Loupes for Podiatric Surgery

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HalluxSlicer

HalluxSlicer

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Many of the general surgery and other surgical residents at my hospital started their orders on Loupes so I was wondering which brands are a go to for our profession! Currently checking out Orascoptic but feel free to suggest brands that y'all are using! Much thanks
 
HalluxSlicer said:
Many of the general surgery and other surgical residents at my hospital ...
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No and no.
You are a podiatrist, sir.
Those other surgeons you speak of will be using the mag in fellowship and as attendings.
They may be doing hand, plastics, vasc, CR, CT, etc surgery with 6-0, 7-0, 8-0, anastamosis hours long, transplants, operating microscope... but you are a foot doc, my man.

You'd use the loupes for maybe 5 or 10 cases on the vasc month of your residency, and then they are forever a paperweight.
If they are somehow paid for with money you CAN'T use for another purpose, sure... but they'll be a trinket with little/no resale after residency (maybe you can sell them to a dent student if they're not custom?). If they come out of your limited CME allowance, hard pass.

And yes, a few resident/fellow/attending podiatrists [try to] use loupes for foot and ankle... and yes, they're generally tools that take waaay too long in the OR and accomplish nothing ordinary pods do not. No joke... you will see these goofballs going through skin when they are trying to close subcut and missing many things as their field of view is neutuered by loupes they don't need for the neuroma or ganglion whatever they are putzing with at 3x and 4x mag. Think about if F&A ortho ever uses loupes (no); they don't want the looks to the mayo or back table or flouro or talke to anesthesia all being messed up by superfluous eyewear. Basically, if there is anything in the foot a DPM cannot see well with plain eyesight, then it's about dat time to retire. 🙂

...Use your CME for something useful for podiatry (because you're a podiatrist).... books, vids, scope course, trauma course, board prep, things you can resell for cash, things you can use in your own clinic after training (foot models, posters, handheld dopp, etc), etc. 👍
 
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I spent $0 on board prep materials--didn't need it--plus I sold all my books, so I had some extra money lying around and I got some loupes from orascoptic.

They're 3x magnifier. Handy for neuromas, flexor tendon transfers, plantar plate, ligating pulsatile bleeders after a TMA. I guess they're not necessary in the grand scheme of things but like an expensive ergonomic office chair, it makes the work more comfortable. I suppose I'm a bit of a tool, but I never take too long in the OR, I finish cases precisely when I intend to 🧙‍♂️
 
Always thought it was weird to use loupes when you’re doing cases that use 3-0 and 4-0 suture.

TMA bleeders can be taken care of with a big ol instrument tie for tamponade even if you can’t see it. Neuromas are usually visible enough. Plantar plate troubles aren’t so much the visualization as it is working around the crappy angles and crowded space. I don’t think using loupes would make me hate plantar plate repairs any less but I’m also a lobster TFP so 🦞
 
I have a pair from designs for vision, and yes the money was set to expire and had to use it on something, so why not loupes?? The number of cases I have used them on? Zero. The number of times I have used them in the clinic for foreign body exploration/removal? countless. They're great for finding that little shard of glass. And patients love when you pull them out. Special glasses for their special feet.
 
Flip-flop-flerpity said:
I have a pair from designs for vision, and yes the money was set to expire and had to use it on something, so why not loupes?? The number of cases I have used them on? Zero. The number of times I have used them in the clinic for foreign body exploration/removal? countless. They're great for finding that little shard of glass. And patients love when you pull them out. Special glasses for their special feet.
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Yes, this is the one occasionally good podi application for mag (finding splinters or glass in office), but you don't need $500-1000+ loupes for it...

You (and any doc in the office) can use a $100 wheeled mag + light like any ER or UC or most PCP, derm, plastics, etc offices have. You get more mag, light, and still see your mayo or patient, assistant, etc well.

61v+3uLbCML._AC_SL1500_.jpg
 
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Feli said:
Yes, this is the one occasionally good application for mag (finding splinters or glass in office), but you don't need $500-1000+ loupes for it...

You (and any doc in the office) can use a $100 wheeled mag light like any ER or UC or most PCP offices have... and still see your mayo well.

61v+3uLbCML._AC_SL1500_.jpg
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Or that ¯\_(ツ)_/¯
 
Flip-flop-flerpity said:
I have a pair from designs for vision, and yes the money was set to expire and had to use it on something, so why not loupes?? The number of cases I have used them on? Zero. The number of times I have used them in the clinic for foreign body exploration/removal? countless. They're great for finding that little shard of glass. And patients love when you pull them out. Special glasses for their special feet.
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At the end of the day though you’re still using basic forceps to grab that object. Something that is big enough to fit into the teeth of it.

In a clinic setting this usually means just a small incision and feeling around for the crunchy part
 
Adam Smasher said:
they're not necessary in the grand scheme of things
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So we can all agree podiatrists don't need loupes. But I've done cases with them, and I've done cases without them, and there is a difference. I bought mine as a lowly associate for $1700 nearly a decade ago. $170/year isn't that much. I've spent more money on ABPM and ABFAS dues. I choose to be comfortable. Anyone's allowed to disagree with me. However blanket statements to the effect of "all podiatrists should use loupes" or "all podiatrists should not use loupes" are not what the OP was asking about.
 
Get the cheap 2.5x loupes on Amazon. I find them more useful in the clinic than I do in surgery (especially with a built in light)...great for taking out the occasional difficult suture...and especially great for digging around for a foreign body in the clinic (small glass, wood).

Definitely no need in surgery....they just get in the way and you lose the the big picture.
 
definitely don’t need them for foot and ankle surgery. If this is coming from your CME/book money I would for sure pass and use that money on other things like ACFAS conference, BoardWizards subscription when that time comes around, getting your own lead, etc.
 
PODIATRYCRAZE said:
Serious question. I have never had to repair an accidentally cut DP or PT artery. Have any of you? In this scenario do you need loupes?
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If you're wearing loupes and you still cut either of those arteries, maybe you have bigger problems than magnifying your field of vision.
 
PODIATRYCRAZE said:
Serious question. I have never had to repair an accidentally cut DP or PT artery. Have any of you? In this scenario do you need loupes?
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dog glasses GIF

make sure it has the wipers attachment so the squirting blood doesnt ruin the lenses
 
PODIATRYCRAZE said:
Serious question. I have never had to repair an accidentally cut DP or PT artery. Have any of you? In this scenario do you need loupes?
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You are 4 months outta residency. I would hope you haven't accidentally cut anything... besides calluses.
Are you planning to hit the DP with a stray toenail fragment on a thin-skin 92yo patient in the office?
Or thinking more wrap up the PT artery near the knee doing a quad ring Ilizarov on a 400lb charcot recon?

Serious answer, no... both of those vessels are outer diameter of about the size of a coffee straw depending on what level... and you should have a fair safety margin for any major vessels and nerves (PT, AT, sural, pero).

Serious question, how are your surgical privileges coming along?
 
I’ve seen the DP artery tied off in training. To my knowledge the patient ended up doing well with no symptoms. I think ideally you should repair it or get vascular notified immediately. but not sure how realistic that is at most places. If you hit the PT you better get vascular involved I feel. I’m not touching tarsal tunnel surgeries or anything near the PT so not worried about that one.

Good question that we all should have a plan for.
 
MortonExtension said:
I’ve seen the DP artery tied off in training. To my knowledge the patient ended up doing well with no symptoms. I think ideally you should repair it or get vascular notified immediately. but not sure how realistic that is at most places. If you hit the PT you better get vascular involved I feel. I’m not touching tarsal tunnel surgeries or anything near the PT so not worried about that one.

Good question that we all should have a plan for.
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DP doesn't matter a lot (at foot level)... you can tie it off (or repair it if able). We all bag the plantar communicating branch a good amount of the time on Lapidus... ppl using a tourniquet and/or using jig probably just don't even know it. The only pts that bagging the DP would really hurt are pretty severe PT and overall PAD stenosis where you definitely wouldn't be doing elective anyways. It could sure give trouble for wound healing on forefoot slams/recons; heck, I kinda assume it was bagged when doing revision midfoot/forefoot stuff.

PT you have to repair, yeah... 5-0 nylon or prolene (not cutting needle). If you have vascular, call em... but in reality, most of us won't have them in the building or even the city/town. If PT is damaged, it almost surely won't be with scalpel nick or something fairly easily repairable. In 99+% of normal pod situations, you shouldn't be nearer than 1cm to those AT, PT, sural, pero neurovasc stuff. The PT really just comes into play in some ankle fusions or fractures (for screws/pins), and it'd be torn to shreds if you drilled or put a wire or saw on it. It'll be beyond repair. If anyone manages to bag PT nerve or artery with saw or osteotome or drill on calc osteotomies or FHL xfers or stuff, then that's pretty much a manufactured crisis. But don't get me wrong... I do tell techs, "it's real important you hold that army navy right there to protect" when I do TA tendon, anterior ankle approach, FHL stuff, deltoid, Achilles, etc. 🙂

The only ppl I know personally who hit the PT a good bit are doing pointless Charcot recons (for rvu, for resident cases, whatever) with rly sloppy and over-fixated fusions... the hopeless stuff I and any normal doc will just cast or CROW or TCC until they get their amp. In normal pod practice, serious chance of hitting PT's really not an issue (aside from just being aware of PT when doing lateral calc stuff like osteotomies, calc ORIF, nails, etc).

The proper "tarsal tunnel surgery" (barely ever necessary, but occasional need for a ganglion or varicose or SOL) is just to dissect down, cut the lacinate carefully, sew skin only. You don't want to touch the nerve or artery. Those ppl who try to separate everything, loop the nerve branches, over-dissect, etc usually cause way more harm than good.
 
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that big old first met bleeder on aggressive TMAs is the most common enemy. Don’t think I’ve ever hit DP or PT. Most don’t talk about it because it’s an insta jinx
 
Feli said:
You are 4 months outta residency. I would hope you haven't accidentally cut anything... besides calluses.
Are you planning to hit the DP with a stray toenail fragment on a thin-skin 92yo patient in the office?
Or thinking more wrap up the PT artery near the knee doing a quad ring Ilizarov on a 400lb charcot recon?

Serious answer, no... both of those vessels are outer diameter of about the size of a coffee straw depending on what level... and you should have a fair safety margin for any major vessels and nerves (PT, AT, sural, pero).

Serious question, how are your surgical privileges coming along?
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Applied to 8 hospitals. 8/8 hospitals with surgical privileges. 7/8 gave me whatever I want. The last hospital said I cannot do pilons, and I cannot do scopes there without scope training. Said I did not do enough in residency.

Thats fair. Only have 1 pilon and roughly 20 scopes. ABFAS would not have given me any extra benefit. Scopes course with arthrex, ACFAS, or IFAF would help. Doing another 14 pilons in residency would probably also have helped.

Doing roughly 3-5 surgeries per week. Sometimes more sometimes less.
 
PODIATRYCRAZE said:
Applied to 8 hospitals. 8/8 hospitals with surgical privileges...
...Doing roughly 3-5 surgeries per week. Sometimes more sometimes less.
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Yes, but I was saying you've done surgery for less than a month now.
More than 5 cases/wk is a ton for podiatry.
Good luck, and don't worry about loupes. Lol
 
Feli said:
DP doesn't matter a lot (at foot level)... you can tie it off (or repair it if able). We all bag the plantar communicating branch a good amount of the time on Lapidus... ppl using a tourniquet and/or using jig probably just don't even know it. The only pts that bagging the DP would really hurt are pretty severe PT and overall PAD stenosis where you definitely wouldn't be doing elective anyways. It could sure give trouble for wound healing on forefoot slams/recons; heck, I kinda assume it was bagged when doing revision midfoot/forefoot stuff.

PT you have to repair, yeah... 5-0 nylon or prolene (not cutting needle). If you have vascular, call em... but in reality, most of us won't have them in the building or even the city/town. If PT is damaged, it almost surely won't be with scalpel nick or something fairly easily repairable. In 99+% of normal pod situations, you shouldn't be nearer than 1cm to those AT, PT, sural, pero neurovasc stuff. The PT really just comes into play in some ankle fusions or fractures (for screws/pins), and it'd be torn to shreds if you drilled or put a wire or saw on it. It'll be beyond repair. If anyone manages to bag PT nerve or artery with saw or osteotome or drill on calc osteotomies or FHL xfers or stuff, then that's pretty much a manufactured crisis. But don't get me wrong... I do tell techs, "it's real important you hold that army navy right there to protect" when I do TA tendon, anterior ankle approach, FHL stuff, deltoid, Achilles, etc. 🙂

The only ppl I know personally who hit the PT a good bit are doing pointless Charcot recons (for rvu, for resident cases, whatever) with rly sloppy and over-fixated fusions... the hopeless stuff I and any normal doc will just cast or CROW or TCC until they get their amp. In normal pod practice, serious chance of hitting PT's really not an issue (aside from just being aware of PT when doing lateral calc stuff like osteotomies, calc ORIF, nails, etc).

The proper "tarsal tunnel surgery" (barely ever necessary, but occasional need for a ganglion or varicose or SOL) is just to dissect down, cut the lacinate carefully, sew skin only. You don't want to touch the nerve or artery. Those ppl who try to separate everything, loop the nerve branches, over-dissect, etc usually cause way more harm than good.
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It would be interesting to see a thread on what everyone thinks a proper tarsal tunnel release encompasses
 
Flip-flop-flerpity said:
It would be interesting to see a thread on what everyone thinks a proper tarsal tunnel release encompasses
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I wouldn’t do it unless there is a clear etiology like a mass, varicose vein, or some other space occupying cause. If there is nothing on exam or MRI/US I send them out to plastic surgery and they can operate on it if they want. People do not do well after tarsal tunnel surgery without pathology. I see people all the time who come in with this and have had 2 or 3 releases and chronic pain already and want to try another one, which is insane. Others come in after having it done and wish they had just lived with it because it is worse after surgery. I can’t remember anyone I’ve seen that has said they are so happy they had their tarsal tunnel released.
 
Podstar said:
I wouldn’t do it unless there is a clear etiology like a mass, varicose vein, or some other space occupying cause. If there is nothing on exam or MRI/US I send them out to plastic surgery and they can operate on it if they want. People do not do well after tarsal tunnel surgery without pathology. I see people all the time who come in with this and have had 2 or 3 releases and chronic pain already and want to try another one, which is insane. Others come in after having it done and wish they had just lived with it because it is worse after surgery. I can’t remember anyone I’ve seen that has said they are so happy they had their tarsal tunnel released.
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I've revised quite a few where people have had 2 or 3 releases. One patient I did had 5 prior attempts. I never do it without a clear positive tinel's AND positive NCV. I agree with Feli that you dont need to even visualize the nerves much less dissect them out. Every one that I've revised still had either intact deep posterior compartment fascia AND/or intact abductor hallucis anchoring fascia to calc. IMO if you don't release these structures as part of the procedure you're doing the patient a disservice and likely creating scenarios that you describe. Sometimes you see a varicosity or a ganglion but most of the time you dont see anything abnormal. Look for it in those patients that are coming in for 2nd/3rd/4th opinions for pain and have difficulty describing their symptoms. It's not common pathology but it's definitely out there and if you have a busy surgical practice and don't do them you're missing the diagnosis. Also it's good practice to do a prophylactic release on your cavovarus recons.
 
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