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.
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
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
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
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
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 68th 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.
Planning for Haiti: week 1
Exactly 1 week ago, I agreed to go to Haiti on a humanitarian mission. Given a little experience in Vietnam and Afghanistan, I thought I had the skills to help. The difference was that in those missions, a preexisting infrastructure of care and healthcare delivery had already been established. So the challenge was to build the medical team that could make a difference in Haiti, just 3 weeks after the earthquake.
The response was immediate and complete. Of course Minh Nguyen, MD, was on board. He started the whole effort in the first place. His interest started when he rode his bicycle across the country to raise money for charity. He ran into Project Help Haiti and knew it was a good cause with good infrastructure. As a chief resident at the Ohio State University, he is at the pinnacle of his knowledge of Orthopedics. Working on a daily basis in a level 1-trauma center, there is little he hasn’t seen or hasn’t done.
David Kasserman MD. General Surgeon volunteered after only 6 hours of contemplation. After training in New York City, he has amassed a ton of experience with both rural and urban general surgical emergencies. Well regarded in at least 4 different hospitals., he’ll bring expertise to abdominal trauma and injuries.
Amy Bush RN serves currently as the VP of Operations at Dublin Methodist Hospital. A former critical care nurse with experience in mission work in the Caribbean and well as travel experience through China, travel into inhospitable environments are not foreign to her. In addition, she has an MBA!
Regina Chen, RN is probably one of our best PeriOperative nurses. She knows the ins and outs of getting patients ready for surgery and getting them through surgery. With little equipment in Haiti, she’ll be able to put her resourcefulness to the test.
And finally, Ed Chen, MD. Chief of Anesthesia at Dublin Methodist Hospital. I’ve known Ed since he was a resident at Ohio State University. Even then he was an agile clinician who found physiology more interesting than the mundane world of surgery. He got even better as he got specialized training at the Cleveland Clinic. With a recent trip from Africa under his belt, he’ll be our best asset on the trip.
Logistical planning into a disaster zone is difficult. There are no commercial flights to Haiti currently. Landing slots are tightly controlled. We were able to get clearance for our mission dates of February 13 to 20 through Project CARE. With a lot of pleading through Facebook and Twitter we were able to acquire a jet. But with every victory, there is a little loss, and we found out the pilots who have been shuttling teams nonstop have reached their monthly quota of flight time. We may have a jet, but we don’t have a pilot. Our search continues.
In addition, the xray machine, which was marginally operational, finally broke. Again with more pleading and begging on Facebook and Twitter, we found a mini-C arm. With a weight of almost 900 lbs, we face the challenge of shipping it down to Haiti.
Interest from the orthopedic community remains high despite negative reports from some of the earlier missions. Ruth Thomas MD from Little Rock, head of the Humanitarian Committee of the American Orthopedic Foot and Ankle Society is beginning to plan her own mission 3 weeks following ours. Rob Veith, MD, my teammate from a Vietnam mission is flying to the Dominican Republican and plans to get to Haiti overland! Mark Slovenkai, MD, another surgeon with Vietnam background is considering a mission shortly. Joao De Carvalho Neto, MD
But the greatest interest comes from our friends, families, and neighbors. I get daily volunteers willing to join. Regardless of skills, there is a great sense of desire to come into a dangerous region and just help. Pretty inspiring.
We’ll be evaluating all of our donated medical supplies this week. Hopefully finalize flight plans. With continued contact with teams 1,2, and now 3 (leaving today), we’ll try to define our medical goals in the coming days. We’ll keep you up to date through Twitter, Facebook, and this blog. I anticipate the chaos to only get worse with time.
My thoughts after a week revolves around the many offers to help. Volunteerism seems to be a root element of our culture. It is yet another aspect of our community that we can be proud of.
Skin grafts are a critical part of care for patients suffering from acute wounds, chronic wounds or burns. Currently, a split thickness skin graft is the gold standard for coverage when treating these conditions. However, donor site morbidity or a lack of donor skin due to the size of the wounds needing covered create situations where split thickness skin grafts (or allografts and xenografts) may not be feasible.
At the Orthopedic Foot & Ankle Center, I had the opportunity to be the first in Ohio to use a “Minced” skin autograft for the coverage of chronic wounds. This exciting technique has several advantages over a split thickness skin graft in certain situations. Split thickness skin grafts are usually expanded no more than six times with a maximum of nine times. With a minced skin technique, we’re able to expand the skin autograft up to 100 times, enabling us to effectively to cover much larger wound areas with less donor skin.
THE FOLLOWING PHOTOGRAPHS GIVE YOU A GLIMPSE INTO THE MINCED SKIN AUTOGRAFT TECHNIQUE.
A single-use disposable kit with dermatome and mincer.
The wound bed is prepared in the typical fashion to receive the graft.
The graft is taken with the non-powered dermatome.
The donor site after the graft is taken.
The autograft skin placed on the back table.
The autograft skin is then minced into pieces 0.8mm X 0.8mm.
The minced skin ready to be grafted.
The graft is then inserted into the wound and covered with a non-adherent dressing.
Using this new technique, we’re now able to cover acute and chronic wounds as well as burns while using minimal donor tissue. We’ll be following this patient and carefully watching his progress. I encourage you to check back often to see the benefits of this technique in treating chronic wounds.
I’ve always wanted to be on the forefront of medical technology and perform the latest procedures – that’s what inspired me to be a surgeon. At OFAC, that’s exactly what I’m able to do every day. I’m glad I can help more patients with the minced skin autograft technique, and I look forward to even more advancements.
Will DeCarbo, DPM, AACFAS – Fellowship Trained Foot & Ankle Surgeon
The OFAC team has three recent publications in scholarly, peer-review medical journals. I’ve posted the title, reference and abstract of each below. In addition to our many lectures at local, regional, national and international medical meetings, our focus on scholarly research and publication of our results continues to forge us ahead of any other foot and ankle practice in the country.
Complications associated with autogenous bone marrow aspirate harvest from the lower extremity: an observational cohort study
J Foot Ankle Surg. 2009 Nov-Dec;48(6):668-71.
Roukis TS, Hyer CF, Philbin TM, Berlet GC, Lee TH
The purpose of this article is to report the complications associated with autogenous bone marrow aspirate harvested from the lower extremity (ie, tibia and/or calcaneus) for soft tissue and/or osseous healing augmentation. This is a multisite, multisurgeon, observational cohort study involving retrospective review of prospectively collected data of 548 autogenous bone marrow aspirate harvests from the lower extremity of 530 consecutive patients between August 2000 and March 2009. Each patient underwent autogenous bone marrow aspirate harvest from the proximal medial tibial metaphysis, distal medial tibial metaphysis, medial malleolus, lateral calcaneus, medial calcaneus, or a combination of both the proximal tibial metaphysis and lateral calcaneus for application to split-thickness skin graft application sites or for mixture with allogeneic bone graft material for osseous defects or arthrodesis. Patients were kept non-weight bearing based on the index procedure and followed until clinical healing occurred or failure was declared. There were 324 female and 206 male patients with a mean age of 54.7 +/- 14.1 years (range: 14 to 84 years). There were 276 left feet/ankles and 272 right feet/ankles undergoing operative interventions with 18 harvests occurring from the proximal medial tibial metaphysis, 183 from the distal medial tibial metaphysis, 11 from the medial malleolus, 325 from the lateral calcaneus, 3 from the medial calcaneus, and 8 from both the proximal tibial metaphysis and lateral calcaneus. All procedures were deemed successful with no nerve-related injury, infection, wound-healing complications, or iatrogenic fracture occurring. When properly performed, autogenous bone marrow aspirate harvest from various locations about the lower extremity as described here represent safe and minimally invasive techniques useful for soft tissue and osseous healing augmentation. Level of Evidence: 4 (Case Series; Therapeutic Study).
Transosseous fixation of the distal tibiofibular syndesmosis: comparison of an interosseous suture and endobutton to traditional screw fixation in 50 cases.
J Foot Ankle Surg. 2009 Nov-Dec;48(6):620-30.
Cottom JM, Hyer CF, Philbin TM, Berlet GC
In this prospective cohort study, we compared screw fixation to interosseous suture with endobutton repair of the syndesmosis. Outcomes of interest included preoperative and postoperative modified American Orthopedic Foot and Ankle Society (AOFAS) hindfoot and ankle scores, and Short Form-12 health status scores, as well as radiographic measurements and the time to full weight bearing. Mean averages and ranges were calculated for numeric variables, and outcomes for each fixation group were compared statistically with Student t test. The cohort consisted of 50 patients; 25 in the screw fixation group and 25 in the interosseous wire with endobuttons group. The mean patient age was 34.68 (15 to 55) years in the interosseous suture endobutton group and 36.68 (17 to 74) years in the screw group, and the mean follow-up was 10.78 (range 6 to 12) months in the interosseous suture endobutton group, and 8.20 (range 4 to 24) months in the screw group. No statistically significant differences (P < or = .05) were noted in regard to age, follow-up duration, time to postoperative weight bearing, or subjective outcome scores between the fixation groups; although statistically significant improvements were noted in the subjective scores for each fixation group between the preoperative and postoperative measurements. The results of this study indicate that the interosseous suture with endobuttons is a reasonable option for repair of ankle syndesmotic injuries, and may be as effective as traditional internal screw fixation. Level of Clinical Evidence: 2.
Results of lapidus arthrodesis and locking plating with early weight bearing.
Foot Ankle Spec. 2009 Oct;2(5):227-33
Sorensen MD, Hyer CF, Berlet GC
In the endeavor toward Lapidus fusion, the authors have studied a new application of locked plating for the first tarsometatarsal joint. The goal was to assess the time to fusion, time to ambulation, rate of delayed union/nonunion, rate of revision, and need for hardware removal following the use of locked-plate technology in the fusion of the first tarsometatarsal joint. The findings denoted an average of 6.95 weeks to radiographic fusion, an average of 2 weeks to ambulation, a 9.52% rate of asymptomatic mal-union, a 0% rate of delayed union or nonunion, and a 0% rate of revision. The rate of need for hardware removal was 4.76%.
Check back often for more updates on our mission on improving foot and ankle education