True Stories From Podiatric Residency

[jonwill]

Presented at an international Orthopaedic meeting in Leeds, UK last Thursday and Friday and staying for another week for vacation so I don't have any good OR stories from the last week.

Sounds fun. We met a lot of Brits at the limb deformity course in Baltimore.

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[krabmas]

Presented at an international Orthopaedic meeting in Leeds, UK last Thursday and Friday and staying for another week for vacation so I don't have any good OR stories from the last week.

Awesome.

Is that something that your program does regularly or how did you get selected?

 

[Foot Doc]

Awesome.

Is that something that your program does regularly or how did you get selected?

It was based off of research I've done with one of the Ortho Trauma MD's at Univ of Louisville.....just happened to be working on a project and then submitted it and got it selected.

I presented at the same conference last year when it was in Nuremberg, Germany. Good Times

I fly back to Louisville in the am.

 

[krabmas]

It was based off of research I've done with one of the Ortho Trauma MD's at Univ of Louisville.....just happened to be working on a project and then submitted it and got it selected.

I presented at the same conference last year when it was in Nuremberg, Germany. Good Times

I fly back to Louisville in the am.

That sounds really awesome!

 

[Feli]

Got to assist with a minimally invasive endoscopic tibial plateau fx repair today... motorcycle accident.
Out of DPM scope, but good experiece and food for thought when applying those principles for calc, pilon, etc fx.

Also put 5th cast in 5wks on noncompliant clinic pt with 5th met base fx

 

[krabmas]

I finally got to do an arterial repair.

Wrist lac w/ radial artery lac repaired w/ 6.0 prolene. Very exciting for me. I've seen many but this was the 1st one that I got to do!

 

[cool_vkb]

Got to assist with a minimally invasive endoscopic tibial plateau fx repair today... motorcycle accident.
Out of DPM scope, but good experiece and food for thought when applying those principles for calc, pilon, etc fx.

Also put 5th cast in 5wks on noncompliant clinic pt with 5th met base fx

Just out of curosity to educate myself for future. can you please elaborate more on this technique and fxs of tibial plateua. plzz.

i never thought of that scenario. i mean its a flat surface and i always assumed proximal tibia (mainly knee area) is mostly the site of sprains, tears,ruptures etc but didnt thought of fractures.

Do you think you can use that endoscoping technique in the tibial plafond fracture?

 

[jonwill]

Did a plantar fasciotomy, ankle scope, and finished off with a calcaneal fracture.

 

[Feli]

...Do you think you can use that endoscoping technique in the tibial plafond fracture?

That's what I was suggesting. There are a few papers out regarding use of ankle scope to assist with ankle, or esp pilon, fx repairs. There's also STJ scoping during calc fx repairs. Just like the tibial plateau I was in on yesterday, the idea is just to use the scope to see the joint surface, recognize stepoffs, defects, etc and debride or excise damaged cartilage fragments better than you could with just intra-op XR... and with less incisions and soft tissue damage than traditional open approach.

For the plateau, it was neat since you could see just where the tips of the guide pins were hitting, that the screws were engaging, etc without opening up the joint widely.

 

[krabmas]

That's what I was suggesting. There are a few papers out regarding use of ankle scope to assist with ankle, or esp pilon, fx repairs. There's also STJ scoping during calc fx repairs. Just like the tibial plateau I was in on yesterday, the idea is just to use the scope to see the joint surface, recognize stepoffs, defects, etc and debride or excise damaged cartilage fragments better than you could with just intra-op XR... and with less incisions and soft tissue damage than traditional open approach.

For the plateau, it was neat since you could see just where the tips of the guide pins were hitting, that the screws were engaging, etc without opening up the joint widely.

I have seen the papers you speak of and there is one that recomends that all ankle fractures get scoped due to the high (70-80%) incidence of OCD and loose bodies found in the joint. This paper also recommends only spending 20 minutes on the scope and then moving on. (I do not recall the authors)

The other thing to think about is the soft tissue envelope. If you are not skilled with the scope, and you spend too much time, and the soft tissue envelope swells - which is already swollen from injury, with just enough wrinkle to allow the surgery, that could be detrimental to your soft tissue envelope.

Just something to think about.

In the knee this is completely different, there is more room for swelling, and some of the tibial plateau fx like the purely spine fractures that are avulsive from the cruciate ligaments can be repaired with the ACL jig and arthroscopically. Even the ones that need to be opened distally could still be scoped due to the better soft tissue envelope at the knee.

 

[krabmas]

Just out of curosity to educate myself for future. can you please elaborate more on this technique and fxs of tibial plateua. plzz.

i never thought of that scenario. i mean its a flat surface and i always assumed proximal tibia (mainly knee area) is mostly the site of sprains, tears,ruptures etc but didnt thought of fractures.

Do you think you can use that endoscoping technique in the tibial plafond fracture?

Just for your info look up - Schatzker tibial plateau fx classification. This is one that is fairly useful and agreed upon by orthopedic traumatologists.

 

[krabmas]

Last reply for now - I think.

Yesterday - ankle scope and christman snook (sp?)

And another random thought...

Yesterday I was reading one of Hanson's foot surgery books and he compares calc fx's to pelvic fx's. The reason that I find this interesting is that...

The only orthopods that are truely qualified to surgically treat pelvic and acetabular fx's are those that did trauma fellowships (usually).
He compares the irregular joint surfaces and the difficulties of exposure.

I's sure some of you have read this but I just wanted to mention it so students would understand the gravity of the injury and treatment.

Ok - I think I am done for the evening.

 

[Foot Doc]

I have an INBONE TAR this Tuesday

 

[Foot Doc]

I have an INBONE TAR this Tuesday

damn it cancelled

 

[jonwill]

damn it cancelled

thumbdownthumbdownthumbdown

 

[Feli]

GSW to the foot Friday, on Abx for a bit, maybe ORIF later next week...

 

[krabmas]

Started Georgetown last week.

Wounds, wounds, wounds.

Apligraf, integra, Xenograft, skin graft

I&D, debridement, I&D, debridement

Drainage amp, toe amp, trans met, choparts

occasional primary closure

It is fun though!

 

[jonwill]

Started Georgetown last week.

Wounds, wounds, wounds.

Apligraf, integra, Xenograft, skin graft

I&D, debridement, I&D, debridement

Drainage amp, toe amp, trans met, choparts

occasional primary closure

It is fun though!

Puss Princess???!!!

 

[Feli]

Got to see a SutureBridge for superior/retro calc exostosis yesterday... just me and the attending scrubbed in. Didn't get the C, but still a cool case to be first assist on. Also flushed and pinned an open hallux IPJ dislocation yesterday; got the C on that one for my first C log for a trauma surg procedure (yah, yah... I know it's just just digital, but I'm a newbie and it's cool to get any C surg case that's not I&D)

I'm up to around 60B and 20C procedures in just 5wks on pod surg service...
...and I've still got about 81wks of scheduled pod surg service left in my 3yrs, so I think I might reach my minimum numbers to graduate

 

[janV88]

Awesome posts everyone! Very informative and also entertaining. Keep up the good work!

Quick question...What are the minimum number of A, B, and C cases needed to graduate?

 

[jonwill]

Awesome posts everyone! Very informative and also entertaining. Keep up the good work!

Quick question...What are the minimum number of A, B, and C cases needed to graduate?

I think you need a total of 525 B & C with 350 being C's. And its broken up into categories like digital, first ray, soft tissue, etc.

 

[Foot Doc]

I think you need a total of 525 B & C with 350 being C's. And its broken up into categories like digital, first ray, soft tissue, etc.

yep....the big push right now is to ensure residents have both the volume and variety necessary to be well-rounded in the OR.

 

[janV88]

Good to know. Thanks!

 

[GoldenGustie]

Scrubed my first case as a student a week ago. Exostectomy of the 1st proximal phalanx. Got to hold the retractors. Though all you residents are probably chuckling I thought it was SWEET! Feels good to actually be doing something!

 

[Foot Doc]

Yesterday:
Lapidus x 2
Ankle Fusion
Brostrom
Ankle ORIF

Today:
Inbone TAR
Haglunds Excision
Ankle Scope

 

[krabmas]

Yesterday:
debridement w/ apligraf
revision BKA
debridement w/ apligraf
revision BKA


Today:
Round on 15 or so patients
bedside debridement

Tomorrow:
Round on same patients
bedside I&D

 

[Feli]

Yesterday:
debridement w/ apligraf
revision BKA
debridement w/ apligraf
revision BKA

Today:
Round on 15 or so patients
bedside debridement

Tomorrow:
Round on same patients
bedside I&D

Sounds like our 1st year when we're on floor duty. So many wounds, beads, BATs, and VACs that you'd think it's a VA.

 

[krabmas]

Sounds like our 1st year when we're on floor duty. So many wounds, beads, BATs, and VACs that you'd think it's a VA.

No, just Georgetown!

 

[GoldenGustie]

Got the opportunity to scrub an ankle fracture, isolated STJ arthrodesis from medial approach, and chevron bunionectomy

 

[gustydoc]

Got the opportunity to scrub an ankle fracture, isolated STJ arthrodesis from medial approach, and chevron bunionectomy

Did a faculty member do the ankle and STJ or was it with Barp?

 

[GoldenGustie]

I've been with Dr. Michael Lee the past 2 weeks...Its been awesome! Did an ankle scope with microfracture this week which was sweet. Also saw my first modified lapidus which was a pretty cool case.

How's DMC treating you Gustydoc? Hope you are having a great time up there!

 

[krabmas]

Today's cases:

DBT - excision 5th met, 4th met base, cuboid and peroneal longus tendon
STSG to L heel
STSG to 1st wespace with bolster dressing
DBT b/l heels
DBT ankle wound - blue/green from pseudomonas

Tomorrow:
Fillet of hallux
V-Y advancement flap

 

[Foot Doc]

just finished

calc ORIF
Ankle Fusion
STJ Fusion Revision
Shoulder I&D

 

[krabmas]

Argon Beam Coagulator - awesome!

That is all I have to say

 

[jonwill]

I had a good week. Besides the regular stuff, I did a revisional evans (non-union) with iliac crest graft, achilles tendon rupture, lapidus, and flatfoot (gastroc recession, evans, fdl transfer).

 

[krabmas]

DBT, DBT, DBT, amoutation, amputation, amputation, apligraf, apligraf, apligraf, STSG, STSG, STSG

and .... pinch graft from sinus tarsi to dorsal hallux - very exciting case for me!

Does anyone know who described the first pinch graft?

 

[doclm]

http://www.rima.org/web/bcmonline/11416.html

Reverdin (1870)

 

[jonwill]

DBT, DBT, DBT, amoutation, amputation, amputation, apligraf, apligraf, apligraf, STSG, STSG, STSG

and .... pinch graft from sinus tarsi to dorsal hallux - very exciting case for me!

Does anyone know who described the first pinch graft?

Dr. Pinch???

 

[krabmas]

http://www.rima.org/web/bcmonline/11416.html

Reverdin (1870)

nice!

Isn't that interesting useless info?

 

[jonwill]

It's been absolutely crazy around here. The program has had 65 cases in the past three days. I guess everyone is trying to squeeze their surgery in before the new year (probably for insurance purposes). I'm doing a few calcaneal fractures tomorrow morning and am not working again until Monday.

 

[jonwill]

Did a cavus foot today (DFWO, Dwyer, Longus to Brevis). Interesting case.

 

[krabmas]

Did a cavus foot today (DFWO, Dwyer, Longus to Brevis). Interesting case.

CMT?

if so, what did you do with the PTT?

 

[jonwill]

CMT?

if so, what did you do with the PTT?

No CMT, just really high arches.

 

[PADPM]

Jonwill, krabmas,

You are both in residency programs putting out "big numbers" and performing complicated cases.

Since I've been involved with resident training, and in the past we've run into problems with sometimes finding quality attendings to bring challenging cases to the program, I have a question for the two of you.

Realistically, how many attendings are actually performing the majority of the "strong" cases you are performing? Is it a very small number performing the majority of the challenging cases? Are some of these attendings members of the same group?

We have always found that although there were a very large number of attendings, it was actually about 5 that performed 90% of the surgery.

I was wondering if the majority of your RRA cases were being performed by a very small number of your attendings, or if there are actually a significant number of attendings performing that many challenging cases.

Thanks.

 

[Feli]

...Realistically, how many attendings are actually performing the majority of the "strong" cases you are performing? Is it a very small number performing the majority of the challenging cases? Are some of these attendings members of the same group?...

This was one of my key concerns when evaluating programs to rank. I was pretty concerned about the "depth chart" of attendings at residency programs and the cases/benefits that they bring. Every program has attendings that are more crucial to the program than others, but you never want to end up in a program that's too "top heavy" and totally leaning on a couple guys to even get their minimum RRA numbers or do any academic meetings/workshops.

DeKalb was probably the program I saw that had the most impressive depth... nearly all of their attendings are well trained and highly interested in teaching. They could theoretically lose their director plus probably half of their top 10 surgical attendings and still be a "top program." They could probably lose ALL of their top 8-10 and still get their min numbers. Very few, if any other programs can say that. Heck, a lot of programs out there unfortunately couldn't stand to even lose their director or single main RRA attending's cases and get their min numbers.

...My program gets around 3-4x our forefoot numbers and 2-3x our RRA min reqs. There's ~50 DPMs right now that board cases... I think more are on staff, but that's how many I see on the list that I've also seen on the OR schedules. About one half do RRA at least sometimes, and maybe 8-10 of them do it on a regular basis (at least a couple good blocks per month). We scrub with ortho sometimes if we have our pod cases covered and they're on the board doing LE stuff, but we get barely any C level cases so they aren't depended on to any extent for numbers. Overall, we could probably stand to lose our director and half of our top 6 other RRA attendings and still get our min RRA reqs, but it'd obviously go from a good program to pretty mediocre. Still, I think that's relatively good depth. Most of our major RRA attendings are in different groups... seems that most groups have one guy who does the majority of the group's RRA.

We lost a few good RRA attendings in the past few years (couple left the state, couple alumni started their own programs and now take stuff there). However, our program isn't one of those where the graduating residents can't stay on staff (I think that's against COTH regs, but seems reasonably prevalent among top programs?). A fair amount of our grads stay local, and we gain those new alumni who bring RRA. Seems things even out for the most part. The changes in RRA attendings changes the diversity of the numbers a bit though (ie lost a guy who scoped ankle a lot, but another guy is getting a lot more active with Charcot recons).

 

[jonwill]

Jonwill, krabmas,

You are both in residency programs putting out "big numbers" and performing complicated cases.

Since I've been involved with resident training, and in the past we've run into problems with sometimes finding quality attendings to bring challenging cases to the program, I have a question for the two of you.

Realistically, how many attendings are actually performing the majority of the "strong" cases you are performing? Is it a very small number performing the majority of the challenging cases? Are some of these attendings members of the same group?

We have always found that although there were a very large number of attendings, it was actually about 5 that performed 90% of the surgery.

I was wondering if the majority of your RRA cases were being performed by a very small number of your attendings, or if there are actually a significant number of attendings performing that many challenging cases.

Thanks.

We have some crazy number like 140 pods on staff but we consistently see 40-50 of them on a weekly basis. The others board cases less consistently. Of the consistent ones, I'd say we have 15 or so that bring rearfoot and the rest bring a ton of forefoot. We also get a fair amount of rearfoot/ankle trauma out of the ERs that we do with the attending on call that week.

 

[krabmas]

Jonwill, krabmas,

You are both in residency programs putting out "big numbers" and performing complicated cases.

Since I've been involved with resident training, and in the past we've run into problems with sometimes finding quality attendings to bring challenging cases to the program, I have a question for the two of you.

Realistically, how many attendings are actually performing the majority of the "strong" cases you are performing? Is it a very small number performing the majority of the challenging cases? Are some of these attendings members of the same group?

We have always found that although there were a very large number of attendings, it was actually about 5 that performed 90% of the surgery.

I was wondering if the majority of your RRA cases were being performed by a very small number of your attendings, or if there are actually a significant number of attendings performing that many challenging cases.

Thanks.

We have one attending that we spend 3 months with for a large number of RRA cases - at least 4/week while we are also performing administrative chief duties and scrubbing other cases if wanted.

Almost all of our trauma is done with ortho trauma except for a few ankles, calcs, and other fractures occasionally obtained by podiatry.

all of our attendings add quality cases to the schedule.

Maybe I am wrong about the statement that I am about to make but it is IMO... I don't think you need a ton of RRA cases. You need your numbers to graduate and get privlidges (sp). I do think that we need to do tons of surgery. Even if you were born with good hands and you don't need to practice to get your hands to do what you want, sh_t happens and to know what to do takes experience. I think we can learn alot from other surgical specialties and should take advantage of them whenever possible.
If you know your anatomy, the deformity present and how to correct it and good surgical technique I don't think you need to do 100 flatfeet or 50 cavus feet, or 30 ankle fusions. Again, just IMO and maybe I will rethink this after a few years of practice.

 

[Feli]

...Maybe I am wrong about the statement that I am about to make but it is IMO... I don't think you need a ton of RRA cases. You need your numbers to graduate and get privlidges (sp). I do think that we need to do tons of surgery. Even if you were born with good hands and you don't need to practice to get your hands to do what you want, sh_t happens and to know what to do takes experience. I think we can learn alot from other surgical specialties and should take advantage of them whenever possible.
If you know your anatomy, the deformity present and how to correct it and good surgical technique I don't think you need to do 100 flatfeet or 50 cavus feet, or 30 ankle fusions. Again, just IMO and maybe I will rethink this after a few years of practice.

I agree here. One of our attendings repeatedly says "as a resident, you want to see as many complications as possible." He is mainly suggesting intra- and post-op complications, and I realize more and more that he's absolutely right. As funny as it sounds, I've probably learned more from the small % of cases I've been scrubbed in that are revisional or don't go 100% smoothly than I have from the many many many cases that were uneventful and pretty much "textbook" from start to finish.

If you know anatomy well, formulate a good plan (with backup ideas), and have the instrument/technique skill set (along with some confidence), it seems that you should be able to do anything in our scope. The hardest part, IMO, is definitely those intra-op changes on the fly... having backup fixation ideas if planned fixation fails, knowing sequential resection/release if the deformity doesn't reduce as planned, etc.

The other surgery services are neat since it's all experience with the instruments, layers, closure, etc. You definitely gain general hand/instrument skills, but I think it certainly does help to get repetitive experience with the most applicable F&A dissections and incision approaches so that they are almost second nature by the time you leave the nest of residency. Dissections can be done in cadaver lab and fixation can be practiced on sawbones to supplement the actual caseload, but the pressure can't really be replicated unless it's an actual complex F&A case.

 

[jonwill]

I did one of those Stryker T2 Ankle Arthrodesis Nails on Monday. It was a really fun case and a good system. The patient was in a car wreck in 2007 and had a pilon and talar body/neck fracture. She was ex-fixed followed by ORIF a couple of months later. Of course she developed severe ankle/stj arthritis so I fired a nail through her rearfoot and into the tibia.

 

[Feli]

We had a case today of a DM neuropathic ankle fx that was way underfixated at StElsewhere and went into bad Charcot valgus. We did tibiotalocalc fusion with a BioMet Phoenix IM nail, platelet concentrate, and then an OrthoFix Ilizarov style ring fixator to protect it all. A lot of fixation, but the pt is big, neuropathic, and gonna weightbear on it almost right away, so the attending wanted to hedge his bets. Our 2nd year did most of the case, and I scrubbed for awhile until I got paged out for ER and some consults. Good case, but a lot of stuff looks good on the table and doesn't end up so well on long term follow up. Time will tell... tough neuropathic salage attempt. I will try to get a clinical pic of this frame on my rounds if he stays the weekend.

Also had an adult flatfoot case and an ankle scope + stab case on the sched yesterday in addition to the usual HAV, digitals, Tailors, etc.