Potential Complicating Circumstances

The Keystone has been a simple solution to rectify difficult orthopaedic cases where other methods have been unsuccessful, never forgetting no procedure, including the Keystone, is ever devoid of complications and the keystone helps to solve many of these intermittent problems. As they say in the overseas units, only liars do not get complications and the Keystone is not exempt from these issues in spite of its acronym P.A.C.E.S. synopsis. Smokers, diabetics, patient compliance and wound management issues where premature removal of tension sutures may lead to wound breakdown, as most keystones are closed under tension, are all factors that have surfaced during the compilation of this series. The Keystone characteristics seem to summarise the satisfactory outcomes from the patient’s point of view—the final arbiter. The success of the Keystone technique has helped form the basis of an acronym which epitomises keystone characteristics—P.A.C.E.S. Pain free: The patient’s absence of pain, avoiding the need for narcotics. Usually, the donor site for the skin graft causes the most discomfort Aesthetics: The Keystone has achieved like-for-like in tissue match in reconstruction Complications: Vascular complications are a rare finding but one should always be cautious in using such a technique in those with peripheral vascular disease, even diabetes II is a clinical restriction in its application Economics: When compared with microsurgical alternatives, the shorter operative exposure - particularly relevant in the elderly and fulfilling the requests of the anesthetic team and the need for a shorter operative period, the numerical reduction in staff members intraoperatively and postoperatively is an economic perspective that always needs addressing, the lack of need for postoperative monitoring—a prerequisite in microsurgical techniques—and the consequent low return to theatre necessity. All these factors need no further elaboration but economically based from an observational point of view. Sensory Recovery: Like any surgical wound temporary denervation is a characteristic of a surgical procedure and usually resolved in a few months. This is also characteristic of the Keystone when over the same period there is resolution of oedema and swelling of lower limbs as in Case 3.1.7 (18) and Case 3.1.10 (21) likewise resolves over a similar timeframe, as evidenced in the reviewed cases above. Wound Management Closure Technique An important development in the 3-phase single layer locking mattress suture technique and these just reflect the experiences we have all gained from our surgical mentors when one of the important general surgeons in the surgical field had what he called the ESR Hughes suture which is really an anchor knot closure, developed from maritime experiences of the sailing ships using multiple strands to self-stabilise, eventually being locked in the definitive position for safety. This single layered suture technique does not need fascial apposition but is incorporated as part of the locking mattress method with a single strand which tends to avoid any vascular restrictions in the suprafascial and infrafascial anastomoses. The locking mattress suture provides a simple layered closure alternative. Further locking mattress sutures may be duplicated to provide perfect alignment before the continuous nylon achieves epidermal seal.