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02/20/2020 Michael M. Rosenblatt, DPM
Should a wound care rotation be a part of residency? (Robin Lenz, DPM)
Robin Lenz, DPM recently wrote a letter explaining how important wound care issues are and should be a part of every DPM residency. I strongly agree. Some years before I retired, I heard an orthopedist who routinely used Achilles Tendon lengthening and gastrocnemius recession to treat very severe diabetic ulcerations, even for patients with very poor circulation. He presented sound evidence that this should be a “part of podiatric care” for diabetic ulcers. He made the point that DPMs should be doing MANY more of these than presently done. He also used some tendon releases in other tendons, but most of his surgery was gastroc recession and Achilles tendon lengthening.
When questioned about malpractice risk for patients with very poor circulation, he provided data that showed virtually NO amputations after his surgeries. I found this shocking and unexpected.
I had always thought that surgery on diabetics is rife with malpractice risk and that DPMs should be wary of attempting it. Perhaps this should be “restricted” to DPMs, DOs and MDs associated with a large medical group or academic environment that would provide deep pocket back-up. Or so I thought. This orthopedist strongly disagreed. (We should also mention that these types of procedures are available in minimal incision format which makes them even more attractive.)
This represents a “marriage” between foot and ankle biomechanics, foot type diagnosis, severe metabolic disease, ulcerations, and surgery. It fits together like a jigsaw puzzle. I present this argument with multiple literature references:
https://www.podiatrytoday.com/tendon- lengthening-best-treatment-diabetic-foot-ulcers Excellent bibliography of references
https://www.researchgate.net/publication/268129 13_Midfoot_Ulcers_Treated_with_Gastrocnemius- Soleus_Recession
Surgery and ulcer healing in patients with equinus | Lower Extremity Review Magazine Excellent discussion of various types of tendon lengthening procedures. (Very good list of 11 specific references)
I applaud Dr. Lenz for very modern thinking about diabetic wound care. We are now graduating thousands of nurse-practitioners and others who are looking to take on a role in foot care. Surgery on diabetics and others with severe lesions are not only very successful (according to the literature), but also keeps us firmly planted in a range that is consonant with our excellent training. It keeps us relevant.
All indications point to a continued epidemic of Type II diabetes in our populations. This is an important arena where podiatrists can maintain their legitimacy in care we provide to patients.
Michael M. Rosenblatt, DPM, Henderson, NV
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