Postoperative surgical site infection in patients treated with lumbosacral fusion has been believed to be caused by perioperative contamination (Perioperative Inside-Out infections) in patients with comorbidities. With the proximity of these incisions to the perianal region and limited patient mobility in the early post-operative period, local contamination from gastrointestinal and/or urogenital flora (Postoperative Outside-In infections) should be considered as a major source of complication. A single center, retrospective review of adult patients treated with open posterior lumbosacral fusions between January 2014 and January 2021. We aimed to identify common factors in patients experiencing deep postoperative infections. Oncological, minimally invasive, primary infection, and index procedures carried out at other institutions were excluded. We identified 489 eligible patients, 20 of which required debridement deep to the fascia (4.1%). Mean age (62.9 vs 60.8), operative time (420 vs 390 minutes), estimated blood loss (1772 vs 1790 mL) and median levels fused (8.5 vs 9) were similar between the infected and non-infected groups. There was a higher percentage of deformity patients (75% vs 29%) and increased BMI (32.7 vs 28.4) in the infected group. The mean time from primary procedure to debridement was 40.8 days. Four patients showed no growth on culture. Three showed Staphylococcus species (Perioperative Inside-Out infections) requiring debridement at a mean of 100.3 days (95%CI 0- 225 days). Thirteen patients showed infection with intestinal or urogenital pathogens (Postoperative Outside-In infections) requiring debridement at a mean of 20.0 days (95%CI 9-31 days). Postoperative Outside-In infections led to debridement 80.3 days earlier than Perioperative Inside-Out infections (p= 0.007). In this series, 65% of deep infections were due to early local contamination by gastrointestinal and/or urogenital tracts pathogens. These infections were debrided significantly earlier than the Staphylococcus species infections. Due to the proximity of the incisions to the perianal region, there should be increased focus on post-operative local wound management to ensure these pathogens are away from the wound during the critical stages of wound healing

The recognition of the role of TFCC as a major distal radioulnar joint stabilizer and a buffer to compressive forces indicates the importance of preserving as much of this structure as possible. We developed arthroscopic technique for repair of Palmer I B tears of TFCC using a hypodermic needle which obviates the need of any additional skin incision. With wrist under traction important landmarks like radial styloid process, ulnar styloid process, Lister's tubercle and extensor tendons are marked using skin marker. For placement of the arthroscope, 3–4 portal is used and for instruments 6 R and 6 U portals are used. An outside-in technique is used. A 19 G needle is inserted upward from 5mm proximal to the level of the 6 R portal through skin, subcutaneous tissue, capsular tissue and then through the 2mm inner side of detached area of TFCC, while stabilizing it with probe. A 2–0 polydioxanone-PDS suture is passed through needle and caught by grasper placed in the 6 R portal. Now needle is withdrawn and then suture is retrieved out of the joint through the 6 R portal. The procedure is repeated for required number of sutures for dorsal part of peripheral tear. Thus we have stitches with one limb exiting the joint through portal and the other limb entering the joint percutaneously. A small mosquito forceps is passed through the 6 R portal undermining subcutaneous area and these percutaneously passing limbs of sutures are withdrawn through the portal. Now we have sutures entering and exiting through the 6 R portal. Similar procedure is done for ulnar part of peripheral tear through the 6 U portal. Knots are tied and slid beneath the subcutaneous tissue. It offers advantages of a lower risk of neurovascular damage, reduced postoperative pain, faster rehabilitation and better cosmesis