James here...I was finally able to get time to do a make-up week in Charlotte now that my brain is no longer trying to fall out of my skull (see previous posts).  Dr. Hsu was gracious enough to let me crash at his place for the week as we had a high yield week ahead of us.  Each day was different and allowed me to experience a different type of practice than what he and I shared when I was a resident with him in San Antonio many moons ago.

A group shot of the department after morning report.

Each day started off with morning report and then to clinic on Monday where we saw a slew of new patients for treatment of their nonunions and osteomyelitis as well as more complex followups to include acute subtalar arthrodeses for intraarticular calcaneus fractures and proximal femoral lengthenings for a short transfemoral amputation with intentions to perform osseous integration.  After clinic I was allowed to sit on the department's Clinical Competency Committee meeting as I will still be intimately involved in resident education after my military commitment is fulfilled next Spring.

Tuesday and Thursday were OR days at the main operating rooms and the days were filled with some acute trauma but also some acute derotational osteotomies, deformity correction using the BANG technique (Blocking screw Assisted Nailing Guide), and nonunion repairs.  It just so happened that Dr. Hsu had set up a circular external fixator course for his residents on Tuesday and Thursday night that Dr. Brighton and I helped teach.

Wednesday was a real treat as we had an OR in same-day surgery and saw nonunion repair techniques with small incisions that allow for patients to be weightbearing as tolerated and be discharged on the same day with astonishingly high union rates.  The day ended with a reverse sural flap for a large anterior distal 1/3 soft tissue defect which was very high yield.  That evening culminated with a trip to the Charlotte Motor speedway!

Friday morning was an early trip back to the airport and flight home to El Paso.  All in all, it was an outstanding week and I got to see everything that I wanted!  Dr. Hsu has a very unique post-traumatic and limb deformity practice that I highly encourage future LLRS Traveling Fellows to see.  

Thanks for checking out the blog and I hope to see you all at the LLRS Annual Meeting on July 17-18, 2020 in New York City!    https://llrs.org/

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Last stop - Columbus!

We met Dr Iobst and his amazing team (including nurse practitioners, psychologist, radiology techs, cast tech, and physical therapists) bright and early Monday morning for a full day of limb deformity clinic. We saw a wide variety of patients and learned a lot about how to organize an efficient clinic with excellent “customer service” for patients needing complex limb reconstruction

The next few days we spent in the operating room observing some great cases...PRECICE nails in the femur and humerus, external fixative and guided growth for Blount disease, fixator for distraction hip arthrodesis, and a soft tissue procedure for knee contracture associated with femoral deficiency. Dr Iobst was kind enough to let Megan borrow his old lead (she was well protected). We also reviewed and templated a lot of cases and learned about the exciting research Dr Iobst is doing in the basic science lab.

Nationwide and the magic forest did NOT disappoint. We were so impressed with the hospital and the entire orthopedic team.

Who knew Columbus was such a foodie town? Dr Iobst lined up some fantastic dinners for us during the week

The Center for Limb Lengthening and Reconstruction at Nationwide is truly amazing. We saw a lot of special touches designed to deliver optimal care for these patients. Even the child life specialist created a lego ex-fix for spider man to educate the patients. The children of Ohio and the midwest are lucky to have Dr Iobst

Thanks to the LLRS for this wild ride. We learned a ton, met new friends and mentors and had a blast! Now off to Poland for Claire as she begins her new journey at the Paley Institute and home to DC for Megan where she is hoping to implement some changes and offer some new techniques to her patients

Here we go!! Final destination on this long ride.  Cleveland.  We arrived on Sunday, and started off with some old Cleveland Indian's baseball!  Chief Wahoo was not seen, but his spirit was there...The Indians made a huge comeback in the 9th inning, but unfortunately lost in extra innings!  It was a good game. Dr. Sontich showed us a good time!

The medical illustration and production team was busy at work preparing for the course that educates thousands of surgeons worldwide on the art of limb deformity and reconstruction

We kicked off Week 3 at the Rubin Institute for Advanced Orthopedics with Dr H, Dr Standard and Dr McClure before heading to the Baltimore Limb Deformity Course. Supposedly the clinical schedule was on the “lighter side” in preparation for the course, but Claire and I found no shortage of patients with complex lower limb problems to discuss. Dr Standard walked us through the stages of a tibia hemimelia reconstruction in the OR. Don’t let the picture fool you (if you are focusing on the fluoroscopic image in the background) We completed the OR day with an upper extremity case

We met the whole team at Sinai and learned how each member has a vital role in making the institute so special. This is one of the 3D printers that can create models from a scan.

Dr H took us to the frame “graveyard” and showed us one of the original TSF models. Parts can be recycled for use in various parts of the world to treat children and serve as education tools for trainees.

At the Ponsetti precourse we got to fine tune our casting skills, learn tips for managing atypical clubfeet by watching casting of live patients, listen to the “best of the best” debate how to define and manage the relapsed clubfoot using live patient examples, and discover treatment options for the neglected or untreated clubfoot in older children. It was a great day embracing the history and evolution of the care of children with clubfeet

If you have never been to the BLDC...we highly recommend it! What a great all around learning experience and excellent opportunity to pick the brains of experts in our field

We enjoyed mingling with colleagues and meeting new mentors at the reception overlooking the Harbor...just in time for the bad storms to roll in! The week was exhausting but we both gained new knowledge that we can use in practice to care for our complex limb deformity patients. Special thanks to Dr Herzenberg and Dr Standard for hosting us during such a grueling week. Their commitment to educating young surgeons is truly amazing!

It was a good week of social events, learning, sharing, and of course cases. We finished the week of with a trip (a wet one..it rained cats and dogs on the way there, so forgive the hair!) to a local coffee / craft beer / dessert hangout to watch one of the pediatric attendings sing/play guitar. It was good times to be had by all.  Shown here: Dr. Hsu holding a future deformity expert (my son!)

We finished off the week at Carolinas Medical Center going over deformity cases, some adult cases, some pediatric cases. We shared ideas, concepts, and experience.  Great collegiate experience. 

It's been a great week here with Dr. Hsu. Dr. Hsu was kind enough to tailor the week to areas of interest in my practice.  So...we put some of the frames aside for the week, and focused on nonunion treatment. Nonunions galore!  Dr. Hsu shared some insight into his pain control regimen and his pathway for the treatment of nonunions in the outpatient setting. 

James here - why does Paul get to have all the fun?? Where has James been? Funny you should ask...

A bout of freak headaches and neck pain sent me to the ER at New York Presbyterian hospital where I was diagnosed with Spontaneous Intracranial Hypotension from a CSF leak somewhere in my spine. Five nights in the hospital, multiple MRIs, and two blood patches later, I got sent home for the week to lay flat and let this thing heal. With any luck, I’ll meet back up with Paul in Cleveland for our last week and get to Atrium later in the year. Don’t worry - I’ll blog then too!

Just like I tell my patients, it can always be worse...

What a great week in NYC. Lots if patients lots of cases! I Can't believe we are halfway done with the fellowship. Great last day at HSS! Bilateral high tibial osteotomies, a distal femoral osteotomy, a TSF for an HTI, precise nail for lengthening, frame removal and contracture release, not mention some peroneal releases! Fun times with Dr. Rozbruch and Dr. Fragomen! But, all times must come to an end...next stop is Charlotte with Dr. Hsu!

After a great day with Dr. Rozbruch, Dr. Fragomen decided to turn it up a notch with some complex foot/ankle reconstructions and limb lengthening nails. A true visit isn't complete until we got to see the outcome of these complex patients in clinic.  The number of success stories for these patients is incredible!  In clinic we went through preoperative planning and post operative management for some involved deformities and reconstructions...for instance, an 18cm cable bone transport into a knee fusion...talk about a head spin!  To top it all off, we went to dinner and enjoyed some good food and stories of some interesting experiences! For me (Paul) this was a very special visit, because my interest in deformity started as a medical student, spending the summer with Dr. Rozbruch and Dr. Fragomen...and now I have come full circle visiting as an attending back to where it all started!