August 2016 Journal Club

[SLCpod]

Journal club overview:
- An article will be selected and posted each month. Please PM me an article you are interested in and I will select one.
- The person who suggested the article will give a BRIEF overview of the article
- We will discuss how we can use what we learned in practice and perhaps share some clinical experiences (remember not to disclose specific patient information)

This is open to DPM's, students and pre-pods!! All are invited.

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Our previous journal club topic had almost 900 views. Thanks to all who participated and read the article.

Our journal article for the month is the following:

Percent Change in Wound Area of Diabetic Foot Ulcers Over a 4-Week Period Is a Robust Predictor of Complete Healing in a 12-Week Prospective Trial

Link: http://care.diabetesjournals.org/content/26/6/1879.long

I chose this article because it was mentioned in another thread recently and hopefully we can share some thoughts on wound care. I like the article because it gives some good data for wound healers vs nonhealers. There have been quite a few patients during my education that seem to be in the clinic every week receiving wound care and those who heal rapidly.

In this article, patients were chosen for this study if they had diabetes and a wound measuring at least 1cm^2. In total, 276 (203 completed the study) patients were included in the study and the wounds were treated and evaluated at 4 weeks and 12 weeks. The results indicated that, "the absolute change in ulcer area at 4 weeks was significantly greater in healers versus nonhealers. The 4-week percent change in wound area was a strong predictor of complete healing. Therefore, using the 53% reduction in ulcer area as the cutoff point, very satisfactory sensitivity (91%) and negative predictive value (91%) were observed."

This will change how I practice because I can evaluate my wound care patients at 4 weeks and determine if my treatment plan is appropriate. If it is not, I can use other treatment options and consult with other podiatrist and specialists.

Besides your thoughts on this article, what are some of the wound care products you prefer to use?

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[AttackNME]

Journal club overview:
- An article will be selected and posted each month. Please PM me an article you are interested in and I will select one.
- The person who suggested the article will give a BRIEF overview of the article
- We will discuss how we can use what we learned in practice and perhaps share some clinical experiences (remember not to disclose specific patient information)

This is open to DPM's, students and pre-pods!! All are invited.

------------------------------------------------------------------------------------------------------------------------

Our previous journal club topic had almost 900 views. Thanks to all who participated and read the article.

Our journal article for the month is the following:

Percent Change in Wound Area of Diabetic Foot Ulcers Over a 4-Week Period Is a Robust Predictor of Complete Healing in a 12-Week Prospective Trial

Link: http://care.diabetesjournals.org/content/26/6/1879.long

I chose this article because it was mentioned in another thread recently and hopefully we can share some thoughts on wound care. I like the article because it gives some good data for wound healers vs nonhealers. There have been quite a few patients during my education that seem to be in the clinic every week receiving wound care and those who heal rapidly.

In this article, patients were chosen for this study if they had diabetes and a wound measuring at least 1cm^2. In total, 276 (203 completed the study) patients were included in the study and the wounds were treated and evaluated at 4 weeks and 12 weeks. The results indicated that, "the absolute change in ulcer area at 4 weeks was significantly greater in healers versus nonhealers. The 4-week percent change in wound area was a strong predictor of complete healing. Therefore, using the 53% reduction in ulcer area as the cutoff point, very satisfactory sensitivity (91%) and negative predictive value (91%) were observed."

This will change how I practice because I can evaluate my wound care patients at 4 weeks and determine if my treatment plan is appropriate. If it is not, I can use other treatment options and consult with other podiatrist and specialists.

Besides your thoughts on this article, what are some of the wound care products you prefer to use?

Love this article. I've always wondered... Does anyone really calculate the 50% reduction and if so, how?

 

[Weirdy]

Love this article. I've always wondered... Does anyone really calculate the 50% reduction and if so, how?

Is there a professional way to quantify 50% or do they just kind of eyeball it?

Will comorbidities affect the 50% technique?

 

[ldsrmdude]

Love this article. I've always wondered... Does anyone really calculate the 50% reduction and if so, how?

At the wound center I am at, the nurses input the measurements at each visit and the EMR tells us percent reduction. That's the easy way. Now, how accurate is it? There are a lot of variables in it. The biggest is that using the (length)x(width) assumes that a wound is uniformly shaped. We sort of make that assumption even though it is rarely, if ever, true. However, if you read the article, that's the same way they figured it out, multiply the longest length and the widest width. Another variable is the person measuring the wound. There are a lot of variables in measuring, especially in odd-shaped wounds. I know there has been some interest in other ways to measure this, like taking a picture and having a program map out the exact area, but I don't know anyplace that actually does that

Is there a professional way to quantify 50% or do they just kind of eyeball it?

Will comorbidities affect the 50% technique?

Comorbidities do affect it in the sense that those patients are more likely to not meet the 50% threshold at 4 weeks and will need advanced methods to promote wound healing.

By the way, this is a classic article that is quoted all of the time. Critical stuff to know as a student/resident

 

[ldsrmdude]

As far as products I use on a regular basis, it seems to always be in flux a little. I've gotten away from Dermagraft and Apligraf. I like Grafix. I've used Theraskin occasionally. I used Oasis a lot in residency, but not so much in practice. I've used Cellutome. To be honest, if I can, I prefer to put a split-thickness skin graft on or do a rotational flap or something like that to close wounds. I will occasionally catch myself getting into a routine with a patient and not looking outside the box at surgical options or taking into consideration some of the other factors that affect wound healing and making sure that I address those. Wound care is a challenging aspect of our profession and at times can be very frustrating

 

[SLCpod]

How do you approach a wound secondary to charcot deformity? How quick are you to consider surgical repair of the deformity?

Has anyone tried a exostectomy with a medial plantar artery flap?

 

[dtrack22]

How do you approach a wound secondary to charcot deformity? How quick are you to consider surgical repair of the deformity?

Has anyone tried a exostectomy with a medial plantar artery flap?

I think you go to surgery when your DM shoe/boot/brace/CROW (semi-permanent to permanent offloader of your choice) fail to heal the wound or fail to prevent recurrence. Assuming the deformity is the primary cause (pressure) of the wound.

We are moving away from recon and towards exostectomy + frame (when indicated). It's a pretty conservative surgical plan in the world of podiatry-residency-Charcot-recon, but when so many of these people ruin that sweet looking bolt you put in... less feels like more. I don't really see the utility in a traditional medial plantar artery flap in coverage of most Charcot wounds. Plus, if pressure is the primary cause then the frame (which you're going to put on with your flap), should allow the wound to heal all on its own. I wouldn't do anything more than graft the wound site.

 

[ldsrmdude]

How do you approach a wound secondary to charcot deformity? How quick are you to consider surgical repair of the deformity?

Has anyone tried a exostectomy with a medial plantar artery flap?

I sometimes get the Charcot patient after they have been treated by another practitioner at the wound center and haven't healed. If they have a wound I will usually go to a total contact cast and try to get the wound to close. If the wound is slow to heal even with casting, I will recommend some sort of surgical intervention. If the foot is non-plantigrade, I would recommend recon. If it is plantigrade but just has the deformity causing pressure, I may recommend an exostectomy. Never done an exostectomy and medial plantar artery flap, but wouldn't say I never would do it.

I think you go to surgery when your DM shoe/boot/brace/CROW (semi-permanent to permanent offloader of your choice) fail to heal the wound or fail to prevent recurrence. Assuming the deformity is the primary cause (pressure) of the wound.

We are moving away from recon and towards exostectomy + frame (when indicated). It's a pretty conservative surgical plan in the world of podiatry-residency-Charcot-recon, but when so many of these people ruin that sweet looking bolt you put in... less feels like more. I don't really see the utility in a traditional medial plantar artery flap in coverage of most Charcot wounds. Plus, if pressure is the primary cause then the frame (which you're going to put on with your flap), should allow the wound to heal all on its own. I wouldn't do anything more than graft the wound site.

I think that there are some patients that are better suited for exostectomy and some that need reconstruction. I think what separates the two is whether the foot is plantigrade or not. If it is, an exostectomy will work, but if not, I would lean more towards recon. Not a big fan of bolts personally, had several of them end up not doing well in residency.

When you're doing an exostectomy and frame, are you using the frame simply for offloading or to prevent further collapse of the Charcot?

 

[dtrack22]

When you're doing an exostectomy and frame, are you using the frame simply for offloading or to prevent further collapse of the Charcot?

The frame is simply for offloading. When we are doing the exostectomy the patient has typically coalesced and still presents with a non-healing, central to lateral plantar wound. I think when you catch charcot acutely and the patient is mildly complaint, TCC's, boots, CROWs do a good job of preventing significant deformity. I've put a frame on an acute (let's say stage 1 to very early stage 2) charcot foot where the lisfranc joint was already subluxed. In that case the frame was used to correct and stabilize the deformity, which I was able to do pretty much entirely percutaneously with some forefoot olive wires to pull the deformity into place.

The exostectomies we do are primarily for lateral column collapse/prominence. I think the medial column needs fixed more often than not (can't get away with just an exostectomy in as many instances) because an unstable medial column will lead to lateral column problems and often times further medial column collapse.

 

[ldsrmdude]

The frame is simply for offloading. When we are doing the exostectomy the patient has typically coalesced and still presents with a non-healing, central to lateral plantar wound. I think when you catch charcot acutely and the patient is mildly complaint, TCC's, boots, CROWs do a good job of preventing significant deformity. I've put a frame on an acute (let's say stage 1 to very early stage 2) charcot foot where the lisfranc joint was already subluxed. In that case the frame was used to correct and stabilize the deformity, which I was able to do pretty much entirely percutaneously with some forefoot olive wires to pull the deformity into place.

The exostectomies we do are primarily for lateral column collapse/prominence. I think the medial column needs fixed more often than not (can't get away with just an exostectomy in as many instances) because an unstable medial column will lead to lateral column problems and often times further medial column collapse.

For the sake of discussion, if you're already putting a frame on, why not use it in a reconstruction? I'd imagine it would decrease the re-occurrence rate for the ulcer and potentially make long term shoes/bracing easier.

 

[dtrack22]

For the sake of discussion, if you're already putting a frame on, why not use it in a reconstruction? I'd imagine it would decrease the re-occurrence rate for the ulcer and potentially make long term shoes/bracing easier.

I'll answer your question with another question...why unnecessarily increase risk of complications (more incisions + more dissection + hardware...in a patient with an A1c of 11) by doing a big recon when cutting off the plantar 1/3 of the cuboid will solve their problem?

I know this is all for the sake of discussion, but I hope everyone keeps in mind that hopefully nobody (myself included) is speaking in absolutes. We tend to do exostectomies in many patient who would have gotten more extensive recon. By no means am I suggesting that this is all I would do, or that it somehow makes recon unnecessary. There is always a patient that I would do procedure A on despite the fact that someone with very similar pathology would get procedure B, and often times the difference between those patients is very small. IMO sticking with well studied or well thought out and principled indications is the key to improving your surgical outcomes.