How come Orthopods can do F&A surgery?

[ucd]

I'm not well versed in an orthopedic residency program, but how come hospitals allow orthopods to do forefoot and rearfoot surgery only after a 1 yr of a F&A fellowship? The reason I ask is b/c in med school, they never took a special "Lower extremity Anatomy" course, they never took Biomechanics, never spent their 3rd or 4th year focused on learning the foot and ankle. Also,how much of their 5 year residency is actually spent looking at foot and ankle cases, considering they have to learn so much about all the other joints of the body. Whereas, a podiatrist focuses on F&A from 1st year, can do a 3yr residency, and still not feel comfortable doing rearfoot surgery. What gives?

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[densmore22]

Alright, I'm calling you out. Troll...

You make good points, but don't drop down to the level of the few out there that still have disdain for us. I would say the big academic centers have the greatest resistance, but even some of them are changing their ways. Duke is a prime example, they have Pods on staff in the Dept of Orthopedics. And some Ortho residencies just simply can't find a true F&A Orthopod to train their residents and are turning towards Podiatrists to fill that void. Anyways, don't worry about them, if you focus on what you want to do and study hard, get good training and love what you do, then you should not have to worry about a single F&A Orthopod (or competing Podiatrist) who may have a chip on their shoulder(s) against you.

 

[ucd]

Thanks the reply. However, I'm not really sure why you assumed my question was "trollish"? I was simply trying to understand the training of an F&A orthopod vs a podiatrist. In my opinion, I think that podiatrist have the skill sets to be the "go to guy" for all F&A cases, however, I'm not sure how orthopods can perform all these F&A cases when they didn't have as much focus and training on the foot.

 

[Adam Smasher]

Assuming you're not trolling, this is a pretty interesting question.

I once met a hand surgeon who told me he did a 5 year gen surgery residency followed by a 1 year hand surgery fellowship. (Then followed by a 2 year cosmetic surgery fellowship, but that's another story!) I don't think he ever took a course on "upper extremity anatomy" or "upper extremity biomechanics," so he must have learned all that stuff on his own.

Similarly, I'm guessing that the foot and ankle orthopods had to read up on a lot of lower extremity anatomy and biomechanics in their down time. And what do orthopedic surgeons do? They do orthopedic surgery. They don't do wound care or manage infectious disease, or at least not to the extent DPMs do. I'm not denegrating anybody, just saying what you do with certain levels of training. So if you cut out all the aspects of podiatry not involving fixing bones, you could probably cram it all into a 1 or 2 year fellowship.

Still, in my opinion, 6-8 years of postgraduate education is a long time to spend if you're going to pick a body part where you'll have to compete with the 15k DPMs in the country qualified to do the exact same thing.

 

[347932]

Similarly, I'm guessing that the foot and ankle orthopods had to read up on a lot of lower extremity anatomy and biomechanics in their down time.

You're guessing incorrectly. ALL the F&A Orthopods I've had the pleasure of rubbing shoulders with didn't have the first clue about foot biomechanics.

I think I've talked about this article somewhere, but the AMA released a study they did about F&A Ortho fellowships (the maximum of which is 1 year), and they found that 80% of the institutions that offered F&A Ortho fellowships didn't have a F&A Ortho trained attending at that institution. Guess who taught all these Ortho fellows how to do F&A surgery? You guessed it...we did.

Most "F&A" trained orthos ended up seeing mostly trauma related cases. There is a self proclaimed F&A Ortho "Expert" in town that does bunion surgery that takes him 3-4 hours...to do an Austin. I did more bunions in residency than he's done in his illustrious 35 year career. Who's the expert?

 

[that1guyfromFL]

There is a self proclaimed F&A Ortho "Expert" in town that does bunion surgery that takes him 3-4 hours...to do an Austin.

 

[skiz knot]

I'm not well versed in an orthopedic residency program, but how come hospitals allow orthopods to do forefoot and rearfoot surgery only after a 1 yr of a F&A fellowship? The reason I ask is b/c in med school, they never took a special "Lower extremity Anatomy" course, they never took Biomechanics, never spent their 3rd or 4th year focused on learning the foot and ankle. Also,how much of their 5 year residency is actually spent looking at foot and ankle cases, considering they have to learn so much about all the other joints of the body. Whereas, a podiatrist focuses on F&A from 1st year, can do a 3yr residency, and still not feel comfortable doing rearfoot surgery. What gives?

You don't need a whole "special 'lower extremity anatomy' course" to learn the relevant anatomy of the foot and ankle. We learn it in gross anatomy as medical students and re-learn it as it pertains to our training and specific cases. It is not that difficult to master the muscles/tendons, ligaments, nerves, and vessels of the foot and ankle.

In terms of biomechanics, we are responsible for learning the principles of biomechanics and gait analysis, and we are tested on such as part of our in-training and board certification exams. Most training programs have appropriate biomechanics faculty to teach us these topics.

A considerable portion of our residency training is in foot and ankle pathology. Obviously trauma is 60-70% lower extremity, heavy on ankles, pilons, foot fractures, lisfrancs, soft tissue wounds, etc... Pediatrics is very foot and ankle heavy, with operative and non-operative management of acquired and congenital issues. Foot issues often help us to diagnose disorders of the CNS in the peds and spine clinic. Private practice is still full of ankle sprains and bunions and tendonitis and flatfoot. A sports medicine rotation worth its weight in dirt will teach you to examine the feet to see how they may affect foot/ankle/knee/hip/back pain. Hand surgeons often have to resort to harvesting needed "parts" from Hand Depot (the foot), and we have to know about what is ok to take with minimal morbidity to the patient. We are heavily involved in vascular surgery rotations during our intern year managing diabetic/vasculopath wounds and amputations. Additionally, most places also have a dedicated foot and ankle rotation(s). If we desire additional training in the foot and ankle, we can pursue a fellowship.
In my opionion, a successfully completed orthopaedic surgery residency program more than qualifies us (orthopaedic surgeons) to manage foot and ankle problems within our comfort zone. Most do not venture outside of their comfort zone and will refer complex cases to a more qualified individual. In many communities that means a podiatrist.

 

[densmore22]

You don't need a whole "special 'lower extremity anatomy' course" to learn the relevant anatomy of the foot and ankle. We learn it in gross anatomy as medical students and re-learn it as it pertains to our training and specific cases. It is not that difficult to master the muscles/tendons, ligaments, nerves, and vessels of the foot and ankle.

In terms of biomechanics, we are responsible for learning the principles of biomechanics and gait analysis, and we are tested on such as part of our in-training and board certification exams. Most training programs have appropriate biomechanics faculty to teach us these topics.

A considerable portion of our residency training is in foot and ankle pathology. Obviously trauma is 60-70% lower extremity, heavy on ankles, pilons, foot fractures, lisfrancs, soft tissue wounds, etc... Pediatrics is very foot and ankle heavy, with operative and non-operative management of acquired and congenital issues. Foot issues often help us to diagnose disorders of the CNS in the peds and spine clinic. Private practice is still full of ankle sprains and bunions and tendonitis and flatfoot. A sports medicine rotation worth its weight in dirt will teach you to examine the feet to see how they may affect foot/ankle/knee/hip/back pain. Hand surgeons often have to resort to harvesting needed "parts" from Hand Depot (the foot), and we have to know about what is ok to take with minimal morbidity to the patient. We are heavily involved in vascular surgery rotations during our intern year managing diabetic/vasculopath wounds and amputations. Additionally, most places also have a dedicated foot and ankle rotation(s). If we desire additional training in the foot and ankle, we can pursue a fellowship.
In my opionion, a successfully completed orthopaedic surgery residency program more than qualifies us (orthopaedic surgeons) to manage foot and ankle problems within our comfort zone. Most do not venture outside of their comfort zone and will refer complex cases to a more qualified individual. In many communities that means a podiatrist.

Well said. In the end, it's all about what you want to do and comfort level. I may train to fix Pilon's, but that doesn't mean I'm going to do them when I'm done. Whether that's by choice or whether it's by where I choose to work.

As for the biomechanics component, I think a lot of it is just experience. Why is that every freakin' Pod or Orthopod out there says "I do it this way and I have great results." Well, to me, it seems like if everyone has their own way, then why are we spending all of this time and energy trying to learn one way or the other? Yes, I'm sure Pod X is doing a similar thing than Orthopod Y, but again, I think a lot of that stuff is trial and error and making your mistakes and learning from them. You need to know the basics, beyond that, there's no real EBM to support most of the orthotic or shoe therapy out there that we use to treat biomechanics. Why does one type of orthotic work for one person, but someone else with the SAME issue doesn't benefit from the same treatment? Anyways, I digress, so yeah, that's my rant. I know a lot of the attending's on here will probably flame me for the above, but I've had a lot of really smart attending's who know biomechanics better than the average tell me they don't know why things work (beyond the obvious).

 

[PADPM]

You don't need a whole "special 'lower extremity anatomy' course" to learn the relevant anatomy of the foot and ankle. We learn it in gross anatomy as medical students and re-learn it as it pertains to our training and specific cases. It is not that difficult to master the muscles/tendons, ligaments, nerves, and vessels of the foot and ankle.

In terms of biomechanics, we are responsible for learning the principles of biomechanics and gait analysis, and we are tested on such as part of our in-training and board certification exams. Most training programs have appropriate biomechanics faculty to teach us these topics.

A considerable portion of our residency training is in foot and ankle pathology. Obviously trauma is 60-70% lower extremity, heavy on ankles, pilons, foot fractures, lisfrancs, soft tissue wounds, etc... Pediatrics is very foot and ankle heavy, with operative and non-operative management of acquired and congenital issues. Foot issues often help us to diagnose disorders of the CNS in the peds and spine clinic. Private practice is still full of ankle sprains and bunions and tendonitis and flatfoot. A sports medicine rotation worth its weight in dirt will teach you to examine the feet to see how they may affect foot/ankle/knee/hip/back pain. Hand surgeons often have to resort to harvesting needed "parts" from Hand Depot (the foot), and we have to know about what is ok to take with minimal morbidity to the patient. We are heavily involved in vascular surgery rotations during our intern year managing diabetic/vasculopath wounds and amputations. Additionally, most places also have a dedicated foot and ankle rotation(s). If we desire additional training in the foot and ankle, we can pursue a fellowship.
In my opionion, a successfully completed orthopaedic surgery residency program more than qualifies us (orthopaedic surgeons) to manage foot and ankle problems within our comfort zone. Most do not venture outside of their comfort zone and will refer complex cases to a more qualified individual. In many communities that means a podiatrist.

I know you're in your orthopedic training, so I thank you for your diplomatic response to what I personally consider an insulting question.

 

[347932]

You don't need a whole "special 'lower extremity anatomy' course" to learn the relevant anatomy of the foot and ankle. We learn it in gross anatomy as medical students and re-learn it as it pertains to our training and specific cases. It is not that difficult to master the muscles/tendons, ligaments, nerves, and vessels of the foot and ankle.

In terms of biomechanics, we are responsible for learning the principles of biomechanics and gait analysis, and we are tested on such as part of our in-training and board certification exams. Most training programs have appropriate biomechanics faculty to teach us these topics.

A considerable portion of our residency training is in foot and ankle pathology. Obviously trauma is 60-70% lower extremity, heavy on ankles, pilons, foot fractures, lisfrancs, soft tissue wounds, etc... Pediatrics is very foot and ankle heavy, with operative and non-operative management of acquired and congenital issues. Foot issues often help us to diagnose disorders of the CNS in the peds and spine clinic. Private practice is still full of ankle sprains and bunions and tendonitis and flatfoot. A sports medicine rotation worth its weight in dirt will teach you to examine the feet to see how they may affect foot/ankle/knee/hip/back pain. Hand surgeons often have to resort to harvesting needed "parts" from Hand Depot (the foot), and we have to know about what is ok to take with minimal morbidity to the patient. We are heavily involved in vascular surgery rotations during our intern year managing diabetic/vasculopath wounds and amputations. Additionally, most places also have a dedicated foot and ankle rotation(s). If we desire additional training in the foot and ankle, we can pursue a fellowship.
In my opionion, a successfully completed orthopaedic surgery residency program more than qualifies us (orthopaedic surgeons) to manage foot and ankle problems within our comfort zone. Most do not venture outside of their comfort zone and will refer complex cases to a more qualified individual. In many communities that means a podiatrist.

Thank you for your insight. All the F&A Orthopods I've known have been "old school", so it looks like I need to start opening my eyes to the newer practitioners who likely have better training and knowledge then their older counterparts.

 

[Podfather]

Thank you for your insight. All the F&A Orthopods I've known have been "old school", so it looks like I need to start opening my eyes to the newer practitioners who likely have better training and knowledge then their older counterparts.

Hey everyone years ago I came to the realization that you are either a foot and ankle surgeon or you're not. You get your education and residency/fellowship training and you dedicate your life to this portion of the human body. You can be a DPM, MD, or DO and be an excellent or terrible surgeon. I see good and bad from all. I respect those who care (even if they bad mouth my profession) about their patients enough to be the best they can be. I readily admit there are good orthopedic foot surgeons and some bad DPMs. Where some of my ortho colleagues fail me is they can not say the opposite. In the end I can say I have done my best for my patients. One group isn't better than another and in fact the good ones are on the same team regardless of degree.

 

[ucd]

Thank for all the replies. Looking at some if the responses, I probably should have rephrased my question. I didnt wanna come off as a troll or start a flame war. I want to thank skiz knot in particular for giving us a glimpse into the life of an ortho resident. Very informative. My buddy is starting ortho and wasn't even sure what was entailed in terms of F&A cases. Im glad that future podiatrist and orthopods can work together in that aspect.

 

[Feli]

... In the end, it's all about what you want to do and comfort level...

This is the bottom line.

F&A surgery is done by many specialties: pod surg, gen ortho, F&A ortho, trauma ortho, vascular, plastics, derm, and even gen surg sometimes.

A gen ortho might have had a high volume F&A trained guy at his program - or maybe even just a gen ortho attending who happened to do a lot of F&A cases. In a 5yr gen ortho program, they get a short F&A dedicated rotation, but they also run across plenty of F&A stuff on their gen ortho, trauma, sports, etc rotation blocks. If they decide after residency to prep on the F&A anatomy, they obviously knows the principles of bone/joint and musculoskeletal surg... as well as AO (internal fixation, plates & screws). If a gen ortho then feels comfortable and efficient at F&A and will prep for the tough cases, then he can go for it. Chances are usually that most gen orthos focus more on higher pay procedures (total joints, long bone fx, etc) and stuff they're more efficent at, but if a gen ortho guy gets good income, satisfaction, and patient results on F&A, then by all means.

Vasc surg obviously does the amps and revascs in the lower extremity. Derm and plastics do the soft tissue stuff. In the end, it's about interest and comfort level. If a surgeon (of any specialty) is doing procedures they're marginally qualified for or have little to no residency/practice volume with, then they will typically be short lived due to one reason or another... can't get privileges, malpractice, poor results and low efficiency leading to them abandoning those types of cases due to frustration, etc. Everything has a way of working itself out.

We're back to the 4 pillars of good surg:
1 Personal interest and motivation
2 Education, training, prep, and exp
3 Natural motor ability and hand skills
4 Balls (err, confidence level)

 

[javajava]

4 Balls (err, confidence level)

Ahh.. Size Does Matter

 

[PADPM]

This is the bottom line.

F&A surgery is done by many specialties: pod surg, gen ortho, F&A ortho, trauma ortho, vascular, plastics, derm, and even gen surg sometimes.

A gen ortho might have had a high volume F&A trained guy at his program - or maybe even just a gen ortho attending who happened to do a lot of F&A cases. In a 5yr gen ortho program, they get a short F&A dedicated rotation, but they also run across plenty of F&A stuff on their gen ortho, trauma, sports, etc rotation blocks. If they decide after residency to prep on the F&A anatomy, they obviously knows the principles of bone/joint and musculoskeletal surg... as well as AO (internal fixation, plates & screws). If a gen ortho then feels comfortable and efficient at F&A and will prep for the tough cases, then he can go for it. Chances are usually that most gen orthos focus more on higher pay procedures (total joints, long bone fx, etc) and stuff they're more efficent at, but if a gen ortho guy gets good income, satisfaction, and patient results on F&A, then by all means.

Vasc surg obviously does the amps and revascs in the lower extremity. Derm and plastics do the soft tissue stuff. In the end, it's about interest and comfort level. If a surgeon (of any specialty) is doing procedures they're marginally qualified for or have little to no residency/practice volume with, then they will typically be short lived due to one reason or another... can't get privileges, malpractice, poor results and low efficiency leading to them abandoning those types of cases due to frustration, etc. Everything has a way of working itself out.

We're back to the 4 pillars of good surg:
1 Personal interest and motivation
2 Education, training, prep, and exp
3 Natural motor ability and hand skills
4 Balls (err, confidence level)

In two of the hospitals where I'm on staff, the orthopods run (quickly) if the word amputation is mentioned, and vascular won't touch an amputation below the knee. Our group performs a significant number of amputations regularly. These patients usually come through the ER with neglected, end stage wounds. Wound care isn't my favorite, especially considering that some of my partners have greater expertise, but we all are on call to cover these cases.

 

[skiz knot]

I know you're in your orthopedic training, so I thank you for your diplomatic response to what I personally consider an insulting question.

I was going to reply with "because we're awesome" but I had a few extra minutes to spare.

 

[hematosis]

nice