Reconstruction is the rebuilding of tissue, anatomy, and function after congenital difference, disease, trauma, or surgical resection. This lecture (CFB OT04, Dr. WY Ip) uses orthopaedic and hand-surgery cases to teach the 5 Rs: Remove, Repair, Replace, Regenerate, and Rehabilitate. They are a planning checklist, not a mandatory sequence: a case may need only some of the five, and rehabilitation begins during planning rather than after surgery. ^[1]

To understand the whole range of conditions & tissues requiring reconstruction; to appreciate multiple methods of reconstruction; to understand such with examples; to be motivated by the challenges with reconstruction. ^[1]

Remove: extra digit. Repair: various tissue layers after trimming. Rehabilitate: foot orthosis or hand splint to protect repaired tissue during early stage. ^[1]

What the photographs add (slides 14–18): the deck shows a postaxial extra toe and a duplicated thumb, followed by operative and early postoperative images. This is not simply "cut off the smaller digit." The surgeon assesses which digit has the better skeleton, nail, neurovascular supply, tendons, and joint stability; excises the less useful component; then reconstructs alignment, collateral ligament, tendon balance, nail fold, and skin. A temporary K-wire or splint may protect the reconstruction. Complex duplications therefore require radiographs and a tissue-by-tissue plan.

Remove: fibrous tissue connection between digits. Replace: skin deficit with skin graft. Rehabilitate: hand function training. ^[1]

Multiple-stage operations to further improve function; cosmesis not the key concern. ^[1]

What the operative markings add (slides 19–23): interdigitating zig-zag flaps recreate the web and avoid a straight longitudinal scar that could contract. Separation creates a skin deficit, so a graft or local substitute may be needed. When several adjacent digits are joined, surgeons usually release one side of a digit at a time to protect its blood supply; this is the key reason for staged surgery. Later revision may be needed for scar contracture or web creep as the child grows. The priority is useful grasp and independent digit motion, not a perfectly normal appearance. ^[11]

Remove: infected & necrotic tissues. Repair: cut tissue repaired. Replace: skin deficit with skin graft, lost muscle with tendon transfer if can be done. Rehabilitate: maximise remaining muscle function with training. ^[1]

What the photographs add (slides 24–25): viable-looking skin can overlie extensive fascial and muscle necrosis. Management is immediate resuscitation, broad-spectrum IV antibiotics, and urgent exploration with radical debridement; repeat debridement is often required. Negative-pressure wound therapy (NPWT) may temporise a clean defect, but it does not replace source control. Graft/flap coverage and tendon transfer come only after infection and tissue viability are controlled.

Remove: inflamed tissue. Repair: lax ligament. Replace: damaged joint by fusion or arthroplasty. Rehabilitate: protect reconstructed tissue initially with splintage, training after tissue healing. ^[1]

Why tendon transfer in RA? Chronic synovitis erodes tendons (especially extensor tendons over the dorsal wrist). The ruptured tendon cannot be repaired directly because the ends are frayed and attenuated. A working tendon is transferred to restore the lost function.

Current framing: the image shows established rheumatoid hand deformity with imbalance and loss of active function. Disease-modifying control of inflammation is foundational; synovectomy, tendon transfer, ligament balancing, arthrodesis, or arthroplasty are selected for pain, instability, rupture, and functional goals. "Bone: no need to operate" is only the lecturer's simplified tissue inventory for this case, not a general rule.

Remove: tophaceous material. Repair: lax ligament. Rehabilitate: protect reconstructed tissue initially with splintage. ^[1]

Do not mistake the photograph for first-line treatment: slides 29–32 show bulky hand/foot tophi being excised. Current care for tophaceous gout is treat-to-target urate-lowering therapy; ACR strongly recommends urate-lowering therapy when subcutaneous tophi are present. Excision is reserved for selected problems such as ulceration/infection, nerve or tendon compression, mechanical block, severe deformity, threatened skin, or diagnostic uncertainty. Surgery does not correct the underlying urate burden. ^[7]

Reading slides 33 and 35: the clinical photographs show hip/knee axis deformity, while the radiographs show non-uniform joint-space loss with osteophyte formation, subchondral sclerosis, and deformity. The operative montage contrasts load-redistributing osteotomy, motion-preserving arthroplasty, and motion-sacrificing fusion. Radiographic severity alone is not an indication for surgery; symptoms, function, goals, and response to non-operative care matter.

The conservative-treatment pictogram (slide 34) represents walking aids, activity/environment modification, footwear, raised seating, local heat, and analgesia. The aspirin bottle is a historical illustration rather than a current instruction. Core current management is information and self-management support, therapeutic exercise, and weight management when appropriate; medicines and aids are adjuncts. ^[8]

Operative options: ^[1]

• Osteotomy — Realigns the limb to shift load from the diseased compartment to the healthy one. Best for young patients with unicompartmental disease.
• Total joint replacement (arthroplasty) — Consider when pain, stiffness, and functional loss substantially affect quality of life despite appropriate non-operative care; the decision is shared and patient-specific. ^[8]
• Arthrodesis (fusion) — Eliminates painful motion to gain stability. It is commoner as salvage in selected small joints/ankle than for hip or knee OA; the fused knee and hip images are historical/salvage examples, not routine modern first choices.

Remove: tumour with a cuff of normal tissue. Repair: cut tissue. Replace: lost tissue with composite tissue. Rehabilitate: protect reconstructed tissue initially with splintage, training after tissue healing. ^[1]

Latissimus dorsi muscle with skin island for wound coverage & coverage of post-operative radiotherapy tubes & restore finger extension. ^[1]

What the sequence shows (slides 37–41): the forearm tumour and planned resection create a composite defect. A free functional latissimus dorsi muscle transfer brings artery, vein, motor nerve, muscle/tendon, and a skin paddle. The skin paddle closes the wound and covers the illustrated radiotherapy catheters; the reinnervated muscle is tensioned to power wrist/finger extension. The final image demonstrates both contour and active limb function, while the donor site leaves a long back/axillary scar.

Why latissimus dorsi? It is a broad, relatively expendable muscle with a reliable thoracodorsal pedicle and motor nerve. However, the lecture's "cuff of normal tissue" is conceptual: suspected sarcoma requires specialist MDT planning, a planned core-biopsy tract, and en-bloc resection to a negative margin determined by tumour biology and anatomical barriers. ^[9]

Remove: fibrous band & fascial layers. Repair: skin. Regenerate: axon distal to compression at 1 mm per day. Rehabilitate: mobilisation exercise and splintage to prevent deformity while waiting nerve regeneration. ^[1]

What the images show (slides 42–44): severe cubital tunnel syndrome can produce first-dorsal-interosseous wasting and an ulnar claw; the second image shows endoscopic-assisted decompression at the medial elbow. The target is complete release of compressive fascia while protecting the ulnar nerve, followed by splintage/therapy when indicated.

Key fact, with a caveat: regenerating peripheral axons are often estimated at about 1 mm/day, but this is an approximation after axonal injury, not a stopwatch for recovery after simple decompression. Recovery also depends on injury grade, duration, age, distance to the target, remyelination, and whether motor end plates remain viable. Final improvement after cubital tunnel release may take 12–18 months; severe longstanding wasting may not reverse even when decompression prevents further deterioration. ^[10]

Endoscopic-assisted release is a minimally invasive option. ^[1]

Remove: necrotic tissue. Repair: fix fracture. Replace: lost tissue with composite tissue. Rehabilitate: protect reconstructed tissue initially with splintage, training after tissue healing. ^[1]

Use tissue in neighbouring digit for coverage. Fix the bone. Preserve the severely damaged digit. ^[1]

Reading the image sequence (slides 45–50): the radiograph shows a severe open fracture, followed by external fixation. After debridement and bony stabilisation/grafting, a cross-finger flap from the neighbouring digit supplies vascularised skin to exposed structures. The two fingers are temporarily joined; at a later operation the pedicle is divided and the donor defect is skin-grafted. The trade-off is donor-finger morbidity and stiffness, so early supervised hand therapy after safe healing is integral to salvage.

Why arthrodesis of PIPJ? If the articular surface is irretrievably destroyed, fusion can provide a painless stable post for grip. The fusion angle is chosen by digit and task; there is no single 30–40° position for every PIP joint.

• Surgical approaches: Open surgery, minimally invasive surgery (minimise scar), other destructive devices (cauterisation, cryosurgery, topical agents, laser ablation, radiofrequency, focused ultrasound)
• Resection margins for cancer: the older deck supplied fixed example figures; use current tumour-specific guidance rather than carrying those figures across cancers ^[9]
• Principle: Pathology dictates resection; reconstruction follows

• Free cutaneous flaps after intraoral tumour resection → improve tongue mobility → better function
• Free osteocutaneous flaps for mandibular reconstruction → restore swallowing and speech
• Myocutaneous flaps or free jejunal grafts for pharyngeal reconstruction after laryngopharyngectomy
• Stomach pull-up for oesophageal reconstruction after total laryngopharyngo-oesophagectomy

• Prosthesis (implant) — Silicone or saline, placed submuscular or subglandular
• Autologous — TRAM flap, DIEP flap, latissimus dorsi flap
• Combination — Implant + autologous tissue

The formal reconstructive ladder from senior notes:

1. Healing by secondary intention
2. Primary closure
3. Skin grafting (requires vascularised, uninfected bed)
4. Local tissue transfer (flaps)
5. Distant tissue transfer (pedicled flaps)
6. Free tissue transfer (microsurgical)