North West Podiatric Foundation Summer Surgical Seminar – CLONTARF CASTLE, Dublin – 15 th August 2008 David R Tollafield, Consultant Podiatric Surgeon.

North West Podiatric Foundation Summer Surgical Seminar

– CLONTARF CASTLE, Dublin – 15th August 2008

David R Tollafield, Consultant Podiatric SurgeonPodiatric Surgical Services Walsall NHS Community Trust, West Midlands, U.K.

Adapted for the Consultant and clinical governance GroupMidlands Region. Solihull 27th November 2008

“I dressed the wound. God healed it.”

Illustrated: Primary wound healing with subcuticular PDS 4/0 [author]

What do you do when you What do you do when you have a problem...have a problem...Then you have another?Then you have another?

Case history management

• Mechanical• Nutritional• Age and health• Compliance• Social• Physical• Surgeon technique• Factors outside surgeon control

Factors disrupting normal surgical wounds

Negative effects of delayed wound healing

Economic factors patient loss of work

Drug supplyDressingsEscalate

laboratory testsImagingAdmission Theatre

Pyscho-social drug side effectssocial morbidityDepression &

suicideComplex regional

pain

36 sequelae?

Wound problems

Podiatric audit in surgery and clinical outcome measurementSociety of Chiropodists & Podiatrists(c)

% of all 36 sequelae entries n=2543 in over 80% females

Sutures and materials

FREQUENCY OF REPAIR TECHNIQUES

Simple interrupted 38-50% Simple running 37-42% Subcuticular 28% Vertical mattress 3-8%

Nylon 51% Polypropylene44% Polyglactin 910 73%

Abdullah-Tawfik et al 2007

Adams et al 2006

Frederick J et al 1996Poly-p-dioxanon

Multinucleated foreign giant cells without infection

Sutures technique and Sequela

Sequela N=1000

% One layersuture

% TwoLayersutures

%

Tissue reactivity

335 33.5 177 31.6 158 35.9

Dehiscence 65 6.4 30 5.4 34 7.7

Infection 17 1.7 9 1.6 8 1.8

Gabrielli, et al 2001 No antibiotics were used in this trial

0.35

1.2

4.1

Comparing different operations: healing versus infection Proven.Source PASCOM Four centres same surgeon

Known's: haematoma causes problems!Known's: haematoma causes problems!

Signs of poor healing are obvious, The decision to undertake surgical intervention may not be.

Type 1 SADWound

Management of wounds with directional

advancement flaps

Vaughan et al 2006Steristrips n=60

24 days

Dystrophiccalcification

Post first surgery-foreign body-At 2 months

SecondRevisionarySurgery

Zonal hist0logyZonal hist0logy

necrosis

Org. haem

FBGC

39 days

48 days

31 days

2 days

5days

21 days

Secondary intention healing 48 days following management of wound

-0.5

0

0.5

1

1.5

2

2.5

3

3.5

0 50 100 150 200

uncomplicated healing

0

0.5

1

1.5

2

2.5

3

3.5

0 50 100 150 200 250 300

complicated healing

Primary surgery

SAD system (based) wound classificationWithout infection

0 skin intact

1Skin and subcutaneous tissues

2Tendon exposed

3Joint space

Macfarlane & Jeffcoate 1999 modification of San Antonio/Texas system

Primary surgery

Case 1

Case 2

48 days

"Minimal to slight foreign body responses have been routinely seen in multiple preclinical tissue reaction studies with VICRYL suture (usually muscle implantation), a typical tissue response to a foreign body that on occasion included foreign body giant cells. The tissue responses were not excessive and were considered a normal response to a foreign body." Dr Jim Oldham, pre-clinical safety group. Geraldine Harkins Marketing Manager ETHICON Products UK August 2008

In regard to internal suturesPg-910 showed a 66% increaseIn risk when compared to PGA

Gabrielli et al 2001Plastic & Reconstructive surgeryVol.107, No 1 pp 40

Allergenic tendency

steroidHaematoma

InfectionSuture reaction

enhanced

Allergies: in last case triadcortyl, aminophyliine, antzoline hydrozyzine Hcl, mepyramine malleate, piperazine, neomycin, bacitracin, soframycin, gentamycin and kanamycin

Conclusion

•We need to be clearer when describing wound problems

•Not all wounds lead to complications

•Haematomata may not be obvious for 21 days

•Steroids may compound haematoma effects

•PG-910 reaction is accelerated with haematoma

•Infection remains unproven

Thank you you

Murphy’s Law

“If all seems to be going well you probably don’t know what the hell is going on”.