Previous studies have demonstrated higher infection rates following elective procedures on the foot and ankle as compared with procedures involving other area of the body. Previous studies also have documented the difficulty of eliminating bacteria from the forefoot prior to surgery. The purpose of the present study was to ascertain that preoperative chlorhexidine bathing provide significant local flora reduction than placebo in elective foot and ankle surgery. From October 2005 to October 2006, a prospective study was undertaken to evaluate 50 consecutive patients undergoing planned, elective surgery of the foot and ankle. 50 patients were prospectively enrolled and randomly assigned to have preoperative footbath with Chlorhexidine Gluconate (Hibitane) (Group 1) or placebo (Group 2). Culture swabs were taken from all web spaces, nail folds, toe surfaces and proposed surgical incision sites before the preoperative antiseptics bath, during the procedures and immediately completion of surgery. 50 patients were enrolled (mean age: 42.6 years; range: 19–85; F: M = 29:21). 25 patients are assigned to each groups. 100% bacterial isolation preoperatively in both groups prior to antiseptics bathing. In group1, bacteria grew on intraoperative culture in 60% cases and 0% in immediate post-operative culture. In group 2, 96% in intraoperative swab culture and 16% in postoperative swab culture. The intraoperative swab culture bacterial count is statistically significant (p= 0.002). The postoperative swab culture bacterial count is marginally significant (p=0.055) when comparing 2 groups. No complications were recorded in both groups. These data indicate that chlorhexidine provides better reduction in skin flora than placebo. Based of these data, we recommend the use of chlorhexidine footbath as well as the surgical preparatory agent for the foot and ankle surgery.
Two clinic appointments later he was still complaining of pain. X-rays taken at that time showed what appeared to be some evidence of callus formation at the fracture site. Six weeks later he had clinical and radiological signs of what appeared to be “huge callus formation”. He was given a 3 month appointment for what was expected to be a final review. Before his next fracture clinic appointment, however, he became jaundiced and complained about this to his GP who felt it was obstructive jaundice and referred him to the physicians who admitted him to the hospital, and began to investigate him as to the cause of the jaundice. These investigations included an Ultrasound Scan of the abdomen which showed a bulky head of pancreas with biliary and pancreatic ductal dilatation; and a CT scan of the upper abdomen which showed the presence of a cystic mass within the caudate lobe of the liver. Soft tissue vascular encasement around the portal vein and hepatic artery were reported as in keeping with malignant infiltration. Extensive tumour was present within the retroperitoneum involving local vascular structures. He came down to the fracture clinic for his next clinic appointment from the ward. At this point he was very ill, deeply jaundiced and frail. The swelling of the clavicle was the size of a large orange, firm to touch with dilated veins. X-ray at this point showed complete radiological destruction of the medial 1/3 of the left clavicle. At this point palliative care was the mainstay of his management. A week later the chest x-ray report came back as showing collapse of the left upper lobe with whiteout appearance and bulky hilum indicating an underlying bronchogenic carcinoma. Three days later, almost 5 months after initial presentation following a fall, this patient finally succumbed to his disease.
Significant complications can occur after sarcoma surgeries. Patient should be adequately informed and educated about the complications Surgeon should properly plan his surgery liaising with other specialities Radical excision offers no significant advantage over wide local excision followed by radiotherapy.
We report on two patient groups questioned about travelling for surgery outside of their base hospital to cut waiting times. Firstly 30 patients travelled approximately 50–60 miles to have hip replacements. After surgery we asked them their thoughts regarding an unknown surgeon, self and relatives expenses and any inconvenience. Five (17%) were anxious about taking part and 3 (10%) incurred extra expense (transport was provided). Eight (27%) stated that relatives incurred extra expense and 5 (17%) stated relatives had difficulty visiting. All were not concerned about having their operation carried outside of the local area by a new surgeon. Asking the question as: how keen were you on having the surgical team you first met at your local hospital to do your joint replacement? responses were: 1 not keen (4%), 25 not bothered (83%) and 4 very keen (13%). Three (10%) stated that relatives had to take time off work to visit them. All patients thought that the idea of reducing waiting lists by doing the operation in a private hospital was good. We felt their response was perhaps too positive and decided to look at a local preoperative group. Our preoperative group involved thirty patients. Four (13%) were anxious about taking part in a waiting list initiative and 10 (33%) were worried about extra expense. Seven (23%) were worried about their relatives extra expense and 6 (20%) would be discouraged if their relatives had difficulty visiting. Fourteen (47%) raised concern about having their operation carried outside of the local area by a new surgeon. Fourteen were keen to have treatment from their original surgeon. None felt that relatives having to take time off work to visit them was a problem. All patients thought that reducing waiting lists by doing the operation early in another hospital was a good idea. We conclude that patients are accepting of waiting list initiatives if their preoperative wait can be decreased.
