Scrotal reconstruction with pedicled gracilis muscle flap following Fournier’s gangrene: a case report and literature review

Background Fournier’s gangrene is an acute soft tissue necrotizing infection involving the perineum and the external genitalia which can result in a major loss of the scrotal wall with exposure of the testicles. Reconstruction of such major defect is quite challenging; the use of pedicled gracilis muscle flap helps to create an aesthetically acceptable scrotum with minimal donor site morbidity. Case presentation We described the case of a 60-year-old man with a large scrotal loss from Fournier’s gangrene following bladder outlet obstruction and perineal abscess. He had multiple debridement and reconstruction with pedicled left gracilis muscle flap with a good aesthetic and functional post-operative outcome. The major challenge encountered was the loss of the skin graft as a result of the retraction of the muscle flap due to too early ambulation; this can thus be avoided by adequate pre-operative counseling and enforcing bed rest. Conclusions The use of gracilis muscle flap in the reconstruction of large scrotal defect described in this report has the additional advantage of creating a pliable and soft feel like that of the original scrotum with minimal donor site morbidity.

Dynamic Medial Patellofemoral Ligament Reconstruction in Patellar Instability: A Surgical Technique

Background: Patella instability with recurrent dislocations is a result of various pathologies, for example, patella alta, trochlea dysplasia or medial patellofemoral ligament (MPFL) rupture. The recurrent dislocation rate of conservatively treated chronic patellar instability is high; therefore, it is recommended to manage it surgically. This video presents a new operative approach to stabilize the patella in a dynamic MPFL reconstruction, which addresses the most common complications occurring in static reconstructions: malpositioning and overtensioning the graft. Indications: Surgical indications for the new dynamic procedure mirror the indications for static MPFL reconstruction. This is MPFL insufficiency (patella instability in the first 30° of knee flexion), which is most frequently seen in recurrent lateral patella dislocations. Moreover in very rare cases of first patella dislocation with a patellar instability severity score equal or higher than 4. Technique Description: The dynamic MPFL reconstruction consists of 3 steps: First, detaching and mobilizing the gracilis muscle at its anatomical insertion. Second, redirecting the freed gracilis muscle to its new patellar insertion. Third, reinserting the gracilis muscle at the patella. Results: The dynamic MPFL reconstruction has the advantage of lesser risk of overtensioning and malpositioning the graft. The insertion point of the MPFL surrogate is easier to locate, and the patella is dynamically stabilized through reflectory gracilis muscle contraction. Compared with the static reconstruction, only one instead of 3 holes have to be drilled and only 1 interference screw has to be placed, thus shortening the surgery time. From a theoretical biomechanical perspective, the dynamic tensioning is superior to the static procedure. The few accomplished studies published so far by Becher et al and Ostermeier et al show good or better functional results (Kujala, Lysholm, Tegner scores) with the dynamic MPFL reconstruction, yet higher evidence studies need to be performed. Conclusion: Dynamic MPFL reconstruction appears to be a simpler and more effective surgical technique for MPFL reconstruction. Because of its novelty, high evidence studies assessing long-term therapeutical outcomes are still lacking and need to be conducted in order to compare it conclusively with the static procedure.