Surgical Protocols

 

Wound-Healing Protocols For Diabetic Foot And Pressure Ulcers
Harold Brem, M.D., Tom Jacobs, B.A., Loretta Vileikyte, M.D., Sarah Weinberger, D.E.C., Marc Gibber, B.A., Kiran Gill, B.A., Alina Tarnovskaya, B.A., Hyacinth Entero, B.A., Andrew J.M. Boulton, M.D.

 

  • Abstract
    • Diabetic foot and pressure ulcers are chronic wounds by definition. They share similar pathogeneses; i.e., a combination of increased pressure and decreased angiogenic response. Neuropathy, trauma, and Ddeformity also often contribute to development of both types of ulcers. Early intervention and proper Wound-Healing Protocols for Diabetic Foot and Pressure Ulcers treatment should result in complete healing of non-ischemic diabetic foot and pressure ulcers, as defined by 100% epithelialization and no drainage (if no osteomyelitis is present). We developed the following paradigm, which has proved to be highly effective for complete healing of these wounds: 1) recognition that all patients with limited mobility are at risk for a sacral, ischial, trochanteric, or heel pressure ulcer; 2) daily selfexamination of the sacrum, ischium, buttocks hips, and heels of all bed-bound patients and the feet of patients with diabetes with risk factors (e.g., neuropathy); 3) initiation of a treatment protocol immediately upon recognition of a break in the skin (i.e., emergence of a new wound); 4) objective measurement by planimetry of every wound (at a minimum, weekly) and documentation of its progress; 5) establishment of a moist woundhealing environment; 6) relief of pressure from the wound; 7) debridement of all non-viable tissue in the wound; 8) elimination of all drainage and cellulitis; 9) cellular therapy or growth factors for patients with wounds that do not heal rapidly after initial treatment; and 10) continuous physical and psychosocial support for all patients. If this paradigm is followed, most diabetic foot and pressure ulcers are expected to heal.

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Healing of Elderly Patients with Diabetic Foot Ulcers, Venous Stasis Ulcers, and Pressure Ulcers
Harold Brem, M.D., Marjana Tomic-Canic, Ph.D., Alina, Tarnovskaya, B.A., H. Paul Ehrlich, Ph.D., Edwina, Baskin-Bey, M.D., Kiran Gill, B.A., Miriam Carasa, Ed.D., R.N., C.N.A., Sarah Weinberger, D.E.C. Hyacinth Entero, B.A., Bruce Vladeck, Ph.D., Gordon Freedman, M.D., Conrad Cean, M.D., Vincent Duron, B.A., Alina Tarnovskaya, B.A., Harold Brem, M.D.

 

  • Abstract
    • Although elderly patients have physiologic impairments in wound healing, their wounds should be expected to heal with the same frequency of closure as those in younger populations, albeit at a slower rate. AHowever, compared to the general population, the elderly population has a higher incidence of chronic wounds: diabetic foot ulcers, pressure ulcers, and venous stasis ulcers. Experimental and clinical data indicate Healing of Elderly Patients with Diabetic Foot Ulcers, Venous Stasis Ulcers, and Pressure Ulcers physiologically impaired healing is characterized by decreased angiogenesis and synthesis of critical growth factors. Further, compared to younger populations, the elderly have a higher rate of mortality associated with specific morbidities, such as sepsis and acute respiratory distress. As these morbidities may develop directly from the wound, early intervention is mandated. In this report, 40 consecutive elderly patients (65-102 years old) with chronic wounds were analyzed. All patients were provided the same treatment protocol and healing was defined as 100% epithelization and no drainage. Despite the wounds presenting in a nonhealing and/or infected state, 73% of these chronic wounds in elderly patients healed. This suggests that elderly patients with diabetic foot ulcers, pressure ulcers, and venous stasis ulcers close their wounds at a similar frequency as younger patients. Therefore, early intervention and comprehensive treatment that includes safe topical therapies, in addition to growth factors and cellular therapy used for chronic wounds, ensure these patients will be spared the morbidities of pain, amputation, osteomyelitis, and even death. We hypothesize that if all elderly patients with chronic wounds are provided early treatment, morbidities (e.g., amputation, sepsis, pain) and associated costs will decrease.

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Rapid Recovery Protocol for Peri-Operative Care of Total Hip and Total Knee Arthroplasty Patients
Keith R. Berend, M.D., Adolph V. Lombardi, Jr., M.D., F.A.C.S., Thomas H. Mallory, M.D., F.A.C.S.

  • Abstract
    • Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are among the most successful procedures performed in terms of quality-of-life years gained. The long-term goals of arthroplasty, to relieve pain, increase function, provide stability, and obtain durability, are accomplished in the vast majority of cases. The short-term goals, however, have become the target of aggressive peri-operative programs that aim to speed recovery, reduce morbidity and complications, and create a program of efficiency while maintaining the highest level of patient care. The concept of rapid recovery is built upon the burgeoning interest in less-invasive and small-incision surgeries for (THA and TKA). However, the incision size does not appear to be the most critical aspect of the program. This article outlines the specific elements of the rapid-recovery program for lower-extremity arthroplasty patients, including pre-operative patient education, peri-operative nutrition, vitamin and herbal medication supplementation, preemptive analgesia, and post-operative rehabilitation. A holistic peri-operative, rapid-recovery program has lead to a significantly decreased hospital length of stay and significantly lower hospital readmission rates in patients who undergo primary THAs and TKAs. Combining these results with minimally invasive techniques and instrumentation should make recovery even faster.

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