True Stories From Podiatric Residency

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This is my first time posting in this thread. Yesterday I wanted to punch my entire hospital in the face. I've been day call since the beginning of the month, and the overnight resident got a page for a "routine ulcer" consult around 8PM. I came in that morning and before beginning rounding checked out this patient on the computer and saw that he was tachycardic, 103F temp, WBC 14. I looked at his x ray and read the report first, which said "small air foci representing ulcer at lateral foot." Okay cool. Opened up x ray...obvious gas. So the entire ED staff taking care of this patient, the radiologist, and the admitting team completely dropped the ball on this patient. This patient sat over night with sepsis and a gas infection and no one batted an eye. I went up to his room and examined him. He had a 10cm track from his plantar sub met 5 ulcer going proximally with brown murky pus coming out and bulla formation at the lateral foot. I called my attending right away and sent him a pic and then boarded him for the OR. We basically did a whole 5th ray resection, left the base. He's on vanc/zosyn. Today his white count went down a little but still very febrile. Praying we cleared everything out, and a great way to start yesterday morning!

I'm assuming you guys don't have computer access at home? We use EPIC and have home access. I like to check labs and order X-rays if I get an ulcer consult after hours.

That's happened to me TWICE with no consult until the morning. And of course neither were NPO. Very frustrating.

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The key is how you define surgical volume. Sure, volume at a level 1 trauma is high (high energy trauma and limb salvage) but after about 6 months of first year you can keep the limb salvage hallux amps and I&D; I'd rather do elective cases and recon. But again; it's how you are defining volume, that's what you say.

I think most all programs get "limb salvage". No shortage of that in our profession.

High energy trauma and elective / recon are not mutually exclusive. There are programs out there that get a lot of both.

Yup; high energy trauma and high complexity cases go to level 1 trauma centers. Again, all you seem to talk about is trauma and limb salvage. Trauma represents such a small percentage of this profession and the vast majority of residency graduates will not be doing pilon fractures, calc fractures, etc. after residency. How many residents from your program are practicing the type of environment you are hyping?

Both of my senior residents already have offers and contracts with a hospital and an ortho group looking for a foot and ankle surgeons. One of the reasons they got these offers were due to their high volume in all the above. Both have said that what has really set them apart has been their rearfoot and trauma training. Neither of them have had trouble finding jobs. Hospitals and ortho groups want to hire well rounded surgeons. Podiatry groups are looking to hire an adjunct to their practice, not a competitor, so they tend to like more trauma and rearfoot training.

You absolutely can. I'd rather expand my fundamental skills to do a SMO or TAR than to teach myself a lapidus or cotton. What's more likely for your first case out of residency, an open pilon fracture or a bunion on a 50 year old lady?

One of the residents that graduated back in July had a trimal ankle fracture for his first case. He has done way more ankle fractures / calc fractures / "trauma" than bunions. I believe he has done like 3 bunions since starting. The reason for this...he has a good relationship with a big ortho group we work with in my program. None of them have an interest in foot and ankle so they've been funneling foot and ankle issues they get from surrounding immediate care centers to him. Because they trust him and know his training.


Any students reading this need to know that there are all types of practice possibilities out there for podiatrists. Look for a program that gets training in ALL aspects of foot and ankle surgery, from elective bunions and hammertoes to flat foot recon/rearfoot fusions/deformity correction, to total ankle replacements, to trauma. A well rounded high volume surgical program will open a lot of doors for you.
 
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I'm assuming you guys don't have computer access at home? We use EPIC and have home access. I like to check labs and order X-rays if I get an ulcer consult after hours.

That's happened to me TWICE with no consult until the morning. And of course neither were NPO. Very frustrating.
This is my first time posting in this thread. Yesterday I wanted to punch my entire hospital in the face. I've been day call since the beginning of the month, and the overnight resident got a page for a "routine ulcer" consult around 8PM. I came in that morning and before beginning rounding checked out this patient on the computer and saw that he was tachycardic, 103F temp, WBC 14. I looked at his x ray and read the report first, which said "small air foci representing ulcer at lateral foot." Okay cool. Opened up x ray...obvious gas. So the entire ED staff taking care of this patient, the radiologist, and the admitting team completely dropped the ball on this patient. This patient sat over night with sepsis and a gas infection and no one batted an eye. I went up to his room and examined him. He had a 10cm track from his plantar sub met 5 ulcer going proximally with brown murky pus coming out and bulla formation at the lateral foot. I called my attending right away and sent him a pic and then boarded him for the OR. We basically did a whole 5th ray resection, left the base. He's on vanc/zosyn. Today his white count went down a little but still very febrile. Praying we cleared everything out, and a great way to start yesterday morning!

Edit: I think this proves that we're a very vital service because no one likes to examine the feet. I had another consult on New Years Day that was paged in as "fungal nail." This 91 y/o lady was getting discharged in like 2 hours. She was a diet controlled diabetic. I immediately noticed a very red swollen warm 2nd toe with pus coming out of a pinhole sized ulcer at the medial aspect. Even with her dementia she yelled in pain every time I touched the toe. They were going to send her home with no prior antibiotics, cultures, or x ray. Obviously the primary team never noticed the cellulitis or her pain. I ended up sending her home on Keflex after getting cultures and negative x ray. I looked up the cultures a few days later...MRSA and Morganella. I guess she'll be back.
Unfortunately stuff like the above stories are all too common.
 
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Any students reading this need to know that there are all types of practice possibilities out there for podiatrists. Look for a program that gets training in ALL aspects of foot and ankle surgery, from elective bunions and hammertoes to flat foot recon/rearfoot fusions/deformity correction, to total ankle replacements, to trauma. A well rounded high volume surgical program will open a lot of doors for you.

These are true words

There are also differences in the amount of surgery that you, the resident. are actually doing. There are plenty of programs where residents are logging cases as "1st assist" simply because they were the only one scrubbed with the attending. Not because they actually meet the "1st assist" criteria. Sure "volume" looks great on paper but when you look at how much practice a resident has had planning their own surgery, picking their rep/hardware, handling instruments, making intra-op decisions, etc, it isn't as impressive. Everyone has there own preferences though. I, for example, would much rather go to a program that is trauma heavy where I am the one actually doing the case, skin to skin, than go to a program where I have to watch a lot of elective surgery at surgery centers. Not everyone feels that way and there is no single right answer.

There is no such thing as a perfect program, and there is so much more that goes into evaluating a residency program than can be typed up in a single post on SDN. Back to actual true stories of residency...
 
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Last weekend I got a call first thing in the AM, "Hi this is the children's hospital ED. I have an 11yo kid with a 9cm x 2cm piece of glass stuck in his foot. Can you help me out here?"

I texted my attending to give him a heads up. Went down there. Knife shaped piece of glass completely in this kid's foot. Entered the lateral 5th met mid shaft, coursed plantarly, with the point exiting the plantar 3rd met head area. The entire 9x2cm was in this kids foot. Apparently this kid was resting his foot on the glass window when the window broke, pierced his foot, and broke off inside. NV intact. Outside ED already gave IV abx. I had the ED continue IV abx, took it out in the OR, flushed it, closed, then sent home on PO clinda.
 
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Absolutely, "high volume" at a trauma center can be ambiguous. As I alluded to before, fractures and diabetic limb salvage are our bread and butter. A private podiatrist, in their first year, will most likely deal with forefoot procedures but you can bet your bottom dollar your clinic will be filled with diabetics. It's extremely rare to have a purely MSK practice. I'm sure there are podiatrist out there that do but if that's what your expectations are you might be disappointed.

Diabetic limb salvage is a huge part of what we do as podiatrists. Getting good at it is just as important as getting high patient satisfaction on your bunions, hammertoes, etc. It might be monotonous and mind numbing surgery but it's incredibly valuable. The medical management side of it is paramount to ensure positive outcomes and in most cases requires good communication among a variety of specialists (IM, vascular, endo). It is an art form and it's why some of podiatry's biggest names are so devoted to it (Armstrong, Lavery, Steinberg, among others

Just to play devil's advocate a bit, I'm in an orthopaedic group and my practice is 100% MSK. I do zero diabetic limb salvage, zero wounds, zero palliative care. My practice consists entirely of elective case volume (mainly ankle/rearfoot reconstruction, TARs, etc.) and foot/ankle fracture care. This was my choice, based on what I enjoy (and don't enjoy) doing. I finished residency about 1.5 years ago, so my practice is still quite new. These opportunities are out there as well, just to give some outside perspective. Opportunities abound, it's a matter of what you're looking for. To each their own, just some food for thought.
 
I was thinking of you when I made the prior statement based on what you have mentioned in the past. I think we can agree your job situation (being 100% MSK) is relatively unique for a podiatrist (in comparison to all practicing podiatrists). Thanks for your input though. Sounds like things are going well.
Certainly so, couldn't agree more. Just wanted to point out that there are several avenues someone can pursue. Yes, thank you, things are going very well. Sounds like things are going well for you as well, keep up the hard work!
 
I was 1st assist on a Zimmer TAR today. Terrible ankle joint with tons of osteophytes and almost 30 degrees of varus talar tilt. The medial shoulder of the talus was eroded. Mild tibial varum and and mild forefoot valgus. Lateral ankle ligaments were shot.

I've seen 2 other TARs, last week and last month. This was the first time I assisted. The process wasn't overly complicated, just a lot of little steps. Overall it was a pretty interesting experience.
 
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The only imaging studies you need are x-rays initially. Getting a CT is a waste of resources. You need to get the pilon fracture back out to length and in a corrected position with the application of an ex-fix before fully assessing the fracture pattern with a CT. The CT obviously will help with your surgical planning a couple weeks down the road.

Good stuff Ankle Breaker :thumbup:. X-rays initially then CT after ex-fix is what should be done with complicated trauma that is being managed in a staged procedure. At my program we did the same with a combined ankle, talar, calcaneal fracture a couple months ago.

Today I had a great time on my "pathology" rotation. Checked in with my pathology attending for about an hour then covered 2 trimal ankle fractures.
 
Good stuff Ankle Breaker :thumbup:. X-rays initially then CT after ex-fix is what should be done with complicated trauma that is being managed in a staged procedure. At my program we did the same with a combined ankle, talar, calcaneal fracture a couple months ago.

Today I had a great time on my "pathology" rotation. Checked in with my pathology attending for about an hour then covered 2 trimal ankle fractures.

But think how much more you could have learned in Path by sitting next to a dude doing a manual WBC differential...
 
The icey conditions these past 2 weeks has made my pathology rotation a lot more interesting than expected. I had a bimal ankle fx yesterday and a fibula fx today.

The bimal ankle fx was a PER type with transverse medial mal fx and short oblique fx of the fibula about 7-8cm above the ankle joint. We plated the fibula fx with a 4 hole plate, 6 cortices syndesmotic fixation, 2 parallel screws for medial mal.

BTW, does anyone else have trouble screwing in the drill guides for the wright medical contoured fibula plate? Zimmer's just screws in no problem.
 
Last week a gentlemen sustained a STJ/TNJ dislocation during basketball. 3rd year was on call but being that this was a rare dislocation I decided to help out. Calc was dislocated medially with talar head tenting dorso-lateral. Couldn't reduce in the ED so we took it to the OR for closed reduction/possible open. Once the patient was paralyzed and with some muscle...the STJ popped right back in. TNJ was a bit more difficult but it we got it reduced. Discharged patient to home with order for CT. Pretty interesting case.

This past saturday I covered another 3 ankle fractures. I'm on Ortho Trauma so technically I'm not on service but the other residents didn't want them...so it was mine for the taking :) 2 solitary fibula fractures and 1 trimal equivalent (fibula and posterior mal fxs with deltoid tear). Throughout the day the on call resident had to reduce 5 dislocated ankle fractures and 1 STJ dislocation. One of the ankle fractures couldn't be properly reduced. It was a really bad trimal with a decent sized posterior mal piece. So my attending and I went downtown after our cases and I put on a delta frame closed reduced it. I guess I had my own version of AO this past weekend haha. It's been trauma trauma trauma recently with the snow/ice! Too bad it's finally warming up.
 
I cant wait until the day that i can really understand what you all are talking about....:(
 
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Terrible ankle joint with tons of osteophytes and almost 30 degrees of varus talar tilt.
Have a feeling I'll get torn up for this, but here it goes.

Although I know it was probably neat to see such a case, please realize how far outside of the recommended indications this degree of deformity lies. A lot of guys will stretch the limits just to say that they do totals. Ankles don't commonly wear out like hips and knees, so the "ideal" TAR candidate is actually quite a rarity. It's your job as a resident to learn not only HOW to perform surgery but also WHY and WHEN. I'm sure the post-op x-ray looked great, but you should be training to be a surgeon with critical thinking skills, not simply a surgical technician/monkey. If you're not asking the question "should we be operating on this patient" occasionally, then you're likely a monkey. I'm not saying raise a stink, not at all; just learn from your attendings' mistakes/misjudgements. And realize a 30 degree tilt is solidly DOUBLE the recommended deformity.
 
Have a feeling I'll get torn up for this, but here it goes.

Although I know it was probably neat to see such a case, please realize how far outside of the recommended indications this degree of deformity lies. A lot of guys will stretch the limits just to say that they do totals. Ankles don't commonly wear out like hips and knees, so the "ideal" TAR candidate is actually quite a rarity. It's your job as a resident to learn not only HOW to perform surgery but also WHY and WHEN. I'm sure the post-op x-ray looked great, but you should be training to be a surgeon with critical thinking skills, not simply a surgical technician/monkey. If you're not asking the question "should we be operating on this patient" occasionally, then you're likely a monkey. I'm not saying raise a stink, not at all; just learn from your attendings' mistakes/misjudgements. And realize a 30 degree tilt is solidly DOUBLE the recommended deformity.

I agree with you wholeheartedly. Knowing when to and when not to perform surgery is crucial.

For this case the ankle itself had minimal to no deformity. Like I said in my original post the lateral ankle ligaments were shot causing the 30 degrees of varus TALAR tilt. Completely kosher to do the total ankle + lateral ankle ligament repair.
 
To add to my previous post. For TARs, deformity is a relative contraindication. You must correct the deformity, boney vs soft tissue, either concomitantly or prior to the TAR. Deviations with distal tibial angles should be corrected prior to the TAR procedure with supramalleolar osteotomies. Hindfoot deviations should be corrected with calcaneal osteotomies and/or fusions. Ligamentous, such as lateral ankle ligament tears, corrected with repair and/or augmentation. The recommended "maximum" deformities are based on how much correction is possible with the tibial and talar bone cuts. They say up to 10 (some say 15) degrees of varus/valgus angulation can be corrected with your bone cuts. With my previously mentioned TAR case the LDTA and ADTA were spot on for normal range. The talus was in various 30 degrees due to incompetent ATFL and CFL. We used the Zimmer TAR system and started off with performing the lateral fibular incision. Fibular osteotomy and then gained access to the ankle joint. The jig was then placed and centered onto the mechanical axis of the leg. Pins were placed through the calcaneus and talus to correct the tilt. The tilt easy corrected since it was supple. After everything was lined up the cuts were made and implant placed. Afterwards the ATFL and CFL were repaired and augmented using bone anchors. Lastly we looked at the alignment of the hindfoot and found no need for any calcaneal osteotomies. From what I saw and some of the difficulties with the case I think the TARs with anterior approach are better. Another attending is looking to start doing TARs but with the new Wright Medical infinity prophecy system. I'm looking forward to getting experience with that system to see if the anterior approach is superior or not.

On another note, today I scrubbed 2 ankle fractures and a 5th metatarsal base fracture. First ankle was a fibula non-union. Fairly straight forward. Second ankle was a bimal with severely comminuted fibula fracture. We counted 5 fracture fragments. We got the fibula out to length, put a screw proximally and distally on the plate to bridge with comminuted fracture. Then reduced the fracture fragments into place and placed 1 screw along the large fragments to keep things together then filled our proximal and distal plate screws. The medial mal was completely rotated and what made it more difficult was my incision placement. Slightly too posterior. I gotta keep in mind that these SER type medial mal fractures tend to extend more along the anterior edge of the tibia. The 5th metatarsal base fracture was fun. This will be my 3rd and I've used the wright medical carolina screw system twice already and really like it. The k-wire they use is sturdy and allows you to easily tap it down the 5th met intramedullary canal. And I'm really liking the solid screw option. All in all a good learning experience today.
 
Seems that ankles are the big sexy things these days. Do you ever do any forefoot surgery?

I would say my residency experience is:
60% forefoot and 40% rearfoot.
85% elective and 15% trauma.
 
Informative response. Did you get full leg films prior to implantation? Doesn't matter how well aligned the ankle joint is if there is genu varum/valgum. Just curious...I doubt most people do. Especially if they are asymptomatic at the knee joint.

No full leg films. We did take c-arm up to the knee. My attending said the patient didn't have any appreciable deformity on clinical exam other than very mild tibial varum which we accounted for when we lined up the jig.

According to my logs I'm at:
75% forefoot, 25% rearfoot
25% diabetic, 50% elective, 25% trauma
~300 cases and ~340 procedures

At my program the 1st years do the less complicated cases such as a hammertoe or bunion, simple fracture trauma, diabetics, etc. The 2nd years do more electives such as forefoot slams, triples, flat foot, cavus foot, multiple procedure/bigger cases. 3rd years cherry pick. Ankle fractures are common at my program due to podiatry getting foot and ankle call and the weather. It gets icey here during the winter. We usually average like 1-2 per week then when the ice hits it just comes pouring in. 2nd and 3rd years get tired of covering them so it trickles down to the 1st years. Ankle replacements are new and the 3rd years have been splitting them among the residents evenly. So far each resident has scrubbed 1.
 
Since you are so kindly posting your numbers I'm interested in knowing how many months of off service rotations you have done this year and have to do in total during your three years of training.

18 months off service which includes 6 months of ortho trauma and 3 months of electives. That's 6 months off service each year. So far I've been on podiatry for 4 months this year
 
Since you are so kindly posting your numbers I'm interested in knowing how many months of off service rotations you have done this year and have to do in total during your three years of training.
I'm on service for 36 months, and I have done 857 trimall ORIFs and 432 ankle fusions. Not to mention I have taken 7 months of vacation so far as an intern....
 
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