The management of localized soft tissue sarcomas remains complex. This is a retrospective review of a single institution experience with manual afterloaded brachytherapy following intra-operative implantation of the tumor bed during surgery.

Ten patients over a 4-year period had resection for localized soft-tissue sarcomas and desmoids with insertion of intra-operative brachytherapy implants combined with resection for localized soft-tissue sarcomas. Manual afterloading of the implant with iridium wires was done postoperatively in all patients. The low dose rate brachytherapy dose varied from 13 to 20 Gy. Supplementary external beam radiation was administered pre-operatively or postoperatively to bring the total dose of adjuvant irradiation to 60–65 Gy.

After a median follow-up period of 30 months, the 4-year local disease-free survival rate was 80%. The 4-year actuarial survival rate was 85%. There were no failures within the high-dose region of the implant. No patients had locoregional failures. One patient developed distant metastases. No serious side effects were noticed. Pro-phylactic intramedullary nailing was done in 1 patient. Pathological fractures occurred in 2 patients. All patients had good cosmetic and functional outcomes.

Intra-operative implantation of the tumor bed in combination with tumor resection for soft-tissue sarcomas results in a high degree of local control with acceptable complications. This modality offers the patient a high chance of avoiding a more radical surgical procedure such as limb amputation.

Sternoclavicular joint infections are uncommon but severe and complex condition usually in medically complex and compromised hosts. These infections are challenging to treat with risks of infection extending into the mediastinal structures and surgical drainage is often faced with problems of multiple unplanned returns to theatre, chronic non-healing wounds that turn into sinus and the risk of significant clinical escalation and death. Percutaneous aspirations or small incision drainage often provide inadequate drainage and failed control of infection, while open drainage and washout require multidisciplinary support, due to the close proximity of the mediastinal structures and the great vessels as well as failure to heal the wounds and creation of chronic wound or sinus. We present our series of 8 cases over 6 years where we used the plan of open debridement of the Sternoclavicular joint with medial end of clavicle excision to allow adequate drainage. The surgical incision was not closed primarily, and a suction vacuum dressing was applied until the infection was contained on clinical and laboratory parameters. After the infection was deemed contained, the surgical incision was closed by local muscle flap by transferring the medial upper sternal head of the Pectoralis Major muscle to fill in the sternoclavicular joint defect. This technique provided a consistent and reliable way to overcome the infection and have the wound definitively closed that required no secondary procedures after the flap surgery and no recurrence of infections so far. We suggest that open and adequate drainage of Sternoclavicular joint staged with vacuum dressing followed by pectoralis major local flap is a reliable technique for achieving control of infection and wound closure for these challenging infections

Aim. Simultaneous use of Ilizarov techniques with transfer of free muscle flaps is not current standard practice. This may be due to concerns about duration of surgery, clearance of infection, potential flap failure or coordination of surgical teams. We investigated this combined technique in a consecutive series of complex tibial infections. Method. A single centre, consecutive series of 45 patients (mean age 48 years; range 19–85) were treated with a single stage operation to apply an Ilizarov frame for bone reconstruction and a free muscle flap for soft-tissue cover. All patients had a segmental bone defect in the tibia, after excision of infected bone and soft-tissue defects which could not be closed directly or with local flaps. We recorded comorbidities, Cierny-Mader and Weber-Cech classification, the Ilizarov method used, flap type, follow-up duration, time to union and complications. Results. 26 patients had osteomyelitis and 19 had infected non-union. Staphylococci were cultured in 25 cases and 17 had polymicrobial infections. Ilizarov monofocal compression was used in 14, monofocal distraction in 15, bifocal compression/distraction in 8, and bone transport in 8. 8/45 had an additional ankle fusion, 7/45 had an angular deformity corrected at the same time and 24 also had local antibiotic carriers inserted. Median time in frame was 5 months (3–14). 38 gracilis, 7 latissimus dorsi and 1 rectus abdominus flaps were used. One flap failed within 48 hours and was revised (flap failure rate 2.17%). There were no later flap complications. Flaps were not affected by distraction or bone transport. Mean follow-up was 23 months (10–89). 44/45 (97.8%) achieved bony union. Recurrence of infection occurred in 3 patients (6.7%). Secondary surgery was required to secure union with good alignment in 8 patients (17.8%; docking site surgery in 6, IM nailing in 2) and in 3 patients for infection recurrence. All were infection free at final follow-up. Conclusions. Simultaneous Ilizarov reconstruction with free muscle flap transfer is safe and effective in treating segmental infected tibial defects, and is not associated with an increased flap failure rate. It shortens overall time spent in treatment, with fewer operations per patient. However, initial theatre time is long and a committed multidisciplinary team is required to achieve good results

Aim of the study: The outcomes of 50 consecutive patients with chronic periprosthetic total hip arthroplasty infections were evaluated based on a staging system developed at the authors’ institution. The staging system includes three categories: infection type (acute versus chronic), systemic host grade, and local extremity grade. Methods: The initial treatment plan was a two-stage resection followed by reimplantation if clinically indicated. Treatment was modified for each patient according to how the patient responded to initial debridement. The average follow-up was 23.2 months (range, 0–74 months). Of the 50 patients, 29 had reimplantation with a total hip arthroplasty (58%), 17 patients had permanent resections (34%), and four patients had amputations (8%). Five patients died (10%). Fifteen patients had muscle flap transfers into the hip for soft tissue coverage. Results: Significant correlations were seen with the staging system and outcome parameters. Patients who were very medically ill were far more likely to die or have their leg amputated. Conversely, healthier patients were more likely to have successful reimplantation. A strong correlation was seen with a compromised local wound and the need for muscle. ap transfer. Complication rates were strongly related to worsening medical condition and a worsening local wound. Conclusion: Based on these results, a staging system for periprosthetic infection is a useful tool that with additional refinement will provide more objective evaluation of treatment methods for periprosthetic hip infection in the future

The dorsal interosseous muscle (DIM) may be indicated in the coverage of small defects of the hand as a proximally or distally based muscle flap. The objective of his two-part study was to define the vascular supply of the interosseous muscles of the hand, and to identify the dominant arterial pedicle of each muscle for potential use of these muscles as muscle or musculocutaneous flaps. A radio-opaque injectate (lead oxide, gelatin and water mixture) was injected into the femoral artery of 10 fresh cadavers. The intrinsic muscles of the hand were meticulously dissected along with their vascular pedicles, removed and radiographed. The number, type, diameter of vascular pedicles of muscles and their distribution were analyzed. The area of the vascular territory supplied by each source vessel was calculated. Ten embalmed cadavers were injected with red latex into their axillary arteries and a similar dissection protocol was followed. Vascularisation of the interosseous muscles is by palmar metacarpal arteries of the deep palmar arterial arch and dorsal metacarpal arteries. In addition to these constant axial blood supplies, there are rich perimuscular plexus from adjacent nutrient arteries. The origins and insertions of the muscles are also supplied by very fine vessels from this plexus. The diameters of the dominant branches ranged from 0.6 to 1.4 mm (mean 1.0 mm). The vascular territories of the dorsal metacarpal and common palmar arteries extend along the medial and lateral parts of the dorsal interosseous muscles. The dorsal interosseous muscle or musculocutaneous flap are more useful than other intrinsic muscles of the hand because the DIM are easily accessible via the dorsal hand and can be split distally or proximally, and a split musculosseous flap based proximally or distally on the dorsal metacarpal artery can be performed. The functional defect in the donor site after an interosseous muscle flap transfer of the second and third interosseous space is tolerable. This anatomic study provides further information to help design various flaps from the hand for local transfer. The authors describe a thirty-two-year-old male patient in whom the third dorsal interosseous muscle was used as a distally based myocutaneous flap to reconstruct a defect in the hand