Jarrod Shapiro, DPM discusses the importance of maintaining a questioning attitude with exploration and reassessment of evidence-based practices. Dr Shapiro cites examples of famous people and their experiments and how doctors have built upon previous discoveries to improve current medical practice.
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Jarrod Shapiro, DPM
Associate Professor, College of Podiatric Medicine
Western University of Health Sciences, Pomona, CA
Associate Editor PRESENT Podiatry Online
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TAPE STARTS – [00:00]
Male Speaker 1: We're going to hear again from Dr. Shapiro [phonetics], demolishing sacred cows, reassessing what we know. Thank you and welcome back to the podium, Dr. Shapiro.
Dr. Shapiro: Thanks again. Chris, I appreciate it. If I could just really quickly -- I just want to make a couple comments. Dr. Wilde [phonetics] mentioned a couple of things and I have to say I agree with him as far as -- first of all from learning CPT and coding and stuff, that’s actually something that you should start learning as a resident. We actually trained for that as when I'm -- in my residency program, we teach our residents coding. So definitely do that. I have to say what I loved about what Dr. Wilde said was that were that he is intentionality. And I think that kind of thoughtful approach is really good. So looking at things, looking at the money and that type of thing, it's good. To go through an exercise like that is useful, but you have to realize that what you are getting into is a complicated field and it's hard to cover everything in 30 minutes, but it is something that you want to look at and I think that thoughtful process that he was advocating is something that will help you in the future. So with that said, I'm going to go through a quick discussion about some things that have basically been known -- at least we thought they were known. And then when you start looking at them in some detail, you start to question whether or not these things are actually real or not. So we're going to look through those things. For those of you who are residents, your job is really about exploration. You are trying all the things you can, learning everything you can and then creating and applying those things in your practice when you are actually out. So the other part of this is that when you are in the operating room, you are surrounded by history. There is so much of it. I mentioned before I like history, so to maybe as a kind of fun part of this, I'm going to throw in some things. Here are some instruments. They all have names. You probably know most of them hopefully. And in there, there is literally hundreds of years of history, different people who have done just amazing things. So just kind of fun, keep this interesting, we'll touch on some of those. So we're going to look at the known and we're going to look at things through new eyes. So that’s Isaac Newton. He came up with Newtonian mechanics and came up with all the things we know about physics. We thought we knew it all for hundreds of years and even to the point where in the late 1800s, somebody said we know everything we need to know about the world. And then this fellow came along and completely upended everything. Through new vision of things, he proved actually quite a bit of what Isaac Newton taught us is wrong once you get to a certain level of detail. So without Einstein, we wouldn't have things like GPS and satellites. We wouldn't have those fun computers that everybody likes to use and internet and phones and just whole slew of things. By looking at things through different eyes, I think you can grow and learn. So watch this? For those of you who are residents, what's the name of this instrument? Shout it out. A freer, right, but it's not. So you pronounced it like this, a freer. People ask for it in operating room, I need a freer elevator. This is actually a freer which is named after this guy. This is Otto Tiger Freer who is a surgeon in the late 1800s. So this was a device that he used in nasal surgery to support the septum during the procedure. So this isn't a freer as in elevator to free tissues. This is actually just something named after this guy. Alright, so let's get into one. So you can see the ankle fracture. And if I ask you to classify it, you might give me a Danis-Weber and say it's a Danis-Weber B. You might give me a Lauge-Hansen classification. You look at that, that’s going to be an SER 4. So is that true? Is Lauge-Hansen a legitimate classification? You all taught it. Probably everybody who goes through the CRIP gets asked a question about ankle fractures and Lauge-Hansen classification. So is it legitimate? So if you look at Lauge-Hansen's original study, he actually had five papers that looked at the ankle fracture through various methods and what he did in his original study was he took recently amputated mid femur legs, everything that and distal to it.
He then mounted the foot onto a board. He nailed the foot on the distal aspect of the foot and then the heel in different positions either supinated or pronated into the board. He removed the skin and subcu, so the only thing left was the joint-related structures, the ligaments and those kinds of things. And then he axially loaded the legs and then by hand, he manually rotated the extremity into the positions and then would actually hear or feel a crack of the fracture happening. He did this by hand. He then dissected the leg and took x-rays of it and then he used that to correlate what happened with the fracture. Okay now, if you think about this for just a second, most ankle fractures don't happen with the patient's foot hanging up in the air, right? Most of them happen with the patient standing. So then he kind of diagnosed those different types of fractures and he related how the fracture occurred and what tissues were injured along with the classification. So this had major methodological flaws. So one of them being that he used his hands to manipulate the leg. He actually grabbed the femur above the knee and rotated that which actually in many cases caused a pronatory movement in all situations including when the foot was in a supinated position. So some real issues about this. This study looked specifically at the Lauge-Hansen classification as it pertained to SER type fractures. And they tried to do everything they could to repeat Lauge-Hansen study. Now, one of the major aspects of this scientific method is to repeat the studies that you have done and to see if you can get the same results twice. So he mimicked those and they did that and they looked at 10 fresh frozen cadavers. This is a little busy, but this is their graph. If you look at this, so, the first -- so SER one is supposed to be in AITFL rupture or fibular rupture or a fracture or a Tillaux-Chaput fracture off the tibia. So what they saw was only in a couple of these, was the AITFL and that’s stage 1 actually ruptured in 2 of 10 cases. The fibula was fractured in a certain number of them but not in all of them, so that’s stage 2. Stage 3 involves the PITFL or the posterior malleolus and you noticed how many of those are intact. Lauge-Hansen said specifically that this was a clockwork injury and you had to rupture or fracture one thing in order to get to the next. They were not able to reproduce this classification scheme. And then finally with your stage 4, you have your medial malleolar fracture or a deltoid ligament rupture. So in some of those cases, they were also intact. So again they showed that Lauge-Hansen didn't correlate with the predicted pattern of injury and that obviously is important if you're using this classification to determine how you're reducing a fracture, how you're fixing it and determining what is injured from the soft tissue standpoint that you can actually see. Okay so here is another one where they looked at this. They did a slightly different method. They looked at about 30 fresh cadaver ankles and they tried to do a similar kind of things. They weren't able to reproduce the injury unless they valgus rotated the foot. So again they found the similar thing. So we now have a couple of studies. So is it really legitimate? Obviously for -- you have to know it just because everybody still talks about it, but it has really been shown to not be something that is predictable as far as using it in practice. So a bunch of issues with that. So my suggestion would be to not to use it. Okay, how about this one? What's this called? I heard somebody say it. It's a Kocher. It's a Kocher forceps. Okay, so this is Dr. Kocher. He was back in 1800s, early 1900s. He is actually one of only five surgeons in history to get the Noble prize. That’s the Noble prize by the way, that’s the Noble prize in medicine. If you get that plus -- I think it's somewhere in the million dollar range now. So if you get it, good on you. So he got that for work with the thyroid gland and he actually invented his instrument in order to grasp the thyroid without crushing it. And for those of you who have crushed metatarsals and various bones in the foot. If you've ever scrubbed the surgery with me and my students and residents, I've seen it happened. The Kocher is not the easiest thing to not to destroy things. So that’s what he used it for. I think you can see -- in orthopedics and podiatry, we claim a lot of these instruments for our own use.
Okay, so now I mentioned that ankle fracture, Lauge-Hansen classification isn't so high, isn't so special. So there is another way to look at this. This is a relatively recent article from back in 2009 where these folks from Johns Hopkins looked at a different method of this. So what they did was they tried to reproduce a PER fracture. So they did their mechanism. They did a lateral load after they put the foot on a slope and that slope created a valgus foot on the ankle. So what they got was -- if you look at this, this is actually an SER appearing fracture. So 8 of their 15 specimens -- they split this up in to -- that 30 was split into 15 on one part where they didn't apply a lateral force and then the other half was that they applied a lateral force and that will be important in just a minute. So what they found in this pronated foot that they externally rotated was that you had disappearing fracture which looks like your SER 2 and you will notice that the middle malleolus is intact. So in a PER, one of the first thing that goes is the medial malleolus. I think it's fair to say that the deltoid ligament doesn't look fractured or ruptured. There is no medial clear space enlargement. So they're creating an SER type of injury. So when they applied -- this is without a lateral force, basically just pronating the foot and then externally rotating and then when they apply a lateral force against the foot, so essentially fixing the forefoot into place that causes the foot to abduct and then they would see what looked like a high like the Maisonneuve fracture, so a higher fibular fracture. So what they found when they explained this was that this typical -- maybe 90% of this fracture is outside of the adduction type of injury, that most of the fractures occurred in this kind of mechanism. It depends on the amount of force that you're applying when the rotation occurred. So one on the left, that low oblique that looks like SER injury is if you mostly externally rotate the foot and then it fractures, you get this kind of fracture pattern. And then if you apply somewhat of that external rotation, but then also abduct the lower extremity at the same time, it will cause that higher PER kind of fracture appearance. And from my experience somebody who takes care of these, these are the most common appearances that we tend to see. And also if you think about this, how you reduce the ankle fracture is more consistent with this explanation than it is what Lauge-Hansen talked about. So what I tend to see is that if I supinate, plantar flex and invert the foot, while I'm doing my maneuver, that’s like Quigley position, Quigley maneuver that will allow the fibula to come back and everything goes back into alignment. That doesn't work if you're talking about a supination external rotation injury. You should actually be pronating the foot if you're going to reduce it according to what Lauge-Hansen recommended and that’s not typically what we tend to do. We tend to see this type of thing. So that’s a new explanation. Okay. Here is another one. What are these? Mayo scissors, right. So you guys have heard of the Mayo clinic, right? So these two guys, these two brothers. This is Dr. Charlie and Dr. Will. They were the Mayo brothers. They were doctors and where they started in, I believe, it was in Iowa if I remember right. There was a tornado and it destroyed a large amount of area and so they sort of ran a free ambulance service and started this hospital in order to help the nurses that were in the area. So from that came the Mayo Clinic. So you have these like three locations around the country and they do this amazing work. This is the result of these two guys who basically ran an ambulance service from the start.
Okay. I'm going to move on to a couple of other things. Here are radiographic [Indecipherable] [0:15:04]. How about elevatus? So I think dorsiflexion of the medial column is a real thing. I'm just going to say that right now. Okay. I don't think it comes from the 1st metatarsal cuneiform joint, but I do think there is elevation. Now, what we're talking about here specifically is elevatus on x-ray. So this study was done actually by one of my partners at the university, Dr. Chrisman [phonetic] who looked at this. What they did was they took radiographs of what they called kind of a shadow foot. This is sort of a plastic model of a foot and then they took the x-ray with the beam angled either straight at the foot or elevated a little bit like on a higher pitched angle or just the entire thing elevated kind of shooting above the foot. So they found something that looked a little bit like this. So the one in figure 7 is with that tube head angled right at the foot kind of a normal way, you do this 90 degrees. Figure 8 is where they rotated it so that it was still at the same level but angulated at 80 degrees instead of 90, okay. You can see that there is a little bit more of an elevation of the 1st metatarsal in comparison to the 2nd. And then the third one there, the one in the bottom is a figure from slightly later in the paper where they brought the entire tube head up so that it was about 10 degrees or so above the foot but still angled at 90 degrees. And you can see there is a little bit more of an elevatus from that. So this is purely by looking at the position of your x-ray. Okay, so what they found -- what they suggested was that you will have an increased elevatus if you have a decreased beam angulation. So basically if the beam is angling upwards, you're going to see more of the metatarsal. And then if that central beam was upwards above the level of foot to some extent, you'll also see a greater amount of elevatus. I don't think elevatus doesn't exist. I don't think I'll be on the record to say that, but it really depends, it's really important, so where your x-rays -- what kind of technique you're using and how consistent you are.
Okay. How about gloves during surgery? This is going to sound kind of weird. We all wear gloves. You are required to. Why do you wear them? Have you ever thought of that? You wear them because everybody tell us you have to wear them. Okay. What is this? This is going to start to answer our questions. That’s a mosquito, right? That’s a mosquito, but it's also called Halsted and this was invented by John Stewart Halsted. Before him, there came Lister. Probably everybody thought like Listerine that was named after Lister. Lister is the one that came up with our antiseptic technique. So this is what he used. He used 5% phenol and he would spray it all over the patient, the doctor, the doctor would literally be like in the shower of phenol. This is what it kind of looked like. They were preparing the surgical field. Just in case if you don't remember they called it carboxylic acid back then. We called it phenol now. We use a little stronger version, so 89% phenol, you don't want to breathe that in obviously. So they did this and he was not wearing gloves. He didn't wear gloves and I found this really significant. I believe it was somewhere in the range of 80% to 90% decrease in the infection rates after Lister started his antiseptic technique and that was good except he didn't wear gloves. So then came along this guy. This is William Stewart Halsted. He is one of the main doctors who actually started Johns Hopkins medical school and their hospital and he is considered the father of modern surgery. So he advocated meticulous dissection. So prior to him, doctors were showmen. The surgeons would [Indecipherable] [0:19:20] things. They move as fast as they can. If you could do a surgery in a few seconds, then you are really good. At this time, they had just started anesthesia. So he was one of the first guys in the United States who was using it and he invented his little Halsted hemostat in order to stop bleeding and be meticulous with his hemostasis. But interestingly, he fell in love with his scrub tech. And so he was smitten, he was not that old at the time of course. She was young, but when they scrubbed their surgeries and he used Lister's technique and she would get really severe rashes as a result of the phenol. So he contacted a rubber company who today still makes tires and they invented some gloves that she could put on. This is kind of what they look like. Nowadays -- so the gloves were so comfortable for his staff that everybody started using them. And so he started using them and of course he is famous and everybody knows who he is. So now gloves are used by everybody. So it's not necessarily to decrease infection rates. It's the fact that some guy fell in love and he wanted to make her better. Okay, so I think all of this gets back to things staying current. Reading about the things, questioning what you are coming in contact with and just exploring and having that kind of open mind for new things. Thank you very much.
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