Best/Most Attended Conferences?

[347932]

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I would say that the ACFAS and the APMA conferences are the best/most attended conferences of the year.

Any others that are of very high quality and attract big attendance numbers?

 

[PADPM]

I've always enjoyed the seminars sponsored by the Podiatry Institute.

 

[347932]

I've always enjoyed the seminars sponsored by the Podiatry Institute.

Is there a particular lecture series/venue you enjoyed more within their series? I'm looking to expand my palate and would like to know more about their lecture series from an attendee perspective rather than from talking to their educations director. Thanks a bunch!

 

[Feli]

I've always enjoyed the seminars sponsored by the Podiatry Institute.

x2^^
The PI resident rate is also fantastic. Sanibel this Nov will be my 5th PI seminar (Sanibel x3, Phila, Napa). I still haven't been to the biggest one in Atlanta, but I've enjoyed them all. Those guys are very well trained, and I like their surgical philosophies for the most part:
Know anatomy + AO, and stick with what works. Be aware of advances, but stay far enough behind the "cutting edge" that you don't get your respect (and malpractice) shaved off.

The APMA ones are just not that great. It's unfortunate, but it's also true. A jack of all trades is a master of none. If you want surgical lectures, go ACFAS or PI. If you want wound care, go to Georgetown, etc. If you want prac mgmt, go with AACPM or ACFAS prac mgmt meetings.

For pod surgery, ACFAS is #1, PI a close #2. Kalish's SuperBones seminar lectures are solid from what I saw based on the ones he posted on the website. I'm sure the Northwest ones are also of high quality. West Penn's seminars with many of their alumni speaking as well as are also great, but they didn't have one this past year. I would also like to go to some AAOS foot and ankle track or AOFAS meetings and just listen quitely in the back rows. You have to mix it up to keep new ideas flowing. It's great we have so many good opportunities.

 

[jonwill]

The Baltimore Limb Deformity Course was really good.

 

[krabmas]

ACFAS as a student is great. If you keep up with the literature then as a resident and practitioner not so great... same thing every year with little new info mentioned. At ACFAS 2010 there was a talk about talar fractures with the literature supporting the talk from the 1970's and it was not the land mark studies. Just one thing that stuck out in my head.

Most of the MD conferences (AOFAS for example) do not have all the review lectures, their main course is the Abstract presentation - the latest and greatest where medicine and surgery is headed not where it is stuck.

For students review is great, for practitioners, not so much.

Baltimore Limb deformity course was awesome. They set up the entire conference as a workshop, even the morning lectures are interactive. It is the only place to get this type of deformity training.

APMA might have the worst conference in podiatry, I have not been to all of the courses but....

The AO courses are supposed to be good once in residency, I did not do them.

ACFAS Arthroscopy is a great course.

For wound carelimb salvage either DFCON in LA or Diabetic Limb Salvage (DLS) in DC

 

[347932]

Interesting assessments as I've lectured at each of the last 5 APMA Annual Scientific Meetings and I find they are getting better and better, and that the conference gives a nice smattering of all things podiatry. Its also quite a good vibe as there are colleagues from all over the country attending.

I have not been to an ACFAS conference yet, as I lecture so much that I have plenty of CMEs, and generally won't attend a conference unless invited to lecture. The ACFAS has a rule which states that they won't consider inviting you to lecture for them unless you've attended one of their conferences in the last 5 years. I may end up going to St. Lauderdale this year just to see what the hub bub is about.

I may have to attend a PI conference as I've also heard they are quite good. I've also lectured at the NWPF conferences and can attest that I'm impressed with the speakers I've heard at these.

Thanks for the info all!

 

[gustydoc]

Headed to Baltimore today for the limb deformity course, should be great. APMA annual conference doesn't even come close to the quality of lectures at ACFAS. I did go to superbones in the bahamas last year. It was a fun conference and I got a great tan, but the lectures were so so. The Ex-fix symposium in San Antonio was interesting and there is a full day of board review lectures before hand that were pretty good.

 

[347932]

Headed to Baltimore today for the limb deformity course, should be great. APMA annual conference doesn't even come close to the quality of lectures at ACFAS. I did go to superbones in the bahamas last year. It was a fun conference and I got a great tan, but the lectures were so so. The Ex-fix symposium in San Antonio was interesting and there is a full day of board review lectures before hand that were pretty good.

AS someone who has never attended an ACFAS meeting please elaborate. The APMA ASM focus on many aspects of podiatry so it stands to reason that the scope is more broad. I found the surgical tracks over the last two years at the APMA ASM to be quite good.

What is it that makes the ACFAS meetings so spectacular? The lecture (what topics)? The lecturers (who are they)? The exhibitors?

One thing I can say, as someone who is actively on the lecture circuit is that there are few and far between lectures that present new technologies. After graduating from residency, I went to a few conferences and I found that they were lecturing about the same things I learned in school, with an anecdote thrown in here and there. If you look at many of these conferences, you'll see the roster doesn't change much and the lecture topics are largely the same.

I'll give you an example. I look for conferences that deal with Ankle Sprains since I see a lot of these in pratice. The same lecture every time. Open repair of the ATFL using Braumstrom Techniques or Peroneal Tendons. Once in a blue moon someone will talk about using grafting with anchors for these repairs. This is nothing new. I learned about this and I graduated from Temple in 1999. Alternately, I've been repairing ATFL using Thermocapsular Shrinkage techniques for YEARS. You know how many lectures are available on this topic in the Podiatry Realm that I've seen? NONE! I'll be lecturing on this topic for the first time at any Podiatry Conference this October according to the organizers of that conference.

 

[Podfather]

AS someone who has never attended an ACFAS meeting please elaborate. The APMA ASM focus on many aspects of podiatry so it stands to reason that the scope is more broad. I found the surgical tracks over the last two years at the APMA ASM to be quite good.

What is it that makes the ACFAS meetings so spectacular? The lecture (what topics)? The lecturers (who are they)? The exhibitors?

One thing I can say, as someone who is actively on the lecture circuit is that there are few and far between lectures that present new technologies. After graduating from residency, I went to a few conferences and I found that they were lecturing about the same things I learned in school, with an anecdote thrown in here and there. If you look at many of these conferences, you'll see the roster doesn't change much and the lecture topics are largely the same.

I'll give you an example. I look for conferences that deal with Ankle Sprains since I see a lot of these in pratice. The same lecture every time. Open repair of the ATFL using Braumstrom Techniques or Peroneal Tendons. Once in a blue moon someone will talk about using grafting with anchors for these repairs. This is nothing new. I learned about this and I graduated from Temple in 1999. Alternately, I've been repairing ATFL using Thermocapsular Shrinkage techniques for YEARS. You know how many lectures are available on this topic in the Podiatry Realm that I've seen? NONE! I'll be lecturing on this topic for the first time at any Podiatry Conference this October according to the organizers of that conference.

There is a reason why thermal shrinkage is not a common lecture topic. I actually meet the authors of the original article ( I believe from Romania?) when I lectured at the European Foot an Ankle conference over 10 years ago. Their science was flawed and I would say has not been proved out scientifically. As far as why ankle sprains are treated the same. There is a reason: the treatments that exist work!

I have no issues with emerging technology but the problem is when the technology and not the patient's problems become the indication for surgery. I have DPMs saying you should only use a frame on a Charcot or have your tried PRP or another treatment for Plantar fasciitis (or fasciosis if that is sexier) when tried and true non-operative techniques cure plantar fasciitis 95% of the time. Tight rope for bunions make me laugh. The Lepenhager? suture was tried in the 1800s, then the adductor tendon transfer in the 1980s and now the tight rope to lasso in those high IM bunions that really need a Lapidus. This too will pass.

New technology is needed when what we do now has a low success rate, decreases operative time, or somehow decreases morbidity and healing time. For us old schoolers we have seen the same technology repackaged over and over again and cycle through.

Often time the if we build it , make it cool , and increase reimbursement they will come.

 

[347932]

There is a reason why thermal shrinkage is not a common lecture topic. I actually meet the authors of the original article ( I believe from Romania?) when I lectured at the European Foot an Ankle conference over 10 years ago. Their science was flawed and I would say has not been proved out scientifically. As far as why ankle sprains are treated the same. There is a reason: the treatments that exist work!

I have no issues with emerging technology but the problem is when the technology and not the patient's problems become the indication for surgery. I have DPMs saying you should only use a frame on a Charcot or have your tried PRP or another treatment for Plantar fasciitis (or fasciosis if that is sexier) when tried and true non-operative techniques cure plantar fasciitis 95% of the time. Tight rope for bunions make me laugh. The Lepenhager? suture was tried in the 1800s, then the adductor tendon transfer in the 1980s and now the tight rope to lasso in those high IM bunions that really need a Lapidus. This too will pass.

New technology is needed when what we do now has a low success rate, decreases operative time, or somehow decreases morbidity and healing time. For us old schoolers we have seen the same technology repackaged over and over again and cycle through.

Often time the if we build it , make it cool , and increase reimbursement they will come.

Yes the treatment for Ankle Sprains work. That is not the issue. The issue is whether there are better treatments available.

I've been trying for close to ten years to have an study initiated to substantiate the effectiveness of the Thermocapsular shrinkage technique. It has been proven to work in the shoulder in multiple studies that were actually well conceived and well executed. After an attempt to reproduce the results in the knee, it was found that in the ACL and PCL injuries, the results were horrendous. I'm sure there is plenty of data to suggest that it should be done more in the ankle, but no solid studies have been done. The ONE study that showed good results had a whopping 10 patient population. Not enough to convince people.

That being said, when I ask at conferences why this procedure isn't done more, most confess that they just aren't proficient enough at Arthroscopy to offer this treatment modality to their patients. THAT'S the problem. So its not that the new technology doesn't work in some specific situations, but the proficiency isn't there. How to address that?

My Shrinkage patients are back in a sneaker and active in two weeks (with a brace on) and few of them ever need PT and in the last 8 years, I've had 2 patients re injure. The biggest complication I've had with the procedure is transient neuritis from the Arthroscope. I did a ton of classic ATFL repairs in residency and the results across the board were somewhat good, but nothing like they have been with this procedure. The better mouse trap? I think so.

 

[Podfather]

Yes the treatment for Ankle Sprains work. That is not the issue. The issue is whether there are better treatments available.

Better how? Wound healing is wound healing. Skin, tendons, ligaments, and bone all heal in a specific fashion. Yes compression changes secondary to primary bone healed in certain types of fractures, has been proven scientifically and therefore is utilized. But to change say the treatment of plantar fasciitis with newer expensive procedures when it it is cured quickly, safely, and relatively inexpensively 95% of the time is purely fiscally driven. Better would mean to me higher efficacy, less complications, faster return to activity, and yes if possible cheaper (when has a cheaper technology come forward?).

I've been trying for close to ten years to have an study initiated to substantiate the effectiveness of the Thermocapsular shrinkage technique. It has been proven to work in the shoulder in multiple studies that were actually well conceived and well executed. After an attempt to reproduce the results in the knee, it was found that in the ACL and PCL injuries, the results were horrendous. I'm sure there is plenty of data to suggest that it should be done more in the ankle, but no solid studies have been done. The ONE study that showed good results had a whopping 10 patient population. Not enough to convince people.

That being said, when I ask at conferences why this procedure isn't done more, most confess that they just aren't proficient enough at Arthroscopy to offer this treatment modality to their patients.

Todays DPMs routinely use arthroscopy in their practices. Arthroscopic ankle arthrodesis, endoscopic gastroc recession, plantar fascial releases, subtalar arthroscopy, and even tenoscopy are being lectured about, studied, and being performed. So I do not believe that is the reason capsular shrinkage is not being performed. Studies supporting it (with more patients than 10) that have good science will drive increase use of this technique.
I am not saying it will not be a proven technique in 10 years but as of today and over a I believe 15 years it has not proved out or being utilized. Perhaps you will be the tipping point study in 5 years. That would be cool.


THAT'S the problem. So its not that the new technology doesn't work in some specific situations, but the proficiency isn't there. How to address that?

My Shrinkage patients are back in a sneaker and active in two weeks (with a brace on) and few of them ever need PT and in the last 8 years, I've had 2 patients re injure. The biggest complication I've had with the procedure is transient neuritis from the Arthroscope. I did a ton of classic ATFL repairs in residency and the results across the board were somewhat good, but nothing like they have been with this procedure. The better mouse trap? I think so.

Well let's not think. Get us some data. Seriously. Even though the Brostrom can be performed in 15 minutes and most do nicely with low recurrence rates (proven scientifically in multiple studies). If I can clean the joint and provide stability arthroscopically I would jump for joy. I had tried the Hawkins staples (performed arthroscopically) for instability in the late 80s with average results. Actually the Brostrom is an example where something changed as a result of science. Peroneal sacrificing procedures were the mainstay for ankle instability patients. They had great results from a stability point of view but limited STJ ROM and it was demonstrated that this could lead to DJD. The Brostrom was proven to provide stability with little effect on the STJ and today is the procedure of choice for the chronic sprainer. Peroneal procedures are reserved for those with failed Brostroms and STJ instability. That is how the system works. Unfortunately today companies will try to tell you that you need at least 3 products to make sure the Brostrom heals LOL.

 

[347932]

Well let's not think. Get us some data. Seriously. Even though the Brostrom can be performed in 15 minutes and most do nicely with low recurrence rates (proven scientifically in multiple studies). If I can clean the joint and provide stability arthroscopically I would jump for joy. I had tried the Hawkins staples (performed arthroscopically) for instability in the late 80s with average results. Actually the Brostrom is an example where something changed as a result of science. Peroneal sacrificing procedures were the mainstay for ankle instability patients. They had great results from a stability point of view but limited STJ ROM and it was demonstrated that this could lead to DJD. The Brostrom was proven to provide stability with little effect on the STJ and today is the procedure of choice for the chronic sprainer. Peroneal procedures are reserved for those with failed Brostroms and STJ instability. That is how the system works. Unfortunately today companies will try to tell you that you need at least 3 products to make sure the Brostrom heals LOL.

When enough of us start doing Thermocapsular shrinkage our studies will have more of a chance of being funded. Multi center studies are required for big numbers and no one is willing to fund them. Find me a funding source (I've been looking) and I'll get you the study. I promise😀.

Also, endoscopic procedures are not even close to requiring the same proficiency as Arthroscopic procedures. Arthroscopic procedures of the STJ? I love Larry Rueben as much as the next guy, but is there really any practical application to that procedure? Arthroscopic Athrodesis requires destruction. Arthroscopic Repair requires preservation. Big difference in technique and expected outcome there.

Let's agree to disagree until I get my study done. I'll be around!

 

[Podfather]

When enough of us start doing Thermocapsular shrinkage our studies will have more of a chance of being funded. Multi center studies are required for big numbers and no one is willing to fund them. Find me a funding source (I've been looking) and I'll get you the study. I promise😀.

Also, endoscopic procedures are not even close to requiring the same proficiency as Arthroscopic procedures. Arthroscopic procedures of the STJ? I love Larry Rueben as much as the next guy, but is there really any practical application to that procedure? Arthroscopic Athrodesis requires destruction. Arthroscopic Repair requires preservation. Big difference in technique and expected outcome there.

Let's agree to disagree until I get my study done. I'll be around!

I do them to. Many of my peers do. You need a road trip back to Houston 😀

 

[347932]

I do them to. Many of my peers do. You need a road trip back to Houston 😀

Oh man, I'd love that!!!! Get Sam to invite me down there to lecture...pretty please??? 😀

 

[Feli]

...I have no issues with emerging technology but the problem is when the technology and not the patient's problems become the indication for surgery...

...New technology is needed when what we do now has a low success rate, decreases operative time, or somehow decreases morbidity and healing time. For us old schoolers we have seen the same technology repackaged over and over again and cycle through.

Often time the if we build it, make it cool, and increase reimbursement they will come.

Hear, hear.

 

[347932]

Hear, hear.

How do you advance the technology then? We should have stopped at the synthes screw then for internal fixation.

Everyone uses external frames for Charcot Recons. Is that the BEST thing out there? It is satisfactory for sure, but there is better.

The better mouse trap exists.

 

[krabmas]

How do you advance the technology then? We should have stopped at the synthes screw then for internal fixation.

Everyone uses external frames for Charcot Recons. Is that the BEST thing out there? It is satisfactory for sure, but there is better.

The better mouse trap exists.

for internal fixation, yes, we should have stopped at synthes screws. they work and are inexpensive compared to the over priced cheap quality screws of most of the new companies. If you want a specific plate that is different and makes sense to use the screws that come with said plate. But, for just a screw synthes is fine.

 

[347932]

for internal fixation, yes, we should have stopped at synthes screws. they work and are inexpensive compared to the over priced cheap quality screws of most of the new companies. If you want a specific plate that is different and makes sense to use the screws that come with said plate. But, for just a screw synthes is fine.

Aren't the old synthes screws still made of stainless steel? Its been shown that titanium is a better material than stainless steel especially in the surgical realm.

Any comments?

 

[krabmas]

Aren't the old synthes screws still made of stainless steel? Its been shown that titanium is a better material than stainless steel especially in the surgical realm.

Any comments?

Better material for what? (strength against bending, torque, pull out?) were the studies on cadavers or real people with actual healing potential?

 

[Feli]

Aren't the old synthes screws still made of stainless steel? Its been shown that titanium is a better material than stainless steel especially in the surgical realm.

Any comments?

Gold is also a "better" material than lead for radiation shielding. You gonna use that too? 😕

...Also, just a minor point of interest, but do you have any of these studies which even show titanium being "better" than steel? I'd prefer something besides rep handouts of studies the companies sponsored. As far as I was taught, titanium is a bit softer and less reactive than steel... not any stronger than steel, though. Aside from IM nail studies (which have secondary bone healing as a goal, and some flexibility and softness of the implant may be desired), I couldn't find any regarding screws saying titanium is anything more then maybe equivalent...
http://www.ncbi.nlm.nih.gov/pubmed/10810488 (diameter is main determinant)
http://www.ncbi.nlm.nih.gov/pubmed/11602832 (solid steel is strongest)
http://www.ncbi.nlm.nih.gov/pubmed/15589915 (no diff in syndesmotic steel or titanium)

All I know is that I've definitely stripped a few mod hand titanium screws on HWR, and since the screwdriver is stainless... well, hmm? It's become pretty common knowledge that the titanium mod hand mini plates + screws don't usually hold up in the foot, but I think that's more due to small size than material. Who knows, though? I basically view titanium as a backup for when the pt has severe nickel allergy.

 

[347932]

Gold is also a "better" material than lead for radiation shielding. You gonna use that too? 😕

...Also, just a minor point of interest, but do you have any of these studies which even show titanium being "better" than steel? I'd prefer something besides rep handouts of studies the companies sponsored. As far as I was taught, titanium is a bit softer and less reactive than steel... not any stronger than steel, though. Aside from IM nail studies (which have secondary bone healing as a goal, and some flexibility and softness of the implant may be desired), I couldn't find any regarding screws saying titanium is anything more then maybe equivalent...
http://www.ncbi.nlm.nih.gov/pubmed/10810488 (diameter is main determinant)
http://www.ncbi.nlm.nih.gov/pubmed/11602832 (solid steel is strongest)
http://www.ncbi.nlm.nih.gov/pubmed/15589915 (no diff in syndesmotic steel or titanium)

All I know is that I've definitely stripped a few mod hand titanium screws on HWR, and since the screwdriver is stainless... well, hmm? It's become pretty common knowledge that the titanium mod hand mini plates + screws don't usually hold up in the foot, but I think that's more due to small size than material. Who knows, though? I basically view titanium as a backup for when the pt has severe nickel allergy.

I've stripped many a stainless screws.

Here's a study comparing titanium and stainless steel in spine surgery:
http://www.ncbi.nlm.nih.gov/pubmed/11593519

And another:
http://www.ncbi.nlm.nih.gov/pubmed/9438811

Just curious, how many Synthes screws are people using for Chevron/Austin bunion surgery? My training was to put two in or use One screw and one Orthosorb pin. Now I only use one titanium, high compression screw. I took out a significant amount of synthes screws in residency and at first, in practice, until I switched to the one screw method. I saw plenty of issues with Orthosorb pins in the met head.

You know how many screws I've taken out since switching? NONE.

That makes a big difference to me and the patient. Just saying.

 

[Feli]

...Just curious, how many Synthes screws are people using for Chevron/Austin bunion surgery?...

Most of my attendings usually use long dorsal arm with two synthes 2.7mm screws or a screw and a k-wire. Some use two OsteoMed cann screws, single Wright cann MUC screw, Vilex cann, Ascension cann, etc. Synthes seems to be the most popular, and I'm glad... it sucks to have those HWRs where another DPM did the orig bunion and you have no idea what the aftermarket screws are. We had one bunion HWR and mpj1 desis where the XR showed a pretty weird screw. Thankfully, our attending got the patient to acquire the original bunionectomy op report, and it was some small obscure fixation company which was pretty much out of business now. We had to have the screwdriver FedEx-ed from Grand Rapids to Detroit lol.

...I think I'm going to use long plantar arm on Austins. That just makes the most sense to me based on blood supply pattern and stability (think Mau/Ludloff). Chevron's a stable osteotomy, esp with a long plantar arm, so I will likely fixate with with two tensioned k-wires a la the late great Gerard Yu. If it's a bigger patient who will have real trouble with NWB, hopefully I can avoid the surgery altogether - but that's probably an indication for a 2.7 screw + wire or two mini frag screws IMO.

 

[Feli]

...Here's a study comparing titanium and stainless steel in spine surgery:
http://www.ncbi.nlm.nih.gov/pubmed/11593519

And another:
http://www.ncbi.nlm.nih.gov/pubmed/9438811 ....

I'm not sure I'll ever be doing much spine surgery... esp spine surgery on Chinese pigs 😉

 

[347932]

...I think I'm going to use long plantar arm on Austins. That just makes the most sense to me based on blood supply pattern and stability (think Mau/Ludloff). Chevron's a stable osteotomy, esp with a long plantar arm, so I will likely fixate with with two tensioned k-wires a la the late great Gerard Yu. If it's a bigger patient who will have real trouble with NWB, hopefully I can avoid the surgery altogether - but that's probably an indication for a 2.7 screw + wire or two mini frag screws IMO.

I think I misunderstood. Why are you NWB your Austins? Why use two points of fixation if you can do the same job with one high compression screw? I can safely say that on my 3 years of residency and 8 years in private practice, I never seen anyone fixate an Austin with 2 K-Wires. I have seen complications with tensioned K-Wires and removing them after these complications was not easy, but not for Austin fixation.

Gerard Yu was in fact one of the pillars of our profession. I knew him personally and can say he is sorely missed by all his friends and colleagues. Rest in peace my good man.

 

[Feli]

I think I misunderstood. Why are you NWB your Austins?...

I didn't really elaborate on NWB, but yes, I would do one week on NWB in a bivalve cast followed by 2wks protected and limited WB in a CAM walker (or office mods of the bivalve cast if poor insurance) for dist metaph osteotomies or digit work... stiff soled shoes and passive and active mpj1 ROM for awhile after that depending on clinical eval. The main reasoning for non and protective WB, IMO, is just to limit edema, pain, scarring, and potential for wound problems. It obviously helps prevent any dislocation or migration of the osteotomy site or fixation if they get snowed on narcs and have a trip, fall, excessive walking, etc also... to "save the patient from themself" if you will.

I think the immediate WBAT in darco shoe and "back to tennis shoes in 2 weeks" with forefoot surgery are just BS to convince the patient to undergo the procedure. The point of a bunionectomy is to releive pain and deformity by getting good long term correction. I don't really think you're doing them any favors in the long run by letting them walk in a surg shoe from day 1 and get back to tennis shoes soon afterwards.

...Why use two points of fixation if you can do the same job with one high compression screw?...

You're right, one well placed screw gives good compression. However, just like a Kouts osteotomy or med mall fx, the second point of fixation is mostly for rotaitonal stability... in a Austin, that means PASA maintenance, etc.

 

[347932]

I get excellent results with Austin type bunion corrections with full WB and back to a sneaker in 2-4 weeks. One high compression screw placed correctly eliminates any torsion that can rotate the osteotomy in my hands. No BS in that.

NWB in these patients tends to cause scarring in the capsule and excessive edema which can be avoided easily by immediate return to WB. ROM home exercises after the first week. My patients love it as it is "interactive". Just my experience.

I hate to intervene like this, but this is where sometimes "old school" thinking may not necessarily benefit the patient in the long run. If you dig way back, the first generation of Podiatric Surgeons weren't fixating their Austins at all, and full weight bearing in Sx shoes immediately. I wouldn't go that way, but it still did work. Why NWB an inherently stable osteotomy, particularly with the fixation available?

 

[newankle]

One high compression screw placed correctly eliminates any torsion that can rotate the osteotomy in my hands. No BS in that. ...
NWB in these patients tends to cause scarring in the capsule and excessive edema which can be avoided easily by immediate return to WB.

What is "one high compression screw"? There's a difference between "compression" and "stability". Compression being one part of a more complex formula in determining stability. The "highest compression" based purely on the fixation/bone relationship would be one in which the screw(s) is(are) placed purely perpendicular to the fracture/osteotomy interface with good bicortical purchase, right? No surprise this is also true in the locking plate concept - see the recent JBJS article showing when using the locking plate/screw construct, having the screws purchasing the plate also purchase the far cortex increases stability of the entire construct. Placing a "high compression screw" does not ensure rotational stability. Most podiatrists I know throw their screws for austin-type bunionectomies perpendicular to the osteotomy interface and parallel to the long axis of the 1st metatarsal however I and most orthopaedic surgeons I know throw it from proximal-dorsal-medial to distal-plantar-lateral because it provides compression but also good rotational stability assuming good purchase because it crosses all 3 planes in axis of motion. I agree that the earlier you can safely have the patient move the part, the better for function and edema control but moving the part is very different from weightbearing. Regardless of the complexity of your procedure, for the foot and ankle, gravity is a problem. Surgery causes bleeding and hyperemia. Blood will pool to the feet aggravated by gravity. When you walk you do so on your feet so if you WB in the 1st week when you are most prone to swelling you will swell more, period.

 

[newankle]

Aren't the old synthes screws still made of stainless steel? Its been shown that titanium is a better material than stainless steel especially in the surgical realm.

Any comments?

What? The "old" synthes screws? Do you think titanium is in vogue and that's why people use titanium screws? Most products are available in both stainless and titanium. Do you fixate ankle fractures with stainless plate/screws or titanium? I mean really, how often does anyone fixate the fibula of an ankle fracture with a 1/3 tubular titanium plate over a stainless plate? With the exception of the synthes titanium LCP locking plates/screws or a patient already with titanium implanted, why would you use titanium. Stainless is stronger. For foot surgery, especially forefoot surgery it doesn't matter if you use stainless versus titanium because the forces aren't great enough usually to make a difference.

 

[krabmas]

I think I misunderstood. Why are you NWB your Austins? Why use two points of fixation if you can do the same job with one high compression screw? I can safely say that on my 3 years of residency and 8 years in private practice, I never seen anyone fixate an Austin with 2 K-Wires. I have seen complications with tensioned K-Wires and removing them after these complications was not easy, but not for Austin fixation.

Gerard Yu was in fact one of the pillars of our profession. I knew him personally and can say he is sorely missed by all his friends and colleagues. Rest in peace my good man.

3 of my attendings in residency use k-wire fixation.

2 use crossing burried k-wires w/ a traditional austin, no long arm, less elevation of the head w/ early WB this way.

the other uses 1 perQ k-wire w/ a traditional austin, k-wire pulled at 6wks no implants left in the foot.

 

[347932]

What is "one high compression screw"? There's a difference between "compression" and "stability". Compression being one part of a more complex formula in determining stability. The "highest compression" based purely on the fixation/bone relationship would be one in which the screw(s) is(are) placed purely perpendicular to the fracture/osteotomy interface with good bicortical purchase, right? No surprise this is also true in the locking plate concept - see the recent JBJS article showing when using the locking plate/screw construct, having the screws purchasing the plate also purchase the far cortex increases stability of the entire construct. Placing a "high compression screw" does not ensure rotational stability. Most podiatrists I know throw their screws for austin-type bunionectomies perpendicular to the osteotomy interface and parallel to the long axis of the 1st metatarsal however I and most orthopaedic surgeons I know throw it from proximal-dorsal-medial to distal-plantar-lateral because it provides compression but also good rotational stability assuming good purchase because it crosses all 3 planes in axis of motion. I agree that the earlier you can safely have the patient move the part, the better for function and edema control but moving the part is very different from weightbearing. Regardless of the complexity of your procedure, for the foot and ankle, gravity is a problem. Surgery causes bleeding and hyperemia. Blood will pool to the feet aggravated by gravity. When you walk you do so on your feet so if you WB in the 1st week when you are most prone to swelling you will swell more, period.

IN my hands many of the headless screw designs offer better compression AND more stability. I am not a consultant for any of these companies, I just like their products and have had less complications and return to the OR for removal than with the Synthes products. I did hundreds of bunions in residency with Synthes screw fixation, so its not a matter of technique.

Edema is hightened by lack of movement AND lack of elevation. The only effective way to move edema out of the foot for long term healing is to move it, to allow the vascular pumps in the foot to move the blood and edema fluid more proximally into the lower leg. This accelerates healing and minimizes pain from excessive swelling. I'm sorry but I see much more edema from my NWB pateints than I do from WB bunions. I'm not sure I agree, physiologically, with your assessment of why to NWB bunions. My experience with this proves otherwise.

 

[347932]

3 of my attendings in residency use k-wire fixation.

2 use crossing burried k-wires w/ a traditional austin, no long arm, less elevation of the head w/ early WB this way.

the other uses 1 perQ k-wire w/ a traditional austin, k-wire pulled at 6wks no implants left in the foot.

Any reason why they prefer these methods? How many pin tract infections did the attending who removes the k-wire get in a given year? How many broken K-Wires? Retained hardware or not, having a k-wire stick out of your foot for that long is not comfortable. Why 6 weeks? Are they looking for radiographic evidence of healing?

In my community this is not the standard of care. One pin tract infection that gets to another podiatrist, and I can get into some trouble.

Ultimately, its what you're comfortable with I presume. No right or wrong way.

 

[Feli]

Oh man, I'd love that!!!! Get Sam to invite me down there to lecture...pretty please??? 😀

You could email the man... and while you're at it, also ask him how he fixates his Austins 😉

 

[347932]

You could email the man... and while you're at it, also ask him how he fixates his Austins 😉

LOL I have personally spoken to him about lecturing and it seems you need to be an "insider" for an invite.

I think he goes back and forth between tensioned K-Wires and 2 Synthes Screws. That was years ago though. He may have evolved since then...or not...dunno.

 

[PADPM]

Interesting discussion, however I can't really say that I use one type of fixation for "all" my Austin type osteotomies. Each patient is unique and that often will dictate my choice of fixation. Bone stock, width of the metatarsal head, the amount I was able to shift the bone, etc., all come into play. Once in a while, a bone is so narrow, after removing the "bump" (even when respecting the sagittal groove), there isn't a whole lot of room for hardware.

I do like some of the new headless screw designs, because I have been happy with the compression and the low profile. However, K wires are always a trusted friend when all else fails and Synthes screws are certainly no frills.

I believe that although there are too many various screw sets on the market, the problem with having to locate the correct screw driver to remove the screw is often over exaggerated. If you don't have the proper screw driver, there are many creative ways to remove the screw (without traumatizing the bone).

I'm relatively aggressive with my distal osteotomy patients post operatively if I believe I've achieved adequate fixation. I will place the patient in a removable walking cast to help off-load the area due to the rocker-bottom for about 3 weeks and transition into a supportive sneaker if indicated at that time.

Naturally, this is always case dependent, and when in practice you simply have to follow the formula that works best for you and your patients. After all the years I've been in practice, I've found that I do NOT like surgical shoes post op, but do like to utilize removable walking casts. That works for me and my patients. Similarly, I do not like to use crutches for distal osteotomies, since I believe cructches cause more post op injuries and problems than the benefits.

There is no wrong or right answer. Use what works for you and more importantly your patients. Results are what counts, as long as you have an open mind regarding change.

 

[347932]

Excellent post PADPM.

I spend a lot of brain time planning and going over my cases before hand and rarely go into a case without having the whole case worked out, including several options in case things don't quite go as planned. This includes even the simplest of procedures.

I was trained this way and it has never steered me wrong. I agree that you always need a backup, but I never have needed to fall back on K-Wire fixation for my bunions. Its always either been Synthes Screws or the PGA/PLLA pins, but in the last 4 years, this has been few and far between.

Use what works best for you and what you feel is the best for your patient. Totally agree with this. You have to realize too that everyone is different in their skills and what works for them. What that means is that if they find a mode of fixation that really works for them, whether its "old school" or "newer and more expensive", if it works for that surgeon, it works and will likely benefit the patient. Regardless of price or the latest, greatest technology.

 

[PADPM]

It's my preference to "fall back" and use a Kwire prior to using an absorbable pin. I'm just not a big fan of the absorbable products, nor can I justify the expense vs a K wire if I'm in pinch.

 

[krabmas]

Any reason why they prefer these methods? How many pin tract infections did the attending who removes the k-wire get in a given year? How many broken K-Wires? Retained hardware or not, having a k-wire stick out of your foot for that long is not comfortable. Why 6 weeks? Are they looking for radiographic evidence of healing?

In my community this is not the standard of care. One pin tract infection that gets to another podiatrist, and I can get into some trouble.

Ultimately, its what you're comfortable with I presume. No right or wrong way.

the 2 crossing k-wires seems to have less elevation than a screw, and they are doing traditional austins not long arms

the perQ wire attending has not had any pin tract infections, no broken wires.

just because it is not standard of care does not mean it is wrong, maybe everyone in your community is doing the wrong thing, it takes someone for progress to occur, but it also takes someone to realize when progress just costs more money.

 

[krabmas]

I do like some of the new headless screw designs, because I have been happy with the compression and the low profile. However, K wires are always a trusted friend when all else fails and Synthes screws are certainly no frills.

Synthes screws may be no frills, but their screw driver with the compressed linen handle is certainly better than the newer "plastic" handles that slip in a gloved hand.

 

[347932]

the 2 crossing k-wires seems to have less elevation than a screw, and they are doing traditional austins not long arms

the perQ wire attending has not had any pin tract infections, no broken wires.

just because it is not standard of care does not mean it is wrong, maybe everyone in your community is doing the wrong thing, it takes someone for progress to occur, but it also takes someone to realize when progress just costs more money.

I find it hard to believe that that attending has NO pin tract infections and no broken wires. Whenever I hear "never" I always get suspicious. We all have complications.

Inherently progress costs money. That is what is so expensive about forward thinking. There are 50 Podiatric Surgeons in my area. You think we are all wrong? I think some one would have noticed lol.

Sorry, but PerQ K-Wire fixation for bunions is archaic. It has a place as a bail out, but I just can't subscribe to that thinking. I'll continue using my headless screws and have excellent results thanks.

 

[PADPM]

Synthes screws may be no frills, but their screw driver with the compressed linen handle is certainly better than the newer "plastic" handles that slip in a gloved hand.

I'm not sure if you took my post out of context. I was praising K wires and Synthes screws. I wasn't insulting the Synthes set when I stated they were "no frills", it was a compliment.

Shinier and fancier with more bells and whistles doesn't always equate with better. I was simply stating that I do have to admit, I have been happy with some of the headless screws for the reasons I stated, though K wires and Synthes screws are "no frills".