North West Podiatric Foundation Summer Surgical Seminar – CLONTARF CASTLE, Dublin – 15 th August 2008 David R Tollafield, Consultant Podiatric Surgeon Podiatric Surgical Services Walsall NHS Community Trust, West Midlands, U.K. Adapted for the Consultant and clinical governance Group Midlands Region. Solihull 27 th 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 have a problem... Then you have another?

Scar line keratoma dystrophic calcification Acute wound dehiscence management Post operative scar dystrophic calcification Chronic dehiscence management Due to haematoma 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 supply Dressings Escalate laboratory tests Imaging Admission Theatre Pyscho-socialdrug 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

Sutures and materials FREQUENCY OF REPAIR TECHNIQUES  Simple interrupted38-50%  Simple running37-42%  Subcuticular28%  Vertical mattress3-8%  Nylon51%  Polypropylene44%  Polyglactin 91073% Abdullah-Tawfik et al 2007 Adams et al 2006 Frederick J et al 1996 Poly-p-dioxanon Multinucleated foreign giant cells without infection

Sutures technique and Sequela Sequela N=1000 %One layer suture %Two Layer suture s % Tissue reactivity Dehiscence Infection Gabrielli, et al 2001 No antibiotics were used in this trial

Comparing different operations: healing versus infection Proven. Source PASCOM Four centres same surgeon Known's: haematoma causes problems!

Signs of poor healing are obvious, The decision to undertake surgical intervention may not be. Type 1 SAD Wound Management of wounds with directional advancement flaps Vaughan et al 2006 Steristrips n=60

24 days Dystrophic calcification

Post first surgery -foreign body -At 2 months

Second Revisionary Surgery Zonal 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

Primary surgeryPrimary surgery SAD system (based) wound classification Without infection 0 skin intact 1Skin and subcutaneous tissues 2Tendon exposed 3Joint space Macfarlane & Jeffcoate 1999 modification of San Antonio/Texas system Primary surgeryPrimary surgery Case 1 Case 2 48 days

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." Dr Jim Oldham, pre-clinical safety group. Geraldine Harkins Marketing Manager ETHICON Products UK August 2008 In regard to internal sutures Pg-910 showed a 66% increase In risk when compared to PGA Gabrielli et al 2001 Plastic & Reconstructive surgery Vol.107, No 1 pp 40

Allergenic tendency steroid Haematoma Infection Suture 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

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