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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 3 2.5 2 SAD system (based) wound classification Without infection s u r g e r y 1.5 1 0.5 0 -0.5 0 50 3.5 3 2.5 2 1.5 1 100 150 Case 2 complicated healing P r i m a r y 200 skin intact 1 Skin and subcutaneous tissues 2 Tendon exposed 3 Joint space Macfarlane & Jeffcoate 1999 modification of San Antonio/Texas system s u r g e r y 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