Recalling The Toughest And Most Rewarding Cases of Residency

Third-year residents discuss challenging surgeries, difficult complications, and rewarding cases from their residency programs thus far, and what they have learned from these experiences.

Q:

What was the most challenging case you have worked on in your residency so far? How did you prepare for it? What, if anything, surprised you during the case? What feedback did you receive afterward from the attending or residency director after the case?

A:

Christopher Forsbach, DPM, recalls a patient who had sustained a calcaneal fracture 12 years prior without any surgical treatment prior to presentation. The patient had developed a valgus foot deformity due to the collapse of the talus into the calcaneus with severe post-traumatic arthritis of the subtalar joint. Dr. Forsbach says the patient had significant exostosis on the lateral calcaneal wall and was unable to ambulate properly without significant pain.

“The plan was for a lateral wall exostectomy and a subtalar joint fusion with fresh femoral head allograft to use as a strut to swing the foot back into rectus position,” notes Dr. Forsbach.

He remembers preparing for the case by studying the X-rays and measuring the angles and size of allograft that would be needed to get the patient’s foot into a rectus position. The hospital had fresh femoral head allografts on back order and only had femoral shafts. After performing the lateral wall exostectomy, Dr. Forsbach says they cut the graft to size on the back table and placed it perfectly in the void after distracting the STJ open and fixating it appropriately for a fusion.

“This was a difficult case,” he acknowledges, “but with H. John Visser, DPM, FACFAS as the lead surgeon for the team, we were able to perform the procedure without complication.”

For Raymond S. Murano, DPM, the most challenging case involved a complex Charcot reconstruction on a patient who presented with previous osteomyelitis and a Charcot deformity with an associated wound that had not healed despite aggressive wound care and offloading measures. In this case, Dr. Murano says a multidisciplinary approach was essential for ensuring medical optimization for the patient and the associated post-op recovery period. Vascular surgery, medicine and infectious disease specialists all helped to coordinate the care of this patient, according to Dr. Murano.

“Recognizing that all Charcot deformities are different, we reviewed our patient’s imaging studies as well as the literature to develop a game plan regarding the most appropriate steps in reducing the deformity and preparing a solid hardware construct,” says Dr. Murano.

The podiatric surgeon team worked together to plan incisional placement, the location and size of bone wedges for reducing the deformity, and both internal and external hardware placement.

During the operation, Dr. Murano recalls the dissection being more challenging than expected as the deformity has significantly altered the anatomy. Once they reached the stage of performing the bone cuts, Dr. Murano was surprised by the poor bone quality and the amount of bone required to achieve a plantigrade foot. He remembers the team needing to alter the fixation construct due to the alignment changes that resulted after the corrective bone cuts.

Ultimately, Dr. Murano reports that the patient healed with a stable foot that requires bracing but there has been no recurrence of foot ulcers.

For Jacob Jensen, DPM, the most challenging case of his residency centered around a patient who required a revision of a through and through Akin osteotomy with inadequate fixation.

“Simple deviations from an organized plan led to unanticipated events,” recalls Dr. Jensen, “turning an otherwise straightforward case into a nightmare.”

Prior to the case, Dr. Jensen viewed preoperative radiographs to aid in surgical planning. The revision, including the removal of a dorsal staple, curettage of the osteotomy site and anatomic reduction, was followed by temporary axial k-wire fixation of the hallux. However, during the procedure, Dr. Jensen remembers that an inappropriately sized drill was chosen in haste, prior to placement of a cross-screw. This resulted in the screw breaking while it was being advanced and the team was unsuccessful in several attempts to remove the remaining screw.

Dr. Jensen acknowledges that this difficult scenario could have been avoided by following proper AO principles of screw fixation.

“As a resident, it can be difficult not to have the final say in certain decisions when you have been trained to follow correct principles,” says Dr. Jensen. “Proper preoperative planning and always putting the patient first, as outlined in the Accreditation Council for Graduate Medical Education (ACGME) definition of professionalism, can help avoid these scenarios.”

Paxton Riding, DPM, recalls the challenges he faced for a patient who had an acquired equinovarus deformity. They removed the talus entirely and then followed with a tibial/calcaneal fusion via IM nail with no bone grafting planned.

Aside from the technical difficulty of such a case, Dr. Riding remembers how the patient had several significant comorbidities that further complicated the procedure. At the beginning of the case, he says, they lost tourniquet pressure and the entirety of the procedure was completed “wet.” The patient received three units of packed red blood cells (PRBC) during the operation.

“To make things even worse,” Dr. Riding recalls, “he experienced EKG changes and essentially had a mild heart attack during the case.”

The anesthesia department pressured the attending surgeon to complete this case as quickly as possible, according to Dr. Riding. In the end, it took a total of five and a half hours, much longer than the anticipated three to four hours. The patient spent two weeks in the hospital, including 11 days in the ICU. But in the end, Dr. Riding says the patient had a functional and plantigrade foot that greatly increased his quality of life. In retrospect, the patient never should have gone to the OR, in his opinion.

Q:

What was the most rewarding case you have worked on so far? What did you learn from the case?

A:

Dr. Murano recounts a recent limb salvage case in which a patient was transferred from another hospital with gas gangrene and sepsis. Despite early and aggressive surgical intervention of the infection, the patient’s condition initially appeared to deteriorate.

“We had to balance saving her limb versus saving her life during her admission,” Dr. Murano remembers.

Each day, they carefully considered the option of amputating her leg. However, with the assistance of their medical and plastic surgery colleagues, they were able to save the patient’s foot. Dr. Murano credits the team approach with the success they achieved in managing this challenging case.

“It’s amazing how you can bounce ideas off each other to achieve the best possible outcome for our patients,” says Dr. Murano.

Dr. Jensen also finds it rewarding to work alongside his co-residents and attendings on a challenging case.

He remembers a patient with osteomyelitis and multiple ulcerations who went on to develop Charcot arthropathy over the course of two years. Dr. Jensen says the patient was often non-adherent and very challenging to treat. However, after the patient received appropriate treatment, he was able to return to work and ambulate safely. The patient required partial first and fifth ray amputations at different times. He then developed acute Charcot with extensive midfoot collapse and a nonhealing midfoot ulceration. Dr. Jensen treated this with external fixation, plantar planning and closure of the previous ulceration. The patient went on to coalesce and heal after four or five months, eventually ambulating in a Charcot restraint orthotic walker (CROW). "Seeing him then return to his employment, now able to ambulate without ulceration, was extremely rewarding," notes Dr. Jensen.

For Dr. Riding, it’s not a unified collaboration that stands out in his mind, but rather, a lesson in trusting your own judgment.

“Just into my third year, an attending who I have only scrubbed with one time, requested me for a closing base wedge procedure,” he remembers. “I realize now that he was really looking for someone to take the lead and essentially do the case.”

Not initially realizing the attending’s intentions, Dr. Riding avoided placing too much pressure on himself. It was the first time he had done a case skin to skin and he remembers making all decisions without any input from the attending. Without any other direction, Dr. Riding gained the confidence to proceed with his plan and make all decisions, including the angle and size of the osteotomy and the type of fixation. In the end, the radiographs and clinical picture of the foot looked very good, both post- and intra-operatively.

“It gave me a little taste of what it must feel like to be a surgeon on your own,” says Dr. Riding.

Dr. Forsbach recalls an 80-year-old patient who was unable to walk due to a severe rheumatoid foot with laterally subluxed digits and severe pain. Due to her age, multiple surgeons had refused to perform surgery on her.

Together with Dr. Visser, Dr. Forsbach performed a pan metatarsal head resection with temporary k-wires through the digits and metatarsal shafts in addition to a first MPJ fusion. The patient healed well and was able to walk again with very minimal pain.

“She is now active and able to exercise, and enjoy the remaining years of her life,” says Dr. Forsbach. “She is extremely grateful and I learned that with a proper medical workup, any surgical correction is possible.”

Q:

What was the toughest complication you had to deal with? How did you handle it?

A:

Dr. Murano acknowledges that complications are an unfortunate part of the job. While he has dealt with everything from hardware backing out to incision breakdowns, Dr. Murano recalls a situation he describes as “the hardest thing I’ve ever had to do”—the impossible task of explaining to a family that their loved one had coded during a routine case in the OR and was now on life support.

Dr. Murano remembers bracing himself for the discussion. He knew the family would have so many questions, some that he could answer and some that he could not. The surgical team as well as the ICU and anesthesia teams reached a decision to jointly meet with the family. This meeting allowed for all the information to be clearly communicated at one time in the hope of giving the family some closure.

“It was a whirlwind of emotions for both the family and all the teams involved,” says Dr. Murano. “It is something I will never forget and hope I never have to do again.”

For Dr. Riding, coming across a patient with severe complications has not been a routine occurrence.

“Minor or moderate post-operative complications are almost never seen by residents in my program,” he explains. “If the complication is severe enough to require hospitalization, then we as residents are heavily involved in the management and course of the patient’s care.”

Dr. Riding does recall one instance of a patient who dehisced both the medial and lateral incisions of a trimalleolar ankle fracture. The surgical team employed open reduction internal fixation utilizing hardware for both the tibia and fibula.

Initially, the surgeons thought that IV antibiotics and perhaps a washout of the incision wounds would be needed as the incisions didn’t appear to be open with hardware exposed. However, Dr. Riding recalls what occurred when he changed the patient’s dressing on the second day of her hospital stay.

“I counted six of the nine screws that were in the fibula plate poking right through the incision,” says Dr. Riding.

Dr. Riding says the surgical team took the patient to the OR that night to remove the hardware and apply an external fixator as the fractures were still very unstable. Subsequent bone biopsies confirmed osteomyelitis and the patient stayed in the hospital for another week or so.

“We were able to debride the infected bone and get clean margins,” says Dr. Riding. “A delayed primary closure was done for the incisions and they healed nicely.”

While the ex-fix was used for definitive fixation, Dr. Riding says the damage to the patient’s ankle joint was severe and she ended up with a fusion.

Dr. Forsbach remembers a patient who had previously sustained a displaced calcaneal fracture that was fixated with percutaneous screws. Two weeks after surgery, she fell and re-fractured the site while she was in her cast. She went back for a second surgery, an open procedure and the surgeons used a plate and additional fixation. Three weeks after this second surgery, the patient was working with a physical therapist in her skilled nursing facility when she fell yet again while in her cast. The surgeon was out of town and unavailable for follow-up so the patient was referred to Dr. Visser.

Dr. Forsbach remembers the patient as having various comorbidities that further exacerbated the situation. She was morbidly obese, smoked two packs of cigarettes a day and was very non-adherent.

At her follow-up appointment, the patient presented with a full-thickness ulceration with the tongue fracture fragment eroding through the Achilles tendon and ulceration with exposed hardware. The patient developed a pulmonary embolus after her second surgery and just received an inferior vena cava filter so she had to be cleared by her cardiologist for another surgery.

“We removed the hardware during her third surgery and excised the fracture fragment through the central portion of the eroded Achilles tendon,” says Dr. Forsbach. “It was determined that her medial and lateral Achilles attachments were intact.”

They worked alongside a plastic surgeon, who performed a flap to cover the large wound on the patient’s posterior Achilles attachment.

Eight months after her initial injury, Dr. Forsbach says the patient’s wound is completely closed, the central aspect of her Achilles is scarred in and she is working with physical therapy to get her range of motion and strength restored with a functional Achilles tendon.

Dr. Forsbach is a Chief Resident with the Foot and Ankle Surgery Residency program at SSM Health DePaul Hospital in St. Louis.

Dr. Jensen is a third-year resident with the Chino Valley Medical Center PMSR/RRA Podiatric Residency in Pomona, Calif.

Dr. Murano is a third-year resident with the Podiatry Surgical Residency Program at the Beth Israel Deaconess Medical Center in Boston.

Dr. Riding is a third-year resident with the Podiatric Residency Program at Bryn Mawr Hospital in Wayne, Pa.

Dr. Bernstein is the Director of the Podiatric Residency Program at Bryn Mawr Hospital in Wayne, Pa. He is a Fellow of the American College of Foot and Ankle Surgeons.