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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
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“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?
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Scar line keratoma dystrophic calcification Acute wound dehiscence management Post operative scar dystrophic calcification Chronic dehiscence management Due to haematoma Case history management
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Mechanical Nutritional Age and health Compliance Social Physical Surgeon technique Factors outside surgeon control Factors disrupting normal surgical wounds
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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
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36 sequelae ? Wound problems Podiatric audit in surgery and clinical outcome measurement Society of Chiropodists & Podiatrists (c)
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% of all 36 sequelae entries n=2543 in over 80% females
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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
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Sutures technique and Sequela Sequela N=1000 %One layer suture %Two Layer suture s % Tissue reactivity 33533.517731.615835.9 Dehiscence656.4305.4347.7 Infection171.791.681.8 Gabrielli, et al 2001 No antibiotics were used in this trial 0.35 1.2 4.1
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Comparing different operations: healing versus infection Proven. Source PASCOM Four centres same surgeon Known's: haematoma causes problems!
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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
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24 days Dystrophic calcification
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Post first surgery -foreign body -At 2 months
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Second Revisionary Surgery Zonal hist0logy necrosis Org. haem FBGC
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39 days 48 days 31 days 2 days 5days 21 days Secondary intention healing 48 days following management of wound
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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
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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
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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
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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
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you Thank you Murphy’s Law “If all seems to be going well you probably don’t know what the hell is going on”.
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