Welcome to the Podiatry Arena forums, for communication between foot health professionals about podiatry and related topics.
You are currently viewing our podiatry forum as a guest which gives you limited access to view all podiatry discussions and access our other features. By joining our free global community of Podiatrists and other interested foot health care professionals you will have access to post podiatry topics (answer and ask questions), communicate privately with other members (PM), upload content, view attachments, receive a weekly email update of new discussions, earn CPD points and access many other special features. Registered users do not get displayed the advertisments in posted messages. Registration is fast, simple and absolutely free so please, join our global Podiatry community today!
If you have any problems with the registration process or your account login, please contact contact us.
Hi, I have been asked to do a debridement workshop next year for mostly nurses and would like to have a acess to video material on sharp debridement of foot ulceration/ callus etc. Does anyone have one that I could use please.
All material concidered, it will be a good oppotunity to show case podiatry skills to a new audience and would like to give it the wow factor.
__________________ Craig Payne
__________________________________________________ ___________________________________ Follow me on Twitter | Run Junkie God put me on this earth to accomplish a certain number of things - right now I am so far behind, I will never die.
I have used the CLEAR video in presentations to other health professions.
The best part is that it makes those who think it is a straightforward job to debride a wound, to reconsider, and seek the input of a podiatrist. It puts any significant wound debridement way out of their comfort zone (eg nurses, GPs).
LL
__________________
***************************************** Remember, it's just a foot.
Thanks for that. The organisers are so excited that they would like me to also include autolytic, enzyme and laval with a new group of 20 rotating through every 20min.
If anyone has run one of these before or attended one and has any tips for organisation or what they liked or disliked during there own attendence I would be grateful for your insights.
I have attended different workshops myself at conferences and been left cold by the lack of hands on oppotunities. Look forward to your ideas.
Yes I was hoping for something a little less aggresive - makes me wonder why I spend time on debriding wound margins? So if anyone has something else that wont leave my audience quite so shocked I would welcome a copy.
Also anything on other forms of debridement .
If the video debridement approach is not utilised over 'less invasive' debridement around a completely mascerated avascular margin; you may wonder why some practitioners are struggling with wounfd care and may find their techniques fail.
If the video debridement approach is not utilised over 'less invasive' debridement around a completely mascerated avascular margin; you may wonder why some practitioners are struggling with wounfd care and may find their techniques fail.
Drummond, and a goodaye to you.
Got to differ. With a 'less invasive' debridement the trauma inflicted by that clinician would be avoided. Debridement of said tissue could be attained without the trauma with scalpedl blade held near parallel to the skin surface. If the practitioner had 'stuck' to the 'completely macerated avascular margin' I'd have no problems. The reason why some practitioners are struggling might have nothing to do with their scalpel technique.
All the best, mark c
Of course, how much you debride is down to the patient's presenting problem, ulcer grade/history and neuro/vascular status, but I think this thread could still make an interesting poll.
Perhaps we could vote on whether the CLEAR method is:
The clinicians behind CLEAR are podiatrists almost beyond peer review.
This is appropriate surgical debridement - not to be confused with trimming hyperkeratosis around the periphery.
NOBODY is beyond peer review! LOL
I'd go so far as to say this isn't really surgical debridement anyway, it's just a clinical chop. I guess it comes down to the individuals - patients and clinicians. We can't be 100% prescriptive about how to do something for every single patient that walks through the door as everyone's at least a little bit different. I guess it's what works in your hands best, if that's a minimal nibble at the edges, or a more invasive approach. The most difficult bit is knowing whether you've gone too far or not enough, and in a diabetic foot with a big neuropathic ulcer this isn't always as straightforward as you'd like. It's good to see instructional videos like these being produced to see how their technique differs from your own, and I am sure this approach works in the right ulcer and patient, but there is a place for less (and more) invasive debridements - depending on the foot, patient and clinician.
The clinicians behind CLEAR are podiatrists almost beyond peer review.
Bob's said it.
Quote:
Originally Posted by LuckyLisfranc
This is appropriate surgical debridement - not to be confused with trimming hyperkeratosis around the periphery.
LL, does "appropriate surgical debridement" always involve injury to viable tissue as in this technique? Certainly not in my (limited) surgical observations.
Methinks the same degree of debridement could be attained without the 'damage' in the hands of your "average" plebian podiatrist.
Quote:
Originally Posted by LuckyLisfranc
I am surprised and concerned that some posters appear shocked by this.
And I am certainly concerned that you're concerned, and 'wacko" back at you.
mark c
LL, does "appropriate surgical debridement" always involve injury to viable tissue as in this technique? Certainly not in my (limited) surgical observations.
Methinks the same degree of debridement could be attained without the 'damage' in the hands of your "average" plebian podiatrist.
And I am certainly concerned that you're concerned, and 'wacko" back at you.
mark c
All this concern about concern is concerning me!
Concerning surgical debridement of an infected diabetic ulcer, generally, you want to debride back to healthy bleeding tissue. So, yes, you're more than likely going to chop a bit of the good stuff out too, but if you're able to clear all infected tissue out, this is not so much of a worry. Less isn't always more, but neither is more. It's horses for courses and every other cliché you can think of!
Yes, in our egalitarian evidenced-based society - no-one is meant to be beyond peer review. Hence the use of the word - almost. However, if I had any of the CLEAR team supporting me as my defence experts in a litigation case, I would be feeling rather relaxed and confident. The body of evidence they have amassed over the past decade is ALMOST without comparison.
For those not too familiar with different debridement techniques, this video demonstrates the most direct form of surgical debridement - complete ulcer excision (or saucerisation).
It is aggressive, though technically rather straight-forward, and achieves the goal of instantly turning a chronic wound into an acute wound. It is commonly used also in general, vascular and plastic surgery and has many benefits in well perfused neuropathic lesions - particularly where there is extensive bioburden, wound bed senescence or chronic infection.
LL
__________________
***************************************** Remember, it's just a foot.
Googled 'surgical debridement' with 'contraindications' and top of the list 'Wound Healing and Ulcers of the Skin', 9.4.1.1, p 123 "Avoid damaging Health Tissue: While debriding wounds, be cautious and ensure that only necrotic tissue is removed. When nearing vital tissue, the procedure should be discontinued and further debridement may be accomplished by using an alternative method"
may I suggest "change your blade to skin angle!"
One must remember that there is more than one way to skin a cat - and as CLEAR demonstrates and as Tony has suggested, this is a perfectly reasonable way to address surgical debridement of a neuropathic lesion. Sure it may appear aggressive to some initially, however in high risk foot management this would only be the tip of the iceberg so to speak.
May I suggest a peer reviewed journal search engine rather than Google for more information on the topic. Although I find Google highly stimulating and incredibly informative, peer reviewed searches just make me feel all warm and fuzzy inside
I also understand Tony's comment that the team members of CLEAR are almost beyond peer review. Although there may have been some deep sarcasm seated somewhere in that comment (whether he realized it or not), I am sure Tony was intending to convey that this Team is at the top of their game in nearly every aspect of high end wound management and care.
Paul, what worries me is this almost certainly is a type 2 diabetic pt, so there's a HUGE possiblility there's a degree of PVD. With the scalpel blade held perpendicular to the skin surface the 'tip' of the blade seems to be incising deeper than is necessary to debride the non-viable tissue. I fail to see how this is insignificant.
Why I mentioned the google search was to intimate it was that easy to find 'support' for my stance. Of course it's unsuitable for real enquiry.
And I certainly don't query the CLEAR team members after yours and LL's commendation "in nearly every aspect of high end wound management and care" except their scalpel technique.
All the best, mark c
Without wanting to take an adverserial approach to this debate, there are some misconceptions I would like to address from your post.
Quote:
Paul, what worries me is this almost certainly is a type 2 diabetic pt, so there's a HUGE possiblility there's a degree of PVD.
Type 1, Type 2...irrelevant. Essentially the same issue from a medical and surgical standpoint. PVD (or more accurately, PAD) can be an issue. This is where acknowledging the differences between neuropathic limbs with or without significant ischaemia is essential. Generally speaking, a well perfused neuropathic limb is not of significant concern providing a vascular assessment confirms these findings. These patients are well suited to Class I, II and III diabetic foot procedures, which can commonly be osseous procedures.
One of the great myths of the diabetic foot is that it should never be operated on, nor given an opportunity to bleed, lest some horrendous gangrene set it. This is simply not true, and has been discussed at length in the body of literature of diabetic foot surgery.
Quote:
With the scalpel blade held perpendicular to the skin surface the 'tip' of the blade seems to be incising deeper than is necessary to debride the non-viable tissue. I fail to see how this is insignificant.
I think you have failed to realise that the blade *is not* trying to be kept perpendicular to skin. It is intentionally trying to perform a surgical excision of the ulceration, and this is the intent of a saucerisation procedure.
As an recently dearly departed colleague from the US use to say to me, "you guys just aren't comfortable with turning the blade 90 degrees".
Quote:
Why I mentioned the google search was to intimate it was that easy to find 'support' for my stance. Of course it's unsuitable for real enquiry.
And I certainly don't query the CLEAR team members after yours and LL's commendation "in nearly every aspect of high end wound management and care" except their scalpel technique.
I'm sure if they were trying to trim the hyperkeratosis you would have no problem with the scalpel technique, a la traditional chiropody method. However, complete ulcer excision requires the scalpel to be orientated in this manner to achieve the desired result.
If this method is not favourable to you, that's fine. The point is that the clinician is not doing anything wrong, they are just using a different technique to what you may be familiar with. More than one way to skin a cat.
LL
__________________
***************************************** Remember, it's just a foot.
Ahhh I get it now, in treating a neurotrophic ulcer by the 'saucerization' technique, the aim is to damage viable tissue.
Thanks to LL and Paul for the education. Some research on my part coming up.
How widespread is its use, as the high risk diabetic foot clinics I'm aware of certainly don't utilise it.
Maybe not the most appropriate video for the original poster's needs.
Again i feel truly humbled.
Yep, "more than one way to skin a cat", mark c
Ahhh I get it now, in treating a neurotrophic ulcer by the 'saucerization' technique, the aim is to damage viable tissue.
Mark
In part. The aim is to take a recalcitrant chronic wound and turn it into an acute wound, which is generally easier to close or heal.
eg. To take things a step further, here is a set of images of a complete excision and primary closure in a person with a 3yr history of chronic ucleration plantar to a hypertrophied and degenerative tibial sesamoid, and which could not be healed with standard techniques. This excision was combined with osseous work.
LL
__________________
***************************************** Remember, it's just a foot.
This systematic review published in June may be of relevance to this thread. I have extracted some components from the full-text and pasted below:
Quote:
R. J. Hinchliffe, G. D. Valk, J. Apelqvist, D. G. Armstrong, K. Bakker, F. L. Game, A. Hartemann-Heurtier, M. Löndahl, P. E. Price, W. H. van Houtum, W. J. Jeffcoate. (2008). A systematic review of the effectiveness of interventions to enhance the healing of chronic ulcers of the foot in diabetes. Diabetes/Metabolism Research and Reviews. 24 (1), S119-S144.
Quote:
Sharp debridement
The evidence of benefit of sharp debridement is not strong and is based on a single study comprising a subgroup analysis of cases from an RCT of another intervention [15]. Healing at 12 weeks was more likely following a more vigorous debridement. An earlier paper of similar design was not included because of insufficient reported detail [16].
Quote:
Resection of the chronic wound
The rationale for resecting a chronic ulcer and its bases is that a chronic wound will be replaced by one that resembles an acute one more closely and will proceed to heal more rapidly. Healing may be promoted if underlying bony prominences are also resected. The search strategy identified 879 papers and 152 of these were considered for inclusion, but only 4 were selected after full text review (Table 3).
Quote:
Excision of plantar ulcers with/without removal of underlying bone
Wide excision of chronic plantar ulcers - combined when indicated with removal of underlying bone - reduced time to healing but had no effect on eventual healing rate [29]. A retrospective cohort study of the effect of excising the 5th metatarsal head underlying a chronic ulcer revealed a weak effect when compared to non-surgical management [30]. A similar study involving excision of wounds under the interphalangeal joint of the hallux or first metatarsophalangeal joint, combined with arthroplasty of the metatarsophalangeal joint, reported healing of more ulcers by 6 months as well as reduced recurrence [31].
Quote:
Early excision of infected soft tissue
A cohort study compared outcomes in patients admitted to hospital with extensive infection and who either underwent surgical excision of infected tissue within 3 days of admission, or not [32]. The incidence of major amputation was significantly lower in the group treated surgically (13% versus 41%).
The authors of the CLEAR video talked about this technique back in 2002 in JAPMA (92(7):402-404)- where they hoped to "foster further discussion..." about debridement. I would imagine they will be pleased with this discussion! In the JAPMA article they also talk about this technique being used in their institutions for "nonischaemic and noninfected neuropathic diabetic foot wounds".
I don't think this technique is used very often in my part of the world either. I also don't think that the most appropriate offloading is impemented very well either in my region (or by the way it seems in the US, where a recent paper Diabetes Care paper reports very low rates of TCC use in clinics).
Whilst aggressive debridement and aggressive offloading methods may seem perhaps too aggressive, labour intensive and expensive I think they may actually be more effective in healing this type of ulcer in a shorter amount of time (not getting into how to keep it healed!). The research is there for the use of the TCC, there is obviously a need for the research to be more established for the debridement issue- but I think the rationale is certainly there for such research.
Wow, when I started this thread it was to find debridement footage that I could run in conjunction with a debridement work shop for prodominatly nurses who are often not aware of podiatry let alone what we can offer with in the wound care team. I know from experience that the nurses that send me patients for debridement are very grateful as they are not allowed to do any sharp debridement.
I must admit that I dont do the 'saucerization' technique' but do care for the patients that have it done under the vascular team. I was hoping for a range of footage but instead seem to have opened up some lively debate.
Video of sharp debridement techniques
Linear Mode
