Wisconsin September, Haitian October
Oct 2
Arrived back in Haiti. Ed Miller is back for his second stint helping me. He will be here for
10 days. There are two students from DO school in Colorado here for three weeks. Dr Pat Yoon’s
team covered the last two weeks while we were gone. They left earlier today. Francel is also gone.
He will be spending most of the month of October with Dr Karl Rathjen in Dallas. I accepted a
young teenager with fractures of both of his tibias. Apparently a stack of bags of cement fell
over on him this morning. We won’t have any anesthesia until Maria gets here from the DR Tuesday
afternoon. The fractures are closed so we will just have to wait until Tuesday or perhaps Wednesday.
We checked out the anesthesia machines and then called Freddy again. He wants me to take
pictures of them and email him with more information.

Oct 3
The Monday clinic only had about 40 patients but it took a long time.
I think I saw at least a half dozen patients with TSF and Ilizaroff
frames. Each one took quite a bit of time to study and sort out
potential issues. I also saw a 57 y/o man with a huge fluid filled
cyst that fills his entire popliteal fosso(area behind the knee) and
extends out around the lateral side of the knee and welll up the thigh
behind the back of the knee. He has had the cyst for several months
but in the past few days noted that now he can no longer dorsiflex his
foot and ankle. The cyst was very tense and filled with what felt
like fluid. We put in a needle and drained a lot of dark colored
fluid. I suspect Pigmented Villonodular synovitis. At most we were
able to only get about 20% of the fluid out by aspirating with a
needle. I emailed the clinical data and pictures of his knee to Dr
Bibiloni in Puerto Rico. He is an orthopedic oncologist who teaches
at the University of Puerto Rico in the orthopedic department. He is
helping organize the team from Puerto Rico that will be here next
week. I would prefer to wait for Dr Bibiloni to do the definitive
surgical treatment since that is his specialty. Perhaps keeping the
cyst partially decompressed will relieve enough of the pressure on the
peroneal nerve that it might have a chance to recover. We still don’t
have an x-ray machine working in the clinic and there may be an issue
with the Ministry of Health questioning our use of the C-arm for
clinic patients. We are encouraging patients to go to the xray
department for permanent films. Many of the patients seem to be able
to pay the fee involved. Ed did a couple of cases in the OR with
local anesthesia and also helped in clinic. Clinic lasted until
nearly 6 pm. Jeannie made a really nice meal for us and we invited Ed
and both of the students to join us. We had a good time talking for a
couple of hours. I called Freddy again tonight and he has gotten
permission to come. I’m really excited! I hope this will be the
beginning of a good working relationship with Bella Vista Hospital.

Oct 4
There were 7 cases scheduled for today in anticipation of Dr Adrian
and Lucia arriving early this afternoon from the DR. They didn’t get
in as early as we had hoped and we didn’t get started until after 4
pm. A patient with a calcaneal fracture came into the ER last night.
His fracture is displaced and should have a surgical reduction and
fixation. We should have time to do his surgery on Friday. That will
give the swelling time to go down a bit. We postponed one case until
tomorrow. Ed and the students did the hip hemiarthroplasty with JJ
assisting. ZJ and I did the rest of the cases in the other room
including an arthroscopy on a patient with an AK amputation. We
finished all of the cases and got everythingcleaned up just before
midnight. Dr Adrian did her usual terrific job. It was even more
impressive given the fact that she had hardly had any sleep the night
before because of a neurosurgical emergency that she gave anesthesia
for until 5 am. ZJ did very well with the arthroscopy. He has very
good hands.

Oct 5
Apparently the patient with the calcaneal fracture knows Dr Hans
Larson, the president of the Haitian Orthopedic Society. He wants Dr
Larson to do his surgery. He has been admitted as a private patient.
The clinic including the clubfeet patients was large as usual.
Several more patients with frames came in and took quite a bit of
time. We had three cases including the boy with the bilateral tibia
fractures. Ed did his usual very careful, well thought out, precise
surgical management of a difficult case. The entire medial tibal
plateau, half of the entire growth plate of the proximal tibia was
extruded medially. The ACL was shredded as well. The students, Josh
and Andy, are getting totally inundated with amazing orthopedic
pathology. Jean Sondy, the boy who was an inpatient for so long last
year with the infection in his tibia, finally got his Ilizaroff frame
removed today. He has no infection and the tibia is healed although
it is a bit short yet. He is really happy and expressed his
appreciation for all we have done. His father did likewise. I
continue to be impressed with the Haitian people. Another case was a
4 y/o orphan boy who is being treated for neglected clubfeet. Dr
Nelson put Taylor Spatial frames on both feet and legs in August.
Using the TSFs for these deformed feet is considerably more difficult
than a straightforward frame for a long bone deformity. If I could
have a few more weeks doing these kinds of cases with Dr Nelson,
perhaps I could even do them myself. The reality is that they can
easily wait for a few weeks until an expert can do them and then I can
follow them. This boy’s followup has been a little more complicated
than usual and I had to spend some time on the phone with Scott last
night and again today to get everything right. These cases need two
separate treatment programs. The first is to correct the forefoot and
midfoot so that the navicular bone is reduced on the talus. Then the
wire that is stabilizing the talus is changed from its attachment to
the proximal ring and attached to the distal ring. The new program
then corrects the remaining equinus deformity(foot pointing down
toward the floor). Of course, it requires a completely new
prescription. The data is again entered into the computer including
the amount of deformity(equinus). The patient and the caregivers then
adjust the 6 struts over a period of several weeks to get the foot
straight. It is fairly common for patients to have infections around
pins or wires during the several months that they have the frames.
The simpler infections respond almost always to oral antibiotics. I
have had a couple of patients with infections that were significant
enough to take to the OR for debridement and IV antibiotic treatment.
So far, I haven’t had to take any frames off before finishing with the
full treatment because of infection.
The clinic and surgical cases were all done by 7:30. I admit that the
12 hour days are preferable to the16 hour days.

Oct 6
Seven cases were on the board for today including a 17 y/o girl with
severe Blounts for TSF and osteotomies of the tibia and fibula. About
10:00 I was told that Dr Hans Larson was coming at noon to do the
surgery on the patient with the calcaneal fracture and was going to
start at noon. That left us in a bit of limbo since we were planning
to use the C-arm for two cases that could each take up to 3 hours. We
certainly want the Haitian orthopedists to want to come here and do
surgery without having to wait for a room or equipment. We waited
until nearly 2 pm and didn’t have any word from him so we went ahead
with our shorter case. Then we followed with the TSF. Ed helped me
with it and it went very well. He had never seen one done before. We
had a really good time doing it together. Of course, we had to clean
up all of the instruments and trays and restock all of the trays with
the bone screws, rings, struts, connectors and bolts. We finished
everything by about 8:30. Dr Larson did the calcaneal fracture in the
other room while we were busy in Room 2. I guess he didn’t need the
C-arm.