Male Speaker: For you today before we get to the reception. This is Rodney Stuck, a good friend, also a graduate of the Scholl College of Podiatric Medicine. He did his residency program at the Hines VA Hospital in Loyola University. He didn’t get very far because now he’s the chief of podiatry at the Hines VA and still works at Loyola. He’s going to be talking to us today about the Treatment Options for Surgical Dehiscence.

[Applause]

Rodney Stuck: Good afternoon or evening. I’m not sure if it’s dark out there yet. Dehiscence is something that most of us face as we take care of these people longitudinally that we’ve seen in clinic over the years and we provide care for them. We’ll go first through some of the causes, look at some of the typical treatments that we provide for these people, look at some case studies and then we’ll look at a retrospective review that we did at Hines. Dehiscence mechanisms, the mechanical cause is probably one of the greatest things that we see. I remember my first patient that had a real catastrophe and I went to Michael Pinzur who’s one of the orthopedists that works with us. I was like, “This patient didn’t stay off their foot.” I was blaming the patient entirely and he was like, “It’s not his fault. It’s yours.” He said, “You didn’t read that that patient really wasn’t going to pay attention to you.” I think that it was mentioned earlier the talk of total contact cast and CAM walkers and compliance is a real issue. But oftentimes, it’s because we just don’t educate people well enough as to what they need. Mechanical problems or compliance rates are reported at about 28%. That’s real onus on what we need to be doing for postop care. Tissue nutrition is another factor that we’ll often look at before we do amputations. Don’t often look at it before we do some of the more semi-elective surgeries that we’re doing especially in our diabetics. But it’s looked at mainly as the two different proteins, albumin and prealbumin. They’re not related. But they both are used as measures of tissue nutrition. Albumin is your delivery truck. It’s the thing that gets all your wound healing components out to your tissues, looking at the vasculature beforehand, also major factor for your tissue nutrition. Infection, hematoma and edema, all the things that just pull those wounds apart. Edema somewhat peripherally or superficially infection and hematoma causing not to blow out from within. Immunopathy are diabetics. Sometimes we don’t tell them how important it is to watch their blood sugars postoperatively. Over 200, we know that their immune system shuts down. Greater risk for pneumonia, for urinary tract infections in our diabetics and for wound infection and dehiscence. Renal failure, one of the studies that we did on Syme’s amputations, the renal failure patients had three times the infection rate of the other diabetics. It plays a big factor in how well our wounds are maintained. The American Academy of Orthopedic Surgeons had a report that showed that up to 40% of diabetics when they have surgery will have wound complications. Over the years, the literature has really supported a few things. Mainstays of care are number one get the patient off their foot, rest, elevation, protect it from further injury. But most of these patients, they’ll end up, they come in and by the time we see that their wounds open up, may well be infected. We need to evaluate them for that. Be real cautious, consider admitting them and we need to do an irrigation and debridement or cleaning of that wound depending on how severe it is, how significant the infection is, how significant hematoma is. They may need a trip to the OR just to find bleeders that may be causing hematoma. When you go in there though, making sure that you get cultures and you biopsy tissue. If you have infection or you have dehiscence that has exposed bone, consider getting a bone biopsy as well. They all need cultured-driven antibiotic therapy based on the tissue type. They need to have some type of wound care which we’ll talk about and then do they need adjunctive therapy? After the fact, did you identify that indeed you might have had ABIs, to something that you thought led you to believe that they had adequate vascular flow but you may need to have them looked at again by vascular plastics, some other of your colleagues to look and see do they need something else done.

[05:10]

Debridement, what it consists of is removal of all necrotic and avascular tissue. If you have cartilage that’s going to remain exposed in that wound that needs to be resected. Bone needs to be debrided until you have Paprika sign. Everybody knows Paprika, shake it on salads or things. You’ve got that speckling of red that you need to see to make sure it’s bleeding. Lose fixation, it’s probably infected around the fixation devices. Those need to be removed. Anything that is exposed that’s implanted material comes out, culture watch biopsy, biopsy watch culture. It’s an old saying at least at Loyola. I’m sure it’s other places. But you need to make sure that you have a good idea of what’s in there. You don’t take cultures, you don’t biopsy it. You may miss something critically important. You need to also decide, can I do this? I’ve admitted this person, I can do it in the clinic? Can I do it outside? How significant is this? You might start it outside and say, no, patient’s going to the operating room and you need to take it there, make sure that you choose the best location to get the best result. Wound management then, once you’ve completed all of those things, you need to decide how am I going to take care of this? You need to make decisions on, can I let this close by secondary intention? Will just local wound care treatment provide closure of that overtime? There's several of these that will require trip to the operating room. Delayed primary closures can be very helpful. It’s one of the old things for elective surgeries where you’re brought up to believe could happen most every time. It’s not necessarily true. The things that you have to look at is you’ve got to think of your skin as an envelope. Do you have a big enough envelope to close that wound? Are you going to be able to resect tissue out of there and be able to oppose your wound edges without significant tension? Those are the things you need to think about. Negative pressure, back therapy has been talked about. Wound traction devices have been described that are attached to help pull the wound edges together. Various types of skin grafts, flaps, or rotational flaps can be helpful. Again, some of us are trained in doing those, some of us need to get plastics or one of our other colleagues involved. The other option for some of these, we’ve got wounds that are turning around well as you can be able to use living skin equivalence with those. I’m going to go through about six or seven cases briefly and then we’ll talk further about a retrospective study that we did. First is a guy who had a Keller bunionectomy for a recalcitrant hallux ulcer and I have two of these. We usually try to get the ulcers closed on the hallux before we do their surgery because their postop infection risk drops significantly by having that wound closed. This gentleman dehisced at about 10 days, had a lot of bloody drainage and he probed to bone. It was open all the way down to the joint. He had irrigation and debridement, a bone biopsy, methicillin-sensitive Staph aureus and strep, antibiotic therapy. We initiated that and it was extended based on the bone culture by infectious disease, wound management with saline dressings and then alginates once he was discharged. He was followed weekly and made consistently good progress. He had six weeks of antibiotic therapy and at five weeks, his wound was closed and it remained so. Good wound care, a wound that’s progressing well and he went on to close. Second gentleman who we had difficulty with getting him completely closed preoperatively because of his hallux rigidus and his difficulties with staying off it. He dehisced at 16 weeks postop. He was brought in, irrigation and debridement, bone biopsy, ID consult. He had four weeks of antibiotic therapy based on an ID consult. His initial progression was slow but he was making weekly progress. But once his antibiotic stopped, he begin to fall apart. Second time around, he was admitted, brought in, he had a repeat bone biopsy. It revealed new organisms however. Once he was on new course of antibiotics, his wound improved quickly. He was fully granular after about a week. Local care, moist dressings and then alginates again when was discharged led to his wound closure.

[10:05]

This was a little bit bigger wound. But again, he made weekly progress following a lot of the other outlines of people have talked about. He was making good progress and went on to heal. This third case was a gentleman, he’s not a diabetic, who had a postop wound dehiscence and continued to fail to progress. We’re watching him weekly. Debriding any eschar that he had, his margin, made less than 10% progress as he was going on. At about four weeks, we saw that he was still essentially the same size that he had been. We performed three weekly applications of human fibroblast-derived dermis which is an off-label use but it provided the stimulus to the wound to get that healed. The fourth case, gentleman who we had treated for some time for osteo of his fifth ray with bone biopsy and ID consult but he continued to have problems and was expanding the distal aspect of the wound around his fifth metatarsal head. He had had a previous other ray amputations. We took him, did a midfoot amputation. One week, he had a dehiscence. We followed him for about three weeks providing local care, debridement for the wound and it persisted. No progress at all. He had had proximal biopsy of his fifth metatarsal which showed that he did have some osteomyelitis. He was on an ongoing antibiotic therapy. After that third week however, because his wound is fully granular and it stayed relatively stable in appearance, we began treating him also with human fibroblast-derived dermis. These are the pictures at the third and fifth week. At the fifth week, he was closed. At about six to eight weeks after that, he was placed in inlay depth shoes and gotten back to activity. He has remained close. He’s about six months post now. Another person with a lateral ray amputation, he’d been on I.V. antibiotic therapy for the surgery and was on that for six weeks. But his conventional care after about three weeks had increased in size. His wound was slowly opening, still had a granular base but it was getting bigger. He had five applications and this led to wound closure. Again while he was undergoing antibiotic therapy, he remained closed once he was done. This gentleman was more of an outlier. It took significantly longer to get him closed. He had dehisced after a first ray amputation and he had been open for about 10 weeks. He had only healed about 10%. He was treated with 14 applications and we don’t do that or progress with that lately. They have that many applications. We are real diligent with watching the person to make sure that they’re consistently making progress and that they’re not retreating and gaining size in their wound. He had a deep infection and he went on to close and has remained so. This last one is more related to the patients that underwent a bellow-knee amputation. One of the vascular valgus, had started taking care of because I realized there was few people that were sitting in the extended care center for long periods of time. This gentleman had been in there for two months. The cost of extended care is about $1,300 a day. When you look at that over that extended time period, it’s a lot of money that was spent trying to improve him. He’d only improved by about 10%. These are pictures at four and eight weeks after treatment with human fibroblast-derived dermis. He was fitted within two weeks after that with his temporary prosthesis and was discharged. You have cost considerations with wound dehiscence which can be extensive. First is, return to surgery and admission and return to surgery in that short period one or two days can be over $4,000 because of the cost of surgery. You have the cost of the VA system that are extensive when you have to take care of these wounds for long periods of time. Most critically when you’ve got this group of patients mostly diabetic who have their mortality rate is so high, you have loss of activity and the need to put them in bed, put them in wheelchairs to keep off their foot is profound.

[15:13]

That markedly increases their rehabilitation time and can shorten their quality of life. We’ll look briefly at a study that we did. We’re looking to see are we actually making good progress? We went to the IRP then, got approval to look back at 48 patients that we treated with human fibroblast-derived dermis. That’s been sent to Journal of Foot and Ankle Surgery for publication. But a subset out of that was 21 patients that were postop that we had taken care of in this manner. Eighty six percent of them were diabetic. These are several of the studies that had been done in that past. The first being Hanft, Marston and then these last three, the green, black and yellow are the three groups out of our study. Green being our entire group, black being just the diabetics and then the yellow being our postop patients. Again, these are subsets. There’s crossover between those different groups. The initial surface area comparison though, if you look at the square centimeter size on our postop wounds, they were 20 square centimeters. It’s 10 times what Marston’s sizes were. Look at our week 12 healing and we had 95% ultimate healing in that postop group out of this group of patients that we’re treating. Again, we must figure out what the issues are with what’s caused this patient to dehisce. As we find that out, it may just be that we can immobilize them and take care of them. But more often than not, they need an incision and drainage. They need culture-driven antibiotic therapy. Their wounds need some long-term care. Always be suspicious for osteomyelitis. Wounds that aren’t progressing, continue to be vigilant looking for deep infection. Several of these patients we treated once their wounds were satisfactory and were granulating, we begin to treat them with living skin equivalence and it seemed to make a big difference in getting them healed and we’re able to start them even while they were on I.V. antibiotic therapy. It’s a consideration and it looks like that may be of value. Cost effectiveness of these treatments versus chronic care has to be taken into consideration as well. In summary, prevention, which isn't on this slide, prevention, protect your postop patients, keep them immobilized, have a talk with them beforehand about how serious this can be if their wounds fall apart. That’s our mainstay is to keep this from ever happening. But if it does, try to figure out the root cause for what led to it. Make sure you’re treating their infection, treating it appropriately, use advanced therapies for wound healing if you need to and then continue to protect those people and make sure that they have followup with you and continue with protective footwear and quarterly care. Thank you.