A 56-year-old female with a prosthetic left wrist implanted 8 years before due to chronic polyarthritis presented herself to our emergency department with a massive painful swelling and signs of hand phlegmon (Figure 3a ). Her daily medication was methotrexate and prednisolone. Methrotrexate was paused, while prednisolone was reduced and the pain therapy adjusted by the pain therapist. We immediately performed a first debridement with relieving incisions. Daily wound lavage and antibiotic treatment were initiated. With no tangible improvement of the local wound signs and continuously increasing white blood cell count, we decided to remove the prosthetic wrist (Figure 3b ), stabilizing the hand by external fixation. After two more debridements and wound closure, the patient could be discharged 4 weeks later with external fixation and ongoing low dose prednisolone. After full recovery, the patient was hospitalized again for the removal of the external fixation and for autologous wrist arthrodesis by performing a free fibula flap to the left wrist (Figure 3c ). Once more, the wound healing was not adequate and both, staphylococcus and enteroccus could be verified within the wound. Antibiotic therapy was adjusted and additionally, we performed a gracilis flap to close the wound on the left wrist (Figure 3d ). However, the elevation area of the flap on the lower limb showed wound healing problems requiring a debridement and local skin grafting for wound closure.\nWith an overall hospitalization of more than 14 weeks, we could finally discharge the patient. 6 months after the last procedure was performed, again the patient was transferred to our hospital with the status of an acute sepsis and encephalitis with the left wrist being the focus of infection. As life-saving procedure the left hand needed to be amputated at the distal forearm. Finally, the patient recovered from both sepsis and encephalitis and could be discharged from our clinic to rehab.
A 57-year-old male patient with the initial diagnosis of an advanced malignant melanoma on the left foot was operated in our department with an excision in sano of the tumor and closing of the defect by performing a free anterolateral thigh flap (ALTP). However, diagnostic lymph node biopsy was performed as well and following positive histopathology findings, a groin dissection, which was performed without complications, was necessary. The vascular femoral structures were covered by a transposition of the sartorius muscle. As a matter of fact, the patient could be discharged within five days after an uncomplicated wound healing.\nOver the course of time, chemotherapy and radiotherapy was conducted on the affected groin by the department of dermatology. Unfortunately, positive signs of lymph metastasis were detected in the groin region again, thereby requiring the necessity of another operation for the removal of all stationary lymph nodes and subcutaneous tissue. This time wound healing was prolonged due to the immunocompromised status of the patient and the impaired skin in the groin after radiotherapy. With the formation of a chronic seroma regular puncture was necessary, which led to chronic lympho-edema, recurring erysipelas and a frequent re-hospitalisation of the patient. Finally, we decided together with the patient to re-operate the radiated groin. After several debridements the defect was closed by performing loco-regional advancement flaps. The final wound healing was acceptable with only a small dehiscence and no further seroma so far. Chemotherapy was continued by the department of dermatology after the patient had been discharged.