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Jarrod Shapiro, DPM
Practice Perfect Editor
Assistant Professor,
Dept. of Podiatric Medicine,
Surgery & Biomechanics
College of Podiatric Medicine
Western University of
Health Sciences,
St, Pomona, CA |
Surgeons Should Question the Status Quo
One of the great advantages of being part of a university with a bunch of other physicians is the ability to freely share ideas and experiences. I know this is considered Level 5 evidence, but there’s still an important place for an organic exchange of ideas. A recent conversation with one of my podiatric colleagues is a case in point. During our discussion, my colleague mentioned a surgical approach to a problem that not only had I never heard of, but opened us up to a larger discussion about a surgical principle that I had taken for granted as gospel. I’d like to take this individual discussion and broaden it yet again to another level – questioning the status quo.
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For those of you traditionalist surgeons, hang onto your hat (or your surgical cap). My colleague, during our discussion, told me that he was trained to perform a straight to bone EDL-splitting linear incision to access the digit and MTP joint. No anatomical dissection, no layers...just one incision through the tendon to bone. He’d then perform his PIP joint release, arthroplasty or arthrodesis and metatarsal osteotomy through this incision. The structures are retracted medially and laterally away from the joint in question. He doesn’t repair the split in the EDL. Closure is performed at the deep layers first, subcutaneous layer next, and finally the skin.
When I heard this, I had to have him repeat himself. He told me he has previously applied this approach to hallux valgus repair (for distal osteotomies) and 5th metatarsal head procedures with success.
So, when I first heard this I actually called him – good-naturedly – a heretic. The reason for my faux criticism is that his idea flies in the face of more than 100 years of modern surgical reasoning and technique. The concept of layered dissection was popularized to universal application by the revolutionary William Stewart Halsted of Johns Hopkins hospital around 1900. By the way, he also pioneered the use of gowns, gloves, and masks in surgery, beside the eponymous forceps named after him, which we more commonly today call mosquito hemostats. So, ever since W.S. Halsted essentially created our modern surgical techniques, layered dissection with meticulous hemostasis has been an unquestioned tenet of surgery.
We’ve adopted this tenet in podiatric surgery as well. For example, Chapter 14 of McGlamry’s Comprehensive Textbook of Foot and Ankle Surgery, 3rd edition centers on anatomic dissection of the 1st MTP joint for hallux valgus surgery. It provides an excellent discussion of concepts such as the controlled depth incision, hemostasis, and subcutaneous dissection and even goes so far as to say “the primary control of bleeding both during and after the surgical procedure is most effectively accomplished with the anatomic dissection technique1.”
The argument my colleague makes for his technique is as follows. Because these are linear longitudinal incisions, he’s not violating any neurovascular structures: there’s nothing to damage. Second, he argues, the retraction is easier for the surgeon and less harmful to tissues because they’re moving as a unit. Third, it’s still possible to obtain hemostasis in the usual ways. Fourth, postoperative edema and pain are decreased, because the surgeon is not creating artificial tissue spaces by separating layers. It’s important to mention he no longer uses this technique for his distal 1st metatarsal osteotomies, only due to the inherent limitations on performing capsular work when the capsule remains attached to a complete tissue envelope.
What was my reaction to this? Well, I have a very open mind, but I’m still doubtful. I understand his reasoning, but have trouble quickly accepting something so contrary to my most basic surgical training. On the other hand, when I perform amputations – I’m thinking of transmetatarsal amputations – I incise straight to bone to maintain a full thickness flap. I’ve had very little trouble with this technique and in fact, see very little swelling in the majority of my TMAs. Is this due to the incision technique? Perhaps. I’ve asked him to track his next case performed in this manner with photos, so we can continue the discussion. I performed a quick PubMed literature search, but was unable to find anything specific regarding this topic. Perhaps there’s a future research study here!
I may not be sold on this method, but what I like – on our broadest level – is his not accepting the status quo. My colleague’s technique stands squarely against many years of surgery and many surgeons’ training, and yet he’s exploring an alternate philosophy. Who knows? Maybe he’s correct. Perhaps the concept of a layered, fully anatomic dissection is more applicable to other parts of the body, where W.S. Halsted, as a general surgeon, did the vast majority of his work. Perhaps, because of the “end organ” location of the foot and its particular venous and lymphatic drainage as well as its suboptimal position in regard to gravity, a nonlayered approach is more appropriate in many cases of foot and ankle surgery.
I know there are some of you out there who think this is craziness, and I shouldn’t even consider this idea. I’ll defend my colleague with the very blunt example of the Middle East. If Egyptians all accepted the status quo, Hosni Mubarak, a dictator, would still be in power. The same can be said for much of that region today including Tunisia, Saudi Arabia, Jordan, and Libya, now on the verge of a civil war to change the status quo. Is it going too far to say if Americans accepted the status quo 255 years ago, we’d still be British today? Question the status quo. Improvement always follows.
Keep writing in with your thoughts and comments. Better yet, post them in our eTalk forum. Best wishes.
Jarrod Shapiro, DPM
PRESENT Practice Perfect Editor
[email protected]
References:
- Ruch J, et al. Anatomic Dissection of the First Metatarsophalangeal Joint for Hallux Valgus Surgery (Ch. 14) in McGlamry’s Comprehensive Textbook of Foot and Ankle Surgery, 3rd edition, Vol 1, Lippincott Williams & Wilkins, 2001: 493-504.
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