The intramedullary headless compression screw (IMCS) technique represents a reliable alternative to percutaneous Kirschner-wire and plate fixation with minimal complications. Transverse fractures of the metacarpal shaft represent a good indication for this technique. Non-comminuted subcapital and short oblique fractures can also be treated with IMCS. This technique should not be used in the presence of an open epiphysis, infection and, most of all, in subchondral fractures, because of the lack of purchase for the head of the screw. A double screw construct is recommended for comminuted subcapital fractures of the metacarpal to avoid metacarpal shortening. IMCS can even be applied for peri-articular fractures of the proximal third of the phalanx and in some multi-fragmentary proximal and middle phalangeal fractures. Usually the intramedullary screws are not removed. The main indications for screw removal are joint protrusion, infection and screw breakage after new fracture. Cite this article: EFORT Open Rev 2020;5:624-629. DOI: 10.1302/2058-5241.5.190068

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Introduction. The vascularized corticoperiosteal flap is harvested from the medial femoral condyle and it is nourished by the articular branch of the descending genicular artery and the superomedial genicular artery. This flap is usually harvested as a free flap for the reconstruction of bone defects at forearm, distal radius, carpus, hand, and recently at lower limb too. Case Report. A 50-year-old Caucasian man referred to our department for hypertrophic nonunion of the distal femur, refractory to the conservative treatments. The first surgical choice was the revision of the nail and the bone reconstruction with a corticoperiosteal pedicled flap from the medial femoral condyle. We considered union to have occurred 3.5 months after surgery when radiographs showed bridging of at least three of the four bony cortices and clinically the patient was able to walk with full weight bearing without any pain. At the last follow-up (25 months), the patient was completely satisfied with the procedure. Discussion. The corticoperiosteal flap allows a faster healing of fractures with a minimal morbidity at the donor site. We suggest that the corticoperiosteal pedicled flap graft is a reliable and effective treatment for distal femur nonunion.

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Sarcomas are defined as a group of mesenchymal malignancies with over 100 heterogeneous subtypes. As a rare and difficult to diagnose entity, micrometastasis is already present at the time of diagnosis in many cases. Current treatment practice of sarcomas consists mainly of surgery, (neo)adjuvant chemo- and/or radiotherapy. Although the past decade has shown that particular genetic abnormalities can promote the development of sarcomas, such as translocations, gain-of-function mutations, amplifications or tumor suppressor gene losses, these insights have not led to established alternative treatment strategies so far. Novel therapeutic concepts with immunotherapy at its forefront have experienced some remarkable success in different solid tumors while their impact in sarcoma remains limited. In this review, the most common immunotherapy strategies in sarcomas, such as immune checkpoint inhibitors, targeted therapy and cytokine therapy are concisely discussed. The programmed cell death (PD)-1/PD-1L axis and apoptosis-inducing cytokines, such as TNF-related apoptosis-inducing ligand (TRAIL), have not yielded the same success like in other solid tumors. However, in certain sarcoma subtypes, e.g. liposarcoma or undifferentiated pleomorphic sarcoma, encouraging results in some cases when employing immune checkpoint inhibitors in combination with other treatment options were found. Moreover, newer strategies such as the targeted therapy against the ancient cytokine macrophage migration inhibitory factor (MIF) may represent an interesting approach worth investigation in the future.

Rationale: Degloving foot injuries are challenging to treat and associated with life-long sequelae for patients. An appropriate debridement of ischemic soft tissues with maximal preservation of glabrous skin is key during the reconstruction of these injuries. Indocyanine green (ICG) fluorescence angiography is an established technique for the intraoperative evaluation of tissue perfusion. Patient concerns: Two patients sustained complex foot injuries in traffic accidents, including multiple fracture dislocations and extensive degloving of the plantar skin. Diagnosis: Clinical inspection revealed significant degloving of the glabrous skin in both patients. Interventions: After fracture fixation, ICG fluorescence angiography-assisted debridement with immediate latissimus dorsi free flap reconstruction was performed. Outcomes: In both cases, this technique allowed a precise debridement with maximal preservation of the glabrous skin. The healing of the remaining glabrous skin was uneventful and the 6-month follow-up was characterized by stable soft tissues and satisfying ambulation. Lessons: ICG fluorescence angiography is a safe, user-friendly, and quick procedure with minimal risks, expanding the armamentarium of the reconstructive surgeon. It is highly useful for the debridement of extensive plantar degloving injuries and may also help to minimize the number of procedures and the risk of infection.

La fée Lionne [. . .] bâtit au milieu du lac de vif-argent un palais de cristal, qui voguait comme l'onde; elle y renferma la pauvre reine et sa fille; ensuite elle harangua tous les monstres qui étaient amoureux de Mouffette: Vous perdrez cette belle princesse, leur dit-elle, si vous ne vous intéressez avec moi à la défendre contre un chevalier qui vient pour l'enlever. Les monstres promirent de ne rien négliger de ce qui'ils pouvaient faire; ils entourèrent le palais de cristal; les plus légers se placèrent sur le toit et sur les murs; les autres aux portes, et le reste dans le lac.(M.me d'Aulnoy, Les Contes des fées)

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