HSS – New York City

Our final week of this amazing fellowship has comed. Mani and I spend a great and somewhat different week at the HSS in NYC. Dr. Rozbruch and Dr. Fragomen taught us lots of interesting aspects of deformity correction. We saw artificial talar bones, transparent (carbon) plates and nail, cryo-ablation of phantom pain after resection of nerves (neuromas/amputations). We saw curretage of cystic lesions, lengthening nails, and TSF frames. Proximal tibial osteotomi with TSF frame one side, and TomoFix plate on the other for correction of bilateral varus. We discusses aspects of the subtleties of LATN and LON technique and how to treat regenerate healing issues.

We also lots af patients in the clinic, both public and private. Ankle distraction for talocrural arthritis and how the frame was applied and the mobility maintained. We saw nailing assisted correction of a proximal tibial deformity, including peroneal nerve decompresssion. We had a very nice farewell dinner, together with the recidents. We learned a lot, saw a lot, and met some of the authors and inventors of techniques and articles and text books that we use regularly in our deformity planning. We also interacted with the fellows and medical students and had a fantastic time in sophisticated NYC.
Flying home with the iPhone and the pc full of notes, pictures and personal, unforgettable memories of professional knowledge sharing, friendship and network possibilities…./Ulrik



It was with great excitement that we arrived in Baltimore. Both Natasha and I had previously attended the Baltimore Limb Deformity Course and so we had great expectations for the upcoming week. Monday began with a workshop by Dr Herzenberg on the Multiplier Method using the Multiplier App.  It was fantastic to be able to work through some of the more complex calculations in limb length discrepancy predictions as well as being introduced to some of the additional features, such as the oblique plane deformity calculator.  The remainder of the day was spent in clinic with Dr Herzenberg and Dr Standard reviewing upcoming cases for the week as well as seeing complex deformity patients and children undergoing treatment for Perthes.  The day was rounded off with a crab feast with our families on the crab deck of Phillips Seafood against the beautiful backdrop of the Baltimore Inner Harbor.


Tuesday began with presentations by the fellows, followed by a day in the operating room observing Dr Herzenberg and Dr Standard.  Highlights of the day included an ankle spanning TSF for lengthening and deformity correction in a child with fibula hemimelia and curettage, bone grafting and IM nailing of a femur in Ollier’s Disease.


One of the key to successful outcomes at the International Center for Limb Lengthening is undoubtedly the physiotherapy program led by Anil Bhave.  We were fortunate to have a very interesting lecture on the principles of physiotherapy and splinting in limb lengthening with both practical advice and the theories behind treatment.  We also took a tour of the physiotherapy department, seeing patients undergoing stretches, heat treatment as well as the hydrotherapy pool. Most impressive of all was the gravity reducing treadmill, designed by NASA to simulate weightlessness, which would allow the therapist to dial in the exact amount of weight bearing allowed.


The evening was spent enjoying an Orioles game at the wonderful Camden Yards stadium, its distinctive retro styling made all the more impressive by the profile of the downtown Baltimore skyline.


On Wednesday morning we were fortunate to be able to observe Dr Herzenberg perform a fixator assisted nailing with the Precise system.  Dr H. imparted many pearls and insights into the intricacies of performing this procedure.   We were also able to witness Dr Standard’s technique for repeat osteoplasty following premature consolidation with a lengthening nail in situ. Following this was a highly educational afternoon spent reviewing power point presentations on limb deformity correction, SUPER hip and SUPER ankle procedures as well as joint distraction and advanced techniques for the treatment of Perthes disease.  At the end of the day we were treated to a fantastic dinner at the Food Market.


Thursday morning began with Pre-op conference where the cases for the week were discussed, as were the decision making processes which went along with each patient.  Later on we had a lecture on pre-operative planning for the Precise and were then able to put the theory into practice as we planned and ordered the nails required for the surgeries scheduled for the next week.  During the day we also had the opportunity to observe Dr Standard in his clinic and witness the impressive support team of graphic designers, fine artists, medical editors, photographers, managers and assistants at the ICLL. We were struck by how this dedicated group work tirelessly to provide the extremely professional standard of publications and course material that Baltimore is famous for.


Friday was a change of focus with a club foot day.  We observed a TAL, plantar fasciotomy, PL to PB transfer and tib ant transfer for a residual club foot deformity.  We then observed serial manipulation and casting in the club foot clinic, before heading to the frame lab.  Here we rounded off the week assembling a sawbones model of a TSF for Blount’s with a high riding fibula, including an additional half ring with fixation pins in the fibula for distal fibula transport to re-tension the LCL.


It is with mixed feelings that we now move on to Philly.  We have been touched by the generosity of Dr Herzenberg and his team this past week.  We are extremely grateful for the opportunity to interact on such a personal level with one of the great leaders in the limb deformity world and leave Baltimore having learnt a great deal.

Cleveland at its best

Our week in Cleveland started with a bang, we flew into town in time for Game 7 of the NBA championship, and Ulrik and I were witness to the first sporting victory to “C-town” in over 51 years. Needless to say, the city, the hospital staff, and our hosts were in quite the spirited mood for our visit for the week.

Dr. Sontich welcomed us to University Hospital with a pilon fracture treated definitively with a ring fixator. He spent much of the case offering his dogma for the treatment of pilon fractures and when ilizarov techniques are best suited. His belief that a grade 3A open pilon fracture can be prevented from becoming a grade 3B open pilon fracture in the correct setting by avoiding large plates provides a great context for the use of thin wire fixation for articular fractures. We were then given some time to explore the Rock and Roll hall of fame, a must see when in Cleveland.

Tuesday Dr. Sontich and Dr. Liu presented some excellent cases from their seemingly endless collection of patients with trauma, bone loss, deformities and infections who they were able to help with careful planning and execution of limb reconstruction techniques. Then came one of the best experiences of the entire month, as Dr. Liu presented some of his research using the unclaimed dead bone collection at the Cleveland Museum of Natural History, followed by a tour of the bone collection and unhindered access to this gem of a resource for surgeons, researchers, engineers and paleontologists alike. We were then treated to a wonderful lunch with Dr. Liu at the Cleveland Museum of Art, which we then had time to explore.

Wednesday Dr. Sontich delivered a grand rounds presentation on the treatment of malunions and nonunions, and the department welcomed Ulrik and I with championship Cavalier T-shirts, which the local news made clear were not easy to obtain. We then witnessed our first application of a frame for a bone transport, and it was awesome. The patient had an infected nonunion of a previous open distal tibial fracture. Dr. Sontich’s experience with this technique shined in how he was able to break down the indications and planning, the steps of the procedure itself, and the postoperative TSF program and patient management. We also witnessed Dr. Sontich graft a docking site for a prior bone transport to ankle fusion proceudure, allowing us to see two sides of the same treatment modality. Then we changed pace and observed Dr. Liu use a Precice lengthening nail for a 4 cm lengthening in an adolescent with hemihypertrophy. He made sure to demonstrate the planning, and some very important steps in the successful implementation of this technique. Essential tips in order to masterfully employ lengthening nails and nailing for deformity correction. The day ended with a fantastic French feast at L’Albatros Brasserie, a must visit when near Case Western.

Thursday we were again educated with some didactics, Dr. Sontich gave an excellent talk on limb salvage. We then got to spend some time in clinic seeing limb salvage and deformity patients at different stages in treatment. We then treated a patient with an equinus contracture after a talar malunion with an osteoplasty, percutaneous achilles lengthening, and the application of an equinus frame. We then went over how to run the TSF program for this deformity correction. Dr. Sontich let us in on the trade secret of placing the virtual hinge anterior to where it really is in order to avoid posterior tibio-talar cartilage compression. After another excellent day, Dr. Sontich welcomed us into his lovely home for a fantastic dinner party, and even made us his signature Moscow Mules.

Friday we were privileged to receive yet another talk, this time from Dr. Liu on assessing deformities and planning their corrections. We then joined Dr. Sontich for our last case of the week, the application of a ring fixator for soft tissue management of a complex soft tissue defect. We then participated in a saw bones lab where we got to place equinus frames and run the TSF software, and witness firsthand that it is not always so straight forward as our many hosts this month have made it appear.

Another great week down, next stop HSS.


The Paley Institute



Our week in West Palm Beach began at 6:30 am at the surgical center. By 7:50 am 2 cases had been completed and we were on our way to the Paley Institute at St Mary’s Hospital.  We spent the day in the office with Dr Paley, seeing his pre-op patients for the upcoming week as well as some new and follow-up patients. During the course of the day we lost track of the number of patients we saw, with patients from all over the world coming to seek his expertise.  There were patients with fibula hemimelia, tibial hemimelia, congenital femoral deficiency, Ollier’s disease and multiple epiphyseal dysplasia. We also saw patients with both internal lengthening devices and external fixation devices, including the new rail and hexapod systems designed by Dr Paley.  At the end of a long clinic we had a very enjoyable meal at a Mediterranean restaurant near the hospital.


Tuesday was spent in the OR, observing the insertion of Precise nails in patients with congenital femoral deficiency, bilateral Precise nailing for stature lengthening, hemiepiphysiodesis, derotational osteotomy and femoral osteotomy and triple pelvic osteotomy via the SUPER hip approach in a patient with Multiple Epiphyseal Dysplasia.  After a hard day’s work we were very graciously entertained by Dr Paley.  We took a trip on Dr Paley’s boat around the inlet, followed by a very relaxed and enjoyable barbecue at Dr Paley’s house.


Wednesday morning began with a 35 mile bike ride with Dr Paley around Palm Beach with the southern Florida sun beating down.  Dr Paley cycles 5 days a week and is a force to be reckoned with on 2 wheels!  We went straight from cycling to the OR, where we were able to see a peroneal nerve decompression for a patient undergoing a derotational osteotomy with an IM nail, a proximal femoral osteotomy, a distal femoral extension osteotomy and internal lengthening for Ollier’s disease.


Thursday was again spent in the OR, watching percutaneous application of 8 plates, a distal tibial TSF for lengthening and deformity correction in a patient with fibula hemimelia.  It was very interesting to see the percutaneous distal tibial osteotomy performed via the Gigli saw.  The final case of the day was a patient with congenital femoral deficiency with a knee flexion contracture. He underwent a peroneal nerve decompression, gastrocnemius release, posterior capsular release, distal femoral shortening osteotomy, superknee ligament reconstruction procedure and supra tubercular tibial opening wedge osteotomy.  We were both impressed by the meticulous attention to detail of Dr Paley throughout this long and complicated case.


Friday morning began at 7am with a multidisciplinary case conference where the patients for the next week were discussed with the surgical and anaesthetic teams.  This was followed by rounds of the patients on the floor, and then a tour of the physiotherapy department where we were able to witness many patients undergoing lengthening receiving the treatment that is so imperative to the success of their surgery.  We then had a teaching session with Dr Paley on the SUPER ankle and the SUPER hip, followed by discussion on the TSF and Precise with Dr Robbins.  After this we were straight to the office for another clinic again full of patients with congenital deformity, achondroplasis,congenital pseudarthrosis of the tibia and even upper limb abnormalities.


This week has been a truly invaluable experience.  The sheer volume of patients and the variety of cases is staggering. Dr Paley and his team have been the most gracious hosts, taking the time to teach us and make sure that our every need was been taken care of.  The pace and productivity of Dr Paley and the Paley institute is truly remarkable and both Natasha and I have learnt an immeasurable amount in a short time.

Leaving Charlotte…

Leaving Charlotte: An amazing and very concentrated learning experience: Our week in clean and beautiful Charlotte has come to an end. From early morning to late in the evening. We have learned tons of tips and tricks on frames, flaps, pilons and non-union. We have shadowed fantastic Dr. Hsu, who patiently taught us rotational flaps in the cadaver lab, and it was a great hands on experience. Two days after, we saw one of the flaps applied to a patients An opportunity for rehearsing, testing, reading, taking notes and see the real thing. Awesome. We saw mixing of cement and the setup for antibiotic coated nails applied to non unions. I finally found the recipe that I had been looking for. We saw distraction of a hypertrophic non-union in a frame, and supplementary plating and grafting of a femoral non-union, previously nailed. We saw an ankle fusion in a frame on a diabetic pt. with a failed malleolar fracture ORIF. We did tailor spatial frame planning. We took notes on all the little subtleties of framing, pin and wire placement, the importance of balancing the talus under the tibia when fusing and dorsiflection etc. We had lectures on the rising epidemic of drug abuse on America. We were equally well received by the residents and fellows who also taught us trips and tricks and had prepared cases for us on deformity planning in Rickets and a bone transport case. The social calendar was full, and we had great dinners and discussions on teaching and learning, politics, traveling and culture. Thanks a million to Dr. Hsu and his kind family for an unforgettable week. 

We lived in a guest house provided by the hospital at a very low cost and we could walk to the hospital, making this week very budget friendly. 

Charlotte welcomes the Adult LLRS fellows

Miami set the bar high for the traveling fellowship sites, however Charlotte is quickly winning us over with its charm, friendliness, and of course, the opportunity to work with Dr. Joseph Hsu. Sunday we were welcomed to his house, met his family and enjoyed some sushi and beer. Oh and there may have even been a planking competition.

Dr. Hsu welcomed us to his clinic, where several very interesting cases were presented, including the use of frames or nails for fusions of infected joints (knees and ankles), plating over nails for nonunions, a case of a stump lengthening for a short traumatic BKA, and most impressive is his inclusion of soft tissue management into his practice.

On Tuesday we started our morning with a great talk on the topic of bone defects given by Dr. Hsu himself. We then had the opportunity to watch Dr. Hsu and his team take on an incredibly difficult pilon fracture, then we were off to the cadaver lab where we learned and employed several rotational flaps for soft tissue coverage, including a gastrocnemius flap, soleus flap, reverse sural flap, and the infamous GEM flap. Oh and we got to play around with some frames as well of course.

The night ended with a wonderful dinner with the faculty and residents.

Goodbye Orlando!

Incredibly our first week is over! We spent the remainder of the week observing Dr Iobst in the OR. We were exposed to the whole spectrum of limb reconstruction surgery, varying from monolateral rails, to different types of hexapods, to internal fixation. Highlights for me included the percutaneous proximal femoral valgus osteotomy with concomitant distal femoral lengthening using a monolateral external fixator. I was struck by how a significant deformity with leg length discrepancy could be corrected with such an elegant technique. In addition I was particularly impressed by the fixator assisted fixator technique; a method to accurately achieve acute correction prior to lengthening with a rail.

Both Natasha and I have certainly learnt a great deal from our visit to Dr Iobst in Orlando. It has been a unique experience to spend a whole week with one surgeon, observing clinics, ORs and being able to spend time discussing limb reconstruction strategies in great detail.

We are both incredibly grateful to Dr Iobst and his colleagues at Nemours Children’s Hospital in Orlando for their hospitality. This week has been thoroughly rewarding and we look forward to the next 3 weeks.