The study by Wechselberger et al. showed no relevant decrease in strength of the donor leg after harvesting of the rectus femoris muscle for free muscle transfer. The authors related their positive result to intraoperative linking of the vastus medialis and lateralis muscles and a postoperative training program.
Our study differs from theirs with regard to patient age. In their study, the patients had an average age of 22.1 years, while in our study, the average patient age was 57.5 years. This would eventually explain the discordant results. The younger patients, especially the children (the youngest in the Wechselberger study was 10 years old), may have been able to compensate for the loss of muscle much better than the elderly could. There was almost no difference in follow-up time, with 26 months on average, and the different uses of the muscle (free versus pedicled) also may not explain the different results. Unfortunately, it is not clear whether all the patients in their study underwent a postoperative training program, but if so, that is, in our view, the most probable reason for their better results. As we concluded in our study, and as Wechselberger et al. suggest, a rehabilitation program may significantly improve outcome. In our series, only one patient had extensively trained the operated leg by himself, reaching a maximal torque with the operated leg in 90 degrees of flexion of 120 Nm, compared with 108 Nm for the nonoperated leg, 3 years postoperatively, thereby confirming this assumption. In contrast to Wechselberger et al., we do not believe that transposition of the vasti muscles decreases loss of force, because sutured muscle or fascial sutures are not likely to keep these strong muscles trending to shift back into their biomechanically determined position in the long run. This is speculation as well, however, and to resolve this question, a randomized prospective trial would be necessary.
Adrien Daigeler, M.D.
Department of Plastic Surgery, Burn Center, Hand Surgery, Sarcoma Reference Center, BG University Hospital Bergmannsheil, Ruhr University, Buerkle-de-la-Camp Platz 1, Bochum 44789, Germany
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