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Knee revision arthroplasty following peri-prosthetic joint infections is a formidable challenge. Patients are at a high risk of recurrent infection, and the soft tissue over the revised implant is often of questionable quality. Flap reconstruction has improved the salvage rates of infected arthroplasties, and should be considered in all cases of revision arthroplasty. We present a challenging case requiring staged reconstruction with two free latissimus dorsi flaps after the initial use of a medial gastrocnemius flap.

Background: The goals of limb-sparing surgery in the setting of extremity malignancies are 2-fold: oncological clearance and the rehabilitation of function and aesthetics. Treatment success should be defined by the extent of restoration of the patient’s premorbid function for reintegration into society. Methods: We would like to report an unusual case of a patient with a chronically ankylosed elbow with joint invasion by basal cell carcinoma which resulted from malignant transformation of an overlying, long-standing wound due to inadequately treated septic arthritis from his childhood years. Results: Following R0 resection, upper limb shortening and compression plate elbow arthrodesis were performed with the aim of restoring the degree of upper limb function that the patient had been accustomed to preoperatively. The resultant circumferential defect was then closed with a contralateral, free muscle-sparing latissimus dorsi flap. Conclusions: Functional preservation may therefore be more important than the mere restoration of anatomical defects in these especially challenging situations.

Many chest wall reconstruction algorithms have been proposed, but there is still no general consensus. The purpose of this study is to review our single institutional experience in chest wall reconstruction and identify a working algorithm based on our retrospective analysis. This is a retrospective analysis of 54 patients who underwent chest wall reconstruction in our department from 1996 to 2011. The mean follow-up was 38 months. Central chest wall defects were the most common, while infection and tumour resection were the two most common indications. The pedicled latissimus dorsi flap was a versatile flap, used as a single or combination flap for anterolateral, lateral and posterior defects. The pectoralis major flap was suitable for central and anterolateral defects and the rectus abdominis flap for lower central defects. Omentum flaps were useful in radiation-damage skin or in patients with recurrent infection. Locoregional flaps are the mainstay of chest wall reconstruction. Most skeletal reconstruction, when required, is safely accomplished with the use of prosthetic materials. Free flaps are usually only indicated for large defects or when regional flaps are unavailable. Level of Evidence: Level IV, therapeutic study.

Freon is an industrial refrigerant that can result in serious cryoinjury of the skin. Although there had been a few reported cases, the optimal management is not clear. We present the first case report of a patient with freon-induced cryoinjury of bilateral hands, complicated with compartment syndrome and treated with a combination of surgical decompression, negative-pressure wound therapy (NPWT), and hyperbaric oxygen therapy (HBOT). On follow-up, there was a complete healing without tissue loss or significant atrophy of the intrinsic muscles of the hand. Therefore, we opined that HBOT and NPWT may work synergistically to prevent progressive tissue damage and improve the long-term outcome, especially when vascularity is compromised in severe cryoinjuries of the hand. Level of Evidence: Level V, therapeutic study.

Summary Accurate diagnosis and timely management are crucial to avoid an ischaemic consequence in Raynaud's disease. There is, however, no objective classification of this disorder which guides surgical planning in refractory cases. We propose a new classification system to achieve this. From 2003 to 2009, we treated 178 patients (351 hands) who underwent surgical intervention due to an ischaemic consequence. We analysed the angiographic features of the arterial supply of the hand at three levels: (1) radial or ulnar, (2) palmar arch and common digital and (3) digital vessels. Subsequent surgical interventions were tailored according to disease types, and these included combinations of: digital sympathectomy, balloon angioplasty and end-to-end interposition venous or arterial grafting. We classified Raynaud's disease into six types: type I and II involve the radial or ulnar arteries. Type I (27.3%) showed complete occlusion, while type II (26.2%) involved partial occlusion. Type IIIa (27.1%) showed tortuous, narrowed or stenosed common digital and digital vessels. Type IIIb (1.4%) is a subset which involved the digital vessel of the index finger related to exposure to prolonged vibration. Type IV and V showed global involvement from the main to digital vessels. Type IV (13.7%) showed diffused tortuosity, narrowing and stenosis. Type V (4.3%) is the most severe, with paucity of vessels and very scant flow. Nearly half (47%) of the patients had associated systemic disease. This new classification provides objective and valuable information for decision making regarding choice of surgical procedures for the treatment of patients with Raynaud's disease which had failed conservative therapy.

Large defects of the hand usually require reconstruction with flap resurfacing to provide durable coverage and preserve function. Pedicled flaps are preferred when there are no vessels available or they are of questionable quality for anastomosis. Such clinical settings may be due to the primary pathology, or when the vessels are preserved for secondary reconstruction. We introduce the contralateral pedicled lateral arm flap as a viable alternative. From 1988 to 2006, we treated 22 consecutive patients aged between 6 and 70 (18 males and 4 females). The indications for flap reconstruction included hand defects resulting from trauma (n = 16), infection (n = 3), burn (n = 2), and complication of free flap (n = 1). The flap was designed with extension into the forearm and raised based on the posterior radial collateral artery. All patients underwent intensive postoperative mobilization. The flap was divided 3 weeks later after a week of ischemic preconditioning. All the flaps survived. There was no wound infection. The flap size ranged from 18 cm 2 to 127.5 cm 2 . Eighteen reconstructions were fasciocutaneous and 4 were osteofasciocutaneous. Three patients underwent subsequent toe-digit transfer. All patients achieved activities of daily living independently by the third postoperative day. There was no significant shoulder and elbow joints stiffness. The contralateral pedicled lateral arm flap is a reliable option for resurfacing large defect of the hand where pedicled flap is indicated. There is minimal morbidity associated.

Summary Marjolin's ulcer is a very aggressive form of squamous cell carcinoma arising from chronic wounds or unstable scars. A resection margin of at least 2 cm with clear deep margin is required on removal. A 79-year-old male presented with chronic osteomyelitis of the left anterior tibial region with chronic ulceration. Biopsy revealed squamous cell carcinoma. The tumour, measuring 8 cm, was resected with surrounding unstable scar tissue including en bloc resection of the involved tibial bone, leaving the posterior cortex. Reconstruction was done with a fibular free flap from the contralateral side, but the pedicle length was too short to reach the anterior tibial vessels. To bridge the vascular gap, and to cover the soft-tissue defect, a latissimus dorsi free flap was harvested using the muscle-sparing method. The thoracodorsal vessels were used as an interpositional graft to anastomose the peroneal vessels of the fibular flap. The patient was ambulatory by 4 months, and complete bone union was seen after 6 months. During the 18-month follow-up period, there was no evidence of recurrence.

Summary Background Perforator flaps from the lateral thoracic region have not been as popular as other donor sites because of the misconception that the vascular anatomy in this region is less than predictable. However, the skin over the lateral thoracic region is vascularised by three rows of perforators of varied vascular dominance. Two perforator flaps from this region based on the middle and the posterior row of perforators from the thoracodorsal artery have been described. The lateral thoracic perforator flap based on the anterior row of perforators is another useful option. Patients and results Nine patients underwent reconstructions using the lateral thoracic perforator flap for various defects in the head and neck region and lower limbs as a result of tumour extirpation, crush injury and chronic wound with osteomyelitis. All flaps were raised in the supine position. Three flaps were raised in a chimaeric fashion. The largest flap was 20 × 12 cm and the mean size was 106 cm 2 . All flaps survived without major complication. Conclusion The lateral thoracic perforator flap is a reliable reconstructive option. It can be readily configured in terms of size, thickness and tissue composition. However, it is not the first-choice flap from this region because the resultant donor scar tends to extend visibly beyond the anterior axillary fold and the arterial and venous pedicles frequently have separate courses. The lateral thoracic region has become a versatile and universal donor site for free-style flap harvest with this additional flap option.

The retroauricular flap has many applications, providing coverage for various portions of the face as a pedicled flap or a free flap. The retroauricular skin, having similar attributes to the facial skin, is an ideal donor site for facial reconstruction. Also, the donor site can be primarily closed without morbidity, which is also an advantage. In this article, a large helical defect resulting from a traumatic amputation was reconstructed using the contralateral conchal cartilage graft and a retroauricular perforator-based island flap. Using the "perforator pedicled propeller flap" concept, no meticulous dissection around the perforator was done, and the flap was elevated only until sufficient rotation arc was achieved. There was some degree of venous congestion on the flap for 3 days postoperatively, but the flap survived completely. By using the conchal cartilage from the contralateral side, the final contour of the ear was maintained aesthetically. The flap had some bulkiness on the posterior side of the auricle where it was transposed, but it was inconspicuous on frontal or lateral view because the conchoscaphal angle had not changed. The patient was satisfied with the aesthetic results. The retroauricular flap is useful for resurfacing any portion of the ear, and by using the propeller flap method, significant reduction in operative time can be achieved without compromising the final results.

Summary Background Craniofacial contour defects are challenging to restore because they may involve multiple tissues and span several aesthetic subunits in a non-contiguous manner. Some of these deformities may be associated with significant dead space in the region of sinus and orbit. The numerous subtle contours of the craniofacial regions must be preserved or restored to achieve a pleasing outcome. Patient and Results We managed six patients with various craniofacial contour deformities as a result of hemifacial microsomia, infection, post excision of venous malformation, lipodystrophy, craniectomy for chronic frontal sinusitis and infected pneumocephalus. They were reconstructed with thoracodorsal perforator flaps bearing various components, that is, adiposal, adipofascial, dermoadiposal, adipomyofascial and osteomuscular elements. Half of the flaps were in chimaeric form. The largest flap size was 11 × 17 cm. All flaps survived and no patient required secondary contouring procedure, except for cranioplasty in one patient. Conclusion The thoracodorsal perforator flap is very suitable for restoration of craniofacial contour deformities. Its advantages include: (1) ease of customisation of size and thickness, (2) several choices of donor tissue from the lateral thoracic region yielding multiple tissue components, for example, adiposal, adipofascial, dermoadiposal, adipomyofascial and osteomuscular flaps, (3) presence of adjacent perforators in the thoracodorsal system, allowing chimaeric flap configuration, thereby improving adaptation to non-contiguous contour defects, (4) ability to tailor the donor and recipient vessel size match by varying how proximal to harvest along the thoracodorsal vessels, (5) primary closure of donor site and (6) flap harvesting in supine position allowing a two-team approach.

Severe crushing and degloving injury of the hand often involves multiple tissue structures requiring several stages of reconstructions. This is more challenging when tissue defect and loss of thumb co-exist, requiring vascularised tissue transfer and toe-to-thumb reconstruction in a hand that has severely compromised vascularity. The management variables to be considered include the use of pedicled or free flap, simultaneous or staged procedures, consideration for early rehabilitation and flap selection to facilitate simultaneous free tissue transfers without further jeopardy to the vascularity of the hand. We illustrate these considerations in a case we have managed with simultaneous application of a latissimus dorsi perforator flap and great toe-to-thumb transfer.

Chronic recurrent ischial sores are an important cause of morbidity in paraplegics and geriatric patients. Compared to sacral and trochanteric ulcers, ischial sores are the most difficult to treat, with a low success rate following conservative therapy and a high recurrence rate after surgical treatment. We report the use of the pedicled anterolateral thigh (pALT) flap for reconstruction of a chronic ischial sore. The free ALT flap has an established role in reconstruction in the head and neck and extremities. However, there are few reports concerning its clinical applications for regional reconstruction. As a pedicled flap, it has been used in the primary reconstruction of the perineum, groin, anterior abdominal wall, thigh and ischium. We present the first reported case of a paraplegic man with a recurrent ischial sore treated successfully with an island pALT flap inset via a lateral subcutaneous approach. We discuss the indications and its role as a simple and reliable secondary reconstructive option in the treatment of recurrent ischial ulcers after first-line loco-regional surgical options have been exhausted.

The axillary arch is a vestigial muscle in the axilla, which originates from the latissimus dorsi and inserts into the pectoralis major tendon. The aim of this article is to describe a fan-shaped variant of the axillary arch and its clinical implications. We present a patient who underwent an axillary node dissection during which, a fan-shaped axillopectoral muscle measuring 8 cm by 6 cm was encountered. It was disinserted to provide exposure of the axilla.

Primary pulmonary sarcomatoid carcinoma is rare. It is generally regarded as an aggressive tumor. We report, to our best knowledge, the first case of pulmonary sarcomatoid carcinoma with extensive intracardiac spread. This case illustrated the misleading clinical features of this condition. Previous literature is also reviewed.

Local steroid injections are often administered in the office setting for treatment of trigger finger, carpal tunnel syndrome, de Quervain's tenosynovitis, and basal joint arthritis. If attention is paid to sterile technique, infectious complications are rare. We present a case of suppurative extensor tenosynovitis arising after local steroid injection for vague symptoms of dorsal hand and wrist pain. The progression of signs and symptoms following injection suggests a natural history involving bacterial superinfection leading to tendon rupture. We discuss the pitfalls of local steroid injection and the appropriate management of infectious extensor tenosynovitis arising in such situations.