Pain control

In residency, we used a lot of Vicodin for postop pain with mixed pain control results. I then moved on to Demerol in practice with excellent results. Unfortunately, Demerol has a somewhat poor reputation due to the increased risk of seizures and its age restrictions (not for > 65-year-olds). I still use it occasionally, but with caution, mostly because few doctors in my area use it (community standard of care).

Dressings

I tend to use the same dressing in practice that I did in residency: Owen’s silk, 4x4s, Kerlix, and Coban.  I don’t use Kling, due to increased postop pain from its lack of stretch. In residency, my attendings were quite particular about how the dressings were applied. I thought this was a little ridiculous, but now that I’m in practice, I see some of the wisdom in this. A well applied dressing has a professional appearance and decreases pain, edema, and infections. Put 4x4’s between all toes in spite of what procedure was done – it looks better and is more comfortable.  I use cam walkers and casts for bigger procedures (depending on likelihood of compliance) and postop shoes for anything less than a Lapidus. I fully weightbear toe procedures, head osteotomy bunionectomies, and neuroma excisions (essentially all distal forefoot procedures). I’ll even partially weightbear a 1st MTP joint fusion (though I’ll tend towards a plate in these cases). I non-weightbear Lapidus (although I’m sure you could get away with heel-touch weightbearing). Almost everything else is non-weightbearing.

Anticoagulants

I’m VERY liberal with my use of postop anticoagulants.  Lovenox is my friend. During my second year of practice, I did a Brostrum on a patient who called me 5 days postop with calf pain and shortness of breath. It turns out he had a calf DVT with a saddle pulmonary embolism. Luckily I caught it, and he lived to tell the tale. I now put anyone in a cast or larger reconstructions on Lovenox. Yes, the prescription is expensive, but how much does a patient’s death cost? I’ll never have to say, “Gosh, I should have put them on Lovenox.”

I could probably go on for much longer talking about preferences and methods. Medicine and surgery is about as varied as the doctors who perform it and the patients it’s performed on. You may or may not agree with my methods. Either way write in with your preferences, tips, and arguments. Through our careers we’re likely to change our methods many times. That’s why they call it the “practice of medicine.” Best wishes.

RETRACTION: Please note that last week's issue, inside the Wound Care Surgery section, the amputation images should have been labeled, "postoperative transmetatarsal amputation." We apologize for any confusion this may have caused.

Write in – let’s start a conversation. Best wishes on your next case.