was 32.2% in women and 51.6% in men. Univariate analysis revealed that sex (p = 0.0315) and bed rest >3 days (p = 0.0078) were significant poor prognostic factors for failure, whereas the multivariate logistic regression model showed that length of bed rest >3 days was a significant poor prognostic factor for failure. In the female subgroup, multivariate analysis showed that bed rest ≥3 days was a significant poor prognostic factor, whereas in the male population there was no significant prognostic factor. LIMITATION: This study was limited by its retrospective nature and the heterogeneity of patients. CONCLUSION: Although initial success is <50%, the ultimate success after gracilis muscle interposition and other subsequent procedures is >90%. Patients must be preoperatively counseled that additional procedures will probably be required to achieve successful fistula closure. Furthermore, prolonged bed rest should be avoided after gracilis muscle interposition. See Video Abstract at http://links.lww.com/DCR/B551. INTERPOSICIN DEL MSCULO GRACILIS PARA EL TRATAMIENTO DE LA FSTULA ANAL COMPLEJA EXPERIENCIA CON PACIENTES CONSECUTIVOS: ANTECEDENTES:El tratamiento de la fístula anal compleja es un desafío que a menudo requiere de múltiples procedimientos quirúrgicos. El músculo gracilis se ha utilizado para tratar fístulas y reparar defectos perineales.OBJETIVO:Informar los resultados de la interposición del músculo gracilis para la fístula anal compleja, incluyendo los factores pronósticos para un tratamiento exitoso.DISEÑO:Se efectuó un análisis retrospectivo obtenido de una base de datos prospectiva para pacientes sometidos a interposición del músculo gracilis por fístula anal compleja del 2000 al 2018.METODO:Los datos demográficos de los pacientes, la información del procedimiento quirúrgico y los resultados postoperatorios se obtuvieron de los expedientes clínicos; el seguimiento se llevó a cabo por medio de visitas al consultorio.PACIENTES:Se incluyeron todos los pacientes sometidos a interposición del músculo gracilis por fístula anal compleja; Se excluyeron los pacientes que se sometieron a interposición del músculo gracilis por motivos distintos a la fístula anal compleja.CRITERIOS DE EVALUACION DE LOS RESULTADOS:Curación de una fístula anal compleja después de la interposición del músculo gracilis y procedimientos adicionales, cuando fueron necesarios.RESULTADOS:Se estudiaron un total de 119 pacientes [60 hombres, 59 mujeres; con media de edad de 56 (21-85) años]. La tasa de éxito inicial de la interposición del músculo gracilis fue del 42%; La tasa de éxito final cuando realizaron procedimientos adicionales fue del 92%. La tasa de éxito global fue del 32,2% en mujeres y del 51,6% en hombres. El análisis univariado reveló que el género (p = 0,0315) y el reposo en cama > 3 días (p = 0,0078) en forma significativa fueron factores de pronóstico bajo para el fracaso, mientras que el modelo de regresión logística multivariable mostró que la duración del reposo en cama> 3 días fue un factor de pronóstico significativamente bajo para fracaso. En el subgrupo de mujeres, el análisis multivariado mostró que el reposo en cama ≥3 días fue un factor de pronóstico significativamente bajo, mientras que en la población masculina no hubo un factor pronóstico significativo.LIMITACIÓN:Carácter retrospectivo y heterogenicidad de los pacientes.CONCLUSIÓN:Aunque el éxito inicial es <50%, el éxito final después de la interposición del músculo gracilis y otros procedimientos posteriores es > 90%. Se debe aconsejar a los pacientes antes de la operación que probablemente se requieran procedimientos adicionales para lograr el cierre exitoso de la fístula. Además, debe evitarse el reposo prolongado en cama después de la interposición del músculo gracilis. Consulte Video Resumen en http://links.lww.com/DCR/B551.

Isolated MPTL reconstruction fails to restore lateral patellar stability when compared to MPFL reconstruction.

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.

Early Outcomes in an Emerging Facial Nerve Center: The Oregon Health and Science University (OHSU) Experience.

OBJECTIVES: Nerve transfer (NT) and free gracilis muscle transfer (FGMT) are procedures for reanimation of the paralyzed face. Assessing the surgical outcomes of these procedures is imperative when evaluating the effectiveness of these interventions, especially when establishing a new center focused on the treatment of patients with facial paralysis. We desired to discuss the factors to consider when implementing a facial nerve center and the means by which the specialist can assess and analyze outcomes. METHODS: Patients with facial palsy secondary to multiple etiologies, including cerebellopontine angle tumors, head and neck carcinoma, and trauma, who underwent NT or FGMT between 2014 and 2019 were included. Primary outcomes were facial symmetry and smile excursion, calculated using FACE-gram and Emotrics software. Subjective quality of life outcomes, including the Facial Clinimetric Evaluation (FaCE) Scale and Synkinesis Assessment Questionnaire (SAQ), were also assessed. RESULTS: 14/22 NT and 6/6 FGMT patients met inclusion criteria having both pre-and postoperative photo documentation. NT increased oral commissure excursion from 0.4 mm (SD 5.3) to 2.9 mm (SD 6.8) (P = 0.05), and improved symmetry of excursion (P < 0.001) and angle (P < 0.001). FGMT increased oral commissure excursion from -1.4 mm (SD 3.9) to 2.1 mm (SD 3.7), (P = 0.02), and improved symmetry of excursion (P < 0.001). FaCE scores improved in NT patients postoperatively (P < 0.001). CONCLUSIONS: Measuring outcomes, critical analyses, and a multidisciplinary approach are necessary components when building a facial nerve center. At our emerging facial nerve center, we found NT and FGMT procedures improved smile excursion and symmetry, and improved QOL following NT in patients with facial palsy secondary to multiple etiologies.

Patellar Tendon Versus 4-Strand Semitendinosus and Gracilis Autografts for Anterior Cruciate Ligament Reconstruction: A Meta-analysis of Randomized Controlled Trials With Mid- to Long-Term Follow-Up.

PURPOSE: To compare patellar tendon (PT) autografts with 4-strand semitendinosus and gracilis (STG) autografts concerning knee stability, functional outcomes, as well as complications after anterior cruciate ligament (ACL) reconstruction at minimal follow-up of 5 years. METHODS: A systematic search of the literature was performed in PubMed, Embase, and the Cochrane Library to identify published prospective randomized controlled trials on clinical studies comparing PT autograft and 4-strand STG autografts for ACL reconstruction. The results of the eligible studies were analyzed in terms of knee stability (laxity measurements, Lachman test, and pivot-shift test), functional outcomes (Lysholm score, International Knee Documentation Committee score, Cincinnati score, Tegner score, single-legged hop test, and return to preinjury activity level), and complications (loss of range of motion [ROM], pain, graft re-rupture, revision, and osteoarthritis [OA]). RESULTS: Nine clinical studies with 630 patients (313 PT and 317 STG autografts) met the inclusion criteria. No statistically significant differences were found between the PT and STG group in Lachman test, pivot-shift test, International Knee Documentation Committee score, Cincinnati score, loss of ROM, kneeling pain, graft re-rupture rate, revision rate, and OA rate. The STG group was found with less anterior knee pain (P = .003). There were no clinically significant differences for the outcomes of SSD, Lysholm score, and Tegner score. CONCLUSIONS: Except for significantly greater risk of anterior knee pain, PT autograft had comparable results with 4-strand STG autograft in terms of knee stability and functional outcomes after ACL reconstruction with mid- to long-term follow-up. Besides, we found no statistically significant difference in loss of ROM, kneeling pain, graft re-rupture rate, revision rate, and OA change, but these results were underpowered. LEVEL OF EVIDENCE: Level I, meta-analysis of Level I studies.