Good programs for reconstructive limb salvage?

[Carpe Phalanges]

Good morning!

Was wondering if anyone might have insight as to residency programs with strong reconstructive limb salvage experience. I know Kent Hospital in RI with Dr Glod has some incredible experience in this department, but I’d love to hear of others as well. (I’ve read through the residency review thread, but I know it’s hardly comprehensive and some posts are from quite a long time ago, plus I figure there may be programs folks are aware of that don’t have a review on there.)

Thanks so much!

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[air bud]

Good morning!

Was wondering if anyone might have insight as to residency programs with strong reconstructive limb salvage experience. I know Kent Hospital in RI with Dr Glod has some incredible experience in this department, but I’d love to hear of others as well. (I’ve read through the residency review thread, but I know it’s hardly comprehensive and some posts are from quite a long time ago, plus I figure there may be programs folks are aware of that don’t have a review on there.)

Thanks so much!

San Antonio and then probably everyone else. If you don't get a strong limb salvage residency it's fine you can do one for your fellowship

but serious on San Antonio part

 

[CutsWithFury]

Good morning!

Was wondering if anyone might have insight as to residency programs with strong reconstructive limb salvage experience. I know Kent Hospital in RI with Dr Glod has some incredible experience in this department, but I’d love to hear of others as well. (I’ve read through the residency review thread, but I know it’s hardly comprehensive and some posts are from quite a long time ago, plus I figure there may be programs folks are aware of that don’t have a review on there.)

Thanks so much!

I'll bite.

The answer is that you don't need to train at a residency program that is hyper focused in diabetic limb salvage. I personally think that is short sighted. I did my residency at a historically strong residency program where we were exposed to high volume TAR, elective foot and ankle recon and a lot of revision MSK cases.

Your goal for residency training is to be the most well rounded surgeon you can be. To be able to do the cases that majority of your colleagues can't do. Develop all those skills and get those unique MSK reconstruction experiences in the OR and in the clinic working up those pathologies.

Then and only then can you transition those skills to diabetic limb salvage. If you do it that way you will be one of the top limb salvage surgeons in any area you choose to practice because you know how to do all the MSK recon cases.

Most "limb salvage" experts in podiatry are foot guys who do wounds and get nervous when things go south. They typically punt charcot feet and dehisced ankle/calcaneal fracture surgical wounds, chronic pressure heel wounds, etc to the big recon guys anyways or after their weekly debridements for 6-12 months and 60 sessions of HBOT don't do anything.

If you already have these MSK recon skills you can literally work up any patient from the beginning. You will understand how their underlying deformities are contributing to their chronic wound formation. You can start conservative with wound care, offloading, diabetic shoes and inserts, etc. Then when you have maxed out conservative efforts you can you utilize your robust MSK surgical recon skills and take them to the OR for that charcot recon or you can take them to the OR for that diabetic offloading surgery (tenotomies, gastroc recessions, realignment osteotomies, MIS hammertoe correction etc).

Your MSK recon training will expose you to external fixation which you will utilize in some of these limb salvage cases. Probably the one thing you won't get high volume exposure to in residency would be muscle flaps. But you can do a couple flap and frames courses and be able to do some flaps when indicated.

I want to say this too and I will probably get some flack for it but I don't care. I think the hyper focus in lower extremity flaps is sooooo overrated. I have been doing limb salvage as part of my hospital based practices for close to 5 years now and I can think of 1-2 patients during that time that failed everything that needed a flap. People who are doing high volume flaps are most likely going to it too quickly in my opinion. Nothing beats aggressive wound care with a fundamental understanding of the underlying etiology (biomechanical, vascular, systemic, nutritional, etc) and TREATING it. If the flap fails you burn a lot of tissue and makes salvage even less possible. Just remember that before you start salivating on the reimbursement for a flap and frame.

 

[air bud]

I'll bite.

The answer is that you don't need to train at a residency program that is hyper focused in diabetic limb salvage. I personally think that is short sighted. I did my residency at a historically strong residency program where we were exposed to high volume TAR, elective foot and ankle recon and a lot of revision MSK cases.

Your goal for residency training is to be the most well rounded surgeon you can be. To be able to do the cases that majority of your colleagues can't do. Develop all those skills and get those unique MSK reconstruction experiences in the OR and in the clinic working up those pathologies.

Then and only then can you transition those skills to diabetic limb salvage. If you do it that way you will be one of the top limb salvage surgeons in any area you choose to practice because you know how to do all the MSK recon cases.

Most "limb salvage" experts in podiatry are foot guys who do wounds and get nervous when things go south. They typically punt charcot feet and dehisced ankle/calcaneal fracture surgical wounds, chronic pressure heel wounds, etc to the big recon guys anyways or after their weekly debridements for 6-12 months and 60 sessions of HBOT don't do anything.

If you already have these MSK recon skills you can literally work up any patient from the beginning. You will understand how their underlying deformities are contributing to their chronic wound formation. You can start conservative with wound care, offloading, diabetic shoes and inserts, etc. Then when you have maxed out conservative efforts you can you utilize your robust MSK surgical recon skills and take them to the OR for that charcot recon or you can take them to the OR for that diabetic offloading surgery (tenotomies, gastroc recessions, realignment osteotomies, MIS hammertoe correction etc).

Your MSK recon training will expose you to external fixation which you will utilize in some of these limb salvage cases. Probably the one thing you won't get high volume exposure to in residency would be muscle flaps. But you can do a couple flap and frames courses and be able to do some flaps when indicated.

I want to say this too and I will probably get some flack for it but I don't care. I think the hyper focus in lower extremity flaps is sooooo overrated. I have been doing limb salvage as part of my hospital based practices for close to 5 years now and I can think of 1-2 patients during that time that failed everything that needed a flap. People who are doing high volume flaps are most likely going to it too quickly in my opinion. Nothing beats aggressive wound care with a fundamental understanding of the underlying etiology (biomechanical, vascular, systemic, nutritional, etc) and TREATING it. If the flap fails you burn a lot of tissue and makes salvage even less possible. Just remember that before you start salivating on the reimbursement for a flap and frame.

Everything here is 💯 correct

 

[Feli]

CutsWith is 100%...

Limb salvage is very easy... you will see it anywhere.
The DME and prevention is very key... often moreso than any surgery. It is just not hard to see gas on XR and do a TMA or see forefoot overload and do a TAL. That is stuff most podiatry students can tell you.

Some programs do amp/wounds at higher levels. Bofelli at Regions is solid, others have a lot also. Any good program has more than enough, though. I would never pick it as a focus.

Basically, amps and I&D are first year cases for a reason. First year residents are sent to wound clinic for a reason. Even the venerable Charcot recons are not tough... they're very sick pts who often shouldn't even have surgery and are facing BKA. Sure, it's "bone surgery" and "RRA numbers," but it's often a joke and fails near term. They just have high complication rates due to train wreck pts getting Charcot, re-Charcot, osteo or wound issues... so, in attending land, most are better just cast/CROW until they get their amp.

Elective = high expectations, medium/high complexity
Trauma = medium expectations, high complexity
"Limb salvage" = low expectations, low/medium complexity

Any surgical DPM can do a first ray amp, but only a small % can do a Lapidus or Lisfranc ORIF well. The goal is to have as many services to offer one's patients as possible. Most residents can learn "limb salvage" in first year with only the occasional case afterwards as they focus more on difficult stuff and workups.

 

[Carpe Phalanges]

CutsWith is 100%...

Limb salvage is very easy... you will see it anywhere.
The DME and prevention is very key... often moreso than any surgery. It is just not hard to see gas on XR and do a TMA or see forefoot overload and do a TAL. That is stuff most podiatry students can tell you.

Some programs do amp/wounds at higher levels. Bofelli at Regions is solid, others have a lot also. Any good program has more than enough, though. I would never pick it as a focus.

Basically, amps and I&D are first year cases for a reason. First year residents are sent to wound clinic for a reason. Even the venerable Charcot recons are not tough... they're very sick pts who often shouldn't even have surgery and are facing BKA. Sure, it's "bone surgery" and "RRA numbers," but it's often a joke and fails near term. They just have high complication rates due to train wreck pts getting Charcot, re-Charcot, osteo or wound issues... so, in attending land, most are better just cast/CROW until they get their amp.

Elective = high expectations, medium/high complexity
Trauma = medium expectations, high complexity
"Limb salvage" = low expectations, low/medium complexity

Any surgical DPM can do a first ray amp, but only a small % can do a Lapidus or Lisfranc ORIF well. The goal is to have as many services to offer one's patients as possible. Most residents can learn "limb salvage" in first year with only the occasional case afterwards as they focus more on difficult stuff and workups.

Was more referring to the more complex/interesting/creative recons performed in patients that would otherwise be looking at a BKA. Definitely get that doing a ton of amps isn’t super educational. I know not everyone sees those recons as super valuable, but I’ve really enjoyed seeing patients that were otherwise going to get an amp having a positive outcome from a reconstructive procedure. Really appreciate your input!

 

[deleted285117]

My previous program (East Liverpool, OH) had quite a few interesting ex fix/limb salvage patients. Good diversity of attendings + great ortho/other specialty relationships.

 

[AttackNME]

Was more referring to the more complex/interesting/creative recons performed in patients that would otherwise be looking at a BKA. Definitely get that doing a ton of amps isn’t super educational. I know not everyone sees those recons as super valuable, but I’ve really enjoyed seeing patients that were otherwise going to get an amp having a positive outcome from a reconstructive procedure. Really appreciate your input!

Dunno which programs but these guys I follow on IG seems to do stuff you’re looking for: Noman Siddiqui, Jake Wynes, Johanna Godoy. But like @CutsWithFury said, find a program with the most surgical intensity and you’ll have the skills to do the complex limb salvage stuff you want. Even if the program isn’t exactly known for doing pus cases

 

[air bud]

Ex Fix is OVER rated. If you don't have a good setup (ie residents or a wound clinic) it sucks the life from you .

And ex fix is over rated in terms of limb salvage. Overused. Has it's role though.

 

[MalleableMan]

Limb salvage is rewarding, but at the same time it is humbling. In terms of the bread and butter procedures, such as debridement, offloading, I&Ds, toe amps, TMA, they aren't complex. There's more to taking care of these patients than the ~10-30 minutes in the OR of doing these procedures.

Most training programs treat these cases as purely 1st year cases, which is beneficial for learning soft tissue handling in this high risk population. But learning how to deal with complications (and not blaming it on the patient 100% of the time...) takes experience and attention to detail.

Limb salvage is rewarding if you enjoy working with other specialties and taking extra effort to build a team. There isn't much room for ego with this specialty. If you've been trained to work in isolation, butt heads with other specialties, and focus more on the individual procedures, then you'll get burned out.

To answer your question, learning how to build and apply a stable frame that can allow partial weight bearing and minimize pin tract irritation is important. But external fixation is just a technique, or a means to an end. You can fuse a joint with it, you can stabilize a fracture, or you can supplement and protect fixation, or offload a wound.

Muscle flaps and intrinsic flaps takes special training too. Maybe flaps and ex fix are overused in some settings, but if you follow the reconstructive ladder they can be applied reasonably.

And yes.. amputation could be best course for some patients too

Hopefully you can start with your career with good understanding of limb salvage but also principles in sports, recon, trauma, bread and butter podiatry, etc. There's a lot to offer patients. Some skills you will probably need to learn with courses over time if you have a good foundation.

I'm not going to post names of recommended attendings on here, but you can PM me or anyone else for advice on training programs

 

[CutsWithFury]

Limb salvage is rewarding, but at the same time it is humbling. In terms of the bread and butter procedures, such as debridement, offloading, I&Ds, toe amps, TMA, they aren't complex. There's more to taking care of these patients than the ~10-30 minutes in the OR of doing these procedures.

Most training programs treat these cases as purely 1st year cases, which is beneficial for learning soft tissue handling in this high risk population. But learning how to deal with complications (and not blaming it on the patient 100% of the time...) takes experience and attention to detail.

Limb salvage is rewarding if you enjoy working with other specialties and taking extra effort to build a team. There isn't much room for ego with this specialty. If you've been trained to work in isolation, butt heads with other specialties, and focus more on the individual procedures, then you'll get burned out.

To answer your question, learning how to build and apply a stable frame that can allow partial weight bearing and minimize pin tract irritation is important. But external fixation is just a technique, or a means to an end. You can fuse a joint with it, you can stabilize a fracture, or you can supplement and protect fixation, or offload a wound.

Muscle flaps and intrinsic flaps takes special training too. Maybe flaps and ex fix are overused in some settings, but if you follow the reconstructive ladder they can be applied reasonably.

And yes.. amputation could be best course for some patients too

Hopefully you can start with your career with good understanding of limb salvage but also principles in sports, recon, trauma, bread and butter podiatry, etc. There's a lot to offer patients. Some skills you will probably need to learn with courses over time if you have a good foundation.

I'm not going to post names of recommended attendings on here, but you can PM me or anyone else for advice on training programs

The reconstructive ladder is a phrase coined by the CLESS crowd. Overrated.

If you do aggressive outpatient wound care and your threshold to return to the OR for aggressive debridements, grafts, vac, etc is very low then you can avoid muscle flaps a lot of the time.

Muscle flaps require specialized training and courses. It's like lapiplasty. It's really sexy but nobody promotes their flap failures. That's when you are really screwed because you burned through a ton of tissue. Do a flap in a major hospital and have it go bad. Not a great look.

Outside of trauma, Ex fix should really only be utilized in charcot recon. I also believe charcot recon should be staged. There's a lot of decent research going to be coming out at the next ACFAS conference on this.

 

[deleted1138023]

My previous program (East Liverpool, OH) had quite a few interesting ex fix/limb salvage patients. Good diversity of attendings + great ortho/other specialty relationships.

very underrated program with a great director.

 

[AttackNME]

The reconstructive ladder is a phrase coined by the CLESS crowd. Overrated.

If you do aggressive outpatient wound care and your threshold to return to the OR for aggressive debridements, grafts, vac, etc is very low then you can avoid muscle flaps a lot of the time.

Muscle flaps require specialized training and courses. It's like lapiplasty. It's really sexy but nobody promotes their flap failures. That's when you are really screwed because you burned through a ton of tissue. Do a flap in a major hospital and have it go bad. Not a great look.

Outside of trauma, Ex fix should really only be utilized in charcot recon. I also believe charcot recon should be staged. There's a lot of decent research going to be coming out at the next ACFAS conference on this.

The reconstructive ladder is a topic written about in plastics literature for decades, you sure it’s the CLESF group who coined it? they use that phrase a lot probably due to the heavy plastics nature of work they do

 

[heybrother]

very underrated program with a great director.

I was fairly impressed by a lecture I saw of his on Podiatry Present (was like the only good Podiatry Present lecture I remember seeing).

I seem to recall something bizarre happening to their program like 5 years ago where they had to scramble to find a new base hospital. Pretty sure I'm thinking of the right place.

 

[deleted285117]

I was fairly impressed by a lecture I saw of his on Podiatry Present (was like the only good Podiatry Present lecture I remember seeing).

I seem to recall something bizarre happening to their program like 5 years ago where they had to scramble to find a new base hospital. Pretty sure I'm thinking of the right place.

Yes... Previous hospital where it was closed six months after I left. Thankfully, the new hospital took them on and kept all of the same other hospitals/surgery center rotations. So really the only thing that changed was the base hospital.

 

[diabeticfootdr]

Limb salvage programs aren't only about doing surgery. It is a lot of surgery. Some reconstructive, but a lot of it is knowing when to do complex reconstruction vs. something more simple and preserving limb, life, and function. Both are valuable. But what is the most valuable is choosing a program that teaches you (formally or by observation) how to create and manage your own limb salvage program. You can create your own hospital-based job if you can demonstrate the need and that you have the leadership to put a program together.

UT is the only job I ever applied for. Every other job I had, I created for myself.

Again, the quote on my wall, "Life isn't about finding yourself. It's about creating yourself."

Same can be said for jobs in podiatry - especially limb salvage. If you want to just be an employee and you're just looking for a job to fall in your lap, then you'll be treated like an employee. If you're entrepreneurial, you can create your own program, write your own job description, dictate your own salary and terms.

 

[CutsWithFury]

The reconstructive ladder is a topic written about in plastics literature for decades, you sure it’s the CLESF group who coined it? they use that phrase a lot probably due to the heavy plastics nature of work they do

I learned about it at CLESS and doing some private labs so I figured that's where it came from. Could very well be from plastics literature. It's meaning would be different when it comes to reconstructive plastic surgeons vs podiatrists in my opinion.