My Surgical Tips And Pearls For Residents

William Fishco DPM FACFAS

In this blog, I want to share with you surgical tips and pearls that I regularly teach my residents.

1. Accurate incision placement is critical to avoid neurovascular structures and gain access to your target tissues. If you are operating in a less familiar area or a deformed foot with abnormal anatomy, this simple task of drawing a purple line can be a real challenge. We can perform dissection of the first metatarsophalangeal joint (MPJ) blindfolded due to repetition and familiarity. When you are operating in an area of complex anatomy or areas that you may be less familiar with, take the time to draw out the anatomy. For example, let’s say you are doing a Lisfranc’s fracture or arthrodesis, and the patient has an underlying metatarsus adductus. You can easily get fooled with your incision and a quarter-inch too medial or lateral can make the surgery more difficult than it needs to be.

Here is the tip. While you are injecting local anesthesia, stick the needle on both sides of the metatarsal bone so you get your bearings straight. Use your ink pen to mark the metatarsal and outline the bones to the bases. Another example of using this technique is for subtalar joint arthroereisis. I will stick the needle with local anesthesia into the sinus tarsi. Then I take an ink pen and mark a line medial and lateral to the needle so my incision will be directly over the sinus tarsi.

2. Having access to an intraoperative fluoroscopy machine is critical. Fluoroscopy comes in handy not only to confirm that your screw placement is in the ideal location, but also for making osteotomies. A good example is using a bull’s-eye view (the X-ray beam is directly in line with your instrument or guide pin for a screw). For a base wedge osteotomy, for example, a bull’s-eye view of your axis guide will tell you exactly where you are in the bone. When I do a calcaneal osteotomy (Dwyer or medial slide), I will use a bull’s-eye view of an osteotome to make sure the location of the osteotomy is ideal.

3. Removing foreign bodies from the foot can be a real nightmare. If you have a radiopaque foreign body such as a needle, use fluoroscopy to locate the foreign body by placing a needle through the bottom of the foot and one through the side at the depth that you think the foreign body is located. Then take a picture to see if the foreign body is between your two needles. If so, then go for it and make your appropriate incision.

Another tip is dealing with patients trying to pressure you into removing foreign bodies in the office. I tell patients that if they really want me to try to find it, I will give it ten minutes. If I can’t find it, then I will sew up the incision and then schedule for the procedure to happen at the hospital or surgery center. The last thing you want to do is waste a half an hour poking around causing unnecessary damage to the tissues. Another tip is that if the patient already had a failed attempt to have an urgent care physician remove a foreign body, definitely schedule to do the procedure in the OR.

4. When doing a distal metaphyseal osteotomy for bunion surgery, remove the bump last. Most people remove the bump first and then do a distal metaphyseal osteotomy of their choice (chevron, distal L, etc.). Remember, you can only move the head over about one-third of the width of the metatarsal head, so why remove the bump first? If you do that, you have just reduced the amount of correction that you can get. Make your osteotomy first. Then take your bump off and include the overhanging bone created by the osteotomy. You will have a nice clean resection and won’t have to do a lot of burring to take down uneven bony prominences.

5. Use two screws for a Weil osteotomy. I have found that one screw can lead to clockwise rotation of the capital fragment. As you are turning your screwdriver, you are also turning the head. So instead drill two guide pins for screws. That will stabilize the osteotomy and remedy that problem.

6. When doing a calcaneal osteotomy for pes valgus correction, if you are having difficulty moving the tuber of the heel medially, make a second parallel cut to remove a piece of bone, which will slightly shorten the heel. That will decompress it and allow you to move the heel bone exactly where you want it. Shortening the heel slightly will not have any negative effects on the surgery.

7. When aligning the great toe in an arthrodesis procedure, temporarily pin the toe in the desired position and use a flat plate (cover of an instrument tray) to simulate the ground in weightbearing. Make sure you maximally pronate the foot and then you want the toe slightly off the plate, just enough where you could put a nickel or two under the toe. In the past, recommendations have been for the toe to be 10 to 30 degrees of dorsiflexion, which is too much in my experience. We also learned the technique of placing a finger under the toe, which is also too much elevation. When the toe is too dorsiflexed, a mallet toe occurs and can be an irritant in shoes.

8. Avoid absorbable sutures in tendons. Tendons are avascular. As a result, absorbable sutures do not dissolve well and can be a source of trouble. Stick to non-absorbable sutures such as nylon or braided synthetic sutures like Fiberwire (Arthrex).

9. Avoid intramedullary fixation techniques for repair of hammertoes that have a significant adductovarus component. This typically occurs in the fourth toe. Even when the hammertoe has been fixed, any residual adductovarus influence can cause the implant fatigue and eventually break. Intramedullary fixation works well for hammertoes that have a purely sagittal plane deformity.

10. When cauterizing pyogenic granuloma associated with a paronychia, use an electrocautery (hyfrecator) unit instead of silver nitrate. Silver nitrate causes a mess with the tissues. The tissues develop a gray, soupy collection of material after silver nitrate application. The electrocautery technique dries everything out and is less of a concern to the patient.

11. When performing neuroma surgery, discuss with your patient that most of the time, the mass removed is indeed a neuroma although other potential causes of their pain may be some other soft tissue mass (i.e. intermetatarsal bursa). That way, when your pathology report comes back as a “cyst” or a “bursa,” your patient is not upset with you because you “missed the diagnosis.” Moreover, some patients might think that if it were a cyst rather than a neuroma, you could have drained the cyst, thereby avoiding surgery.

12. When a patient has a primary complaint of a tailor’s bunion, always do an osteotomy versus an exostectomy. I have never “kicked myself” for doing an osteotomy but I can’t say that for the contrary.

13. When patients are in need of a difficult revision or primary reconstruction surgery, never let them feel like you can fix them with one surgery. You have to be honest with patients. Let them know that they have a challenging case and the surgery may need to be staged. If you do get everything done in one surgery, then you are a hero. If not, well, you already prepared them for another procedure. Realistic expectations are critical for a harmonious doctor-patient relationship.

Hopefully, you will pick up a pearl or two. I will add to this list for volume II in the future.

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