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haywanchiudpm

Husband. Father of 2. Podiatric foot and ankle surgeon specializing in wounds and limb salvage. Same-day appointments are available for urgent needs.

Dr. Chiu specializes in diabetic wound care, bone infections, and advanced techniques to prevent amputation. He also provides general foot care and accepts all major insurance plans. If you become an established patient, Dr. Chiu will do everything possible to keep you ulcer-free. If wounds do occur, he provides hands-on care himself—often weekly—and manages all aspects of treatment including the antibiotics. If hospitalization is ever needed, Dr. Chiu or one of his trusted colleagues will care for you directly, with seamless coordination. He is one of the foot doctors at Albuquerque Associated Podiatrists who lead the wound care clinic.

09/24/2025

This is a 52F with DM, well controlled diabetes, developed a left Charcot foot deformity via navicular collapse, underwent attempted ORIF with monorail by a colleague. She was sent to me for reconstruction. Traditional treatment involved fusion of the midfoot and STJ using beams. But those cases are never easy, and results vary greatly. Recently more and more surgeons are starting to fuse the hindfoot and ankle, by locking the talus in the desired alignment the midfoot won’t collapse any further. It is also an easier recovery (and technically easier surgery to perform) than the traditional approach with potentially less risks and better outcomes. I did the standard lateral approach with fibular takedown, and IM nail. She was fusing nicely at 3 months and at that point was permitted to walk and drive, but must wear the CAM boot for any walking activities over 3 minutes. She will need to be in a boot for a year post-op. Final xrays in this post show the 9 months post-op xrays showing excellent fusion.

09/21/2025

This is a case I treated recently, straightforward 2-stage surgery of a 3rd toe necrotizing type infection. The key is looking for that vascular thrombosis which tells me where the bacteria is hiding. Single-stage treatment of necrotizing type infections especially in someone immunocompromised like this patient with DM and ESRD on PD, would be a mistake. Even if the tissues “looked good” at the time, because you don’t know if the bacteria is still in the tissues somewhere. I suggest at least giving it 48 hours, if it’s there it’ll continue to create exotoxin which leads to platelet leukocyte aggregates, and that will manifest itself as the little bits of thrombus. I do rely on broad spec antibiotics to suppress the spread of infection and to continue to kill bacteria, but I still need to do my job as the surgeon to physically remove any remnant of bacteria that the host and antibiotics struggle to completely eradicate. If you’re not sure whether to close or not, I suggest leave it completely open and come back in a few days to re-evaluate.

09/14/2025

Reintroducing the Terashi TMA, published in our home journal (JFAS) in 2011, but its idea deserves more attention. Traditional TMA pays no attention to the soft tissue muscle and periosteum bulk, we make a skin and fascia flap to cover over bone. But if you look at how we do BKA and AKA surgery, we use muscle to cover the tibia or femur. The more you can pad the bone prominence the better the stump can remain ulcer free in a prosthetic. Same for the foot. The more vascularized soft tissue you can put between bone and skin, the better the TMA will remain ulcer free. Look at the next slide, it’ll show a video of how this patient was able to use the intrinsic muscle to flex his foot, he even joked that he can pick up marbles with his TMA foot!

The paper does not describe in detail exactly how to do this. I show several videos of how I do the Terashi TMA on our website footandanklesurgeryacademy.com but basically, it involves a traditional fishmouth incision to bone, key elevator all periosteum off each metatarsal shaft. I now protect interosseous muscles with Hohmann or Senn retractors while performing the osteotomies. I then use a McGlamry elevator in an antegrade direction to reflect the plantar soft tissue off the bone to the level of the plantar plate origin. Then I use a scalpel to dissect the forefoot off, leaving what resembles a rack of lamb. The remainder is a super bulky plantar soft tissue flap that I can use to cover the bone stumps, typically with multilayer closure. It also gives us options to use these intrinsics as muscle flaps to cover defects created from infection.

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08/30/2025

This is a 51 year old patient with DM (a1c 6), TIA, had Fournier’s gangrene, needed multiple debridements and a colectomy with colostomy, was bed bound for 8 months, developed bilateral decubitus heel wounds that became infected, spread into the Achilles tendon causing frank necrosis. I was consulted for the first time after the Achilles were already infected. I got him admitted to the hospital, arterial duplex were triphasic and vascular signed off.

From where I see it, while infected decubitus ulcers typically have a poor prognosis because it is an indicator of the patient’s disease state, that is not so true in this case. The patient has well controlled diabetes, good flow, and relatively young. He developed decubitus wounds because of his Fournier’s gangrene which rendered him temporarily bed bound. He is recovering from that and has plans for colostomy reversal and desire to ambulate again, so this is a different circumstance from a decub on an elder patient at a permanently bed bound state. I don’t think the medical team saw it this way because they pushed for bilateral BKA and deemed poor prognosis for limb salvage. This upset the patient and family obviously, and I advocated for limb salvage. On paper all he needed was a debridement. It’s not easy for us as surgeons to remove the Achilles tendon, but a limb with no Achilles tendon can still perform ADLs with AFO braces, and I think functionally on par or better than having him be a bilateral amputee. I just needed to do one operative debridement and you can see by the photos how he eventually healed by secondary intention several months later. Oh and the gangrenous heel was just to subcutaneous tissue, not even to bone. I didn’t need to do calcanectomy or ex fix. Surgically simple solution. The hard part was reassuring everyone including the medical team that this was salvageable.

08/29/2025

This pt in his late 50s with DM, had gas gangrene of he plantar foot that needed wide debridement, was healing fine up until he ran into housing issues and had to do a lot of walking. He worsened the wound to the point the cuboid bone was exposed and necrotic. He wanted to save the limb at all costs, so we admitted him, I did a cuboidectomy and then staged septic TTC fusion with ex fix and abx cement spacer to the cuboid. The cement was flush with the skin to induce a membrane to help granulate the bones that are still exposed.

A month later, I removed the spacer in clinic and did wound care, eventually getting the wound to heal a year later. This wound was clearly too large to close, and while BKA is a more functional option, this patient elected to save his limb as he was a low level ambulator. I needed a way to get the cuboid defect healed. I think this is a more powerful example of how the induced membrane technique can work for complex wounds with bone exposed. I didn’t use this for structural purposes or reconstruction.

08/25/2025

This is a patient in his late 70s who had gas gangrene of the heel that I treated with open vertical contour calcanectomy with Achilles resection, ex-fix offloading, with concurrent 1st MTPJ wound. Lots to unpack but ignore the posterior work and the frame, this post is focused on the 1st MTPJ gangrene. Its stable and dry, he underwent angiogram and found optimized with collaterals. He is ok with slow wound healing if that means there’s a chance to save his toes. I don’t like wound vacs anymore for many reasons, logistics, compliance, quality of life, cost, and questionable efficacy (Arundel, wound vac RCT 2025 The Lancet) but also with the ex fix there, it makes wound vacs even more difficult. This case was when I started using the induced membrane technique for wounds.

So options are 1st met head resection with primary wound closure. Once the bone is gone, it’s easy to close, and infection risk is reduced with a staged option. But he also has so many gangrenous wounds elsewhere that I didn’t feel the urgency to get the wound healed ASAP when he is needing wound care there anyway.

So what I did was single-stage 1st met head resection with ABX cement spacer application, (vanc + tobra) let it sit for 1 month and pulled it out in clinic. The induced membrane reminds me a bit of a reorganizing hematoma, it’s gelatinous, not quite like bioburden. Keep in mind this patient had a poor healing response so the membrane wasn’t as robust in granulation as I hoped. Anyway I did very gentle debridement and resumed regular wound care, doesn’t matter a whole lot what is done at that point but I recommended twice a week home health dressing changes, they can put anything they want and I’ll OK it. I just saw him monthly for maintenance debridement. Took awhile to heal but we got there, right around the same time all the other gangrenous patches were healing up.

If you find this post useful, help me save more limbs and toes by sharing this post. Thanks!

04/28/2025

This male in his mid 50s presented to the ER with WBC 21, vital signs stable, had a chronic wound for several months that became infected. The infected nidus showed necrosis, and with the dorsal blistering and ecchymoses, this is a classic type 1 necrotizing fasciitis case. We did a 4th ray amputation with I&D to get initial source control. The closure was a bit complex due to the widespread damage.

There were 2 major issues. The large size of the wound wasn’t a problem, the large dorsal wound will heal fine and its a NWB surface. Could also do a hallux fillet flap to cover dorsal. Mostly worried about the large 4th ray defect and 5th metatarsal bone exposed. I didn’t have an exact plan of what I was going to do, but once I was in surgery, I found that the abductor digiti minimi muscle was viable and had some bulk. So I separated the muscle from the overlying skin, flipped it backwards to cover the 5th metatarsal bone. The plantar 5th metatarsal skin was then mobilized medial to cover the remaining defect. The rest was closed in layered fashion, 3-0 monocryl and 2-0 and 3-0 nylon.

The path results confirmed nec fasc with negative bone margins, he was discharged on oral Augmenting. I saw him in office once a week for debridement. Dressing changes consist of betadine gauze. The hallux filet flap struggled a bit at the edges (not unexpected) but it eventually healed by the 16th post-op week.

04/19/2025

I trained ChatGPT to write my SOAP notes. Here’s what happened.

Most AI scribes do a decent job transcribing and summarizing a visit—but they rarely capture real clinical decision-making. And almost none are formatted to meet audit-proof documentation standards.

So I tried to train it myself.

I fed ChatGPT examples of my notes. I uploaded the Novitas LCDs (I’m in New Mexico). I gave it strict instructions to mimic how I document healing trajectory, imaging interpretations, and a few other stylistic nuances. I even asked it to ask clarifying questions before generating the final note.

At first, the output was pretty good.

But then I noticed it was fabricating things—little details I never said or did. After digging, I learned these are called hallucinations—when AI prioritizes sounding smart over being accurate. Just like overconfident humans.

I tried to fix it. I gave it more rules. More structure. More definitions.

That’s when things got worse.

The bot started confusing low vs moderate complexity. Mistook erythema as a systemic symptom and upgraded risk severity. Forgot prior guidelines I fed it. Turns out it was relying on cognitive shortcuts—trained habits to reduce mental strain. When I blocked those, it collapsed.

So I’m pausing the full automation for now. Maybe I need to figure out a different way to instruct it, or maybe it needs more computing power.

But right now, I’m using it for very selectively in clinic: generating smart phrases, documenting medical necessity, and tightening high-risk notes—especially the ones insurers actually request: level 4 or 5 visits with a 25 modifier (like for doing debridements).

Most level 3s don’t get audited. It’s the notes with 25-modifier that need to be airtight. Maybe I’ll try the full bot again later. For now, it’s back to Dragon…with AI-augmented phrasing in my back pocket.

Pro tip: If you’re using skin subs, try uploading the skin sub LCD, pasting a note, and ask ChatGPT to “Review this note for a strict Medicare audit. Make sure I have all documentation requirements and medical necessity explicitly stated”

04/02/2025

As a podiatric surgeon in New Mexico specializing in diabetic limb salvage, I’ve seen complications that never showed up in training—things you won’t find in textbooks.

I had to revise how I think.
I slowly developed a different approach to infection, source control, and surgical decision-making.
It started as stuff I had to constantly remind myself, and then eventually it became instinct. I developed a framework that I could pass onto my colleagues. One of my limb salvage partners I work with told me that it just feels as natural as breathing now.

And together, we started getting better results.

But the truth is—this framework I’ve been building is still too abstract and disorganized to publish.
It lives in mental notes, case photos, and intra-op problem-solving.
Between spending time with my wife and 3 daughters and working my beyond-full time job, I never had the time to turn it into a book, course, or formal teaching tool.

Then I came across something online:
People were building custom versions of ChatGPT and training them to act as teaching assistants.

And I thought—what if I could teach it to what I know now?

So I gave it a shot.
For two weeks, I casually fed it what I knew—voice notes during commutes, uploaded a few cases I’ve already posted on Instagram, random thoughts between surgeries or downtime in the clinic.

When I ask ChatGPT, “What is the current diabetic limb salvage approach?”
It’ll show me all the usual stuff I see in textbooks.

Then I asked it again:
“Show me my limb salvage framework.”

And honestly, it surprised me.

“Limb salvage does not equal wound care”
“You emphasize knowledge acquisition, not just protocols”
“Look for vascular thrombosis at the edge”
“Bacteria move passively via human motion...”

It showed me things I’ve either thought of but never verbalized quite this way, or stuff I say all the time.

Not bad for two weeks.

There’s still a lot to refine—but this might be the start of something bigger.
A chatbot to teach limb salvage?
A real-time reflection tool?
Maybe even the beginning of a textbook I could never sit down to write?

Let’s see what happens if I keep this up for a year.

03/24/2025

These are all TMAs.
But none of them were the same.

Each one required a staged approach:
• First, source control—every infection created a unique defect.
• Then, a different closure strategy based on what was left behind.

This kind of decision-making isn’t usually taught in school.
And if your residency doesn’t have a dedicated limb salvage specialist, you may never see it.

Over the years, I’ve learned how to problem-solve in the OR with techniques I’ve refined, learned, and developed over time.

Scroll through the slides to see a few examples:
• Fillet toe flap
• Intrinsic muscle flaps
• SALSA spike
• Split-thickness skin grafts
• Secondary intention when it makes sense

That’s the difference with diabetic limb salvage.

You can plan your approach…
But the infection doesn’t always follow your plan.

And when things shift mid-case, you need both strategy and flexibility.
• Sometimes the tissue is more infected than you thought.
• Sometimes perfusion isn’t what you hoped.
• And sometimes the closure you mapped out… just isn’t going to work.

In those moments, you can’t force it.
You pivot.
You adapt.

These aren’t things you memorize.
They come from doing the work—and from letting go of the idea that there’s a perfect playbook.

When you stop trying to make the case fit your technique…
and instead adjust your technique to fit the case.

That’s where the creativity starts.

And honestly,
that’s where I have the most fun.

Address

8080 Academy Road NE
Albuquerque, NM
87111

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Tuesday	7am - 5:30pm
Thursday	7am - 4pm
Friday	9am - 4:30pm

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