Rural Bone Doctor

Negros Occidental, Philippines

[orthopedics]

Warning: Graphic Content. Swipe! Diabetic foot ulcers heal. And it takes great skill from the foot doctor, diabetes doctor, nurses, and all the members of the village to make sure that happens. Like all living things, plants and animals in our precious planet, these wounds have to be tended properly. A gardener would certainly bring in the ladybugs to eat invasive pests, pour in the sunshine, irrigate well, and splint crooked branches for his prized subject to bear good fruit. (A) Six weeks postoperative. (B) Fourth metatarsal head ulceration, after debridement, V-Y-S advancement flap, suture removal. As doctors, we need to plant things right. Techniques and principles founded on firm ground produce a bountiful harvest. We should have a green thumb. #orthopaedics #footandankle #woundcare #patienthappy #aotrauma #aoorecon #pieytobillo #bacolodfootdoctor #firstloveistrauma #diabeticfoot #diabeticulcer #plantingisfun #advancementflap https://www.instagram.com/p/BnyML9pBHJD/?utm_source=ig_tumblr_share&igshid=mb8oymcxttkk

[orthopedics]

Swipe! In my practice, it is not uncommon to see patients presenting with multiple bumps and lesions. Involving many joints, these boggy masses are usually from tuberculosis and do very well managed medically. Here, we have a patient with multiple lesions on the leg presenting with night pain, allodynia, and there is neuralgia from mass effect as well as motor weakness in the anterior leg. There are enchondromas present elsewhere in the body but not shown here. (A) Hemangiomas are seen on coronal and sagittal MRI cuts, labelled 1, 2 and 3. The ultrasound slide is included showing tumor vascularity. (B) Inserting needles into the tumor and injecting a radio-opaque sclerosing agent for intralesional control. #maffuccisyndrome #orthopaedics #footandankle #hemangioma #legpain #patienthappy #aotrauma #pieytobillo #bacolodfootdoctor #firstloveistrauma #elderly #radiology #tumor #vascularintervention #trauma #couldbeworse #empathy #fluoroscopy #pregabalin #paincontrol https://www.instagram.com/p/BnctChKgc-q/?utm_source=ig_tumblr_share&igshid=1604fste4a1ua

[orthopedics]

When patients visit the clinic, they come in so that someone competent and trusted can help them with their complaints. In that conversation, listening comprises the key step in establishing their trust in you, and builds up their perception of your competence as the attending surgeon. The reality is that even if there are proper indications to operate, patients still refuse surgery for a multitude of valid reasons. This patient with symptomatic flatfoot, midfoot arthritis, and toe deformities did not want surgery in any form. We explain the benefits and limitations of doing no operation, and the patient is extremely happy with customized shoes to pad the dorsum, insoles to improve arch support, silicone toe covers/spacers to address the forefoot, and regular clinic visits. #orthopaedics #footandankle #flatfoot #midfootarthritis #patienthappy #aotrauma #pieytobillo #bacolodfootdoctor #firstloveistrauma #elderly #radiology #hammertoe #trauma #couldbeworse #empathy #insole #customshoe #siliconetoecover (at Bacolod Foot and Ankle Clinic) https://www.instagram.com/p/BnJIeRJAyg7/?utm_source=ig_tumblr_share&igshid=1mwfrrbbskqf2

[orthopedics]

Swipe! Any ankle fracture needs tender, loving care. As usual, this patient got the injury after crashing a motorcycle.  What makes this unusual is it involves a  really expensive vehicle ending up a total wreck. I can't fix that. For this patient, it was great that motocross boots were worn and dissipated most of the high-energy load. (A) AO 43C3.1 injury, pilon with multifragmentary articular and metaphyseal fragments resembling a Ruedi-Allgower type I fracture. Thank goodness the soft tissue envelope kept the puzzle pieces undisplaced. Above are the injury films, and immediate postoperative slides below. (B) CT cuts in axial, coronal, and sagittal planes show articular involvement above and arthrography scans at three months below show intact joint congruency. Even after the sugical procedure, tender, loving care continues in all phases of patient followup. #orthopaedics #footandankle #ORIF #pilon #patienthappy #aotrauma #pieytobillo #bacolodfootdoctor #firstloveistrauma #motocros #radiology #fracture #trauma #couldbeworse #empathy #sportsinjury #millenial

[orthopedics]

Swipe! Nasty ankle injuries deserve a lot of care well beyond surgery itself. Rehabilitation can be challenging and residual pain should be addressed for patient comfort. (A) Injury film reveals an AO 44C2.2u suprasyndesmotic fibular diaphysis wedge fracture, medial malleolar fracture, unstable syndesmosis and ankle dislocation. Pronation-Adduction III. Below are the reduction images after splinting. (B) The fluoroscopic images show reduction before and after syndesmotic screw application. This was done after bridging the fibula and fixing the medial malleolus. Below are immediate postoperative radiographs. (C) Postoperative 24 months. Syndesmotic screw removal performed 3 months after index surgery. Back to biking! #orthopaedics #footandankle #ORIF #ankle #laugehansen #patienthappy #aotrauma #pieytobillo #bacolodfootdoctor #firstloveistrauma #podiatry #radiology #fracture #trauma #couldbeworse #empathy #biking #morningrounds #postoprecovery (at Bacolod Foot and Ankle Clinic)

[orthopedics]

Swipe! Every now and then, it’s healthy and enjoyable to venture beyond the field of foot and ankle. You review your basic training and apply other principles from sub specialty training. A fall on an outstretched hand outnumbers an ankle sprain at my hospital ER or outpatient clinic any given day. (A) Injury film reveals an AO 2R3A2.2 fracture side by side its latest image at postoperative four years. The surgery performed was a closed reduction with pinning, secured by a cobra device as a non-joint spanning external fixator. They are compared at immediate postoperative and prior to hardware removal. The base of the ulnar styloid is an AO 2U3A1.1 fracture and it has been left alone with excellent function. (B) The contralateral wrist recently sustained a similar injury. I wish I could have shown the amount of displacement here, but the fluoroscopic images reveal improved reduction with the same surgical procedure. Not spanning the wrist joint permits the ability to write and turn a door knob after the operation. Next on the docket is to treat osteoporosis! #orthopaedics #footandankle #CRIF #colles #distalradius #patienthappy #aotrauma #pieytobillo #cobra #exfix #bacolodfootdoctor #firstloveistrauma #foosh #radiology #fracture #trauma #couldbeworse #osteoporosis

[orthopedics]

Bunion pain should not stop you from wearing your favorite pair of shoes or limiting the time you spend outdoors. A diaphyseal scarf osteotomy fixed with two screws corrected the deformity and kept it I place. These are preoperative, immediate postoperative, 12 months and 36 months followup. #footandankle #orthopaedics #halluxvalgus #scarfosteotomy #deformitycorrection #patienthappy #bacolodfootdoctor

[orthopedics]

You will always hear an outpouring of gratitude, and of the tremendous expanse of knowledge gained from those who have completed their respective fellowship programs. I would certainly attest to that now. I will miss all this training, all my residents, co-fellows, professors, and all the hardworking staff at the OR, ward, and clinic; each of whom I know by name, face, and shared experiences. But I also yearn for home, and this is the longest I have been away. It’s finally time to head back, and I extend my sincerest gratitude to all these dear people who have imparted meaningful insight to my learning. #fellowshipcompleted #thankyoukorea #kanshamnida #orthopaedics #footandankle #bacolodfootdoctor #pieytobillo #reconstructivesurgery #anklearthritis #diabetes #trauma #reconstruction #woundcare #diabeticfoot #deformitycorrection (at Konkuk University)

[orthopedics]

Swipe! Feet are very important. They get you to places, they keep you planted on the earth, and where they point leads to the direction you’re heading to. So keep them healthy. Look at them, pamper them, and trust your doctor to take care of them. Whether it’s a stroll in the park with your children, attending to the issues of your world, or taking a literal leap of faith, your feet are with you. (A) Painful left ankle from combined polyneuropathy and post-traumatic talar collapse. (B) Intraoperative fluoroscopy shows talus excision and replacement with a femoral head allograft through a transfibular approach, followed by tibiotalocalcaneal fusion with 7.3mm screws and a Philos plate construct. (C) On yearly follow-up, disuse osteopenia resolves, screws on plate zones B and D start backing off, ultimately with non-locking screw failure at zone F at the time of long screw removal. (D) CT coronal and sagittal cuts preoperative, and postoperative years 2 and 4. The subtalar joint would better if it showed improved state of union. Hardware removal is definitely not routine in this subset of patients. #orthopaedics #footandankle #bacolodfootdoctor #pieytobillo #reconstructivesurgery #ankle #arthritis #talarcollapse #avascularnecrosis #anklearthritis #diabetes #trauma #radiology #transfibularapproach

[orthopedics]

I miss fixing leg deformities with an intramedullary device. I remember using a Küntscher nail for my first tibia done in residency. I cut it, bent it, and filed it myself. The implant easily passed through the proximal fragment only to engage the distal fragment’s medial cortex with its narrow slot. Something felt wrong and I stopped hammering the nail in. Fluoroscopy confirmed my error and we had to backslap the nail out, re-reduce the fracture and drive the implant back in. With newer nail generations, the relative procedural ease is dramatic. Here we have AO 42B3b and 4F2Aa injuries for a fragmentary wedge fracture of the tibial mid-diaphysis and simple transverse fracture of the fibular proximal shaft. Closed, reamed, antegrade intramedullary nailing of the tibia was performed using indirect reduction fixed with relative stability. A small gap was appreciated in the immediate postop xray and with progressive weightbearing, proceeded to break the most distal of two proximal screws at the nail border. Dynamization was done for us by the patient, but it didn’t help us in removing the retained threaded portion later on. This is a very basic case but it is meaningful in that patients always return to your clinic grateful for their mobility and return to activity. And that as you rise up to more sophisticated procedures, the basics always keep you rooted. #orthopaedics #footandankle #ORIF #lisfranc #patienthappy #aotrauma #pieytobillo #bacolodfootdoctor #firstloveistrauma #pedestrian #radiology #fracture #trauma #roadtrafficaccident #couldbeworse #vehicularcollision

[orthopedics]

Swipe! Completing jigsaw puzzles was a big part of my childhood. Each piece had its place, and you had to find out where it belonged with trial and error. As I got older, the puzzles got harder; and that meant having more pieces, or more shapes, even less color variety, and odd dimensions. Now that I am in the position of teaching students about orthopedics, and how fantastic a specialty it is, I reflect on how limited the puzzle pieces are in a fractured human limb, the contours are generally anatomic and predictable, periosteum and soft tissues always surround bone, and it always comes in 3D. (A) A pucker on the medial midfoot is corrected after closed reduction. (B) Radiographs reveal an AO 89B midfoot crush with multiple fractures and dislocations. This is essentially a Myerson A with total dorsolateral Lisfranc incongruity. (C) CT 3D reconstruction shows injury and reduction composites, as well as sagittal cuts. (D) Intraoperative fluoroscopy shows an attempt to fix with a plate, but screws offered a superior final construct. (E) Postoperative x-rays. Keep doing puzzles! A simple hobby can help with your profession. #orthopaedics #footandankle #ORIF #lisfranc #patienthappy #aotrauma #pieytobillo #bacolodfootdoctor #firstloveistrauma #pedestrian #radiology #fracture #trauma #roadtrafficaccident #couldbeworse #vehicularcollision

[orthopedics]

Swipe! Elderly woman, took a wrong step. Diabetic, osteoporotic, with end-stage renal disease, congestive heart failure, thyroid issues, but apparently a youthful teenager in spirit. (A) AO 44B3.1n transsyndesmotic fibula injury, Volkmann's fragment, Tillaux-Chaput fracture in ankle radiographs, resembling a pilon-like Ruedi-Allgower type I. (B) CT cuts in coronal, sagittal, and axial planes show articular involvement and die-punch component. (C) Immediate postoperative x-rays after multiple screw fixation. (D) One year after. (E) Five years after hardware removal. Every step counts. Doctors should take their patients forward. #orthopaedics #footandankle #ORIF #pilon #patienthappy #aotrauma #pieytobillo #bacolodfootdoctor #firstloveistrauma #pedestrian #radiology #fracture #trauma #couldbeworse #empathy #seniorcitizen #millenial

[orthopedics]

Swipe! A broken bone can heal with or without the supervision of a doctor, with or without manipulation, immobilization, or surgery. But having it seen by a professional is a key step in having less pain, getting good outcomes and being productive once more. For this patient, pain got worse after surgery, routine medications weren’t helping, and motivation was poor to do physical therapy. (A) The bone scan was performed to confirm clinically evident complex regional pain syndrome, Sudeck atrophy. There is increased uptake on all three phases with diffuse activity around the knee and ankle. (B) AP and lateral radiographs show an AO 42B3c fragmentary wedge fracture to distal tibia diaphysis and 4F2Ba multifragmentary fracture of the proximal fibular diaphysis. (C) Closed reduction internal fixation with minimally invasive plate osteosynthesis was done. (D) Postop one year with good remodeling. (E) Postop five years with radiologic union. (F) Bone scan at seven years postop shows decreased uptake compared to baseline. Clinically, the patient has improved to work again. We should strive for patient comfort first and foremost. Good x-rays do not necessarily mean happy patients. A nail would have made another excellent option. #orthopaedics #footandankle #CRIF #MIPO #tibia #patientnowhappy #chronicpain #aotrauma #pieytobillo #physicaltherapy #bacolodfootdoctor #firstloveistrauma #pedestrian #radiology #fracture #trauma #roadtrafficaccident #couldbeworse #vehicularcollision #empathy #bonescan

[orthopedics]

This is a pin cushion shaped like a foot. No, wait. This is a foot which resembles a pin cushion. Swipe to see more retained acupuncture needles in the same foot. This elderly gentleman sought our help to address his neuropathic pain. We didn’t observe unusual cutaneous lesions, but showed surprised interest with the wire-like bodies evident in the radiographs. More so that these have been reported to migrate in the body. I think there should be respect for each modality of treatment and for decisions patient make. We can’t just announce that our way of making them better is the best, or that they should’ve gone to us the first time around. We have to work on their beliefs, culture, resources, and fears. That makes us better physicians, more compassionate healers, and better listeners. #orthopaedics #footandankle #pieytobillo #bacolodfootdoctor #compassion #acupuncture #meridian #pain #alternativemedicine #orientalmedicine #brokenneedle #livepainfree

[orthopedics]

So what happens when two mountains collide? It depends really. If you were a resident, that could mean two attendings disagreeing on a treatment plan for the patient which can be amusing or make you want to run for cover. For a geologist, it is clearly seismic. For this elite taekwondo athlete, it is a career-pausing event. He has a spur on the anterior distal tibia marked by the dotted red line. It should be smoothly contoured. He has another osteophyte on the talar neck in yellow. As his dominant leg executes consecutive kicks (yonsok chagi), his supporting foot pivots in dorsiflexion and the two ridges meet. The result of what should have been an effective attack becomes a self-inflicted blow landing him on the mat (sparks). This is an anterior ankle osseous impingement which can be effectively managed by cheilectomy via a mini-open approach or arthroscopically. Unfortunately, there’s no spinning heel kick to this condition with conservative treatment. #orthopaedics #footandankle #bacolodfootdoctor #spurs #taekwondo #osteophyte #pain #cheilectomy #athlete #competition #whenyouandi #collide

[orthopedics]

Swipe! Treating the elderly can be quite challenging, but they are dear patients. Finding out how and why they fell, explaining their options, them nodding in understanding to each statement said, then asking to repeat what you just said for more or less four cycles, addressing pain, and advising on the postop regimen, are real issues. Some of them have hearing problems, some of them can’t see very well. Which is why they probably smile and nod all the time, say how handsome their doctors are, express how the nurses are a delight. But grandparents are rightfully so those and more. They were parents before, perfecting the art of calming their kids who were crying maybe from hunger, an ache somewhere, or just sleepy. They explained well but weren’t listened to, they explained thinking they meant well but the other end wasn’t having any of it. It’s magic to hold a grandmother’s hand during morning rounds to reassure her everything will be fine, even if you know she will not comply with weight-bearing instructions. (A) This is a bilateral ankle injury, forward facing radiograph above with lateral views below show an AO 44B2.2o transsyndesmotic fibula fracture with a medial malleolus fracture and a rupture of the anterior syndesmosis Wagstaffe-Le Fort avulsion (LH SER4) on the right and an AO 44A2.3 Infrasyndesmotic transverse fibula injury with a medial malleolar fracture (LH SAD2) on the left. (B) Intraoperative fluoroscopy shows provisional and definite fixation. (C) X-rays two years after surgery before implant removal. Granny always brings brownies each time she visits the clinic. #orthopaedics #footandankle #ORIF #ankle #laugehansen #patienthappy #aotrauma #pieytobillo #bacolodfootdoctor #firstloveistrauma #dancinginthekitchen #radiology #fracture #trauma #grandma #couldbeworse #vehicularcollision #empathy #morningrounds

[orthopedics]

Revascularization is my favorite procedure for the diabetic limb. In a matter of 17 minutes, the video loop shows improved flow in the ATA and PTA. Good blood flow means better chances of wound healing, less surgery. // After my first year of residency, I had performed 42 below knee amputations (BKA). My two co-residents performed more. Our specialty board was shocked of the figures during their annual accreditation visit. They require only five BKAs among many other procedures for the duration of training. Forty of those were due to infected/ischemic limbs from septic diabetics. The other two were from mangled extremities beyond repair. In my first three cases, I was generously assisted by an attending, a senior resident, and a rotating intern. The rest in the series had me teaching the lone clerk helping me in the OR; important was that I always had someone available outside if rescue was needed. On top of the clear anatomy and technique, explaining why we receive all these feet with large necrotic areas was the most difficult to do. I couldn’t imagine a relative with such a lesion so late into treatment. Looking at my logbook, I progressed to 50 amputations in second year, and more than double that in atypical flaps, soft tissue coverage, and salvage attempts. I developed my script debriefing patients and their relatives how life-saving the surgery would be and impactful it can be. I learned about possible rebound and intermingling among the stages of grief popularized by Ross and Kessler. My wound care improved, my surgeries got quicker, and I would be rewarded the next day seeing the patient looking well despite the loss of limb. I reviewed our hospital data, did research, and got my foot and ankle fellowship by sharing what I knew. Now, I have a clearer algorithm how to manage this epidemic in my small island, involving multiple disciplines, government, the private sector, and many industries. It also informed me that there is a global role for a doctor from the province to teach peer experts on the subject. When I graduated recently, I had the second years logged at over 80 amputations each. The numbers are still bad. And we need to do something about it.