Santi Cazorla has discussed his year-long fight to save his leg (Evening Standard Nov 3 2017). This alone should prompt a rethink about conventional medical thinking, but it also gives some support to the salience of non-infective factors:

"Cazorla discussed problems dating back much further to September 2013, when he suffered a crack in his right ankle...

After undergoing another operation, this time on a tendon in his foot, the wound kept opening up to the extent he was forced into eight surgeries inside 12 months... The problem was that the skin didn't heal and the wounds kept on opening and getting infected... I'd begin to cycle and the stitches would open and there'd be liquid...

They had to study what type of bacteria it was...

After finding no answers in England... he went to see Dr Mikel Sanchez... He saw... I had damaged part of the calcaneus and that my Achilles tendon was eaten away and eight centimetres were missing...

It is claimed that three aggressive strains of bacteria were discovered after the wound had become infected during a previous surgery. Discussing the gangrene-infected heel, Cazorla said... 'The problem was that the skin didn't heal and the wounds kept on opening and getting infected'"

Comment

SC says the fluid leaks predated the infections. Surely it was no coincidence that several different nasty germs converged on his heel? There must have been some underlying generic predisposition.

This redresses the modern imbalance between germs and substrate, and harks back to the old days before infectious organisms had been discovered, when constitutional predispositions and weaknesses were emphasized.

Apart from various reasons, surgical technique and timing are skill dependent factors. Meticulous surgery with good dissection that is done with minimal struggle and tender tissue handling goes a long way to prevent infection

Another large factor that isn't spoken of often is the skill of the surgeon. Damage to the fine vascular layers, damage that creates edema or hematoma formation post operatively or longer surgical time leavint the tissues open to air longer are all contributing factors

What I am proposing goes far beyond general skill and experience factors. I think the main aim should be to stop and prevent leaks.

Anthony do you not think that the skill of a surgeon dictates how much tissues leak? The reason that experienced surgeons have less complications is decreased surgical time and less bleeding in the tissues after closure in my opinion

"Anthony do you not think that the skill of a surgeon dictates how much tissues leak?"

Yes, but it is not tissues in general that are relevant. It is lymph vessels, CSF spaces, blood vessels, where persistent leaks matter. A general clean-up and surgical repair will usually mean fistulas are able to heal themselves. If Cazorla's surgeons been asking themselves, 'Why is there a persistent fistula?, and 'Have I checked to see if there are bone fragments inserted into fluid channels that are preventing sealing', then he may not have needed 9 operations.

" Yes, there are lots of reasons why wounds break down or get infected. "

The ten factors just listed predict surgical wound infection. I am saying these can be reduced to one underlying factor, creation of or failure to identify and fix a fistula. Occam would have approved of this theory.

It is very important to handle tissues gently with application of minimally invasive techniques and reducing the length of the operation.

I agree but this is very surgeon dependent

We have to search the reasons in three fields. 1. The main characteristics of the patient (i.e. diabetes, smoker, etc), 2. The site of the operation (i.e skull, limb, etc) 3. Main characteristics of the surgery (time, skills of the surgeon, etc).

"We have to search the reasons in three fields."

4. The reason for the persistent leak, and particularly why it has not spontaneously sealed itself off.

There is always a persistent germ that you have to diagnose and to fight.

"There is always a persistent germ that you have to diagnose and to fight."

This does not get to the root of the problem. Why do germs persist when the body is usually perfectly capable of dealing with them? Answer: Because an unnatural niche has been created, a collection of fluid outside the reach of the immune system.

The infectious theory of disease is fine for measles, for example, which can be attributed to the action of one specific germ on an underprotected body. It falls down in the Cazorla case (see above) since many different germs are involved. What matters here is the Soil, not the Seed.

The most important issue in wound healing is preventing movement in the wound. Wounds particularly in areas like the groin or a large abdomen are subjected to huge forces that tend to pull the wound apart. The body responds with an inflammatory process which is often mistaken for infection. Abdominal binders around the abdomen have been shown to improve healing rates significantly. After cutting out a skin cancer from the lower leg, a compression bandage is required to reduce swelling and dehiscence of the wound. It is a very mechanical process and this is greatly overlooked.

"The most important issue in wound healing is preventing movement in the wound...It is a very mechanical process and this is greatly overlooked."

Thanks, this supports my theory. Fixed apposition of reparative tissue is needed for sealing of a leak. In the ear, a bone fistula cannot be bridged, hence unstopped growth of scar tissue (cholesteatoma).

Respect for the tissues while dissecting and suturing are important. Immunity status the patient is also important.

However most important is whether drug resistant infective organisms get a foothold into the surgical site and lead to Hospital Acquired Infection in the patient. As most of the infective organisms found in hospital environment are multi drug resistant, it may be difficult and expensive to treat HCAI after its occurrence. Prevention of Nosocomial infections is the best way to cut down on HCAI.

"organisms get a foothold into the surgical site"

The most crucial feature that needs explanation in order to understand the basic causation is: What are these footholds that open the door to different organisms?

In the case cited where wound is on foot and refuses to heal I would consider the following conditions:

• Poor vascularity due to arterail insufficiency such as in Smoker's disease or Thrombo Angiitis Obliterans.
• Poor tissue vitality such as vitamin deficiency
• poor healing capacity such as mal nutrition and low serum proteins and

Immuno compromised status

"In the case cited where wound is on foot and refuses to heal I would consider the following conditions"

None of these are at all likely in a top international footballer.

There are many factors that influence on this problem and most of them are mentioned by comments.

I want to mention 2 more factors that help to decrease the infection rate.

1. Frequent mechanical washing ( lavage) of the wound during the surgery every 10 or 15 minutes with saline solution is important and I practice a lot.

2. Negative pressure suction postoperatively is crucial to avoid creation of hematoma.

A wound on the plantar surface of a foot cannot heal if there is continued pressure on it from walking and so what is needed in this case is either bed rest or a total contact cast. Neuropathic toes also often fail to heal because of mechanical trauma that is not felt by the patient and so these too may need a cast to cover the toes until they heal. Healing is a very mechanical process. We seldom see non healing wounds on arms and that because they do not have to bear the weight of the body.

"Healing is a very mechanical process. We seldom see non healing wounds on arms and that because they do not have to bear the weight of the body."

A simple yet crucial observation. How well-known is this? Any technique, however effective at reducing the presence or influence of germs, needs to avoid increasing concurrent mechanical tissue damage.

Yes , I meant simple lavage with syringe and saline solution, not high pressure pulse lavage

Surgical site infection is a universal issue and every effort must be made to reduce the risk. In my view, there is no single factor responsible. There are pre operative, operative factors and post operative considerations. Pre operative are mainly patient related hence pre opeartive optimization is crucial which is not always possible as in emergency cases. Operative relates mainly to operative room environment, instrument sterilization, surgical skills including gentle soft tissue handling, duration of surgery, anesthetic consideration to optimise the circulation and PO2. Post operative are wound handling, frequent change of dressing, cross infection, staff hand hygiene etc.

"there is no single factor responsible"

I think there is a single underlying factor -- deliberate or inadvertent operative damage to tissue outside the scope of the body's normal reparative mechanisms.

I respect your views but my view is that it is multifactorial and poor tissue handling is one of them

it depends on many factors, related to the patient, operation, surgeon, theater, and post operative care.

"it depends on many factors, "

Yes, but I have proposed a more fundamental underlying cause. A simple theory should always be preferred over a complex multi-faceted one. So why is my theory (mostly plagiarised from Hippocrates!) so wrong?