02/25/2020    Don Peacock DPM, MS

Should a wound care rotation be a part of residency?

Residents need to be trained in surgery. During
school, we are taught how to assess a patient
from a biomechanical standpoint and how to cast
orthotics. We certainly are taught how to
administer palliative care and even contact
casting. We are taught how to interpret
vascular exams and do rotations through
vascular departments while in school.

We were also taught how to do ingrown nails in
school. I did ingrown nails with phenol
procedures while I was in school. These things
can easily be taught in a busy podiatric
medical school clinic. In our fourth year, we
do rotations through the various disciplines
that we pick or we rotate through podiatric
surgery residencies that perform both in-house
and outpatient procedures and techniques.

We only have the residency years to learn as
much surgery in the foot and ankle as you can.
All podiatric surgical residents should have
scrubbed and performed on a minimum of 1,000
cases before practice begins. Until these
criteria are reached we are spinning the
wheels. It makes no sense. You have to do
surgery in your training and lots of it to be a
trained podiatrist.

There are other things lacking in our
training. Podiatric surgery residents need to
be taught better surgical ways to handle
wounds. Minimally invasive techniques are
scientifically proven to outperform many
traditional techniques for wound healing.

We are not taught any of these techniques in
our surgical residencies. This is a tragedy.
Search the literature for minimally invasive
and percutaneous techniques for the resolve of
ulcerations in the foot.

The fact that we are not teaching minimally
invasive techniques for the purposes of wound
care is absolutely crazy. It's an outright
shame. Very few podiatrists know these
techniques and cannot perform them. Our public
searches minimally invasive procedures and the
awareness is growing by leaps and bounds.

Some are afraid to start this type of training
because of things that happened in the
yesteryear. This is not the case today. We are
dropping the ball and hurting our patients by
not teaching percutaneous and MIS procedures in
the foot and ankle as a part of the residency
program.

Don Peacock DPM, MS, Whiteville, NC

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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