Effective pre-surgical preparation is an important step in limiting surgical wound contamination and prevention of surgical site infection. The purpose of this study is to evaluate bacterial skin contamination after surgical skin preparation in foot surgery prior to surgery and at the end of surgery, in order to determine if current techniques are satisfactory in eliminating harmful pathogens, and to compare the results of the cultures obtained pre and post operatively with infection rate.

Twenty consecutive patients scheduled for Hallux Valgus procedures were studied. Each lower extremity was prepared in the regular method with a two-step technique, Septal scrub followed by a Alcohol Chlorhexidine antiseptic solution. After preparation and draping, cultures were obtained at three locations: the hallux nailfold, first, second, third and fourth web spaces, and the anterior ankle (control). Prior to surgery, positive cultures were obtained from 80% of hallux nailfolds and 5% of web spaces. At the end of surgery, positive cultures were obtained from 80% of hallux nailfolds and 25% of web spaces. None of the controls had positive culture. 5% of all cases developed post operative infection.

Based on the findings of the current study, pre-surgical skin preparation with a two-step Septal scrub followed by a Alcohol Chlorhexidine antiseptic solution is not sufficient in eliminating pathogens in foot and ankle surgery. No statistical correlation was found between the results of the cultures obtained preoperatively or post operatively with post operative infection rate. The unique environment of the foot and its resident organisms probably plays a role in the higher infection rates associated with surgery of the foot. Better methods of preparing the surgical site should be searched for.

With advances in surgical technique and instrumentation, the anterior approach to the thoracolumbar spine becomes more popular. Anterior approach is considered particularly when ventral decompression of neural structures is needed, providing optional stability by fusing the involved segment with instruments specially designated for that purpose. The usual approach is done through a 10th or 11th rib thoracotomy, opening of the pleural cavity and a semilunar cut at the periphery of the diaphragm, in order to expose the anterolateral aspect of the vertebral column. This technique involves the risk of phrenic nerve injury and diaphragmatic paralysis combined with morbidity of the chest tube. A variant of that technique is the retrodiaphragmatic approach, which provides the surgeon with the advantages of ventral exposure, potentially avoiding the morbidity of the standard transpleural thoracotomy.

Methods: During a three-year period, all patients with major anterior pathology at the T11, T12 or Ll level, were operated using the retrodiaphragmatic anterior approach. This involved an 10th or 11th rib thoracotomy with the patient in a lateral decubitus position. Following rib resection, blunt dissection of the diaphragm from the chest wall was performed without its surgical incision. The parietal pleural was mobilized medially and left intact and the thoracolumbar spine was exposed for the procedure. In case of a major pleural defect, a chest drain was inserted.

Results: Fifteen patients (10 males and 5 females, mean age: 32.6y) made up by study group. This included six patients who had a thoracolumbar fracture, five patients who were diagnosed as having idiopathic scoliosis and four patients who presented with metastatic disease in the thoracolumbar region. Adequate decompression was achieved in all patients as well as stable fixation of the involved segment. Mean operating time was 4.5 hours, average hospitalization length was six days. Three patients (20%) required a chest drain following the procedure. The drain was removed within three postoperative days of the operation. In five cases (40%) blood transfusion was required. Mainly for the underlying disease. The average decrease in the hemoglobin values, in the patient subgroup not requiring blood transfusion, was 3mg% at discharge comparing to the preoperative level. No intra-operative complications related to the surgical technique or instrumentation, were noted, nor any case of mortality. Complications such as respiratory distress, neurological damage, infection, hardware loosening or failure, pseudoarthrosis or hernia in scar were not observed during the post operative follow-up.

Conclusion: The retrodiaphragmatic approach to the thoracolumbar spine is safe and technically easy to apply in cases where ventral exposure of the spine is needed. This technique spares the need for diaphragmatic incision and in most cases, leaves the pleural cavity intact.

The purpose of this study is to evaluate the results of revision surgery in the treatment failed TKR with the TCP III like prosthesis.

Materials & Methods: Between 1985 till May 2001, 116 failed knees were managed. 91 underwent complete revision, 18 were arthrodesed, 6 underwent patella revision only and 1 arthrolysis. Among the complete revisions: 45 were due to mechanical failure (loosening, wear or instability) 29 for infection and 17 for painful or stiff knee.

In 81 of them the implanted prosthesis was TCP III or CCK and were evaluated in this study. 33 were males and 58 females. The average age at revision was 72 years. Most of the cases were performed by the senior author. All cases were osteoarthritic except one which was rheumatoid. The distribution of TCP III like prosthesis was as follows: 47 were TCP III, 33 were CCK and 2 dual. The infected cases were treated whether by one stage or two stage surgery. Patella was not resurfaced but reshaped if patella bone stock was not adequate.

Results: Nine patients died and 14 patients could not be traced in the last follow-up. The average follow up was around 6 years (range of 6 months to 16 years). As compared to preoperative situation almost all of the patients were on the overall subjectively satisfied. The preop HSS score was poor for all the patients. The average postop HSS score was 82 for mechanical failure, 76 for infection and 77 for painful knee. One infected knee got reinfected after 3 years. Three cases had to be revised for the second time to a rotating hinge prosthesis: 2 due to instability and one due to loosening.

Discussion: The TCP III like prosthesis proved in our hands to be a relatively successful implant in revision knee surgery. The new modular CCK design is quite an improvement over the TCP III design and is more versatile in allowing restoration of previous anatomy and joint line. The obvious advantage of this implant are its immediate inherent stability combined with a reproducible normal valgus alignment. The results were best in the treatment of failed knee due to mechanical failure.