Surgical-site infections (SSIs) due to intra-operative contamination are chiefly ascribable to airborne particles carrying microorganisms, mainly Staphylococcus aureus, which settle on the surgeon's hands and instruments. SSI prevention therefore rests on minimisation of airborne contaminated particle counts, although these have not been demonstrated to correlate significantly with SSI rates. Maintaining clear air in the operating room classically involves the use of ultra clean ventilation systems combining laminar airflow and high-efficiency particulate air filters to create a physical barrier around the surgical table; in addition to a stringent patient preparation protocol, appropriate equipment, and strict operating room discipline on the part of the surgeon and other staff members. SSI rates in clean surgery, although influenced by the type of procedure and by patient-related factors, are consistently very low, of about 1% to 2%. These low rates, together with the effectiveness of prophylactic antibiotic therapy and the multiplicity of parameters influencing the SSI risk, are major obstacles to the demonstration that a specific measure is effective in decreasing SSIs. As a result, controversy surrounds the usefulness of many measures, including laminar airflow, body exhaust suits, patient preparation techniques, and specific surgical instruments. Impeccable surgical technique and operating room behaviour, in contrast, are clearly essential.

IV.

Calcaneal osteomyelitis is characterized by frequent relapse with delayed wound healing. Clinicians should take into account the impact of older age, as well as co-morbidities such as diabetes mellitus or the presence of neuropathy, during the routine management of patients with this difficult-to-treat bone infection.

The authors describe a new method of radiologic measurement of "Haglund's deformity", based on a radiologic study of 31 feet operated for posterior heel pain and more especially for calcaneal tendinopathies related to deformity of the calcaneus, and on a series of 60 asymptomatic feet. This angular approach requires a lateral weight-bearing view and proved positive in 85% of symptomatic feet, with only 14% of false-positives in the control group. It thus proves markedly superior to previously described radiologic formulations, since it allows not only for the size and site of the deformity of the posterosuperior part of the calcaneus but also for the angle of verticalization of the latter.

We report two cases of epicondylitis of the elbow occurring after treatment with fluoroquinolone antibiotics. Both patients had intense pain which appeared very shortly after the first dose of the drug and was not relieved by conservative treatment. Ultrasonography revealed extensive inflammatory lesions with pseudonecrotic areas. MRI confirmed the lesions and also showed a subclinical abnormality of the adjoining tendons. The persistent nature of the pain was the indication for surgical release of the extensor mechanism. After operation pain disappeared completely and the patients were able to return to their normal activities. Lesions of the tendo Achillis are a well-known side-effect of treatment with fluoroquinolone. Our two cases show that such lesions may occur elsewhere. They also indicate the need for caution when prescribing these antibiotics to patients at risk of tendon lesions, such as top-level sportsmen or patients on dialysis or steroid treatment.

No abstract

Studies of the fascio-cutaneous vascularization and innervation of the leg seem incomplete. After reviewing the classical findings, the authors report on their anatomic study 15 dissections. Perforating pedicles, originating from the peroneal artery (3 to 5) and posterior tibial artery (4 to 5) destined for the skin and fascia of the posterior aspect of the leg were constantly found. This study suggests the possibility of a distally based sural fascio-cutaneous flap, a flap which has been successfully constructed clinically.

Very many painful syndromes of the forefoot remain without a satisfactory explanation; although this region contains quite specific structures, it has suffered from the application of analogies with disorders of the hand. Among these specific components, the presence of the supra-transverse intermetatarsocapital bursa provides an explanation of such clinical entities as the acute syndrome of the second intermetatarsal space and gives fresh impetus to the debate on the etiopathogenesis of Morton's metatarsalgia. On the basis of 25 dissections, the authors studied the region between the metatarsal heads, confirming the presence of these bursae and specifying their site and size and particularly their relations with the common plantar digital nerve at its bifurcation into collateral nerves.