The use of the spreaded gracilis flap provides a valuable option for the microsurgeon, especially also to reconstruct large size lower limb defects.

Background Injuries to the thenar muscle mass or the thenar branch of the median nerve and resulting loss of thumb opposition lead to a massive impairment of hand function. For decades, reconstructive approaches were based on tendon transfers. To broaden the reconstructive repertoire, we present the free functional pronator quadratus flap as a viable alternative for functional reconstruction and provide a specification for its indication. We demonstrate our surgical technique to a single incision reconstruction using the free functional pronator quadratus flap. Based on a series of three patients, which were analyzed for hand function using Kapandji’s score and the angle of Bourrel, grip strength and nerve conduction velocity in a two year follow up, we present an indication algorithm. Results After successful reinnervation of all flaps, we found an improvement of Kapandji’s score from 4.3 ± 0.94 preoperatively, to 8.7 ± 0.47 after two years. Accordingly, the angle of Bourrel decreased from 75.75 ± 3.45 degrees to 36.96 ± 3.68 degree. Grip strength also improved from 14 ± 2.2 kg to 26.2 ± 1.2 kg. No impairment of wrist pronation was observed. Conclusion We found excellent functional recovery of thumb opposition and strength, showing similar or even superior results compared to results from tendon transfers. With the benefit of a single incision surgery and therefore minimal donor site morbidity, this free functional muscle transfer is a viable alternative to classic tendon transfers.

Wound healing problems following acute and chronic olecranon bursitis can result in problematic tissue defects around the elbow. These defects often require a regional flap or a free flap for durable tissue coverage. The aim of this study was to assess clinical outcome the lateral arm flap (LAF) used to cover tissue defects caused by chronic olecranon bursitis. Between 2011 and 2015, 13 patients with soft tissue defects of the elbow resulting from chronic bursitis olecrani were treated in an interdisciplinary approach. First sufficient debridement was performed in conjunction with the orthopedic surgeons. Then, using a defect specific algorithm, reconstruction followed using pedicled extended LAFs or reverse LAFs, with and without inclusion of triceps muscle tissue. Mean follow-up was 52.3 months (range 23-72 months). There were no complete flap losses. All flaps healed in nicely without major wound healing complications. No patient showed signs of recurrent infections during follow-up, and all patients were able to achieve full range of motion post-operatively. Depending on the size of the defect, the conditions of the surrounding tissues, involvement of the elbow joint or need for sensate tissue, reconstruction may require different approaches. In our opinion the LAF can be designed to address these demands.

Worldwide obesity has more than doubled since 1980. Given this epidemic change, surgical and medical care has become more complex as obesity is a known risk factor for complications. Consequently, one could expect a higher prevalence of medical and surgical complications in an obese patient collective in the setting of free tissue transfer. Goal of this study was to evaluate whether this assumption holds true. Between January 2009 and June 2015, 838 patients underwent free tissue transfers at a single institution. The cases were divided into three groups using the World Health Organization body mass index (BMI) criteria into a nonobese ( = 751), a moderately obese ( = 59), and a severely to very severely obese group ( = 28). The series was retrospectively analyzed and the groups were compared regarding the potential influence of BMI in respect to surgical complications and outcomes. Overall, there was no significant difference in morbidity between the groups of patients regarding the rate of surgical complications during our 3-month follow-up period. This study analyzed a large series of microsurgical reconstructions, with a focus on the impact of patient obesity on outcomes. Our findings suggest that despite higher rates of patient comorbidities, successful free tissue transfer can be achieved in this population with acceptable risk for complications.

Learning Objectives: There is little in the literature about the impact of coagulopathy on morbidity and mortality for traumatic splenic injuries. EAST guidelines recommend selective management in treating traumatic splenic injuries. The purpose of this investigation was to measure the adjusted effect of on outcomes on traumatic splenic injuries in patients with coagulopaty. Methods: A 4 year retrospective review of the National Trauma Databank (NTDB) (2007 -2010). ICD-9 codes to identify splenic trauma. Gender, race, Injury Severity Score (ISS), mechanism of injury, length of stay (LOS), associated injuries and in-hospital mortality. Multivariable regression analysis to determine independent predictors of intra-abdominal drainage procedures, mortality and complications, adjusting for demographics, injury characteristics and treatment modalities. Exclusion criteria: DOA or death in ED, trauma to head, abdomen or thorax with AIS of 6. Adjusted for hypotension, age, race, insurance, ISS. Results: 58, 896 cases 93% blunt trauma 1.9% bleeding disorder 18% underwent splenectomy On bivariate analysis: Coagulopathic pts more likely to undergo operative management A higher percentage of pts undergoing splenectomy had an ISS score 25-75 Coagulopathic patients had higher odds of operative management, intra-abdominal fluid drainage, sepsis, death and overall complications (except MI) Patients undergoing splenectomy had higher odds of mortality and overall complications Conclusions: Our study shows that coagulopathy has a significant negative impact on mortality and sepsis following splenic injury. Coagulopathy, however, does not appear to be associated with an increased risk of myocardial infarction.