The feasibility of a pedicled flexor digitorum superficialis muscle flap was studied in 10 fresh cadavers. The number, length and distance from the flexion wrist crease of muscular branches from the ulnar artery in the distal 10 cm of the forearm were recorded. The mean number of muscular branches was 2.7 (range 1-4). The mean distance of the most distal branch was 35 mm (range 26-40) from the proximal wrist flexion crease. Its mean length was 20 mm (range 16-26). A partial muscle flap was raised on the most distal branch and transposed over the median nerve in the distal forearm. Dissection and transposition of this flap were feasible in all specimens. The reliable pattern of muscular branches to the flexor digitorum superficialis allows the elevation of a pedicled partial muscle flap that can cover the median nerve in the distal forearm.Level of evidence: V.

The study aimed to assess the efficacy of buccinator myomucosal flap (BMF) compared to Bardach two-flap use in primary cleft palatoplasty on palatal length and fistulation rate. Palatal length in relation to the pharynx is a critical factor regarding velopharyngeal function. The goal was to predict the risk of velopharyngeal insufficiency by comparing the potential of two different techniques in lengthening the palate and to decrease the fistulation rate. A total of 46 patients with complete wide cleft palate were randomly divided into two equal groups: a study group, in which the cleft palate defect was repaired by BMF; and a control group, in which patients\' clefts were repaired by Bardach (two-flap) palatoplasty during primary repair. All patients were evaluated at 1-, 3- and 6-month intervals to detect the fistulation rate and to measure the palatal length by taking impressions, pouring casts to measure the palatal length from anterior reference point (incisive foramen) to the posterior reference point(uvula) and calculating the change of palatal length. There was a significant increase in the palatal length measurements in the study (BMF) group (immediate postoperatively and at 3 and 6 months) compared to the control group (p < 0.001). Regarding the fistulation rate, there was no statistically significant difference (p = 0.346). The use of the buccinator flap during primary repair of cleft palate decreased the fistulation rate.

OBJECTIVE: The aim of this meta-analysis was to compare clinical and angiographic outcomes of skeletonized versus pedicled internal thoracic artery for coronary artery bypass grafting.
METHODS: A comprehensive search on Ovid MEDLINE, Ovid EMBASE and Scopus was performed from inception to December 2022. The primary outcome was follow-up mortality and graft failure. Secondary outcomes were repeat revascularization, cardiovascular death and operative mortality, myocardial infarction, stroke, and sternal wound complications (SWCs). Pooled estimate for follow-up outcomes was summarized as incidence rate ratio (IRR) and 95% confidence interval (CI) while short-term outcomes were pooled as odds ratio (OR) and 95% CI. For all outcomes, inverse variance weighting was used for pooling.
RESULTS: Twenty-eight studies, including 7 randomized trials and 21 observational studies, for a total of 5664 patients in the skeletonized group and 7434 in the pedicled group, were included in the analysis. At a mean weighted follow-up of 4.8 years, there was no difference in mortality between the two groups (IRR 1.14; 95% CI 0.59-2.20). However, the skeletonized group had a higher incidence of graft failure compared to the pedicled group (IRR 1.87, 95% CI 1.33-2.63) but a lower risk of SWCs (OR 0.42; 95% CI 0.30-0.60). There was no difference in short-term outcomes.
CONCLUSIONS: Compared to the pedicled harvesting technique, skeletonization of the internal thoracic artery is associated with higher rate of graft failure and lower risk of SWCs without mortality difference.

BACKGROUND: Skin cancers are the most common human neoplasms with head and neck localization in 90% of cases. Primary therapy is surgery, resulting in absolute skin defects in a number of cases. The reconstruction of these is performed with local skin flaps showing identical colour, texture and follicle density with the defect site.
OBJECTIVE: In the present study, we report our preliminary experience with the head and neck application of double hatchet flap, a random pattern flap.
METHODS: In our study, results of patients undergoing double hatchet flap reconstruction in the period between November 2021 and June 2023 were analyzed prospectively in terms of tumor site, defect size, method of anesthesia, and early and late complication rates. Patients followed up to a minimum of 6 months were asked to fill in a questionnaire concerning their postoperative status.
RESULTS: A total of 13 patients with a mean age of 79.6 years underwent double hatchet flap reconstruction. The most frequent defect site was the scalp and the mean defect size was 40.5 × 32.1 mm. Histopathological examination showed R0 resection of the tumor in each case. The closure of the skin defect was insufficient in 1 case. Partial flap necrosis and mimical paralysis were observed as early and late complications in 2 cases, respectively. The most bothersome sequel reported by patients was scarring.
CONCLUSIONS: For selection of a local flap, the following factors need to be considered: localization and size of the defect, skin elasticity, amount of adjacent skin to mobilize, direction of relaxed skin tension lines and wrinkles, and aesthetic units. If the principles of the hatchet flap design (the ratio of flap length and width and pedicle width to the defect size) are adhered, the resulting technique is reliable with an acceptable complication rate.
CONCLUSIONS: The double hatchet flap as a random pattern flap is a fast, reliable technique especially for the closure of 2-5 cm skin defects of the scalp and forehead. Orv Hetil. 2023; 164(44): 1755-1763.
Bevezetés: A bőr rosszindulatú daganatai a leggyakoribb humán neoplasmák, melyeknek 90%-a a fej-nyaki régióban jelentkezik. Elsődleges terápiájuk a műtéti eltávolítás, melynek során gyakran alakul ki valódi bőrhiány. Ennek zárása ideális esetben színében, vastagságában és szőrtüszőtartalmában a laesio kiindulási helyével megegyező helyi lebenyekkel történik. Célkitűzés: Jelen munkánkban egy random vérellátású helyi lebeny, a kettős bárdlebeny alkalmazásával kapcsolatos első tapasztalatainkról számolunk be. Módszer: A 2021. november és 2023. június között a fej-nyaki bőrtumor eltávolítása utáni defektus kettős bárdlebennyel történő zárásán átesett betegeket prospektív módon követtük. Vizsgáltuk a primer tumor lokalizációját, méretét, az anesztézia módját, továbbá a korai és késői szövődmények előfordulását. A műtét után legalább 6 hónapig követett betegek esetében egy, a műtét utáni statusra vonatkozó elégedettségi kérdőívet töltettünk ki. Eredmények: A vizsgált időszakban 13 beteget operáltunk a kettős bárdlebeny technikájával, átlagéletkoruk 79,6 év volt. A leggyakoribb lokalizáció a skalp volt, a reszekátumok átlagos mérete 40,5 × 32,1 mm volt. Valamennyi esetben R0-reszekciót végeztünk. 1 esetben a defektus teljes zárása nem volt lehetséges. Korai szövődményként 2 betegben részleges lebenynekrózist, késői következményként 2 betegben mimikai mozgászavart észleltünk. A betegek számára a legzavaróbb következmény a hegesedés volt. Megbeszélés: A helyi lebeny kiválasztásakor a defektus elhelyezkedése, mérete, mélysége, a bőr elaszticitása, a defektus környezetében mobilizálható bőr mennyisége, a Langer-féle erővonalak és a ráncok iránya, a szőrzet (hajas fejbőr és szemöldök), valamint az arc esztétikai egységeinek és alegységeinek határai a meghatározó tényezők. Amennyiben a kettős bárdlebeny kialakításának alapelveit betartjuk (hossz és szélesség aránya, a lebeny nyelének szélessége a defektus méretéhez képest), elfogadható szövődményrátával rendelkező, megbízható módszer áll rendelkezésünkre. Következtetés: A kettős bárdlebeny mint random vérellátású helyi lebeny különösen alkalmas a hajas fejbőr és a homlok területén elhelyezkedő 2–5 cm-es bőrdefektusok zárására. Orv Hetil. 2023; 164(44): 1755–1763.

There are two recognized internal mammary artery (IMA) harvesting techniques during coronary artery bypass grafting (CABG): pedicled and skeletonized. This systematic review and meta-analysis sought to compare the clinical outcomes of the two harvesting techniques. A comprehensive electronic literature search of PubMed, Scopus, and Embase was conducted from inception till June 2023. Thirty-one studies with a total of 13005 patients met our inclusion criteria. The results from the included studies were presented as weighted mean difference (WMD) with its relevant standard deviation (SD) for continuous variables, while Odds Ratio (OR) was used for dichotomous variables. A 95% confidence interval (CI) was used, and the results were pooled using a random effects model. The skeletonized IMA demonstrated a significantly reduced risk of sternal wound infection (SWI) compared to the pedicled IMA (OR = 0.45 [95% CI, 0.32-0.66]; p = 0.0001). The conduit length used was significantly longer in the skeletonized IMA (WMD -2.48, 95% CI, [-3.75, -1.20], P = 0.0001) and a significantly higher postoperative flow rate was observed while using skeletonization compared to the pedicled harvesting (WMD -13.11, 95% CI, [-22.52, -3.70], P = 0.006). However, no significant difference was seen in mortality between the two techniques (OR = 1.19 [95% CI, 1.00-1.41]; p = 0.05). Pedicled harvesting demonstrated significantly reduced incidents of MI (OR = 1.38 [95% CI, 1.13-1.69]; p = 0.002), while significant results in graft patency were observed favoring pedicled harvesting over skeletonization (OR = 0.63 [95% CI, 0.40-0.98]; p = 0.04).

OBJECTIVE: Evaluate the outcomes of ACL (Anterior Cruciate Ligament) reconstruction techniques that use a hamstring graft with a preserved tibial insertion and compare them to standard techniques.
METHODS: A systematic literature review and meta-analysis was done of the PubMed, MEDLINE, Cochrane and Ovid databases to identify published clinical studies on ACL reconstruction in which a non-detached hamstring tendon (NDHT) was used as a graft and to compare them to studies in which a detached hamstring tendon (DHT) or other techniques were used. The eligible studies were analyzed for the knee laxity, Lachman test, pivot shift test, joint range of motion, anterior drawer, pain, re-tear, revision surgery, Lysholm score, Tegner score, ACL-RSI scale, KOOS, IKDC, SNQ and Howell scale.
RESULTS: Twelve articles in which NDHT was used for ACL reconstruction were analyzed. There was no significant difference between NDHT and DHT in the Lachman > 1 (p = .07), pivot shift test > 1 (p = .40), re-tears (p = .62), pain (p = .85) and the Tegner score (p = .95). However, the outcomes were somewhat better with the NDHT technique for the Lachman (RR = 0.30; 95% CI 0.08-1.12), pivot shift test (RR = 0.50; 95% CI 0.10-2.49) and re-tears (RR = 0.66; 95% CI 0.13-3.42). The other criteria were not included in the meta-analysis because of lack of data or because specific outcome scores were used in each article.
CONCLUSIONS: NDHT techniques provide similar results to DHT for ACL reconstruction and tend to produce better stability and a lower re-tear rate.

Tissue loss in the forearm is a common entity. There are various etiologies to tissue loss like trauma, burn, post-surgery, etc. Coverage of defect or tissue loss of the forearm is a surgical challenge and options available for forearm coverage are limited. To bypass this difficulty, McGregor pedicled groin flap is used by us to cover large forearm defects with successful outcomes in this case series.

The hamstring tendons (gracilis and semitendinosus) are often used as an autograft for anterior cruciate ligament (ACL) reconstruction. Healing of this graft involves a slow biological process called ligamentization. To encourage this process, some authors have proposed preserving the insertion of the hamstring tendons.
Leaving the tibial insertion of the hamstring tendons intact will provide better early biological incorporation and superior tibial mechanical fixation resulting in various clinical advantages.
In January 2022, a systematic literature review was carried out independently by two authors of the Medline, PubMed and Embase databases. The keywords used were \"pedicular\" or \"pedicled\" or \"preservation of tibial attachment\" or \"hamstring tibial insertion\" AND \"ACL reconstruction\". Each author\'s data was analyzed separately.
Sixteen articles were analyzed. Preserving the hamstring tibial insertion during ACL reconstruction improves the graft\'s biological incorporation during the initial postoperative phase according to clinical studies with MRI analysis and provides a mechanical advantage at the graft\'s tibial attachment according to biomechanical studies (construct up to 65% stiffer). There was no difference in the clinical and functional scores when compared to the conventional technique in which the hamstring tendons are detached from their tibial insertion.
The main conclusion of this systematic literature review was that preserving the hamstring tibial insertion during ACL reconstruction appears to improve the graft\'s ligamentization with biological and mechanical advantages relative to detaching the hamstring tendons. The clinical and functional results were comparable to other techniques. Prospective studies with large cohorts are still needed to confirm these findings.
IV; Systematic review of literature.

How to deal with large soft tissue defects around the foot and ankle is still controversial. The aim of this study was: (1) to display a new pedicled flap, also named the dual-perforator flap with wide pedicle (DPFWP), and (2) to compare it with the sural neurovascular flap with peroneal artery perforator (SNFPAP) in foot and ankle reconstruction. According to different surgical methods, 82 patients were divided into 2 groups: the DPFWP group (42 cases) and the SNFPAP group (40 cases). All cases underwent a flap surgery after radical debridement. The 2 groups were homogeneous in terms of age, sex, body mass index (BMI), etiology, location, and follow-up duration. Operation indexes were compared, including flap length, flap width, operation time and blood loss. Complications, cosmetic appearance, and functional outcome were analyzed, and statistical analysis was performed. The DPFWP group had larger flap length (24.5 ± 4.6 cm vs 16.3 ± 3.8 cm), and flap width (10.5 ± 2.7 cm vs 7.8 ± 1.7 cm) than the SNFPAP group. In postoperative follow-up, DPFWP group showed a lower complication rate and better cosmetic, functional outcomes than SNFPAP group. In conclusion, this study showed that a DPFWP flap brought better results than a SNFPAP flap in terms of complications, cosmetic appearance, and functional outcomes for patients undergoing reconstruction of foot and ankle defects.

This surgical technique of anterior cruciate ligament (ACL) reconstruction uses a 4-stranded hamstring tendons graft (HG), via an inside-out approach with a femoral cortical button and a tibial screw. It offers preservation of the tibial attachment of the hamstrings and enables double tibial fixation: biological and mechanical. This technique, \"BIOFAST HG\", does not require any calculation of the length of the tunnels, nor the use of different sized, or adjustable, buttons. If the sliding in the femoral tunnel fails, it is possible to easily convert to a so-called \"classic technique\". The first 60 cases were reviewed with a conversion rate of 3%. This technique allows the benefits of a pedicled graft over the classic HG technique in a simple way, with minimal conversions to the classic technique.