Transcript Wound healing lecture slide presentation. Case histories

North West Podiatric Foundation Summer Surgical Seminar
– CLONTARF CASTLE, Dublin – 15th August 2008
David R Tollafield, Consultant Podiatric Surgeon
Podiatric Surgical Services
Walsall NHS Community Trust, West Midlands, U.K.
WOUND HEALING IN ELECTIVE FOOT
SURGERY: COMPLICATION OR
SEQUELAE?
Delayed Haematoma Wound Reaction – a rare
occurrence in the foot
Adapted for the Consultant and clinical governance Group
Midlands Region. Solihull 27th November 2008
“I dressed the wound. God healed it.”
What do you do when you have a
problem...
Then you have another?
Illustrated: Primary wound healing with subcuticular PDS 4/0 [author]
Case history management
Scar line keratoma
dystrophic
calcification
Acute wound
dehiscence
management
Post operative scar
dystrophic
calcification
Chronic
dehiscence
management
Due to
haematoma
Factors disrupting normal surgical wounds
• Mechanical
• Nutritional
• Age and health
• Compliance
• Social
• Physical
• Surgeon technique
• Factors outside surgeon control
Negative effects of delayed wound healing
Economic factors
patient loss of work
Drug supply
Dressings
Escalate laboratory tests
Imaging
Admission
Theatre
Pyscho-social
drug side effects
social morbidity
Depression & suicide
Complex regional pain
36 sequelae
?
Wound
problems
Podiatric audit in surgery and clinical outcome measurement
Society of Chiropodists & Podiatrists(c)
% of all 36 sequelae entries n=2543 in over 80% females
4.13
4.92
1.57
dehiscence
infection CS
scarline
delayed healing
suture
haematoma
infection susp
0.12
0.35
0.39
2.16
Wound problems
in the foot
Sutures and materials
Abdullah-Tawfik et al 2007
Adams et al 2006
Frederick J et al 1996
Poly-p-dioxanon
FREQUENCY OF REPAIR TECHNIQUES
 Simple interrupted
38-50%
 Simple running
37-42%
 Subcuticular
28%
 Vertical mattress
3-8%
 Nylon
51%
 Polypropylene
44%
 Polyglactin 910
73%
Multinucleated foreign giant cells
without infection
Sutures technique and Sequela
Sequela
N=1000
%
One
%
layer
suture
Two
%
Layer
suture
s
Tissue
reactivity
335
33.5
177
158
31.6
35.9
0.35
Dehiscence
65
6.4
30
5.4
34
7.7
4.1
Infection
17
1.7
9
1.6
8
1.8
1.2
Gabrielli, et al 2001
No antibiotics were used in this trial
Comparing different operations: healing versus infection Proven.
Source PASCOM Four centres same surgeon
11.9
12
10
7.56
8
6
5.7
7.14
5.1
4.2
4
2.32
2
1.63
0
1.68
0
0.81
0
healing
Infection P
FR
Neuroma
LM
Cheily
keller
Implant
Known's: haematoma causes problems!
Signs of poor healing are obvious,
The decision to undertake surgical
intervention may not be.
Type 1 SAD
Wound
Vaughan et al 2006
Steristrips n=60
Management of wounds
with directional
advancement flaps
Dystrophic
calcification
24 days
Post first surgery
-foreign body
-At 2 months
Second
Revisionary
Surgery
Zonal hist0logy
FBGC
Org. haem
necrosis
Secondary intention healing 48 days following management of wound
31 days
2 days
39 days
5days
21 days
48 days
uncomplicated healing
Case 1
3.5
P
r
i
m
a
r
y
s
u
r
g
e
r
y
3
2.5
2
1.5
1
0.5
SAD system (based) wound
classification
Without infection
0
-0.5 0
50
3.5
3
2.5
2
1.5
1
100
150
200
Case 2
complicated healing
P
r
i
m
a
r
y
s
u
r
g
e
r
y
skin intact
1
Skin and subcutaneous tissues
2
Tendon exposed
3
Joint space
Macfarlane & Jeffcoate 1999 modification of
San Antonio/Texas system
0.5
48
days
0
0
0
50
100
150
200
250
300
Vicryl
PG-910
"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."
In regard to internal sutures
Pg-910 showed a 66% increase
Dr Jim Oldham,
In risk when compared to PGA pre-clinical safety group.
Gabrielli et al 2001
Plastic & Reconstructive surgery
Vol.107, No 1 pp 40
Geraldine Harkins
Marketing Manager
ETHICON Products UK
August 2008
Allergies: in last case triadcortyl,
aminophyliine, antzoline hydrozyzine
Hcl, mepyramine malleate,
piperazine, neomycin, bacitracin,
soframycin, gentamycin and
kanamycin
Haematoma
Infection
Allergenic
tendency
steroid
Suture reaction
enhanced
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
Murphy’s Law
“If all seems to be going well you probably
don’t know what the hell is going on”.
Thank you