O.R. podiatric surgeries?

[mednoob]

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It seems to me like a lot of foot and ankle surgical procedures are just done in an office, like bunions, and not much F+A procedures are full blown OR surgeries. Are there a good number of O.R surgeries in podiatry?

I tried looking up foot and ankle procedures on youtube and all I found were little surgeries done in an office, nothing big really.

 

[SportPOD]

It seems to me like a lot of foot and ankle surgical procedures are just done in an office, like bunions, and not much F+A procedures are full blown OR surgeries. Are there a good number of O.R surgeries in podiatry?

I tried looking up foot and ankle procedures on youtube and all I found were little surgeries done in an office, nothing big really.

There's the problem, YOUTUBE. If you want to see surgical procedures, go shadow a podiatrist. I perform all of my surgical procedures either in a hospital or a surgery center. The only things I do at my office are simple procedures (nail avulsion, warts, draining a superficial abscess or wound care). I do all bunions, hammertoes, soft tissue cases, fusions and such in the hospital. I need the patient anesthetized properly with the help of a trained anesthesiologist. If I do it in that setting, I don't have to buy all that expensive equipment and maintain it either.

 

[mednoob]

There's the problem, YOUTUBE. If you want to see surgical procedures, go shadow a podiatrist. I perform all of my surgical procedures either in a hospital or a surgery center. The only things I do at my office are simple procedures (nail avulsion, warts, draining a superficial abscess or wound care). I do all bunions, hammertoes, soft tissue cases, fusions and such in the hospital. I need the patient anesthetized properly with the help of a trained anesthesiologist. If I do it in that setting, I don't have to buy all that expensive equipment and maintain it either.

I knew Youtube would be the culprit lol 😀

You're right, I should just go shadow a pod and see what they do. Thanks for your reply, I was starting to feel hopeless no one would answer my thread, but I got a great answer from an attending pod. Thanks! 👍

 

[Feli]

There's the problem, YOUTUBE. If you want to see surgical procedures, go shadow a podiatrist. I perform all of my surgical procedures either in a hospital or a surgery center. The only things I do at my office are simple procedures (nail avulsion, warts, draining a superficial abscess or wound care). I do all bunions, hammertoes, soft tissue cases, fusions and such in the hospital. I need the patient anesthetized properly with the help of a trained anesthesiologist. If I do it in that setting, I don't have to buy all that expensive equipment and maintain it either.

This is exactly the way it should be done everywhere.^ 👍

There are and will continue to be many procdural specialists (pod, plastics, derm, ENT, "urgent care" ER docs, GPs, etc) that do a fair amount of stuff in the office. Office procedures and surgeries pay better and you don't have to worry about the surgery before yours running long, etc. Still, the line between minor office procedures and OR cases has to be drawn somewhere. There are too many cowboys out there playing with fire. Many states are passing laws on what can and cannot be done in an office, and rightly so IMO.

I hope for the sake of the patients that those youtube vids of office bunions or RF procedures were produced 10-20yrs ago when that stuff was less frowned upon. I've shadowed plenty of great pods who have a "surgery" room in their office where they did bunions and hammertoes many years ago, but that is an basically an antiquated practice nowadays. Those rooms are now converted to regular patient rooms or just storage space filled with files, boxes of supplies, etc.

The day a patient has a rare unfortunate event such as going into lifethreatening tach from anxiety, 300ml blood loss due to a guy who bagged an artery he can't promptly stat, anaphylactic reaction to lidocaine/valium, etc during something "simple" like an office hammertoe, bunion, plantar fasciotomy, boob job, nose job, etc then you will (or at least should) see that doctor sued for everything he has... and hopefully, his license yanked. Also, many offices that do too many procedures may not even have the proper/required equipment (AED, non-expired crash cart meds, etc) or IV access, which are 100% essentials if **** hits the fan.

 

[NatCh]

I take my patients to the O.R. for almost everything (not counting minor procedures such as ingrown nails and warts). Having proper sedation, support staff, and sterility just makes things go more smoothly.

Pretty much the only in-office surgery I'll do is a flexor tenotomy for a mild, reducible hammertoe. If you are comfortable with managing an ingrown nail in the office, then you can do a flexor tenotomy since it involves just a little work with a 15 blade and some sutures. The patient is happy too because it takes what would've been a $5000 O.R. case (think surgeon's fee, O.R. fee, Anesthesia fee, PCP H&P fee) down to a $500 10 minute office procedure.

Safety is important but overkill is wasteful. I knew a VA Attending who was adamant about doing ALL ingrown nail procedures in the O.R. Imagine being a patient and getting bills totalling $5000 for your ingrown nail! Meanwhile, your neighbor got his fixed for $500 same-day in the office. Cripes. At least as a profession we don't hospitalize for a week after a bunionectomy any more.

I will add though that I've known some docs who have done numerous Austin bunionectomies and PIPJ arthroplasties in the office without any more issues than they had in their hospital cases. I'm too cautious/chicken to do that.

 

[jonwill]

It seems to me like a lot of foot and ankle surgical procedures are just done in an office, like bunions, and not much F+A procedures are full blown OR surgeries. Are there a good number of O.R surgeries in podiatry?

I tried looking up foot and ankle procedures on youtube and all I found were little surgeries done in an office, nothing big really.

All the surgeries I have done have been in hospitals or surgery centers. In the past, some pods did simple things like hammertoes and SIMPLE bunions (there are many different types of bunionectomies and some or fairly complex) in "procedure rooms" in their offices and some still may do so. But you're not going to see a calcaneal fracture or a flat foot reconstruction done in an office.

I did two ankle fractures yesterday that would have been difficult to do in an office! Especially with the general anesthesia

 

[Feli]

...Pretty much the only in-office surgery I'll do is a flexor tenotomy for a mild, reducible hammertoe. If you are comfortable with managing an ingrown nail in the office, then you can do a flexor tenotomy since it involves just a little work with a 15 blade and some sutures. The patient is happy too because it takes what would've been a $5000 O.R. case (think surgeon's fee, O.R. fee, Anesthesia fee, PCP H&P fee) down to a $500 10 minute office procedure...

One of the Podiatry Institute guys (Dr. Stapp in GA) has a neat trick to do a HT flexor tenotomy with an 18g needle. It's actually pretty slick... and you don't even need to suture since all you have is a <1mm puncture from the needle tip. I got to see pics and then practice it in their wet lab during my clerkship there. Definitely unique and smart thinking.

Their seminars are pretty cool; I did FtMyers/Sanibel last year and will again this year. Stapp has a PPT on his office tenotomy technique that I think you'd see or hear about if you ever go to their seminars that he's speaking at (maybe Park City, Napa, or Portland next year are closest to you?). There's also San Diego yet to come this year, but I think that'd mostly be the west coast PI guys lecturing...
http://www.podiatryinstitute.com/2009_seminars.html

 

[NatCh]

One of the Podiatry Institute guys (Dr. Stapp in GA) has a neat trick to do a HT flexor tenotomy with an 18g needle. It's actually pretty slick... and you don't even need to suture since all you have is a <1mm puncture from the needle tip. I got to see pics and then practice it in their wet lab during my clerkship there. Definitely unique and smart thinking.

Their seminars are pretty cool; I did FtMyers/Sanibel last year and will again this year. Stapp has a PPT on his office tenotomy technique that I think you'd see or hear about if you ever go to their seminars that he's speaking at (maybe Park City, Napa, or Portland next year are closest to you?). There's also San Diego yet to come this year, but I think that'd mostly be the west coast PI guys lecturing...
http://www.podiatryinstitute.com/2009_seminars.html

That 18g method is pretty clever. I often make a V-to-Y lengthening incision though, so I do it open.

I like the PI seminars. I go to the Park City one often. Great snowboarding in between lectures! I'm going again this next Feb., so if anyone else here attends, say "hi."

 

[NatCh]

All the surgeries I have done have been in hospitals or surgery centers. In the past, some pods did simple things like hammertoes and SIMPLE bunions (there are many different types of bunionectomies and some or fairly complex) in "procedure rooms" in their offices and some still may do so. But you're not going to see a calcaneal fracture or a flat foot reconstruction done in an office.

I did two ankle fractures yesterday that would have been difficult to do in an office! Especially with the general anesthesia

Imagine doing a rearfoot recon. in the office! What a mess. I heard of a guy in AZ who didn't have hospital privileges and tried to do an Austin in his office. It took "only" 8 hours. Uyyyyy!

One of my business Partners does international medical missions every few years. He's done cavus foot recons in a tent! Yikes. Thank goodness our medical standards are pretty high here in the U.S.

When you think about it, an O.R. is just a very clean room filled with talented people and some expensive equipment. Who's to say those same talented people couldn't do those same procedures in any clean room (or even outside - battlefield medicine?) with the same equipment? Microchips and semiconductors get cleaner rooms than surgical patients.

As a patient I'd be uncomfortable with the idea of anyone suggesting we do anything more than a hammertoe in the office when a perfectly good O.R. is available. I wonder if rural docs do more office surgery? If the nearest O.R. is four hours away and money is tight, then one might be tempted. They could bite on a chunk of leather for anesthesia.

Okay, heading to the kitchen to make double cappucino number 3 now...

 

[whiskers]

Bunions and hammer toes, the podiatric bread and butter surgeries are relatively minor procedures.

Even ankle fractures are junior orthopaedic resident cases.

What were you expecting, a 12 hour bunionectomy in the OR?

 

[krabmas]

Bunions and hammer toes, the podiatric bread and butter surgeries are relatively minor procedures.

Even ankle fractures are junior orthopaedic resident cases.

What were you expecting, a 12 hour bunionectomy in the OR?

There is a reason that trauma cases are lower level resident cases. Patient expectation is lower. In the ortho world anyway.

Elective cases are typically private patients w/ higher expectations.

IMO - Toes are hard and as a first year your fine muscle motor motion is not yet ready for doing toes. Toes should be a 2nd year or higher procedure.

If you look at orthopedic training they start w/ large surgery - Hips, knees, femurs. They then move to smaller areas - ankles, heels, wrists, hands, toes...

If it were my decision I would let 1st year residents start learning on rearfoot and ankle then move to bunions and toes.

Just my 2 cents.

 

[SportPOD]

There is a reason that trauma cases are lower level resident cases. Patient expectation is lower. In the ortho world anyway.

Elective cases are typically private patients w/ higher expectations.

IMO - Toes are hard and as a first year your fine muscle motor motion is not yet ready for doing toes. Toes should be a 2nd year or higher procedure.

If you look at orthopedic training they start w/ large surgery - Hips, knees, femurs. They then move to smaller areas - ankles, heels, wrists, hands, toes...

If it were my decision I would let 1st year residents start learning on rearfoot and ankle then move to bunions and toes.

Just my 2 cents.

👍
Interesting you would say that, I completely agree with you on that point!

 

[Feli]

There is a reason that trauma cases are lower level resident cases. Patient expectation is lower. In the ortho world anyway.

Elective cases are typically private patients w/ higher expectations....

Very good points, and I never understood this way of thinking.^ If you fix trauma well in the first place (restore anat/alignment well), then statistics repeatedly tell us that there are a lot fewer problems years later.

When I state that, IMO, trauma is the hardest surgery and that elective is just controlled trauma, a lot of students/classmates ask "but I thought trauma was easy? Isn't reconstructive and elective surgery the hard part?"

I ask them what the most common indication for an STJ fusion is (post calc fx arthritis). I ask them what the most common indication for an ankle fusion is, etc etc etc. "Ohhh, I see what you're saying" usually follows.

 

[krabmas]

Very good points, and I never understood this way of thinking.^ If you fix trauma well in the first place (restore anat/alignment well), then statistics repeatedly tell us that there are a lot fewer problems years later.

When I state that, IMO, trauma is the hardest surgery and that elective is just controlled trauma, a lot of students/classmates ask "but I thought trauma was easy? Isn't reconstructive and elective surgery the hard part?"

I ask them what the most common indication for an STJ fusion is (post calc fx arthritis). I ask them what the most common indication for an ankle fusion is, etc etc etc. "Ohhh, I see what you're saying" usually follows.

It depends on the fracture. Some will go on to fusion no matter who fixes them.

This morning one of my co-residents on Ortho trauma now got a call to the ER for an open fracture.

The guy was rock climbing on a rock wall and forgot to hook his carbeaner to the rope and was alone. He climbed up 25 feet w/out a rope on a rock wall and had no way down. He held on as long as he could then let go.

he landed on his feet it would seem and sustained a pilon fx on L, L2 and L3 fx, calc fx on R.

The pilon was pretty minor. a medial mal fx and one fx thru the joint at the plafond.

THe calc fx on the other hand looked like a the calc blew out into chunks and little tiny pieces. The talus was sitting between the pieces of the cortex of the calcaneus and it was open plantarly.

For now he is in an ex-fix to maintain length.

This guy will probably not be rock climbing anymore. He will be lucky to keep his leg.

 

[NatCh]

The guy was rock climbing on a rock wall and forgot to hook his carbeaner to the rope and was alone.

He forgot to clip in? No wonder he can't find any climbing buddies.

 

[kmyprimeval]

about a year ago, i would not even understand half of the language you guys are using. Today, I am able to keep up with a majority of the terms/vocabularies that you guys are using on these forums for Pod surgery....this is awesome (for me anyways)

 

[Feli]

It depends on the fracture. Some will go on to fusion no matter who fixes them.

This morning one of my co-residents on Ortho trauma now got a call to the ER for an open fracture.

The guy was rock climbing on a rock wall and forgot to hook his carbeaner to the rope and was alone. He climbed up 25 feet w/out a rope on a rock wall and had no way down. He held on as long as he could then let go.

he landed on his feet it would seem and sustained a pilon fx on L, L2 and L3 fx, calc fx on R.

The pilon was pretty minor. a medial mal fx and one fx thru the joint at the plafond.

THe calc fx on the other hand looked like a the calc blew out into chunks and little tiny pieces. The talus was sitting between the pieces of the cortex of the calcaneus and it was open plantarly.

For now he is in an ex-fix to maintain length.

This guy will probably not be rock climbing anymore. He will be lucky to keep his leg.

I totally understand what you are saying on the level 1 trauma situations. As I'm sure you know, Sanders, in his orig article 15yrs ago, suggested that cat4 calcs were bad news even if you somehow restored alignment. He suggested primary STJ arthrodesis in some cat4s, an option I think a lot of trauma ortho and pods might consider today. I'd be curious to know if the patient you speak of gets a left STJ AD when they ORIF the L calc and R pilon.

I've also ready primary AD suggested in many other intra-articular foot fractures... Lisfrancs, cuboid fx, even first MPJs.

What frustrates me is the clinic patients I've seen who come in with pretty routine trauma that was handled poorly at St Elsewhere. We had one of those in my school clinic last week. PER-3 six months post, and her talus was still translated way lateral on the tib... medial clear space was probably >9mm when we measured it on the digi XR. Her medial malleolar avulsion fx hadn'e even been addressed; they just plated the fibula and put in a transsyndesmotic screw (which was now backing, dehiscing, and growing MRSA at the wound site out since they didn't remove it before WB). You really feel bad for the patient in situations like that.

In school clinics and clerkships, I've also seen Hawkins 2s that were just casted (surprise... AVN!), multiple midshaft met fractures that were perc pinned and allowed to weightbear in a surgical shoe, and many of the craziest ankle alignments that make you simply say "WTF were they doing in the OR?"

Sure, posttraumatic complications happen to even good surgeons, but the lit shows us that the complications happen a lot more when the original fix was subpar. That is understandable in highly destructive pilons, calcs, and lisfrancs where the literature shows that even good alignment still has a decent chance of a bad result. In pretty routine ankles, met fx, or intrarticular foot fx need to either be handled properly or sent to someone who can, though. I'm not sure if it's egos getting in the way or just a lack of properly trauma trained docs (both pod and ortho) out there, but either way, it's bad for patient outcomes - and unfortunately, most trauma patients are fairly young with a lot of (potentially arthritic) years ahead of them.

Wanna see some truly rediculous stuff? Yes, this is a most extreme case of bad trauma fix... these are post-ops (and pre-ops for the DPMs at the hospital). This lady fx her ankle in the Caribbean, had it fixed there, and now she's in a Miami ER a month later having medial mall pains/wound for some reason...

 

[krabmas]

I totally understand what you are saying on the level 1 trauma situations. As I'm sure you know, Sanders, in his orig article 15yrs ago, suggested that cat4 calcs were bad news even if you somehow restored alignment. He suggested primary STJ arthrodesis in some cat4s, an option I think a lot of trauma ortho and pods might consider today. I'd be curious to know if the patient you speak of gets a left STJ AD when they ORIF the L calc and R pilon.

I've also ready primary AD suggested in many other intra-articular foot fractures... Lisfrancs, cuboid fx, even first MPJs.

What frustrates me is the clinic patients I've seen who come in with pretty routine trauma that was handled poorly at St Elsewhere. We had one of those in my school clinic last week. PER-3 six months post, and her talus was still translated way lateral on the tib... medial clear space was probably >9mm when we measured it on the digi XR. Her medial malleolar avulsion fx hadn'e even been addressed; they just plated the fibula and put in a transsyndesmotic screw (which was now backing, dehiscing, and growing MRSA at the wound site out since they didn't remove it before WB). You really feel bad for the patient in situations like that.

In school clinics and clerkships, I've also seen Hawkins 2s that were just casted (surprise... AVN!), multiple midshaft met fractures that were perc pinned and allowed to weightbear in a surgical shoe, and many of the craziest ankle alignments that make you simply say "WTF were they doing in the OR?"

Sure, posttraumatic complications happen to even good surgeons, but the lit shows us that the complications happen a lot more when the original fix was subpar. That is understandable in highly destructive pilons, calcs, and lisfrancs where the literature shows that even good alignment still has a decent chance of a bad result. In pretty routine ankles, met fx, or intrarticular foot fx need to either be handled properly or sent to someone who can, though. I'm not sure if it's egos getting in the way or just a lack of properly trauma trained docs (both pod and ortho) out there, but either way, it's bad for patient outcomes - and unfortunately, most trauma patients are fairly young with a lot of (potentially arthritic) years ahead of them.

Wanna see some truly rediculous stuff? Yes, this is a most extreme case of bad trauma fix... these are post-ops (and pre-ops for the DPMs at the hospital). This lady fx her ankle in the Caribbean, had it fixed there, and now she's in a Miami ER a month later having medial mall pains/wound for some reason...

I really do not understand why she is having pain. According to Meyerson's five things to look at to reduce an ankle this seems well aligned to me. 😱

There are so many cases of trauma fixed badly. We see it all the time here. You sort of think - what the F were the other surgeons thinking? Are they even ortho surgeons?

But every time you see trauma gone bad do you all the sudden lump all orthos together and say I wouldn't want an ortho to fix me if I break? No, you just try to avoid that one surgeon.

Why is that not the same for podiatry?

 

[jonwill]

I totally understand what you are saying on the level 1 trauma situations. As I'm sure you know, Sanders, in his orig article 15yrs ago, suggested that cat4 calcs were bad news even if you somehow restored alignment. He suggested primary STJ arthrodesis in some cat4s, an option I think a lot of trauma ortho and pods might consider today. I'd be curious to know if the patient you speak of gets a left STJ AD when they ORIF the L calc and R pilon.

I've also ready primary AD suggested in many other intra-articular foot fractures... Lisfrancs, cuboid fx, even first MPJs.

What frustrates me is the clinic patients I've seen who come in with pretty routine trauma that was handled poorly at St Elsewhere. We had one of those in my school clinic last week. PER-3 six months post, and her talus was still translated way lateral on the tib... medial clear space was probably >9mm when we measured it on the digi XR. Her medial malleolar avulsion fx hadn'e even been addressed; they just plated the fibula and put in a transsyndesmotic screw (which was now backing, dehiscing, and growing MRSA at the wound site out since they didn't remove it before WB). You really feel bad for the patient in situations like that.

In school clinics and clerkships, I've also seen Hawkins 2s that were just casted (surprise... AVN!), multiple midshaft met fractures that were perc pinned and allowed to weightbear in a surgical shoe, and many of the craziest ankle alignments that make you simply say "WTF were they doing in the OR?"

Sure, posttraumatic complications happen to even good surgeons, but the lit shows us that the complications happen a lot more when the original fix was subpar. That is understandable in highly destructive pilons, calcs, and lisfrancs where the literature shows that even good alignment still has a decent chance of a bad result. In pretty routine ankles, met fx, or intrarticular foot fx need to either be handled properly or sent to someone who can, though. I'm not sure if it's egos getting in the way or just a lack of properly trauma trained docs (both pod and ortho) out there, but either way, it's bad for patient outcomes - and unfortunately, most trauma patients are fairly young with a lot of (potentially arthritic) years ahead of them.

Wanna see some truly rediculous stuff? Yes, this is a most extreme case of bad trauma fix... these are post-ops (and pre-ops for the DPMs at the hospital). This lady fx her ankle in the Caribbean, had it fixed there, and now she's in a Miami ER a month later having medial mall pains/wound for some reason...

That's what my last few ankles have looked like!!