The French Slipper—A Technical Tip

Introduction

A silk-covered slipper, also known as a babouche, hails from the Middle East. ⁶ The slipper became fashionable among French courtiers in the 17th century and has since been an art that all walks of life use. ⁶ Dr Arthur Manoli II was a talented foot and ankle surgeon with many accomplishments over a well-respected 50-year career in orthopaedic surgery. ⁵ During many of his surgeries, he would commonly cover the toes and heel with a so-called French Slipper, his own form of art. Studies have shown a high level of positive toe cultures even after povidone-iodine prep. ⁷ In one study, positive cultures were seen in 80% of halluces and 72% toes, indicating the standard presurgical scrub may not completely eradicate potential pathogens. ⁷ For this reason, some surgeons have adapted to using additional barriers (ie, Ioban, ace wrap, surgical glove, or Coban) to help protect the surgical site from potential residual pathogens. We argue the French slipper can be used as an additional barrier in ankle and lower extremity procedures when access to the toes and hindfoot is not necessary. This article is written posthumously to honor Art Manoli II.

Technique

Coban is used to circumferentially wrap the toes, part of midfoot, and inferior aspect of hindfoot (Figure 1). This technique allows for coverage of the toes, heel, and plantar aspect of the foot where diabetic ulcers, heel fissures, or fomites might hide.

Figure 1.

Lateral, medial and plantar view of left foot demonstrating The French Slipper.

Discussion

Preoperative preparation and prevention of surgical site contamination are areas of top priority for an orthopaedic surgeon. In foot and ankle surgery, the antiseptic preparation may include 70% isopropyl alcohol and chlorhexidine gluconate or povidone-iodine. ³ The literature has shown a decrease in bacterial culture following preparation; however, there may still be residual bacterial contamination even after extensive surgical preparation of the limb.^1,2,4,7 Some studies argue that toe coverage may not be necessary, as an increase in postoperative wound infection has not been seen in patients without toe coverage.^1,2,4,7 However, some of these studies did not involve coverage with Coban, and the highest level study was limited to 40 patients.^1,2,4,7 Regardless, studies have shown high levels of positive culture percentages even after presurgical scrub (80% halluces and 72% toes). ⁷ This high positive culture percentage helps supplement the argument for an additional barrier against these potential pathogens. We choose to cover the toes and heel when possible because heel fissures, toe web spaces, and nails can provide a potential nook for bacteria to hide, and the surgeon does not always get to choose their patients. After antiseptic preparation, an additional barrier may benefit the patient and can help the surgeon sleep better at night.

There are many options for covering the toes and/or heel including Ioban, ace wrap, surgical glove, and Coban. Ioban costs the most at $11.31 and can be difficult to remove from between the toes. ² An ace wrap is the least expensive at $2.75 but does not have great traction on the skin and may easily slip off during surgery secondary to manipulation and positioning of the foot during surgery. ³ Surgical gloves are an excellent option at $2.75 but they do not cover a patient with heel fissures.^3,8 Coban costs $3.34, has great traction on the skin and can cover the toes and heel. Arguably, it provides mechanical compression to the foot during periods of immobility as well. Using Coban to lock in the heel and including the toes prevents the covering from coming off. With this French Slipper technique, many approaches to the foot and ankle can still be performed.

Conclusion

Although surgical scrubs are effective at reducing the number of potential pathogens, we believe an additional mechanical barrier over these potentially contaminated areas is a practical adjuvant. Thanks to Dr Arthur Manoli II, this technique article illustrates an inexpensive method for covering the toes and heel during lower extremity surgery. With the “French Slipper,” we can all rest in peace.

Supplemental Material

sj-pdf-1-fao-10.1177_24730114231185336 – Supplemental material for The French Slipper—A Technical Tip

Supplemental material, sj-pdf-1-fao-10.1177_24730114231185336 for The French Slipper—A Technical Tip by Jake Stahnke, Matthew Marquart and Arthur Manoli in Foot & Ankle Orthopaedics