'Thou shalt not throw away a living thing': A single-centre 10-year experience using the spare parts principle for complex sarcoma reconstruction.

INTRODUCTION: For aggressive limb sarcomas beyond reconstructive reach, an amputation may be the only alternative to achieve a complete tumour resection. However, very proximal amputations result in greater loss of function and quality-of-life impact. The spare parts principle advocates utilising tissues distal to the amputation site, for reconstructing complex defects and preserving the function. We aim to present our 10-year experience utilising this principle in complex sarcoma surgery. METHODS: A retrospective review of our prospective sarcoma database was conducted for sarcoma patients treated with an amputation between 2012 and 2022. Cases in which distal segments were used for the reconstruction were identified. Demographic data, tumour characteristics, and surgical and non-surgical treatment, along with oncological outcomes and complications, were recorded and analysed. RESULTS: Fourteen patients were eligible for inclusion. The median age was 54 years at presentation (8-80 years) with 43% being females. Nine had a primary sarcoma resection, two were treated for recurrent tumours, two presented intractable osteomyelitis following sarcoma treatment and one had an amputation as a palliative procedure. The latter was the only oncological case in which tumour clearance was not achieved. Three patients developed metastasis and subsequently died during follow-up. DISCUSSION: Careful balancing of oncological goals and preservation of function is required for proximal limb-threatening sarcomas. When an amputation is required, tissues distal to the cancer site provide a safe reconstructive alternative, optimising patient recovery and preserving function. Our experience is limited by the small number of cases presenting with these rare and aggressive tumours.

Necrotizing Fasciitis: Myalgia Is Diagnostic? A Case Series and Literature Review.

Necrotizing fasciitis, commonly known as "flesh-eating disease," is an aggressive soft tissue infection that destroys the fascia, subcutaneous tissue, and skin. Specific clinical features (crepitus or radiologic features of gas in tissues) either appear late or are of poor sensitivity. Thus, a high index of clinical suspicion is required for early diagnosis and prompt treatment, which are the best methods of minimizing its high associated morbidity and mortality. We present 3 cases to demonstrate diagnostic difficulties and challenges in management and highlight the feature of pain on muscular activity.

Immediate Application of Biodegradable Temporizing Matrix To a Muscle Free Flap for Complex Soft Tissue Reconstruction.

Background. Extensive degloving skin injuries in children are particularly challenging for the possible complications of restricting growth and function. Biodegradable temporizing matrix (BTM, PolyNovo) is traditionally used for acute burn care reconstruction and in this case was successfully used to manage a child with lower limb open fractures associated with severe degloving injuries. This novel use offers excellent short and intermediate outcomes.

The importance of clear margins in myxofibrosarcoma: Improving local control by means of staged resection and reconstruction.

INTRODUCTION: Myxofibrosarcomas are associated with a locally infiltrative growth pattern, making a clear-margin resection margin challenging. This leads to high local recurrence rates. While immediate wound closure and adjuvant radiotherapy has been proposed to mitigate incomplete excisions, we present our experience treating myxofibrosarcomas with staged excisions until clear margins are obtained, prior to reconstruction. METHODS: All patients with myxofibrosarcomas treated with a curative intent at our centre between 2009 and 2019 were identified. Patient demographics, tumour characteristics, number of resections, method of reconstruction, adjuvant therapy, complications, local recurrence rates, length of hospital stay and overall survival were assessed. RESULTS: 97 consecutive eligible patients were identified. Forty-six (47%) had positive margins reported following a first resection. The median number of resections required to obtain clear margins was two and the median time from first excision to definitive wound closure was 15 days. Local recurrence rate for the whole cohort was 14%. Patients who had staged resection until clear margins were obtained had a significantly lower rate of local recurrence compared to those who had positive margins at time of reconstruction (p-value = 0.001). The estimated 5-year disease-specific survival for the whole cohort was 93%. DISCUSSION: Obtaining clear margins in myxofibrosarcoma via staged resections was associated with lower local recurrence rates for patients who had an initial resection with positive margins. The outcomes of performing staged resections are equivalent to patients for whom a clear margin were obtained in the first instance.

A novel problem, a tested solution: A case of an infected left ventricular titanium plug.

Persistent infection of left ventricular-assisted devices are challenging to treat. We describe a case of a middle-aged man who presented with cardiogenic shock and profound heart failure from sarcoid myocarditis, necessitating the placement of a left ventricular assist device. After recovery of cardiac function, the device was decommissioned but complicated by infection in the implant bed, chest wall, and of the titanium plug left in situ. This to our knowledge is the first report of an infected titanium plug and we describe an option of using a latissimus dorsi flap using its vascularized tissues to treat the infected plug. This is another example where a multidisciplinary approach can yield rewarding results in cases such as these.

Rat Bites in the Diabetic Foot: Clinical Clues.

BACKGROUND: Ulcers in patients with diabetic neuropathy in their feet are quite common but should be differentiated from the distinctive but rare ulceration resulting from rat bites in these insensate feet. We describe and analyze the features of rat bites in 2 patients with diabetic neuropathy in their feet and highlight 8 clinical features that should raise suspicion and alert the clinician to this possibility. METHODS: We describe and analyze the features of rat bites in 2 patients with diabetic neuropathy in their feet and highlight the distinctive clinical features of this condition. RESULTS: The following features were noted: 1) blood on bed sheets on waking; 2) painless, nonsuppurating ulceration; 3) multiple ulcers that are linear, sharp, or with serrated edges; 4) varying depths within the ulcer; 5) sudden onset (was not noted the day before but found in morning); 6) ulcers not contiguous; 7) often bilateral; and 8) the sole of the foot is not involved. Early recognition and prompt treatment resulted in digit and limb salvage. CONCLUSIONS: We describe and analyze the features of rat bites in 2 patients with diabetic neuropathy in their feet and highlight 8 clinical features that should raise suspicion and alert the clinician to this possibility.

Splenic artery pseudoaneurysm presenting with massive rectal bleeding.

Splenic artery pseudoaneursym is relatively rare and its rupture is usually fatal. We report a case of a 48-year-old male with 2 prior episodes of alcoholic pancreatitis that presented with massive per rectal bleeding from rupture of a splenic artery pseudoaneurysm into the transverse colon. Gold standard of diagnosis is CT angiography of the abdomen. We present the first case in the literature where a diagnosis has been made with noncontrast CT of the abdomen and described the radiologic features that facilitated this diagnosis.

Gallstone ileus 1 year after cholecystectomy.

Post-cholecystectomy gallstone ileus (GSI) is very rare with only 16 cases reported in the literature. This condition poses diagnostic challenges both because of its rarity and since the gallbladder had been previously removed. A high index of suspicion is needed for diagnosis. We report a case of a 37-year-old female who presented with GSI 12 months post-cholecystectomy.

Role of oral antibiotics for prophylaxis against surgical site infections after elective colorectal surgery.

Over the past few decades, surgeons have made many attempts to reduce the incidence of surgical site infections (SSI) after elective colorectal surgery. Routine faecal diversion is no longer practiced in elective colonic surgery and mechanical bowel preparation is on the verge of being eliminated altogether. Intravenous antibiotics have become the standard of care as prophylaxis against SSI for elective colorectal operations. However, the role of oral antibiotics is still being debated. We review the available data evaluating the role of oral antibiotics as prophylaxis for SSI in colorectal surgery.