Open lower limb fractures are a difficult problem and often present with significant bone loss and soft tissue damage, particularly in patients with contaminated crush injuries. 1 Yazar S. Lin C.H. Wei F.C. One-stage reconstruction of composite bone and soft-tissue defects in traumatic lower extremities. Plast Reconstr Surg. 2004 Nov; 114: 1457-1466 Crossref PubMed Scopus (250) Google Scholar , 3 Schwabe P. Haas N.P. Schaser K.D. Fractures of the extremities with severe open soft tissue damage. Initial management and reconstructive treatment strategies. Unfallchirurg. 2010 Aug; 113 ([quiz 671–2]): 647-670 Crossref PubMed Scopus (13) Google Scholar Despite an initial thorough wound debridement, there maybe further soft tissue loss due infection or further compromise of the residual lower limb soft tissue vascularity. The recent BAPRAS/BOA National Lower Limb Guidelines re-emphasised the importance of several aspects of lower limb trauma management, including early wound closure. 2 British Association of Plastic, Reconstructive and Aesthetic Surgeons Standards for the management of open fractures of the lower limb. Royal Society of Medicine Press, 2009 Google Scholar Following reconstruction of these defects it is sometimes necessary to undertake secondary wound debridement and closure by import of tissue in the form of a secondary free-flap to cover a new adjacent defect. 4 Lo C.H. Leung M. Baillieu C. Chong E.W.T. Cleland H. Trauma centre experience: flap reconstruction of traumatic lower limb injuries. ANZ J Surg. 2007; 77: 690-694 Crossref PubMed Scopus (17) Google Scholar We present a challenging case and a practical method to treat this potentially intractable problem in an area with limited surgical management options, which has already had successful free-flap reconstruction to close the initial soft tissue defect.

Anomalies of the flexor digitorum superficialis are rare and can present a diagnostic dilemma. Patients present with a painful or palpable mass, or symptoms of carpal tunnel syndrome. This review article summarizes previously reported anomalies of the flexor digitorum superficialis, reports a further case, and proposes a new classification.

We report a case of a 30-year-old lady who became pregnant 3 months after undergoing a DIEP breast reconstruction. There are reports of pregnancy following TRAM, DIEP flap breast reconstruction and abdominoplasty performed after breast reconstruction, however this is the only case in the literature of a pregnancy within 3 months of DIEP breast reconstruction. The literature on breast reconstruction and pregnancy is reviewed.

This study investigated the effect of a single intraoperative application of 5-fluorouracil, which may diminish peritendinous adhesion formation, on the tensile strength of repaired digital flexor tendons after 7, 14 and 21 days of healing. Twenty-seven deep flexor tendons from 14 rabbits were exposed to 5-fluorouracil (50 mg/ml) for 5 minutes immediately after repair whereas matched control tendons were exposed to normal saline. Tensile testing at 7, 14 and 21 days revealed no significant differences in the gap or ultimate strengths of the 5-fluorouracil treated and control tendons.

The formation of restrictive adhesions around the musculotendinous unit after injury is one of the most vexing processes faced by the surgeon. In flexor tendons it has been shown that the synovial tissue is the source of aggressive fibroblasts which contribute to this process. Using a rabbit model, we have examined the effects of treating the synovial sheath with the antimetabolite 5-fluorouracil (5-FU) for five minutes. Inflammatory, proliferative and molecular markers were compared in the response of the treated and control tendons to injury. Compared with a control group we found that the proliferative and inflammatory responses were significantly reduced (p < 0.001) in the treated tendons. Not only was there a reduction in the cellular and cytokine response, but there also was a significant (p < 0.001) reduction in the level of activity of the known pro-scarring agent, transforming growth factor beta 1 (TGF-β1). These pilot studies indicate that the formation of restrictive adhesions may be modulated using a simple single-touch technique in the hope of producing a better return of function.

Using an animal model, the effect of a single intraoperative application of 5-fluorouracil on digital flexor tendon adhesions was assessed. After a standard partial division of the tendon and immobilization with a stitch, the synoxial sheath in 30 rabbit tendons was treated with 5-fluorouracil solution (50 mg/ml)-soaked sponge pledgers for 5 minutes. Buffered saline was substituted for 5-fluorouracil in 30 control tendons. The tendons were harvested 1 week postoperatively, and histologic sections were assessed with a light microscope. There was a significant reduction in synovial sheath thickening (p < 0.001), cell counts (p < 0.001) and proportional length of adhesions (p < 0.001) in the treated tendons. The reduction in synovial reaction and adhesion formation using this "one touch" technique presents a novel strategy for the management of the clinical problem of postoperative adhesions complicating tendon injury and repair.