Residency Rap

This past week was a bit slow from the surgical side here at Botsford, so what does that call to mind? Surgical procedures. At my program we’re constantly talking about different procedures, their indications, complications, and tips for performing them. Just as with attendings, each resident has his or her own well of experience to draw from, providing fodder for some interesting discussion. Of course, part of that discussion involves critiquing the choice of procedures as well as how we can improve our own techniques. So, with all this in mind I started thinking, “What’s my favorite procedure? What’s my least favorite?”

Let’s start with the least favorite. Intermetatarsal neuroma excision. Don’t like ‘em. Especially from a dorsal approach. It’s like performing surgery in a cave! If you’re not careful you end up doing a space-ectomy. At least from a plantar approach the nerve is superficial and easy to dissect out. And how successful is this procedure in the long run? We all know about stump neuromas and have taken out our share of them.

From the forefoot side of things, my favorite procedure is probably a bit trite: the Lapidus bunionectomy. I know what you’re thinking: “He’s just going along with the wave of popularity.” First, no bunionectomy closes the IM angle as effectively while allowing repeated intraop adjustments. Second, it addresses the etiology when first ray hypermobility is located at the first met-cuneiform joint. Third, good stable fixation with a low incidence of nonunion. Fourth, it’s just fun to do! I’m also not sold on nonweightbearing a Lapidus postop. One of the posters at the ACFAS conference prospectively studied a cohort of patients with the Lapidus and weightbearing in a camwalker after two weeks with no nonunions. It would be very beneficial to patients to be able to weightbear them afterwards. What do you think? Will you weightbear you Lapidi when you’re in practice?

With rearfoot it’s a toss up between subtalar fusion and retinaculaplasty (groove deepening) for peroneal subluxation. For patients with subtalar OA and an intact midtarsal joint this fusion provides great symptomatic treatment while being versatile enough to correct some rearfoot deformity. The dissection’s also fun to do. On the other hand, the retinaculaplasty, although not a complicated procedure is very effective for repositioning the peroneals. I like the lateral decubitus position, curvilinear incision starting proximal to the fibular malleolus along the peroneals, inspecting and repairing the tendons as needed, carefully dissecting the cartilage from the retrofibular groove (leaving a deep or medial hinge) and taking a burr to deepen the groove. You simply reattach the cartilage with buried absorbable sutures, replace the tendon, repair and plicate the superior peroneal retinaculum, and close in layers. It’s not complicated, but you get a good, anatomic, lasting result.

What’s your favorite procedure? What do you hate to do? Are you king of the Austins? Are you a triple arthrodesis fiend? How about ORIF of traumatic fractures? Do you get jazzed up about waking up in the middle of the night and relocating a dislocated subtalar joint? All residents are welcome to contribute, no matter what your level of experience. I look forward to hearing your responses.

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