Split Thickness Skin Grafts

[cool_vkb]

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Few weeks ago i assisted in a STSG procedure on dorsum of foot. This was done by a general surgeon so he harvested the graft from the groin area.

I was wondering do podiatrists do STSG procedures frequently? And im sure this is impossible to do in Illinois or wisconsin where we stop right at the ankle. So im assuming they will need a gen surgeon to harvest the graft and then they can place it.

But i know flordia, georgia and NM in their scope allow soft tissue till hips. So could this entire procedure had been done by a DPM in one of these states? Like harvesting from groin area and placement.

And another question,

This might not be a common practice in podiatry where most surgeries are less than 3 hrs. but whenever ent or optho guys do a surgery that exceeds 3-4 hrs they put foley catheter themselves (they dont call any other healthcare professional). Suppose we ever need to put a foley catheter. Now by law can a podiatrist do that or he needs MD or PA to do that for them.

 

[Podfather]

Few weeks ago i assisted in a STSG procedure on dorsum of foot. This was done by a general surgeon so he harvested the graft from the groin area.

I was wondering do podiatrists do STSG procedures frequently? And im sure this is impossible to do in Illinois or wisconsin where we stop right at the ankle. So im assuming they will need a gen surgeon to harvest the graft and then they can place it.

But i know flordia, georgia and NM in their scope allow soft tissue till hips. So could this entire procedure had been done by a DPM in one of these states? Like harvesting from groin area and placement.

And another question,

This might not be a common practice in podiatry where most surgeries are less than 3 hrs. but whenever ent or optho guys do a surgery that exceeds 3-4 hrs they put foley catheter themselves (they dont call any other healthcare professional). Suppose we ever need to put a foley catheter. Now by law can a podiatrist do that or he needs MD or PA to do that for them.

As long as the graft is going on the foot or ankle you can harvest and apply it. That is assuming you have the training and experence to request that privilege. I rarely have a case that exceeds 3 hours but on the few longer cases we have the nurse put in the foley.

 

[347932]

With so many skin substitutes, its rare to need a STSG in podiatric applications. I've had much success with the newest technologies.

I think in my close to 10 years out of residency, I've asked the nursing staff to put a foley in once. Even the more complex procedures shouldn't need that long imo, unless there is a medical condition that requires it.

 

[densmore22]

We have pods at my program put STSG on often, they work really well. And most nurses would love it if you decided to put the foley in yourself, but usually they just do it at the end of the case before the patient is out of anesthesia. I've been seeing a lot of in and out's done lately, this gets the pt to the next level without having a 24 hour indwelling.

 

[347932]

I'm not sure I understand how its in our scope of practice to put Foleys in. I imagine as a resident, it can be within your license to practice as a resident, but once you're in practice and have to carry malpractice insurance based on your scope of practice, how would that malpractice cover you if there is a complication with the Foley if you manage it and insert it yourself?

I understand if you have a nurse do it, its ultimately on you to make sure it is removed in due time, yada, yada, yada, but I haven't put in a Foley since residency and wouldn't want someone with so little experience putting one in ME.

Any comments?

 

[Podfather]

I'm not sure I understand how its in our scope of practice to put Foleys in. I imagine as a resident, it can be within your license to practice as a resident, but once you're in practice and have to carry malpractice insurance based on your scope of practice, how would that malpractice cover you if there is a complication with the Foley if you manage it and insert it yourself?

I understand if you have a nurse do it, its ultimately on you to make sure it is removed in due time, yada, yada, yada, but I haven't put in a Foley since residency and wouldn't want someone with so little experience putting one in ME.

Any comments?

It's OK I would use my loupes on you

 

[PADPM]

I personally have not put in a Foley since I've been a resident and even then tried to avoid touching that thing

Seriously though, in my years of experience, I've never witnessed any doctor of any kind (attendings) insert a Foley. I've only seen that done by residents or nursing staff.

 

[cool_vkb]

I personally have not put in a Foley since I've been a resident and even then tried to avoid touching that thing

Seriously though, in my years of experience, I've never witnessed any doctor of any kind (attendings) insert a Foley. I've only seen that done by residents or nursing staff.

yes but someone has to be responsible for them. I mean nurses and residents are working under the attending. If the resident screws up or as kidfeet said something happens then who takes the blame?

My initial question was that are podiatrist allowed to put foley (whether they use nurses to do the task or do it themselves) for their patients. Or do they need to ask another MD or DO to take responsiblity for that task.

 

[347932]

It's OK I would use my loupes on you

LOL!!!!

 

[347932]

yes but someone has to be responsible for them. I mean nurses and residents are working under the attending. If the resident screws up or as kidfeet said something happens then who takes the blame?

My initial question was that are podiatrist allowed to put foley (whether they use nurses to do the task or do it themselves) for their patients. Or do they need to ask another MD or DO to take responsiblity for that task.

As the surgeon on record you are permitted to ask to have a Foley placed. As the captain of the ship, ultimately you are responsible for what goes on in the OR on your patients. The responsibility rests on your shoulders.

 

[cool_vkb]

As the surgeon on record you are permitted to ask to have a Foley placed. As the captain of the ship, ultimately you are responsible for what goes on in the OR on your patients. The responsibility rests on your shoulders.

thank you.

 

[krabmas]

I agree with the foley issue. you are the boss in your OR and typically the nurse places the foley. The residents place them if they are urology residents or it is a primary teaching hospital, becuase then the nurses do little of any tasks since they can make the residents do it.

About the skin graft...

was it truely a STSG? was a dermatome used? The groin is not the typical location to harvest a STSG. Typically STSG is harvested from the lateral thigh. Full TSG are taken from the groin if you need a large graft, or it can be taken from the sinus tarsi for a much smaller defect.

The "skin" substitutes that are available are great but there are not too many options for epidermis that heals as well as a skin graft.

If you want to perform STSG or FTSG when you are out of residency... find either a well trained DPM (that had good plastics training) or a plastic surgeon to work with who can teach you good technique as well as follow-up care and what to do when it fails.

Putting the graft on is fun and fairly easy. As with most procedures deciding when and what to do it often more difficult. As well as what the typical look of the graft is a certain stages of f/u.

Even if the scope of practice is only the ankle, most places will not say anything about you doing a skin graft from the thigh to put on the foot. If so, find a plastic surgeon to be friends with and have him sign-off on it.

 

[347932]

Even if the scope of practice is only the ankle, most places will not say anything about you doing a skin graft from the thigh to put on the foot. it.

I absolutely disagree with this statement. Most places WILL say something. When you apply for your privileges as a Podiatrist I have never seen a check off list for harvesting a skin graft. Especially when you are harvesting from the upper thigh. You're malpractice insurance WILL NOT cover you if there are issues with the donor site and you harvested it. This has been fought in court and lost every time I've ever read about it. Unless something has changed in the last five years I don't know about, no hospital administration will overlook this.

 

[347932]

thank you.

You're welcome 😀!

 

[Podfather]

I absolutely disagree with this statement. Most places WILL say something. When you apply for your privileges as a Podiatrist I have never seen a check off list for harvesting a skin graft. Especially when you are harvesting from the upper thigh. You're malpractice insurance WILL NOT cover you if there are issues with the donor site and you harvested it. This has been fought in court and lost every time I've ever read about it. Unless something has changed in the last five years I don't know about, no hospital administration will overlook this.

I have those privileges and bone grafting from the entire tibia. I will take cancellous chips from the upper tibia after windowing and have used middle fibular grafts. I also have common peroneal nerve decompression at the fibular neck. If you have a complication at the donor site you consult just like an OB who nicks the bladder or an orthopod who lacerates a major vessel.

Years ago I even had iliac crest graft privileges and took one. I no longer practice there and for local politics consult ortho for the iliac crest grafts. Believe it or not but the foot orthopod signed off on those privileges as chief of surgery. As long as you are treating a foot ankle problem there is not a problem. Heck if I were to fracture a tibia while placing a retrograde nail I would consult ortho. Same deal.

It is crazy that I can legally make an incision at the popliteal fossa for nerve decompression or half way up the leg for a chronic achilles repair with triceps surae advancement and FHL transfer and close those just fine but I am not allowed by state law to repair a laceration of the calf.

Oral maxillofacial guys have iliac crest graft privileges.

 

[krabmas]

I have those privileges and bone grafting from the entire tibia. I will take cancellous chips from the upper tibia after windowing and have used middle fibular grafts. I also have common peroneal nerve decompression at the fibular neck. If you have a complication at the donor site you consult just like an OB who nicks the bladder or an orthopod who lacerates a major vessel.

Years ago I even had iliac crest graft privileges and took one. I no longer practice there and for local politics consult ortho for the iliac crest grafts. Believe it or not but the foot orthopod signed off on those privileges as chief of surgery. As long as you are treating a foot ankle problem there is not a problem. Heck if I were to fracture a tibia while placing a retrograde nail I would consult ortho. Same deal.

It is crazy that I can legally make an incision at the popliteal fossa for nerve decompression or half way up the leg for a chronic achilles repair with triceps surae advancement and FHL transfer and close those just fine but I am not allowed by state law to repair a laceration of the calf.

Oral maxillofacial guys have iliac crest graft privileges.

thank you!

and the only complication I have had so far with the donor site was a patient on therapeutic lovenox (140 or so mg BID) and he actually lost enough blood from the donor site to become hypotensive. Some fluids and lowering his dose of lovenox alleviated the issue.

I have never seen the donor site become infected or not heal from a STSG. This is different if you are talking FTSG from the groin, those incisions do not always do so well.

 

[347932]

I have those privileges and bone grafting from the entire tibia. I will take cancellous chips from the upper tibia after windowing and have used middle fibular grafts. I also have common peroneal nerve decompression at the fibular neck. If you have a complication at the donor site you consult just like an OB who nicks the bladder or an orthopod who lacerates a major vessel.

Years ago I even had iliac crest graft privileges and took one. I no longer practice there and for local politics consult ortho for the iliac crest grafts. Believe it or not but the foot orthopod signed off on those privileges as chief of surgery. As long as you are treating a foot ankle problem there is not a problem. Heck if I were to fracture a tibia while placing a retrograde nail I would consult ortho. Same deal.

It is crazy that I can legally make an incision at the popliteal fossa for nerve decompression or half way up the leg for a chronic achilles repair with triceps surae advancement and FHL transfer and close those just fine but I am not allowed by state law to repair a laceration of the calf.

Oral maxillofacial guys have iliac crest graft privileges.

In Texas??? Really???

I can't get this where I am. Lucky you.

Around here, if a Pod has a complication with a Tibial Fracture from an IM Rod placement or Ankle Implant they are SCREWED. I don't do the IM Rod for exactly that reason.

 

[347932]

thank you!

and the only complication I have had so far with the donor site was a patient on therapeutic lovenox (140 or so mg BID) and he actually lost enough blood from the donor site to become hypotensive. Some fluids and lowering his dose of lovenox alleviated the issue.

I have never seen the donor site become infected or not heal from a STSG. This is different if you are talking FTSG from the groin, those incisions do not always do so well.

Who dosed the Lovenox after the incident? Did you take care of the hypotension and manage the fluid adjustment?

Never is a strong word. What will happen when you do have a complication?

Around here, it would be a nighmare.

 

[Podfather]

In Texas??? Really???

I can't get this where I am. Lucky you.

Around here, if a Pod has a complication with a Tibial Fracture from an IM Rod placement or Ankle Implant they are SCREWED. I don't do the IM Rod for exactly that reason.

I do not want to imply that every DPM can get those privileges and in some orthopedic strongholds we have to fight to do an ankle scope. But at many hospitals there is a good relationship (it took decades to nurture) and it is/was orthopedics who help us get those and H&P privileges. At my main hospital ortho and podiatry help bail each other out when things don't work out.

 

[347932]

I do not want to imply that every DPM can get those privileges and in some orthopedic strongholds we have to fight to do an ankle scope. But at many hospitals there is a good relationship (it took decades to nurture) and it is/was orthopedics who help us get those and H&P privileges. At my main hospital ortho and podiatry help bail each other out when things don't work out.

Very nice!

I guess what my point is is exactly that. When Krabmas mentioned that most places shouldn't have a problem with harvesting graft privileges, this is simply not the case. As you pointed out, it takes time and good relations to secure this and not all podiatrist can expect to be handed these privileges.

I applaud your work and efforts. Docs like you are why Docs like me enjoy the fruits of your labors. My hat's off to you, sir.

 

[krabmas]

Who dosed the Lovenox after the incident? Did you take care of the hypotension and manage the fluid adjustment?

Never is a strong word. What will happen when you do have a complication?

Around here, it would be a nighmare.

The lovenox was previously dosed by some other physician. I do not recall the new dose of the lovenox or if the patient was switched to a different med. this was taken care of by IM. The fluids were taken care of as well by internal medicine because the patient had CHF and I am not comfortable bolusing fluids in a patient with CHF.

 

[diabeticfootdr]

I harvest my own split thickness grafts from the thigh (or where ever else). In California as long as you are applying it in your scope of practice you can harvest it from anywhere. The same applies to iliac crest graft. I find them quite useful and do them frequently. I use a Wound VAC for a bolster dressing in 98% of cases.

Regarding Foley catheters, the nurses put them in if you or anesthesia orders it. It's done before you walk in the room. Usually on cases that are 3-4+ hours, like a Charcot recon. Sometimes I'll have one put in if the patient will be on absolute bed rest post op just to make them more comfortable for a couple days after surgery. Yes, you'd be responsible for complications even if the nurse inserted it, since you ordered it. But conversely, you'd also be responsible for detrusor muscle syndrome/incontinence if you left the patient with a full bladder on the table during a long surgery.

 

[skiz knot]

And another question,

This might not be a common practice in podiatry where most surgeries are less than 3 hrs. but whenever ent or optho guys do a surgery that exceeds 3-4 hrs they put foley catheter themselves (they dont call any other healthcare professional). Suppose we ever need to put a foley catheter. Now by law can a podiatrist do that or he needs MD or PA to do that for them.

You have a nurse do it. If you are not allowed to place that order (I am pretty sure you can), have the attending anesthesiologist place the order, it's their job if the case is expected to last longer than 2-3 hours.

 

[skiz knot]

I use a Wound VAC for a bolster dressing in 98% of cases.

Sometimes I'll have one put in if the patient will be on absolute bed rest post op just to make them more comfortable for a couple days after surgery

These two statements bother me.

First, you order a wound vac for 98% of your stsg? That is a very expensive therapeutic option for a relatively straight forward procedure that generally does well.

Secondly, you place patients on absolute bedrest so they will be more comfortable??? That is terrible management as you increase their rate of DVT, PNA, ileus, deconditioning, etc... If medically/physically able patients should be OOB POD#1.

 

[dtrack22]

Secondly, you place patients on absolute bedrest so they will be more comfortable??? That is terrible management as you increase their rate of DVT, PNA, ileus, deconditioning, etc... If medically/physically able patients should be OOB POD#1.

I won't speak for diabeticfootdr but I'm pretty sure you misread his post. You should re-read his statement regarding putting in a foley IF absolute bedrest is necessary and the catheter making the patient more comfortable...not the bedrest

 

[krabmas]

These two statements bother me.

First, you order a wound vac for 98% of your stsg? That is a very expensive therapeutic option for a relatively straight forward procedure that generally does well.

Secondly, you place patients on absolute bedrest so they will be more comfortable??? That is terrible management as you increase their rate of DVT, PNA, ileus, deconditioning, etc... If medically/physically able patients should be OOB POD#1.

A wound VAC for 3-5 days for a STSG which increases the success rate to 95% vs a bolster at about 80-85% is worth the cost.

If you look across the country most people that are doing lots of skin grafts are now using VACs. It also depends on the size of the graft and location. some anatomic locations do better with a VAC due to dependence issues whereas other anatomic locations are fine for bolster dressings.

When comparing therapies it is not just the immediate cost, it is also effectiveness and cost of repeat/failed procedures.

And, LCR ( I hope you don't mind me talking for you) is typically doing STSG in DM, ESRD, PVD patients where anything that increases the chance of healing is welcome.

 

[347932]

A wound VAC for 3-5 days for a STSG which increases the success rate to 95% vs a bolster at about 80-85% is worth the cost.

If you look across the country most people that are doing lots of skin grafts are now using VACs. It also depends on the size of the graft and location. some anatomic locations do better with a VAC due to dependence issues whereas other anatomic locations are fine for bolster dressings.

When comparing therapies it is not just the immediate cost, it is also effectiveness and cost of repeat/failed procedures.

And, LCR ( I hope you don't mind me talking for you) is typically doing STSG in DM, ESRD, PVD patients where anything that increases the chance of healing is welcome.

I have a question about this. Are you putting on a VAC before you do the STSG to augment the site? If not, how is the hospital getting reimbursed for the VAC and its application post operatively? It is my understanding that there are very specific guidelines to VAC use, and if the patient doesn't have one on before the procedure, it may not be covered under their insurance plan.

I do agree with the use of the VAC to increase healing rates and ultimate success for sure. Its much more cost effective to use a VAC than have to deal with amps, repeat visits to the OR or ED...etc. I was more curious about the reimbursement issues.

 

[diabeticfootdr]

These two statements bother me.

First, you order a wound vac for 98% of your stsg? That is a very expensive therapeutic option for a relatively straight forward procedure that generally does well.

Secondly, you place patients on absolute bedrest so they will be more comfortable??? That is terrible management as you increase their rate of DVT, PNA, ileus, deconditioning, etc... If medically/physically able patients should be OOB POD#1.

I would do it in 100% of cases if I could, but sometimes it's not possible due to location or proximity to hardware/ex fix. It is not a straight forward procedure at all. These are complicated patients who often have had a wound for a long time. Wound VAC for 5 days post op increases the chances of graft take. The 3 main reasons an STSG will fail are seroma, hematoma, and shearing. The VAC mitigates all 3. You have to use a non-adherent interface between the foam and the graft, like Mepitel.

Some patients are on absolute bedrest, about 25% of mine for 24 hours after surgery, then some continue past that point. If they are a bleeding risk and have had foot surgery, I don't want the foot in a dependent position for a couple days. If the wound is over a joint, moving around will delay wound healing. Some patients are so obese they can't offload 1 foot. There are cases where bedrest is the only way to offload effectively. Sure, there are complications of bedrest. But it is a situation where you have dueling risk-benefits to consider. Not offloading may result in worsening of the wound and limb loss. Being OOB early is ideal, but these are not ideal patients who are "fit" and undergoing a typical orthopedic surgery.

 

[diabeticfootdr]

I have a question about this. Are you putting on a VAC before you do the STSG to augment the site? If not, how is the hospital getting reimbursed for the VAC and its application post operatively? It is my understanding that there are very specific guidelines to VAC use, and if the patient doesn't have one on before the procedure, it may not be covered under their insurance plan.

I do agree with the use of the VAC to increase healing rates and ultimate success for sure. Its much more cost effective to use a VAC than have to deal with amps, repeat visits to the OR or ED...etc. I was more curious about the reimbursement issues.

Yes, I VAC it for as long as necessary before the STSG. My average time on a VAC is 6-9 days. Using a VAC pre-grafting is an approved condition on the insurance verification form, as is using is as a bolster dressing.

The hospital (or SNF) doesn't get reimbursed for the VAC - even for approved indications. It falls in the DRG reimbursement. The indications are only important when using it for home care.

Hope that helps.

 

[347932]

Yes, I VAC it for as long as necessary before the STSG. My average time on a VAC is 6-9 days. Using a VAC pre-grafting is an approved condition on the insurance verification form, as is using is as a bolster dressing.

The hospital (or SNF) doesn't get reimbursed for the VAC - even for approved indications. It falls in the DRG reimbursement. The indications are only important when using it for home care.

Hope that helps.

Thanks!