PeaJay

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There are very few programs that supply adequate training to be fully proficient in trauma and TAR. (Exceptions do exist) If these topics are your interest you are best served by going to a solid program and then follow up your three years with an exceptional fellowship.

The people that do not go to an exception program who come out of training and think they can slap in a TAR or manage a calc fx are crazy.

Management of calcaneal fractures require a mastery of fixation technique and tissue handling. A minimum volume is required to maintain competency so doing one here or there will get you in big trouble.

Specifically regarding TAR, there is a huge learning curve with each aspect of care. There is a curve with each system as well as with operative technique, patient selection, and postoperative management. A huge difference exists between being physically capable of putting in a TAR and having the experience and knowledge to do so. Beyond being able to manage TAR you must be ready to handle failure. Or you can skip all this and refer to a center of excellence.
 
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ldsrmdude

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In addition to the above comments, which I totally agree with, I would just add that there are more programs where you can get good exposure to TAR or trauma, but it's a rare program that would give you adequate exposure to both. I'd venture that there are more programs that give excellent trauma exposure than excellent TAR exposure. If you want to be strong in both I would pick a residency strong in trauma and do a fellowship that is strong in TAR or the other way around
 

ldsrmdude

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If you go to a residency program that offers high quality training in trauma but very little or low quality in everything else I think you will find yourself disappointed with your career options. Because your expectations (from previous residency training and experiences) won't coincide with what's out there in reality.
Good point, and it's one that is tough for a lot of students/residents to realize and/or accept. There are clearly exceptions, but most jobs out there are vastly different from the residency experience
 

dtrack22

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I'm going to play devil's advocate since I think you guys are missing what is probably the most important point regarding residency training...

There are very few programs that supply adequate training to be fully proficient in trauma and TAR. (Exceptions do exist) If these topics are your interest you are best served by going to a solid program and then follow up your three years with an exceptional fellowship
why do you need to do a fellowship in order to perform procedures being done by a bunch of other non-fellowship trained podiatrists? How many TARs did Schuberth do in residency? And if he didn't do any TARs in residency and he didn't do a year long fellowship after residency, how on earth can he possibly do the procedure today? I get that if you have an interest (and lets pretend that interest won't change after residency) you would be wise to go to a program that has emphasis in said interest, but for some reason there is this pervasive thought amongst (especially) students and (to a lesser extent) residents that you need to do something in residency in order to do it in practice.

The people that do not go to an exception program who come out of training and think they can slap in a TAR or manage a calc fx are crazy.
Exactly my point. You absolutely can go to a residency program that develops strong clinical and surgical skills/thought process and slap on a TAR. Graduates from our program (lots of trauma, few TARs) put TARs in patient's their first year out routinely. One of our recent graduates who's been practicing for a month has a TAR coming up in a few weeks, he only did one or two by himself in residency and he'll be using a different system this go around. I'm sure the same can be said for many other procedures by graduates from other programs.

As someone looking at jobs now I can tell you most hospital systems and Orthopaedic groups don't see you as an entity that handles LE trauma. They see you as someone who can pump out elective recon procedures, bunions, hammertoes, wounds, orthotics, etc.
This will be a good thread when someone starts it (job search tips/tricks/etc), but orthopedic groups who are ok hiring podiatrists absolutely do expect you to do foot and ankle trauma...that's why they hired you, so that they don't have to do calcs anymore. Hospitals are much more dependant on the system and can be anywhere from "anything foot and ankle from our other providers and our ED is yours" to "ortho gets ED trauma referrals and you take ingrown toenails and foot wounds."

So choose wisely what you want out of your residency training. Those are the skills you will have for life.
I may be taking this out of context but this is exactly right. You should be going to a program that provides you with good "skills." Someone with good hands and enough clinical experience to manage post-op problems can do any elective foot and ankle procedure that they want, TAR included.

A residency that focuses on trauma, forefoot elective, TAR, etc. doesn't really matter. Gaining clinical experience in managing operative patients and surgical skills in the OR is whats most important. Well, other than going to an RRA program, since there are still hospitals that won't grant you certain privileges without it and there is no way to get it without going through residency again. Getting back on topic...If you think that you are going to get to see and do every foot and ankle procedure imaginable, during 3 years of residency, you are an idiot. I mean, you guys realize that many of the individuals teaching current residents did a year or two of residency? With a more limited scope and fewer privileges? Go to a program that provides you with the best clinical and surgical "skills", which is probably dependant on your learning style, that you can get. Simple.
 
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PeaJay

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I hope the “pervasive thought” comment was not pointed in my direction. Despite what is listed below my avatar, I am well into my training.


Despite the differences in our opinions, I could not agree more with your underlying message. Students should not choose a program based on being exposed to one procedure (TAR). The focus should be on just what you stated, “a residency program that develops strong clinical and surgical skills/thought process”. If everyone would focus on gaining a sound foundation of clinical judgment and surgical acumen our profession would be much better than it is today. A solid base will allow a provider to handle many situations/procedures that they did not encounter often or even at all during residency. What you did not state is that additional training in the form of meetings/seminars/industry events is often needed or prudent to help prevent common mistakes. No one should barge into something just because they have a strong foundation.

I would argue your comments regarding providers that only had one or two year of residency and are now well known surgeons/educators. These individuals were often 2 yr trained in a time of 1 yr training or 3 yr trained in a time of 1 and 2 yr training. While many are not 3 yr or fellowship trained, they had far from minimal training. Beyond this point, these forefathers trained and practiced in a far different environment. TAR was far newer and had many more unknowns during earlier times. The climate was accepting of long learning curves and complications in general. They did not have the luxury of having further training to perform the procedure because quite frankly the opportunities were very few.

While I agree that any graduate with sound clinical judgment and surgical skills can technically perform a TAR, I doubt they have yet to fully develop the acumen to head off mistakes mundane to TAR. In my mind, it is best for a patient to have a surgeon that not only has sound skills but also the experience of dealing with the issues that will arise. The ability to perform the surgery is not the issue. There needs to be experience seeing complications so that you can manage them before something catastrophic happens. This experience can come by having scars on the street or by further training. Which is more ethical?
 
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janV88

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I would tend to agree with dtrack on this coming from a similar program of a lot of trauma / rear foot ankle and low TAR. Go to a program with a solid and diverse surgical foundation. You don't need to perform every single foot and ankle surgery in residency to be able to perform them in practice. I have solid training in ankle fx, pilon fx, fusions, tendon- ligamentous balancing, osteotomes, etc but only 2 TARs. That won't stop me from doing them in the future. Just like I won't hesitate doing a opening or closing base bunion, even though I've only done 1 of each, if it's what's best for the patient.
 
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PeaJay

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I would tend to agree with dtrack on this coming from a similar program of a lot of trauma / rear foot ankle and low TAR. Go to a program with a solid and diverse surgical foundation. You don't need to perform every single foot and ankle surgery in residency to be able to perform them in practice. I have solid training in ankle fx, pilon fx, fusions, tendon- ligamentous balancing, osteotomes, etc but only 2 TARs. That won't stop me from doing them in the future. Just like I won't hesitate doing a opening or closing base bunion, even though I've only done 1 of each, if it's what's best for the patient.
I guess at the the end of the day either of our opinions is justified so long as individuals recognize their limits when they reach them and do what is best for the patient.

Addendum: BTW...JanV88 and dtrack if you refer back to my first post in this thread, I would think your residencies fall into the exception category. Most programs do not offer the training that you guys receive.
 
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dyk343

TAR 14.5 RVU
OR Time 2.5-3 hrs? (I don't have tons of experience)

I&D below the fascia 6RVU
Bone Biopsy 3 RVU
Delayed primary closure 12 RVU
I&D with delayed primary closure = 21RVU
OR time 1-1.5hrs

Bunion (Kalish or any head procedure) 8 RVU
Hammertoe 5 RVU
Weil 5 RVU
Forefoot slam (bunion, 4 HT, 1 weil) = 33 RVU
OR time ~2-2.5 hrs

MDCO RVU 10
Evans RVU 10
Cotton RVU 10
Gastroc RVU 6.5
FF recon = 36.5 RVU
OR Time ~2-2.5hrs

If anyone wants my future TAR patients and the long list of complications/risks you can have them.

If an I&D goes south its a salvage case to start with. Pretty hard to get sued.

Forefoot procedures and some of the more common recon is pretty straightforward, pays better, and results are typically good and far less risky than TAR.
 
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dtrack22

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This experience can come by having scars on the street or by further training. Which is more ethical?
This thinking makes much of residency unethical. At least if you are at a program where the resident is actually doing the cases...

Oh and don't ever work with Schuberth for a period of time because he (by nature of doing so many TARs) has some horrendous results. So many scars. And a few prosthetics.

And that's if you can even get your hands on those cases! If you are working for a podiatry group good luck getting those cases. Those fractures are going to the university hospital and getting fixed by the ortho traumatologist or foot and ankle fellowship trained ortho.
Completely missing my point re: trauma in residency. Maybe janv said something I missed. Trauma isn't beneficial in residency because you are going to a lot of it in practice. Trauma is beneficial because of soft tissue and dissection considerations. Because of reduction and fixation principles learned. Because it's not cookie cutter and you have to make more intra-operative decisions than you do in a huge majority of your elective cases. Because you are more likely to have post-operative complications compared to a case when you work on unswollen skin in a patient who you got to select, and you have to learn to deal with those complications if your program is set up to do so. Because trauma heavy programs tend to be at places where the residents have more autonomy than your average podiatry program. It has nothing to do with how many communited naviculars and open calcs and forefoot crush injuries you're gonna get in practice. And I've never said that it's better than recon, in fact my whole point was that it doesn't really matter what the programs emphasis is. Again, it's about skills and many programs with many different emphases can give you those skills. Go to the best one you can.

So let me get this straight...because you guys have great skills and technically can utilize those skills to put in a TAR...what happens when you run into complications? Who are you going to lean on for advice?

....

TAR is still unchartered territory in my book. There is a lot we don't know. Despite having great skills these leaders of our professions do revisions on their patients all the time. It is those experiences which make me feel more comfortable about attempting to perform this procedure during my career.
I'll preface this by saying that the only thing having good surgical AND clinical training without doing a ton of TARs is going to limit in my practice will be the the indications in which I put them in. Meaning, the folks mentioned who do a lot of these put them in people that don't meet the most rigid of criteria, they are pushing the boundaries, more power to em. I will still put them in, just with less frequency and tighter inclusion criteria in my patient selection...until the implants themselves improve.

As for complications, I will deal with the complications just like I do when any case that I did comes in to the clinic (we actually see and treat all our post-op patients which is one of the benefits to our otherwise busy and inefficient clinic). And I'll lean on the same types of people that the aforementioned TAR gurus did when they were starting out. Other people who are putting them in. I mean, if you guys think that you can only do cases that you had significant exposure to in residency and that you'll never talk to friends, former attendings, random docs you meet at workshops and conferences for help and advice...I can't help you.
 
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PeaJay

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dtrack,

First off I am glad to hear you follow your patients. I feel that is something that is truly lacking at a lot of "high power" programs. It will surely pay dividends having that experience.

Also I think you make a good argument, but you are an exception, not the rule. Most graduates do not have the experience that you have. The point I think AnkleBreaker and myself are trying to make is that someone graduating from joe's bunion shack should not go out and think they can do TARs. They probably can figure their way through it, but there is going to be unneeded collateral damage.

And to throw a wrench in this mix. Despite me being a proponent of TAR, we all know fusion is the gold standard right?
 
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MarquetteGuy

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Ankle fusion.......what's that?

I know this comment is made somewhat tongue-in-cheek, but I would mostly agree with this. When treating end-stage ankle DJD in my practice (and I treat a lot of ankle DJD, relatively speaking), I have really transitioned to mostly TARs and very few ankle fusions. A patient must have a significant contraindication to not favor a TAR over an ankle fusion. If I'm being honest with myself, my TAR patients certainly do better than my ankle fusion patients. It's a much quicker recovery (barring any complications), and functionally they do better and are happier. It's not to say that an ankle fusion does poorly, but from a functional standpoint, the TAR does better. This is proven in the literature, and I can certainly attest to this with my firsthand experience in my own practice.
 

dtrack22

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Also I think you make a good argument, but you are an exception, not the rule. Most graduates do not have the experience that you have. The point I think AnkleBreaker and myself are trying to make is that someone graduating from joe's bunion shack should not go out and think they can do TARs. They probably can figure their way through it, but there is going to be unneeded collateral damage.
You are describing something outside of the constraints of the discussion, at least as far as my posts are concerned. Of course someone from a below average program (Joe's bunion shack) should not go out and slap TARs in their patients. But that person didn't get the clinical and surgical management experience of operative patients that I'm talking about. Which was really my original point, number of TARs or trauma your program does isn't as important as the clinical and surgical skills your program develops. I think there are plenty of programs across the country that do give you those experiences and skills. How many programs in our profession do that is certainly up for debate, and we could have that discussion (though we'd all just be guessing). While I do think my training is in the upper echelon within our profession, there are programs all over the country that are pumping out equally well trained/talented/etc podiatrists (or foot and ankle surgeons for all the acfas folks who may read this). Most of whom will do many a procedure that they got little exposure to in residency. They'll do it just like everyone did before us and most patients will be better for it.

Ankle fusion.......what's that?
It's just something to take down and put a TAR in
 
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janV88

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Even if you did manage to get those high energy trauma cases. If one of your patients goes somewhere else and ends up in an anti-DPM ortho office you can bet your bottom dollar you are going to get sued.
We both know that this could happen with any type of complication regardless of the procedure. And I'm willing to bet it will be more common with a TAR than high energy trauma.

One thing I learned from my Ortho trauma attending about bad pilons, calcs, and talar neck fxs is...these patients are f---ed if you do and f---ed if you don't. Much of the damage was done by the actual trauma and complications occur regardless of technique. BTW he sends all his LE trauma to the pod service.


Regarding TAR implant improvements, etc. Much of the problem with TARs isn't so much the implant but the anatomy of the ankle it self. In addition I'm willing to bet that in the next 15-20 years, biologic total joints will make them obsolete.
 
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As someone who is familiar with the training that dtrack, janV, and ankle breaker are all getting, (especially dtrack), I don't want to do TARs. Ever. After AO advanced, Schuberth showing his complications, seems awful. I would love to do trauma in private practice, but if I don't have that opportunity, the skills I have learned from doing lots of trauma in residency will certainly help me put a k wire in a hammer toe.
 
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