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.

 

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.

Miami is off to a great start

Ulrich and I were welcomed warmly at Jackson Memorial. Our first day in Miami was nothing but spectacular. Dr. Hutson and Dr. Quinnan have a very  unique practice, with a mix of acute trauma as well as late complications related to trauma, infection and even pediatric deformities that persisted into adulthood. No shortage of cases that benefit from the use of frames!

Dr. Quinnan started us off with a day of cases, including a distal tibial nonunion treated with a TSF, a severe knee flexion contracture treated with a TSF and posterior releases, and a polytrauma case with a Pilon treated in an Ilizarov. The method of using an ilizarov frame from the very beginning for pilon fractures is an interesting take that has many clear benefits. He of course addresses the articular surface with buried wires, screws and low profile plates. He explained that cases with bone loss or angular deformity are addressed with a transport 6 weeks after injury. A very novel approach indeed that eliminates the need for bulky plates which has a potential advantage in reducing infections and wound complications.

What was impossible to miss today was Dr. Quinnan’s attention to detail. We were guided through the planning, execution and followup plans for these cases, with a plethora of tips from using iced saline for a saw blade, cork on wires to prevent getting stuck with a sharp point, and washing your pins through the cannula to make sure the dog doesn’t have anything to lick! Oh and Ulrik my co-fellow modeled the chic Miami style lead gowns for us.