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Background and Purpose: Soft tissue defects after total knee arthroplasties (TKA) represent a major orthopedic challenge with amputation as a feared outcome. Microvascular free flap coverage (FFC) can increase limb salvage rates, but complications related to the procedure are yet to be explored further. We aimed to review a single-center experience with FFC for soft tissue defects related to revision total knee arthroplasty., Methods: Through a retrospective chart review from 2006 to 2021, we identified all patients who had FFC of a knee with an existing TKA. Typically, patients underwent 2-stage revision arthroplasty. To identify areas of intervention, we divided the entire regimen into 2 phases divided by the free flap surgery (pre- and post-free flap)., Results: We identified 18 patients with a median age at free flap surgery of 69 years (range 39-85), who were followed for a median of 5.1 years (range 2 months to 10.6 years). The median duration from primary TKA to their final operation was 17.5 months (range 19 days to 7 years). Patients underwent a mean of 7.6 surgical procedures on their knee with 3.6 orthopedic revisions prior to the FFC and 0.6 after. Soft tissue coverage was achieved in all patients and no patients underwent amputation. One-third of patients experienced early complications at recipient site after free flap surgery. There were no donor site complications., Conclusion: Microvascular FFC of complex soft tissue defects after revision total knee arthroplasty proved achievable in all patients with successful limb salvage in all patients.

In patients with primary calcaneal malignancies, such as Ewing's sarcoma, radical treatment with amputation of the foot can result in serious functional impairment and chronic pain. Total calcanectomy followed by the reconstruction of the calcaneal defect offers an alternative treatment to amputation. Capanna et al. described a technique for successfully reconstructing long limb segmental bone defects using a free fibula flap placed within the intramedullary canal of an allograft. We present both a review of the literature on calcaneal reconstruction and describe how the principles of Capanna can be adapted to reconstruct the calcaneus. Total calcanectomy due to Ewing's sarcoma and the subsequent application of this novel reconstructive technique was performed in two young patients aged 5 and 16 years. The reconstruction was achieved by inserting a distally pedicled osteocutaneous fibula flap within the reamed canal of an allograft and placing the composite in the calcaneal defect. Reconstruction was successful with complete bone union between the allograft and the adjacent bone. There were no fractures or infections and both flaps survived. Functional outcome was assessed with a physiotherapist at a follow-up period of 2 years postoperatively, showing near-normal ambulance. This novel technique proved excellent as a limb salvage procedure, avoiding amputation, and offering a satisfactory oncological and functional outcome., Competing Interests: Conflict of Interest The authors have nothing to disclose., (Copyright © 2022 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Objectives: Patients undergoing microvascular reconstruction after head and neck cancer typically have several comorbidities, and the procedures are often followed by complications and prolonged hospitalization. Consequently, the application of enhanced recovery after surgery (ERAS) for these patients undergoing microvascular reconstruction has gained attention in recent years. ERAS is a peri- and postoperative care concept that has repeatedly shown beneficial results for a wide variety of surgical procedures, including microvascular reconstruction. This study presents the results after the introduction of our ERAS protocol for head and neck cancer reconstruction., Methods: We prospectively treated 30 consecutive patients according to our ERAS protocol from June 2019 to December 2020 and compared the results of the treated patients with those of patients treated with our traditional recovery after surgery (TRAS) protocol. We are based on our ERAS protocol on the following core elements of recovery: improved patient information, goal-directed fluid therapy, minimally invasive surgery, opioid-sparing multimodal analgesia, early ambulation, and pre-defined functional discharge criteria., Results: The baseline characteristics of the groups were comparable. The ERAS group had a significantly shorter length of stay (13.1 vs. 20.3 days, p < 0.001), significantly shorter time to ambulation (3.0 days vs. 6.4 days, p < 0.001), shorter time to removal of nasogastric tube (13.3 days vs. 22.7 days, p = 0.05), and fewer tracheostomies performed (10% vs. 90%, p < 0.001). There were no differences in complications, flap survival, or 30-day re-admissions between the two groups., Conclusion: The introduction of ERAS in patients with head and neck cancer undergoing microvascular reconstruction seems safe and results in improved recovery., Level of Evidence: 3., Competing Interests: Nothing to disclose, (© 2022 The Author(s).)

Introduction: Despite a trend toward the use of perforator-based flaps for autologous breast reconstruction, the m. latissimus dorsi (LD) flap remains a popular alternative. Several studies have sought to uncover the shoulder-related donor-site morbidity, but the results are inconclusive. This study aims at evaluating what impact breast reconstruction with an LD flap has on shoulder strength, range of motion (ROM), lymphedema, sensory disturbances, and patients' ability to perform activities of daily living (ADL)., Materials and Methods: In a prospective observational study, we examined 20 female patients undergoing delayed breast reconstruction with an LD flap. The primary outcome was a change in shoulder strength, measured with the Biodex System4 Pro-dynamometer. ROM was assessed using two-dimensional photogrammetry. Furthermore, the patients' self-reported pain, lymphedema, sensory disturbances, and ability to perform ADL were assessed using a questionnaire. Measurements were performed pre-operatively at 3 months and 12 months post-operatively., Results: Of the 20 included patients, 17 completed the follow-up. At the 12 months follow-up, a significant loss of isometric shoulder strength of 17% was observed in shoulder adduction (P<0.001) and 21% in extension (P<0.001). Isometric strength and ability to perform ADL and ROM were unchanged. There was a decrease in the number of patients reporting problems with lymphedema (10 to 7) and an increase in the incidence of sensory disturbances (10 to 13)., Conclusion: A loss of shoulder strength was observed following the transfer of the LD flap; however, the procedure did not hinder the post-operative performance of ADLs for the patients. LD reconstruction seems to be a safe procedure., Competing Interests: Declaration of Competing Interest None., (Copyright © 2022 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Introduction: We have previously implemented and published an enhanced recovery after surgery (ERAS) program for autologous breast reconstruction using DIEP flaps. The latissimus dorsi (LD) flap is another commonly used flap for autologous breast reconstruction (ABR). The aim of the present study was to use our experience from the ERAS program in DIEP flap reconstruction to optimize our LD breast reconstruction program., Material and Methods: We examined our data for a 10-year period (n = 135) and compared this with two different surgical team approaches, within the same unit. One team implemented an ERAS program (n = 18), the other did not (n = 12). Data were collected prospectively. In the ERAS group, patient information was revised, multimodal analgesia was introduced, drain handling was optimised and functional discharge criteria was introduced. Fulfilment of functional discharge criteria were assessed twice daily and specified reasons for not allowing discharge registered., Results: All patients had a breast reconstruction using a unilateral LD flap. Patient and surgical parameters were comparable. Length of stay was significantly shorter in the ERAS group (3.2 days) compared to the historical (6.9) and non-ERAS (TRAS) group (6.3) (p<0.0001). Drains were removed significantly faster in the ERAS group (day 3.9) vs day 6.3 (historical) and day 7.0 (TRAS) (p<0.0001). Time to drain removal was the main reason for extended LOS. There were no differences in reoperations, readmissions or complications between the three groups. All patients in the ERP group were ambulating, pain free, had abdominal function, were eating and managing personal hygiene on POD 1., Conclusions: LOS was safely reduced to 3 days for LD breast reconstruction in the ERAS group. By discharging patients with drains, it should theoretically be possible to reduce LOS to 1 day, as all other discharge criteria have then been fulfilled., (Copyright © 2020 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Introduction: Microvascular reconstructions after head and neck cancer are among the most complicated procedures in plastic surgery. Postoperative complications are common, which often leads to prolonged hospital stay. Enhanced recovery after surgery (ERAS) is a peri- and postoperative care concept with the aim of achieving pain- and risk-free surgery. It has been previously established as superior to conventional care for a wide variety of procedures, including microsurgical procedures such as reconstructions of the breast. Several ERAS protocols for microvascular head and neck cancer reconstructions have been proposed, although most of these are based on extrapolated evidence from different surgical specialties. Results from the implementation of ERAS for these procedures are inconsistent., Methods: The current study investigates our clinical experience of head and neck cancer reconstruction for the period of 2014-2016 with the aim of establishing a list of functional discharge criteria. By combining these with the current published knowledge on the subject, we developed an ERAS protocol., Results: We performed 89 microvascular procedures in the study period, of which 58 were in the oral cavity/sinuses and 31 were laryngopharyngeal. Most cases were squamous cell carcinoma (89%). The average LOS was 20.3 days in both groups. Postoperative complications included infection (37%), 30-days re-operations (19%), and re-admissions (17%). Furthermore, we identified the following discharge criteria: adequate pain relief, ambulation, sufficient nutritional intake, normal infection-related blood parameter results and absence of fever, bowel function, and closure of tracheostomy., Conclusion: Based on our retrospective analysis and identified discharge criteria, we present an approach to develop an ERAS protocol for microvascular reconstruction after head and neck cancer., Competing Interests: None, (© 2020 The Authors.)