Background

Forefoot surgery is often performed under regional anaesthesia (ankle block) in awake patients, using tourniquet or esmarch bandage to obtain bloodless field. The purpose of this study was to examine the value and need for local tourniquet pain control using local subcutaneous analgesic mixture in patients undergoing forefoot surgery under regional anaesthesia.

We prospectively randomized 56 patients who underwent forefoot surgery under ankle block to receive subcutaneous local anaesthetic mixture under the tourniquet. We checked for local tourniquet pain score (VAS 0–100) and skin condition during and after the procedure.

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.

Introduction: There is a controversy regarding conservative or surgical treatment of calcaneal fracture. We report our experience in surgical treatment of calcaneal fractures.

Materials and Methods: Between March 1998 and May 2004, 30 patients with 32 calcaneal fractures were treated surgically in our departments. Twenty four fractures were caused after a fall from height, 4 fractures were consequence of a road accident, 2 fractures after a blast injury and one after a football injury. There were 4 females and 26 males. Two cases were bi-lateral fractures. Age range 20–66 (mean 33). Follow-up time 7 to 72 months (mean 24 months). The fractures were classified according to Sanders classification: there were 22 patients with Sanders III, 8 patients with Sanders IV and one patient with Sanders II. All patients were operated with the same procedure and the same surgeon. The surgical procedure was delayed from 10 to 14 days post trauma, until swelling subsided. Open Reduction Internal Fixation was performed using lateral approach, “L” shape with subperiosteal dissection of lateral wall, and using a calcaneal reconstruction plate.

Results: The functional outcome was evaluated according to Rowe Score. The clinical results were excellent in 3 patients (10%), good in 22 patients (70%), fair in 4 patients (14%) and poor in 2 patients (6%). The Boehler angle was reconstructed in 29 of 32 calcaneus. 3 patients returned to their previous level of activity, 9 patients returned to work, 14 patients mentioned some pain in the site of the operation. Two patients were treated successfully with oral antibiotics for superficial wound infection. Six patients suffered from peripheral nerve damage. One patient experienced subtalar pain, and underwent a subtalar arthrodesis, furthermore the patient developed Complex Regional Pain Syndrome (CRPS), finally he underwent below knee amputation (BKA). One patient had a flap necrosis and underwent sural flap coverage with excellent results. All the patients were recognized in a process to be recognized as disabled by the social security.

Conclusion: Our results were good in majority of patients according to the known classification systems. However, the recovery period from calcaneal fractures is long and the majority of patients do not achieve their previous functional level. The secondary gain might bias the results.

The need for better durability and longevity in total hip arthroplasty in high demand patients is a constant challenge. For this purpose a metal-on-metal prosthesis with improved tribology was developed. Our early results of using this system are presented.

Materials and Methods: From 1997 till present 68 Meta-sul hip arthroplasties were performed on 64 patients. 16 cases performed during 2001 were not included in the study due to short follow-up period. Of the remaining 52 cases, 39 were fully followed up (18 male and 21 female) and five were telephonically contacted. Six were lost to follow up and two died for reason not related to the THR. The average age at operation was 57y (27–77y), average height 163cm and average weight 79kg (50–180kg). 18 cases were left and 21 right sides.

4 patients had bilateral THR. There were 3 revision cases due to loosening of cemented cup and 3 post surgical hip procedures. The etiology of the hip pathology was OA in 23, AVN in 10, CDH in 3, two post surgical procedures and one Paget’s disease. The THR prosthesis system consisted of a Wagner type uncemented cup with a factory-assembled Metasul inlay. An uncemented collarless hydroxypaptite coated, Spotorno stem, with a modular 28mm head was used. Long stem was used in 3 cases and reinforcement cage in one. Additional screws (average of 3,4) were used for primary cup fixation. The anterolateral approach, laying either supine or on the side was performed. Average hospitalization time was 12 days. Full weight bearing was allowed as tolerated.

Results: The average follow-up was 30 months. Average Harris Hip Score pre-operatively was 45 (15-74) and post-operatively 75 (15–99). Subjectively, 87% of the primary cases with various etiologies were satisfied with the outcome. The majority of patients had pain-free range of motion and returned to improved daily function. One technical intra-operative complication (false route) was resolved with immediate revision. Two patients required cerclage wiring due to a femoral crack. Immediate post-operative complications included 2 cases of persistent distal peroneal nerve palsy. Three cases of anterior dislocations were reduced and did not recur. A case of positive intra-operative culture was treated successfully with 6 weeks of intravenous antibiotic therapy. Late complications included one case of cup loosening and one of a painful hip with suspected infection that required revision with a cemented prosthesis. Radiographic examination included measuring of radiolucent lines around the femoral stem according to the zones described by Gruen et al. and acetabulum as described by DeLee and Charnley. No femoral radiolucent lines were found. Seven cases revealed partial ace-tabular radiolucent lines.

Discussion: The Metasul metal-on-metal THR system was used so far with relatively satisfactory results in the early follow-up period despite the leaning curve. It is early to draw conclusions as to the superiority of this system over conventional metal-polyethylene bearing prosthesis. Long term follow-up studies are needed.