For those of you who have followed the blog of my surgery recovery I am happy to report that I am back in game shape and training for the Columbus Half Marathon in October. This will be my victory lap of my recovery from repair of my peroneal tendon and ankle ligament tears in December 2011.

UPDATE:

The recovery process is long and requires commitment to the routines of rehab and nutrition.

The purpose of rehabilitation is to reconnect your brain with your foot and this process is not as easy as you think. I strongly disagree that healthy gait patterns will naturally return without some focused attention. My patients often hear me say that formal physical therapy is the starting line of the rehabilitation process but a dedicated home exercise program will take you over the finish line with the average patient taking upwards of a year to make the full recovery. At OFAC we have developed custom rehabilitation programs in conjunction with expert physical therapists. We freely share these rehab protocols with other physicians across the country to promote better outcomes for all.

We also recognize the significant impact that healthy lifestyle choices make on your recovery.  Healing from an injury or surgery places a significant metabolic demand on your body. For years we have counseled patients on healthy diet choices, avoiding smoking, and supplements when appropriate. At OFAC we are now proud to introduce Dr. Ashley Doyle-Lucas as our nutritional consultant.

Dr. Doyle-Lucas began her training in classical ballet in Washington state and completed her BFA in ballet performance at the University of Utah. She danced professionally with the Aspen Santa Fe Ballet and  then later, The Richmond Ballet.  Following her dancing career, she attended Virginia Tech where she completed her PhD in Nutrition in Sport and Disease. Her research focused on energy metabolism and the Female Athlete Triad.  Her research is published in the Journal of Dance Medicine and Science, and she has other publications in Today’s Dietitian, SCAN’s Pulse, livestrong.com, and mdhealthguide.com.

Dr. Doyle-Lucas is now a lecturer in the Department of Dance at The Ohio State University and teaches both ballet and nutrition to dancers across the state of Ohio.  She also develops and implements nutrition education programs for adults at the local YMCAs.  Ashley is currently an intern in The Ohio State University’s dietetic internship and will be a registered dietitian in 2013.  She is a member of IADMS, ADA, and ACSM.

Over the next few months Dr. Doyle-Lucas will provide an educational symposium, via this blog, on nutrition and its affect on healing. She will help us understand how to obtain these vital nutrients from whole foods and supplements when needed. We are also pleased to introduce a line of nutraceuticals to FootSourceMD that GMP (Good Manufacturing Practices) requirements and has achieved organic certification.  Each nutraceutical that we will offer has been custom selected by Dr Doyle-Lucas to facilitate healing from foot and ankle injuries and surgery.

I often say that my hard work as a surgeon is actually the easy part of the whole equation. I get to go home on my own two feet (usually), exercise, and participate in family life and work – all the regular things that define quality of life for me. For the surgical patient, in this case me, all these normal activities are in suspended animation until the body heals.

The recovery process for my surgery (peroneal repair + brostrom) can be broken down into separate distinct stages each important but different.

First, safe execution of surgery, anesthesia and pain control.

As the patient surgery is the one you have the least control of. My advice is to pick a surgeon that you can trust and trust that they will take care of you. I trust all of my partners and any one of them would have done a great job. For this surgery I put my fate in Dr. Hyers’ hands.

Anesthesia is best in the calm, relaxed and trusting patient. I chose to have a regional block at the level of the knee, the same as I recommend to my patients. Although somewhat scary to thi

nk of someone giving me needles at the knee the experience was very good. Dr. Donovan sedated me (ok I fell asleep like a baby with a small dose) and when I was aware again my foot was numb.

The idea behind numbing before surgery is the concept of pre-emptive analgesia. My brain was not to feel any pain stimulus at the time of surgery and for quite awhile after. I used to say to expect 12 hours of numbness but for me the block lasted 36 hours – and I loved it! I was still sedated for the surgery and the first 12 hours or so are somewhat a blurred recollection even though in the recovery room I felt wide awake and alert.

Secondly, my recovery at home.

I went home the afternoon after my surgery and the first 36 hours were spent in a quiet state with my foot elevated. I watched TV, read a book and wrote some emails (not sure the intellectual content was real high on these in hind site). Everything I did, I did with my foot elevated.

The tricks of the trade that helped me:

I used the cold therapy frequently and my family was kind enough to keep the cooler water cold. We used frozen water bottles instead of ice cubes that turned out to be a great trick and avoided running to the store for ice.

I used an anti-inflammatory to keep the inflammation down. Pain and inflammation are directly linked and although you need some inflammation to heal (normal healing pathway for your body) my goal was to prevent excessive inflammation.

I had pain medications available if I needed them. Narcotic pain medications are a double edge sword and my bias was to minimize their use. They do not help you heal but rather help you deal. Pain medications come with side effects like constipation and drowsiness. For me I was able to avoid them by using all the other strategies.

Electrical stimulation was my last trick. Electrical current, via leads attached to the skin, can deliver a low level electrical current (tens unit) as an effective strategy that has been used for years as part of chronic pain management and physical therapy. These same leads can deliver a higher current to keep a small contraction in my calf muscles so as to avoid some of the atrophy inherent in surgery. The low level

contractions can also enhance healing by decreasing swelling (muscle contraction helps pump blood).

For the first 7-10 days after surgery go SLOW. Control the swelling and pain and it will pay dividends for your entire recovery – it did for me.

And…. be nice to your family – you are their hostage!

Next topic: Using crutches and the scooter safely.

Life has a way of throwing ironic curve balls. A few weeks ago, I elected to have surgery on my left ankle. My diagnosis was a peroneal tendon tear with ankle instability. My surgery was a peroneal brevis repair with Brostrom lateral ligament reconstruction. Over the next several weeks I will chronicle my preparation for surgery, post-op recovery & therapy with my end goal in mind of skiing with my family this winter.

Having helped thousands of patients through a similar event I was confident that I knew how to handle this situation. Prior to surgery I made a checklist of items to make my recovery as easy as possible. Some of these items are time tested and true, while others are more evolving technology. I purchased or rented all of these through FootSourceMD, who I must say are wonderful.

My list:
- Crutches that are spring loaded, In Motion (spring loaded) These are more efficient and more comfortable.
- Turning Leg Caddy
- Cast cover so I could shower- FootSourceMD carries 2 types. Seal Tight or Dry Pro (2 styles). Seal Tight is used for patients to sit while showering and will fit both soft or hard cast – Dry Pro is 100% waterproof and fits hard cast only – great for summer swimming.
- Adjustable Shower Bench so I would not fall over balancing on one leg.
- DonJoy cold therapy- DonJoy IceMan- call FootSourceMD to order.
- TENS unit. This gives a low level electrical current that decreases the pain experienced at the brain. Very helpful
- NMES ( neuromuscular electrical stimulation ) to keep my muscles contracting at a low safe level. This is to minimize the atrophy while I am not on the leg and to potentiate the contractions once I begin my physical therapy
-Compression Socks- 20-30 Compression ribbed socks to keep swelling to a minimum.
- Anti inflammatory medication. I chose Celebrex for its long half life and being easier on my stomach.
- Antibiotics. A short duration after surgery so that my wound remains clean.
- Pain medication; which I took very little of.

Home preparation:
- Pillow by bedside to help elevate
- Be really nice to my wife Diane and my kids Logan and Jenna since I am their captive for awhile.
- Computer and Ipad by couch so that I do not get bored.
- Remove any throw rugs, backpacks & shoes from the house so that I will trip over them on my crutches.

The research team at OFAC had a tremendous showing at the annual scientific meeting of the American Orthopedic Foot and Ankle Society (AOFAS) recently in Washington, D.C. This international meeting is the largest orthopedic foot and ankle specialty meeting of the year and has physicians from all across the globe presenting their research and learning new techniques.

OFAC by far had the strongest research presence with 22 poster presentations and 2 abstracts presented on the main stage. Congratulations go out to all the OFAC physician authors including our out-going fellows Drs. DeVries, Cuttica and Ringus. OFAC’s research committee is led by Drs. Berlet and Hyer, but our research success would not be possible without the hard work of Emily Stansbury, our research assistant.

Special Congratulations to Dr. DeVries for winning 3rd Place Award for his poster presentation on Predictive Factors for Major Amputation in Tibiotalocalcaneal Arthrodesis with a Retrograde Intramedullary Nail- Utilization of the RAIN Database

Part of our mission at OFAC is heavily rooted in the education and training of future physician leaders in foot and ankle. In addition to our graduating fellows, we had several surgical residents and medical students actively involved in research as well. Congratulations also to resident Drs. Granata and Swiatek and student Dr. Granata for their work and success.

Two abstracts were presented on the national stage: (1) Interpositional Arthroplasty of the First Metatarsalphalangeal Joint Using a Regenerative Tissue Matrix for the Treatment of Advanced Hallux Rigidus: 5 year Case Series Follow-Up, and (2) A Retrospective Comparative Analysis of Charcot Ankle Stabilization Using an Intermedullary Rod with or without Application of Circular External Fixator.

OFAC's Dr. DeVries presenting at AOFAS national meeting

Our 22 academic posters that were presented included:

1. Magnetic Resonance Imaging Evaluation of Osteochondral Lesions of the Talus Following Arthroscopic Drilling

2. Autogenous Bone Graft Harvest Using Reamer Irrigator Aspirator (RIA) Technique for Tibiotalocalcaneal Arthrodesis

3. Outcomes of Treatment in Osteochondral Lesions of the Distal Tibial Plafond

4. Bi-Plane Chevron Medial Malleolar Osteotomy for Increased Exposure of the Medial Talar Dome

5. Wound Complications in Operative Treatment of Calcaneal Fractures

6. Revision Total Ankle Replacement: Agility ™ to INBONE ™ – Anterior and Posterior Approaches to the Difficult Revision.

7. Comparative Analysis of the Union Rate of Revisional Tibiotalocalcaneal Arthrodesis with Intramedullary Nailing with or without Recombinant Human Bone Morphogenetic Protein-2 – Utilization of the RAIN Database

8. Predictive Factors for Major Amputation in Tibiotalocalcaneal Arthrodesis with a Retrograde Intramedullary Nail – Utilization of the RAIN Database

9. Evaluating Two Types of Fixation for a 1st Tarsometatarsal Arthrodesis: A retrospective comparative cohort

10. Comparative Analysis of the Union Rate of Tibiotalocalcaneal Arthrodesis with Intramedullary Nailing with or without Implantable Bone Stimulation – Utilization of the RAIN Database

11. Retrograde Intramedullary Nail Arthrodesis for Avascular Necrosis of the Talus – Utilization of the RAIN Database

12. The Use of Bone Growth Stimulators in Diabetic Patients: A Retrospective Case Series of Ankle Fusions

13. Subchondral Drilling of Full-Thickness Cartilage Defects of the First Metatarsal Head: A Retrospective Case Series

14. Ankle Arthrodesis in High Risk Patients: A Retrospective Review of Implantable Bone Growth Stimulators

15. Lower Extremity Implant Registries: Has the time come in the US?

16. Cannulated Screw Fixation of Jones 5th Metatarsal Fracture: A Comparison of Titanium and Stainless Steel Screw Fixation

17. Porcine Dermal Matrix for Tendon Augmentation, Prospective Multicenter Series

18. Xenograft Soft Tissue Scaffold for Tissue Augmentation in Foot & Ankle Surgeries

19. Surgical Technique: Retrograde Drilling of Medial Osteochondral Lesions of the Talus

20. A Retrospective Review of Insertional Achilles Tendinosis Treated with the Dual Incisional Surgical Technique

21. Retrospective Review of First Metatarsophalangeal Joint Arthrodesis Using a Locked Plate and Compression Screw Technique

22. Retrospective Comparison of Four Plate Constructs for First Metatarsophalangeal Joint Fusion: Static Plate, Static Plate with Lag Screw, Locked Plate, Locked Plate with Lag Screw.

We’ll be showcasing our research posters in front of our office each day. If you have interest, please stop by.

Hey everyone! We wanted to give you some more information about the satellite clinic Dr. Philbin is opening next Monday.

Orthopedic Foot and Ankle Center (OFAC) is pleased to announce Dr. Philbin will be opening a satellite clinic at the Sports Medicine Grant Pickerington office this Monday, April 26th. The lease has officially been signed and the team is working out operational details as we speak.

Monday will be a big day for Dr. Philbin and his Right Hand Nurse, Angie Dykes. They will spend most of the day training Sports Medicine Grant (SMG) staff members how to assist Dr. Philbin. Our goal is to work with the SMG team in order to give our patients the best foot and ankle care in Pickerington.

Dr. Philbin will initially be on site in the new office twice a month – the 2nd and the 4th Monday of each month. Working at both the Dublin and Pickerington locations is something we’re very excited about because it will provide more convenience and personalized care to our patients. Beginning at 8:00am and working until 11:30am, Dr. Philbin will be available to our patients in Pickerington until he is needed in Dublin.

SMG also acts as a resource to injured athletes from local schools, primarily for orthopedic care. A staff of Trainers work primarily in this field, and with Dr. Philbin in Pickerington, those students now have a new resource for high quality foot and ankle care.

We’re very excited about this expansion and opportunity to better serve our patients. Please join us in congratulating Dr. Philbin and the entire team who helped bring this to fruition.

As was mentioned in Dr Decarbo’s earlier link, the physicians of OFAC were awarded an “Honorable Mention” in the Manuscript Competition at the 68th Annual Scientific Conference of the American College of Foot and Ankle Surgeons in Las Vegas, Nevada. Congratulations to Dr Decarbo, lead author of the winning manuscript!

OFAC also presented 2 other manuscripts and 12 scientific poster presentations. The physicians of OFAC continue to lead the charge in education and research in the field of foot and ankle surgery. This was the single largest presence of any group or institution in the entire country.

Our other manuscripts were:

1. Evaluation of Two Types of Fixation for a 1st Tarsometatarsal Arthrodesis: A Retrospective Comparative Cohort. Authors: Drs. DeVries, Granata and Hyer

2. Age Stratification of Outcomes for Osteochondral Lesions of the Talus. Authors: Drs Deol, Berlet, Hyer, Philbin, Lee

Our scientific posters were:

1. A Retrospective Review of First Metatarsophalangeal Joint Arthrodesis Using a Locked Plate and Compression Screw Technique. Authors: Drs Ringus, Swiatek, Hyer

2. A Retrospective Comparative Analysis of Charcot Ankle Stabilization using an Intramedullary Rod with and without Application of Circular External Fixator. Authors: Drs DeVries, Hyer

3. Xenograft Soft Tissue Scaffold for Tissue Augmentation in Foot & Ankle Surgeries. Authors: Drs Hyer, Berlet, Lee

4. Conversion of Failed Total Ankle Arthroplasty to Tibial Stemmed Prosthesis: Techniques for Anterior and Posterior Approaches. Authors: Drs DeVries, Hyer, Berlet, Lee

5. A Retrospective Comparison of Four Plate Constructs for First Metatarsophalangeal Joint Fusion: Static Plate, Static Plate with Lag Screw, Locked Plate, Locked Plate with Lag Screw. Authors: Drs Swiatek, Ringus, Hyer

6. Surgical Technique: Retrograde Drilling of Medial Osteochondral Lesions of the Talus. Authors: Drs Hyer, Berlet, Lee, Granata.

7. Autogenous Bone Graft Harvest Using Reamer Irrigator Aspirator (RIA) Technique for Tibiotalocalcaneal Arthrodesis. Authors: Drs Cuttica, DeVries,Hyer

8. Porcine Dermal Matrix for Tendon Augmentation; A Prospective, Multi-center Series. Authors: Drs. Hyer, Liden

9. Cannulated Screw Fixation of Jones’ 5th Metatarsal Fracture: A Comparison of Titanium and Stainless Steel Screw Fixation. Authors: Drs Hyer, Cuttica, DeVries

10. Interpositional Arthroplasty of the First MTP Joint Using a Regenerative Tissue Matrix for the Treatment of Advanced Hallux Rigidus: 5-year Case Series Follow-up. Authors: Drs Hyer, Granata, Berlet, Lee

11. Wound Complications in Operative Treatment of Calcaneal Fractures. Authors: Drs DeCarbo, A. Granata, Hyer

If you have any questions or interest in these posters or manuscripts, please don’t hesitate to contact OFAC for more information.

In addition to our large research presence at ACFAS, the physicians of OFAC also led educational lab and lecture sessions on the following:

1. Advanced Techniques in Diabetic Reconstruction Workshop: Dr Hyer

2. The Evolution of Surgery: Dr Hyer

3. Surgery in the Advanced Aged Flatfoot: Dr Hyer

4. Curbside Consult Forum: Dr DeCarbo

5. Traumatic Complications-Malunited Ankle Fractures: Dr Hyer

6. Cavus Foot Reconstruction Workshop: Dr Hyer

As you can see, the physicians of OFAC are the leading experts in all aspects of foot and ankle care. If you need the highest level of expert care, don’t hesitate to contact us.

The American College of Foot and Ankle Surgeons held their 68^th annual scientific conference February 22-26 in Las Vegas.  The physicians of Orthopedic Foot & Ankle Center presented 13 posters, 3 manuscripts and gave multiple lectures at the conference.  Thirty four manuscripts were accepted for the competition.  OFAC won honorable mention for research entitled: “Bi-Plane Chevron Medial Malleolar Osteotomy for Increased Exposure of the Medial Talar Dome”.  The authors of this manuscript include William T. DeCarbo, DPM, AACFAS, Angela Granata MSIII and Christopher F. Hyer, DPM, FACFAS.

We all watched as the little girl sobbed holding her grandmothers hand. The Grandmother’s chest rose and fell agonally for a few moments and then quietly held its peace. We were all there.  We had moved her out of her so called hospital bed a few minutes earlier. The room was the size of a large sauna, sharing its temperature and dimness but not its odor.  It was overfilled with people witnessing an event that would be a story told and retold that night. Perhaps for a week.

As we tried to resuscitate her our medical group continually talked, reviewed, and strategized.  Even if we couldn’t have our modern life saving equipment, at least we’ll act and behave as if we were in the ICU. The only place she really should have been all along.

Her heart was weak. She was anemic. She hadn’t had adequate nutrition in weeks. There were more germs in her bed than my son’s football locker room. Yet, she needed her operation. She was transferred here to specifically get this major operation.  If she didn’t have it, her leg would cease to function, become paralyzed, and the month of constant pain she had already suffered would be permanent. Without the surgery, she would flounder in this bed until she was overcome by the germs of her mucus, urine or feces.

We brought together everyone who was involved in her care that afternoon. I wanted to review her story. Her operation was difficult yet it was quick. It had also been successful. Her pelvic bone returned to normal place. She didn’t have excessive bleeding. After surgery, she was not in excessive pain. Her blood pressure was low but curiously her pulse did not respond to her condition. As if the last month was too much, or perhaps the last 67 years was too much, the heart refused to beat any faster. We did whip the heart with medication, trying to spur a quicker pace. Like the donkey that wakes me every morning, it took a few rapid stumbling steps forward and finally refused to pull any longer.

Oxygen could have helped. So would an EKG machine, a Swan Ganz catheter with a pressor drip and a ventilator. If we had the equipment, we could have done all that. We could have actually improvised many of those things.  But then where would we send her? She and her granddaughter were lying in an open air room behind an iron gate (the closest thing we had to an ICU) for at least 2 hours with an emaciated pregnant dog walking by.

Every day in Haiti, hundreds of people die. Last week, thousands of people died, and the week before tens of thousands of people died. But at least I know it will be less next week. I do not know the stories of all these people. What is important to me is that I know the story behind my patient.  It’s important to our team and all the people who were in her room this morning.

Is the shame that so many people died or that so many stories were never known?

It’s far from comfortable here in Haiti. 2 hours north of Port au Prince, Pierre Payen is dry, arid and hot. The dirt roads have been pulverized to a fine dust that permeates everything. The dust is in your clothes, your hair, even your teeth when you talk. It’s also on your bandages and in your operating rooms.

Your daily routine would never work here. With running water or regular electricity, simple things like brushing your teeth or going to the bathroom require extra thought.  Surgery requires even more thought.  Because there is no infrastructure, every aspect of our advanced procedures has to be provided by our team including preparing our instruments and sterilizing our equipment to IV’s, blood tests, anesthesia, transport, and recovery.  Even giving medications, changing dressings, cleaning up diarrhea and showing a patient how to use an inhaler.  As an orthopedic surgery team, we’ve diagnosed and treated pneumonia, congestive heart failure, and probable parasitic infection.

We had been about to start an unstable leg fracture case when we were told about a child just carried to the hospital.  He was clearly sick and listless. Young children can have spontaneous infections in the hip and it appeared that was what he had.  After bumping our trauma cases and positioning him for surgery, we noticed that he was so swollen and infected that his scrotal areas had been obstructing the flow of urine for the last 3 days. In surgery, we couldn’t even place a tube to release the urine.  With nowhere to turn, an emergency circumcision was performed which allowed the placement of the tube and a release of almost a quart of urine.  We could then proceed with the operation to release almost a quart of pus from his hip muscle, which isolated a probable tuberculosis infection.

Although not comfortable here in Haiti, it is rewarding.

Haiti Day 1

An early morning start to meet our jet at 3 am was uneventful. The jet, generously donated by Ariel Corporation, served our needs well. With over 600 lbs of equipment, we needed the cargo space more than direct access to a private landing strip. Even if a commercial flight had been available, we would soon learn about the tight control over air space at Port au Prince and its strong military presence.

First impressions of Port au Prince are numbing. The airport is filled with the chaos and intimidation of military jets and helicopters punctuated with confetti dots of healthcare workers sprawled over the tarmac waiting to leave.  As we unloaded our carefully wrapped surgical equipment the Gulfstream jet next to us unloads their cache of fresh Domino’s Pizza.

The roads, as well as the infrastructure are clearly fractured. Tents and huts made of permanent indestructible plastic garbage line the road.  Limping dogs and goats give glimpses of the lives their owners must live behind these sheets of plastic. Because so much of the plastic is cheerfully orange and blue, it’s an ironic kaleidoscopic ride through town. In a blur, you would be reminded of the disaster only by the ubiquitous smell of burning garbage and diesel.

The hospital is intact and functional. Today, 22 patients are recovering. Still, many are untreated from the initial quake. Dust from the dirt road permeates the operating room with no signs of antisepsis.

Although there seems to be ample supplies there is little organization. Every team has been generous with their supplies but with the urgency to operate, it’s been difficult to manage an effective system. Working on this may be our biggest contribution.

X-ray rounds revealed some major cases that need to be done. Perhaps spine, perhaps pelvis, but definitely femurs, shoulders, and ankles wait for our team to unpack and work.