The procedures in a Keller's arthroplasty that ensure success are--
- provision of suitable shoes that should be "broken in" before operation;
- wearing metatarsal bars on the shoes for three months postoperatively (it's gratifying the number of women who realise for the first time what "foot comfort" really is, and continue to wear suitable shoes for life);
- removal of enough -- about half -- of the proximal phalanx;
- trimming the metatarsal head down to an even cone flush with the shaft and using a rasp to smooth off the rough edges;
- tenotomy of the extensor hallucis longus just above the upper end of the incision;
- shortening of the 2nd toe (by partial fillet) if it is too long.
There is no better operation for Hallux Valgus or Hallux Rigidis than a properly performed Keller's arthroplasty.
ULNAR NERVE TRANSPLANT
After transplantation of the ulnar nerve never forget to trace and free it proximally for two to three inches above the epicondyle -- otherwise it may be sharply angulated against the unyielding medial intermuscular septum -- a situation likely to cause trouble later. I also believe it is worthwhile burying the nerve in the available flexor carpi ulnaris muscle for better protection. It is right there and no trouble.
My rule in operating is always to use the smallest instrument adequate for the purpose. This also applies to suture material. Remember that the sole purpose of a suture is to approximate cut surfaces until natural healing "takes over". This is rarely more than seven to ten days. It is therefore not only unnecessary, but positively harmful to use suture material that lasts longer than this. For this reason I rarely use anything "heavier" than No. 0 plain catgut, and never use chromicised gut at all. For different reasons, if ever you see anyone tying things up " tightly"--he is a bad surgeon. All he is doing is to "strangle" tissues involved.
Remember to leave skin sutures in girls a day or two longer than boys. "Puppy fat" subcutaneously seems to delay healing just that much longer. It is embarrassing if the wound tends to " gape" in the very patients in whom you hope for a thin hair-line scar.
Assessment of disability in an injured hand can be an extremely difficult problem. Remember there are three cardinal functions of the hand, e.g., grasp, pinch and hook, and they are of equal value--namely, 33%.
Also remember that total loss of the thumb represents a loss of 40% of the function of the hand as a whole.
- Never use a tourniquet when "debriding" a compound fracture. We found years ago, quite by accident, that the use of a tourniquet increases the risk of wound breakdown by at least 500%.
- Never use cortical grafts for an un-united fracture that was originally compound. It can become an unwanted foreign body.
- Always make sure that the medullary canal is reopened when grafting an un-united fracture. I am sure it is worthwhile and is especially useful when "setting" an "emu's nest" of cancellous slithers on, say, an un-united tibia.
- The best site for metallic implants to secure fixation of an unstable fracture of the tibia and fibula or for cancellous grafts for an un-united compound fracture, is the lateral surface of the tibia. It is only a little more trouble and the plates, screws or grafts are comfortably buried under muscle--and nowhere subcutaneous.
- If you want to avoid that horrible "radial creep" that almost invariably follows a Colles' fracture, use an above-elbow cast for as long as you can persuade the patient to put up with it.
- Do you ever use "living sub-cortical grafts" (sometimes known by the irreverent as the "shuttlecock operation")? It is a useful preliminary to the use of Phemistee slithers of