Purpose of the study: Surgical reconstruction procedures using the gracilus myocutaneous flap may be compromised if partial or total necrosis of the skin cover develops. The purpose of this study was to describe the anatomic blood supply to the gracilus muscle and the corresponding skin cover in an attempt to better understand the arterial afferences to the skin and define the safest topography for a transferable zone of skin.

Material and methods: We dissected the thighs of human adult cadavers to detail the vascular bundles feeding the gracilus muscle.

Selective injections of methylene blue were used in the main gracilus pedicle; the area of skin colored was then measured (greatest and smallest diameter) for computation of the surface area using an imaging software.

Results: Preliminary results of nine dissections showed that the main blood supply of the gracilus muscle arose from the deep femoral artery (n=8 dissections) or the common femoral artery (n=1 dissection) then penetrated the muscle 90.55 mm below the pubis with a mean diameter of 1.32 mm. The muscle was fed by one to four accessory arteries. The skin cover was stained in all cases, the area involved lying over the proximal and mid thirds of the muscle. The surface area was irregular, the mean length being 127.5 mm and the mean width 91.66 mm. The computed surface area was 88.08 cm² on average (range 58–120.95 cm²). Each muscle had two to six perforating vessels issuing from the opposite side of the main pedicle and comprised within a 48 mm long segment before dividing at the subcutaneous level. A mathematical model correlated the skin surface area to the number of perforating arteries.

Discussion and conclusion: Our findings suggest it would be possible to determine the surface area of skin transferable with a gracilus muscle flap based on high-frequency duplex-Doppler assessment of the number and position of the perforating arising from the muscle and feeding the skin surface. The linear distribution of the surfaces measured as a function of the number of perforating arteries suggests that more reliable conditions for gracilus myocutaneous flap harvesting could be proposed to minimize the risk of cutaneous necrosis.

Purpose: During surgery for repair of rotator cuff tears, some authors always associate tenotomy-tenodesis of the long head of the brachial biceps. Others decide as a function of the gross aspect of the tendon and its position in relation to the bicipital groove. It is a classical notion the preservation of the long head of the brachial biceps is a cuase of persistent pain in operated shoulders. This study was conducted to search for a histological validation of the decision to perform tenotomy.

Material and methods: Fifty tendons of the long head of the brachial biceps presented a thick and inflammatory aspect with or without subluxation during 68 procedures to repair recent rotator cuff tears (23 men, 27 women, mean age 53.5 years). Tenodesis of the long head of the brachial biceps was associated with proximal tenotomy. The histological examination concerned the most proximal centimeter of the tendon. Four parameters were studied: two concerned the tendon (organisation of the collagen network and aspect of the interstitial connective tissue), two concerned the synovial border (sub-synoviocytic layer and synovial mesothelium). Sixteen tendons which appeared perfectly healthy were harvested from cadaver shoulders to determine the normal aspect of histological parameters (parallel and cohesive orientation of the collagen network, absence of hypertrophic interstitial connective tissue, thin subsynovio-cytic layer and pluristratified synovial mesothelium).

Results: The tendon. The collagen bundles were oriented in 32 cases but thick in 40 and dissociated in 47. Microscopic signs of fissuration or intratendinous tears were present in 17 cases. The tendinous connective tissue was oedematous in 49 cases, presenting fibroblastic hyper-cellularity in 37 and hypervascularity in 43. Scar-like fibrosis was observed in 28 cases. The synovial layer was regular in 11 tendons and clearly thickened in 26 with a mixed irregular aspect in the others. The subsynoviocytic layer was thick in 33 tendons with signs of hypervascularity or hypercellularity in 12. The synovial mesothelium was paucistratifed in 23 cases, thick in 12, and regular in 15. Lesions had an inflammatory aspect and were intense in 26 cases. Degenerative lesions were observed in 21 tendons. These four histological parameters demonstrated that the lesions were advanced and associated with degenerative sclerosis with reactional synovitis in 30 cases, moderate combined lesions in 13, tendon and synovial inflammation alone in four, and advanced degenerative lesions of the tendon and the synovial in six.

Discussion: Histological lesions of the long head of the brachial biceps tendon are generally degenerative and irreversible while most synovial lesions are reversible inflammatory reactions. The zones of intratendinous fibrosis, vascularity and weak or absent cellularity constitute the anatomic conditions before tendon tears in chronic tendinopathy. This histological study confirmed the validity of the intra-operative decision for tenodesistenotomy of the long head of the brachial biceps in 46 (92%) of the cases. The oedematous and fissu-rated aspect of the tendon appeared to be a reliable criteria while inflammatory synovitis, which surrounds the tendon, does not constitute in itself a formal argument in favour of tendon sacrifice.

Purpose: The radial nerve raises several problems during plate fixation of the mid third of the humerus because of its particular anatomic position. Translocation of the radial nerve has been proposed to distend the nerve. There have been few studies studying the feasibility of translocation. The purpose of our work was to validate the translocation effect on nerve distension and the status of the translocated radial nerve branches.

Materials and methods: We report an anatomic study of six cases. These patients had recent communitive fractures of the mid third of the humerus with immediate radial paralysis in three cases. The anterolateral approach was used to expose the nerves that were found to be continuous. Nerve translocation then plate fixation were achieved without neurolysis. The anatomic study was conducted on 15 cadavers: the distance between the last branch for the triceps and the first epicondylar motor branch was calculated in three positions: D0: mean distance in the anatomic position of the nerve; D1: mean distance of the nerve in the anatomic position with the plate; D2: mean distance after anterior translocation of the nerve. We provoked shaft fractures in the mid and lower third of the humerus and evaluated the sensorial and motor branches after translocation.

Results: In this clinical series, translocation was easily achieved in all cases without stretching the sensorial or motor branches. The three radial paralyses recovered in six months. There was not postoperative paralysis for the other cases. For the anatomy study, mean measurements for D0, D1, and D2 were 112, 116 and 106 mm, for a 10 mm gain between D2 and D1. The sensorial branch was stretched making the technique difficult in one case.

Discussion: The results of these two studies confirm the effect of radial nerve distension that facilitates fixation. It frees the posterior aspect of the humerus allowing access in case of nonunion. However, the translocation should be done without neurolysis of the radial nerve and after informed consent from the patient.

Conclusion: Anteromedial translocation of the radial nerve appears to be useful for fractures of the humerus. The ideal indication is an oblique fracture of the mid or lower third of the humeral shaft with immediate radial palsy. A certain degree of comminution facilitates the translocation.