History Corner

ARTICLEHistory corner

“Practical Podiatry”

Philip Basham, BA, FinstCh Jean Truscott, BA, FinstCh

“Usually, the patient may continue his regular occupation with little or no disability. He may stay in his own home making a considerable saving in money and convenience. The worry and dread of a hospital stay is avoided. Fewer complications develop. Saves hospital space for those actually needing bed and nursing care.

Smallness is not at all synonymous with unimportance and the surgeon must constantly be on his guard. Operations upon patients with blood dyscrasias, such as haemophilia or leukaemia, even though the lesions are insignificant, are best performed in the hospital because of the danger of post-operative bleeding. In diabetics, even minor operations should be performed in the hospital because of the danger of metabolic complications.

Ambulatory surgery should be safe surgery.”

Introduction

Radical procedures such as those described herein should not be considered as alternatives to conservative chiropodial measures. The paramount consideration is always effectiveness combined with simplicity and the least invasive technique commensurate with that primary consideration.

The deployment of diagnostic skills in the evaluation of the condition and patient suitability is essential. The practitioner’s expectation of a satisfactory prognosis is not simply dependent upon his surgical skills, but also upon his care in patient selection. In statistical argument it is often claimed that chiropodial/podiatric patients are self-selecting; this may be true but the treatment is chosen by the practitioner.Where one or more alternatives may be equally effective discussions with the patient should incline the decision towards conservative treatment whenever possible. The podiatric procedures described in this small volume are those which have proved themselves over a period of years in the author’s own practice. There are many alternative procedures used by other podiatrists; we merely claim proven success for these procedures that have brought relief to a large number of our own patients. It is not intended that this short book should be used as an instructional manual by those who are inexperienced in surgical methodology. Rather we would wish it to be used as a stimulant to discussion about alternative ways of treating conditions commonly occurring in the foot. There is no substitute for the practical experience to be gained from working with an experienced operator. The authors will be forever indebted to the late Mr Alan Proctor for the practical techniques they acquired under his skillful tutelage. Simply because there is loss of sensation in a digit which has been anaesthetised there is no excuse for forgetting the human being attached to that digit; at all times a caring attitude to the patient should be paramount. We include the quotation (left) from the book Surgery of the Ambulatory Patient by L.K. Ferguson: Lippincott Co because we feel that we cannot improve upon this statement and because we totally agree with the content:

Foot operations performed by Podiatrists are not normally life and death affairs, although successful results can certainly improve the quality of life. We therefore cannot stress enough our point that operative procedures such as those described within this book should only be carried out where they can reasonably be expected to be more successful than any other treatment and where they can be carried out with no undue risk.

Chapter 1

Equipment and environmental considerations

It is a tenet of chiropody that a sharp blade and a steady hand makes an effective practitioner: this is also a sound principle in podiatry. Additionally, familiarity with the instruments used is an essential ingredient in the deployment of skills. Some of the instruments which are employed in podiatric procedures may be unfamiliar to the reader. We have, therefore, taken care to describe all the instruments utilized in this book. The environment in which these podiatric procedures are carried out is of primary importance. A room in which routine chiropody work is done would be totally unacceptable. Reducing the risk of infection to a minimum is only possible when a separate room devoted entirely to podiatry is maintained. The operating theatre should house only the essential equipment, ie. operating chair or couch, mayo table or trolley, the x-ray viewer and the operating lamp. When space is at a premium, as is often the case, the autoclave and the instrument cabinet can also be permitted. Items which never should be kept in the operating room include all paper and linen. Caps, gowns, masks and gloves must always be kept in the scrubroom or anteroom, since that is the place where they are donned before entering the theatre. Dressings and drugs and any other items necessary for the operations may be stored near but not in the theatre itself. Only those items essential for the procedure in hand should be moved into the operating area at the appropriate time. It is prudent to make sure that a duplicate set of readysterilised instruments is easily available in case of accidents.We all have an attack of “dropsy” at times. Obviously, it is also wise to have a back-up set of all equipment used.

Scrub Area Equipment

Wash basin with running h & c water Wrist or elbow taps Nail brushes – sterilisable Suitable germicidal cleaning agent Hot air hand dryer Sterile towels – preferably disposable Waste bin – foot operated

Theatre Equipment

X-ray viewer Autoclave for sterilising instruments Operating chair/table that can be raised to required height, foot controlled Operating light Operating table (Mayo or similar) seamless, stainless Dressings trolley - steel is preferable Foot-operated waste-bin - stainless steel Ambu bag Brook airway

Disposables

Surgical drapes – autoclaveable Steri-bags – assorted sizes Autoclave tape

Clothing

Operators - All clothing worn should be reserved for use only in the operating theatre Operating vests Operating trousers Operating gowns Hats Socks Clogs – washable Masks Surgical rubber gloves

Patient

Scuffers Operating gown

Chapter 2

Analgaesic equipment

1 Hypodermic Syringe – cartridge type 2.2 2 Needles 3 Analgesic cartridges, e.g. Lidothesin 2% plain, 2.2ml* 4 Injecta-swabs (or similar) 5 Hibispray No. 1 Skin Prep. 6 Sterile swabs

*N.B Obviously an alternative local analgesic may be used (e.g. Scandonest 3% (plain) or Citanest 4% (plain)) and the amount injected would therefore be adjusted accordingly. The actual procedure, though, remains the same. It is taken for granted by the authors that anyone carrying out these procedures is competent and qualified in the use of local analgesics.