The half-moon-shaped piece of tissue incised is now carefully dissected away from the external face of the cartilage, until it may be turned up as a flap (see Fig. 141, a), and held from off the cartilage by a tenaculum.
The exposed cartilage is now carefully removed by the aid of a sage-knife and a stout pair of forceps, the same precaution of holding the foot well forward being again taken in order to avoid wounding of the articular capsule.
At this stage in the operation considerable care is required. The operator must remember that close beneath him, and more particularly in front, is the pedal articulation. It is better, therefore, to excise the cartilage piecemeal, and to do it carefully, than to attempt, at the risk of injury to the joint, to make the operation 'showy.'
During removal of the cartilage, the terminal branches of the digital arteries are wounded, as also are the veins of the coronary plexus. Should either of these stand out with extra prominence from the others, it should be picked up with a pair of forceps, and ligatured with either carbolized gut or silk.
Attention should then be given to the flap of skin and coronary cushion. Wherever a sinus has existed in it, it is to be carefully scraped, and all dead portions of tissue removed. This done, the flap is allowed to fall into position, and is there carefully sutured, not only at the skin of the coronet, but along the whole circumference of the incision.
Dressing of the Wound and After-Treatment.—The whole secret of the success of this operation is in afterwards maintaining a strict asepsis of the wound. Unless there is reasonable room for belief that this may be done, the operation had far better not be advised, for if the wound is afterwards suffered to get into a suppurating and dirty condition, the last stage of the case may be worse than the first Synovitis and arthritis, with certain anchylosis of the joint, and a probable loss of our patient, is almost bound to follow.
We cannot, therefore, too strongly insist upon the advice that the whole of the preliminary antisepticising of the foot that we have described, and the after maintaining of asepsis that we are now about to relate, must be methodically and thoroughly carried out. It is of even more importance than little details in the operation itself.
In the first and second methods of operating, directly the actual operation is over, the surface of the wound and both surfaces of the skin-flaps should first be thoroughly douched with a 1 in 1,000 solution of perchloride of mercury. Bayer prefers a 1 in 5 solution of iodoform in ether.
Next, either iodoform or chinosol in the powder should be dusted over the whole surface, including again both inner and outer faces of the reverted skin-flaps. This done the flaps are allowed to fall into position and sutured there with carbolized silk or gut.
Another liberal application of an antiseptic dressing follows this. Iodoform, iodoform and boracic acid, or chinosol, is freely dusted over the wound and for some distance around it. Bayer, however, again prefers a dressing of the wound, and especially the moistening of the line of sutures with the 1 in 5 solution of iodoform in ether.