Apatient with diabetes who has

Transcription

1 Plastic Surgery Reconstruction of the Diabetic Foot THOMAS ZGONIS, DPM; JOHN J. STAPLETON, DPM; ROBERTO H. RODRIGUEZ, DPM; VALERIE A. GIRARD-POWELL, RN; DOUGLAS T. CROMACK, MD 3.6 Apatient with diabetes who has an acute or chronically infected foot ulcer will benefit from surgical debridement performed in the OR. Urgent or emergent surgery to prevent major systemic manifestations or potential limb loss is necessary if the patient also has ascending cellulitis, gas gangrene, necrotizing fasciitis, evidence of a compartment syndrome, or systemic toxicity with metabolic instability In these situations, the clinician assesses and stabilizes the patient for urgent or emergent surgery. Surgery is performed to eradicate the limb- or life-threatening infection, assess intraoperative soft tissue appearance and bleeding, and assess for arterial sufficiency. Soft-tissue reconstruction is delayed until the patient is medically optimized and the infection is adequately controlled and clinically eradicated. 7,9,12 The overall management of complex diabetic foot wounds is best handled by a multidisciplinary team, which may include, but is not limited to, a cardiologist, endocrinologist, infectious disease specialist, nurse educator, nutritionist, orthopedic surgeon, indicates that continuing education contact hours are available for this activity. Earn the contact hours by reading this article and taking the examination on pages and then completing the answer sheet and learner evaluation on pages You also may access this article online at pedorthotist, perioperative nurse, physiatrist, physical therapist, plastic surgeon, podiatrist, psychologist/psychiatrist, reconstructive foot and ankle surgeon, vascular surgeon, and wound care nurse/specialist. 3,13 Team members work cooperatively to assess and manage the presence of multiple comorbidities commonly associated with diabetes mellitus. The entire team coordinates care to determine the best timing for plastic surgery reconstruction of the diabetic foot. An understanding of the need for surgery and good communication among all the team members as well as the patient and involved family members is essential to avoid any delay in ABSTRACT SOFT TISSUE RECONSTRUCTION of the diabetic foot is a challenge for the perioperative team. PRIMARY CLOSURE may not be an option and secondary healing may not be reliable. Therefore, surgery is vital and should be coordinated among a wellfunctioning multidisciplinary team that specializes in caring for patients with diabetes mellitus. TEAM MEMBERS must have expertise in reconstructive surgery to ensure adequate wound healing. THIS ARTICLE EMPHASIZES the appropriate timing and staging of surgery, discusses the most common plastic surgery techniques, and underscores the importance of a team approach in the management of diabetic foot wounds. AORN J 87 (May 2008) AORN, Inc, AORN, Inc, 2008 MAY 2008, VOL 87, NO 5 AORN JOURNAL 951

2 MAY 2008, VOL 87, NO 5 Zgonis Stapleton Rodriguez Girard-Powell Cromack Emergent diabetic foot surgery in the presence of a severe infection is of primary importance. A vascular workup should be performed shortly after the initial surgical debridement to prevent further soft-tissue loss that could lead to major limb amputation. surgical reconstruction that will further compromise the open diabetic foot wound or increase the risk of postoperative complications. The reconstructive surgeon should be the gatekeeper for addressing the type, extent, and timing of the surgical procedure. Obvious issues including, but not limited to, the patient s age, comorbidities, life expectancy, compliance, obesity, infection, vascular insufficiency, poor cardiac output, end-stage renal disease, hyperglycemia, and anemia should be considered before the most appropriate wound closure approach is selected for the patient s specific type of diabetic foot wound. 14 INITIAL EVALUATION The clinician performs an initial assessment that includes a thorough history and physical examination to determine the patient s overall medical condition and physical capabilities. The clinician reviews and documents the metabolic and hemodynamic state of the patient (eg, from serum chemistry analyses, hemoglobin A1C, hematological testing). The clinician also observes and assesses the patient s psychosocial state during this initial evaluation. The clinician may observe signs of self-neglect, noncompliance, depression, delirium, impaired cognition, and stupor. If any of these signs or symptoms are encountered, the clinician should document them and report them to the other team members because this may alter the type of reconstructive procedure selected. 15,16 Next, the patient s peripheral circulation should be evaluated thoroughly. The clinician initially assesses the arterial supply to the lower extremities by palpating for the presence or absence of pedal or lower extremity pulses. Clinical observation of ischemia, gangrene, loss of pedal hair, or dry skin are obvious signs of peripheral vascular disease that the clinician should document. The clinician also notes the presence of lower extremity edema or venous stasis dermatitis. An immediate vascular work - up consisting of noninvasive and invasive vascular studies may be delayed in the presence of a severe, limb- or life-threatening infection. 17 Emergent diabetic foot surgery in the presence of a severe infection is of primary importance. Vascular surgery may be delayed until the limb- or life-threatening infection is controlled through urgent or emergent surgery. A vascular workup should be performed shortly after the initial surgical debridement, however, to prevent further soft-tissue loss that can lead to major limb amputation. 2,18 Delayed reconstructive plastic surgery procedures should be coordinated with the vascular team to determine the best time for definitive soft-tissue closure of the diabetic foot wound. The reconstructive surgeon should consult the vascular surgeon as early as possible, especially when ischemia is present, to reach consensus on the final treatment plan and also to perform any needed revascularization shortly after the initial surgical debridement to obtain successful limb salvage The clinician should closely examine any wound infection to determine its size and degree of tissue involvement. The wound should be inspected, sharply debrided, and probed to determine the presence of muscle, tendon, bone, or joint involvement; sinus tracts; or abscess. The ability to probe to the bone along with clinical and radiographic assessments may indicate the presence of underlying osteomyelitis. 14,22,23 If infection is present, the clinician should determine whether it is localized or deep and 952 AORN JOURNAL

3 Zgonis Stapleton Rodriguez Girard-Powell Cromack MAY 2008, VOL 87, NO 5 Deep tissue specimen cultures taken in the OR provide the most reliable information for identifying the causative pathogens. Swab cultures taken initially at the patient s bedside often can mislead clinicians who are attempting to select appropriate antibiotics. spreading. Deep infections usually present with marked edema, erythema greater than 2 cm in diameter, and drainage from the wound. 14,22,23 Pain on palpation when neuropathy is present also may indicate deep infection. The surrounding tissues should be inspected closely for superficial bullae, petechia, ecchymosis, and softtissue crepitus, which could be clinical indicators of a deep, limb- or life-threatening infection. 2,5,10,24,25 The clinician may obtain blood cultures on initial presentation to evaluate the patient for bacteremia or sepsis if signs of infection are present or if the patient is febrile. Culturing a wound requires special care to ensure an adequate specimen. Taking cultures in the OR allows the surgeon to obtain deep tissue specimens under sterile conditions, which provides the most reliable information for identifying the causative pathogens. Swab cultures taken initially at the patient s bedside are not very useful and often can mislead clinicians who are attempting to select appropriate antibiotics. 26 The clinician should evaluate the patient to determine the presence of peripheral neuropathy and whether protective sensation has been lost to both of the patient s lower extremities. At times, this can be obvious since large open wounds, fractures, or dislocations are present with very little pain. If evidence of peripheral neuropathy is not readily apparent, the clinician can determine whether the patient s protective sensation to the foot is intact by testing for insensitivity to a Semmes-Weinstein 10-g (ie, gauge) monofilament wire. With the patient s eyes closed, the clinician touches different areas on the plantar aspect of the patient s foot that is free of scar tissue or previous ulcers. The patient confirms whether he or she feels the wire. If peripheral neuropathy is confirmed, the clinician should initiate treatment to the areas of plantar pressure to prevent further skin breakdown, particularly to the contralateral extremity and the sacrum. Finally, the clinician should obtain x-rays to evaluate the presence of osteomyelitis or underlying skeletal deformity. If underlying osteo - myelitis is present, osseous resection and intraoperative bone biopsy should be performed before definitive plastic reconstructive surgery and foot closure is performed. If underlying deformity is present, a one-stage versus multiple staged osseous and soft-tissue reconstruction procedure may be performed The clinician should ensure that x-rays are available and displayed in the OR to assist the surgeon in planning the osteomyelitis or deformity correction. Further imaging studies may include a magnetic resonance imaging scan, computed tomography scan, nuclear imaging, or diagnostic ultrasound. PREPARING THE OR It is paramount for the surgeon and circulating nurse to discuss the surgical instrumentation, suture, supplies, and intraoperative imaging that will be needed before the surgery is initiated. An OR that is set up with the basic necessary instrumentation greatly facilitates the surgery for these high-risk patients. The circulating nurse and scrub person cooperatively prepare the sterile surgical field. They ensure that all instruments, trays, equipment, and supplies are in the room, including a basic orthopedic instrument set, a sagittal saw and wire drivers for bone resections, a basic plastic or neurosurgery tray with fine and more delicate instrumentation, a high-pressure pulse lavage system for adequate irrigation, bags of saline hung from an IV pole for pulse lavage, AORN JOURNAL 953

4 MAY 2008, VOL 87, NO 5 Zgonis Stapleton Rodriguez Girard-Powell Cromack antibiotics for the pulse lavage irrigation at the surgeon s request, and a large basin and x-ray cassette cover for use during irrigation via pulse lavage. The scrub person may set up a Mayo stand or an additional back table along with the standard back table to have an area that remains sterile after surgical debridement and pulse lavage irrigation. This prevents contamination from equipment that was used to surgically eradicate infected tissue or bone. Postoperative dressings and splinting materials should be available and ready in the room to prevent prolonged operating time and anesthesia recovery. The circulating nurse ensures that the tourniquet and cuff and electrosurgical unit and grounding pad are available. Often, a patient with diabetic foot complications also has cardiac problems and may have a pacemaker in place. In these situations, the surgeon may use a magnet or a bipolar electrosurgical unit to prevent cardiac complications. PREOPERATIVE PHASE After admitting the patient to the preoperative area, the preoperative nurse assesses the patient and verifies the patient s identity and the accompanying history, which helps the nurse determine whether the patient has been educated about his or her condition and prognosis. The nurse also observes and assesses the patient s psychosocial state. Self-neglect, noncompliance, depression, delirium, impaired cognition, stupor, or any other recent changes in the patient s mental status can signify the presence of an infectious process and medical decompensation that may require urgent intervention. The surgeon arrives in the preoperative area to answer any last-minute questions the patient and family members might have and to ensure that the informed surgical consent process is complete. The surgeon and patient Changes in the patient s mental state can signify the presence of an infectious process and medical decompensation that may require urgent intervention. cooperatively verify the correct surgical lower extremity, and the surgeon marks that extremity with an indelible marker. If amputation of selected toes is to be performed, the surgeon marks them separately as well. The circulating nurse arrives in the preoperative area to meet the patient. After reviewing the patient s medical record, the nurse verifies the patient s identity by verbal confirmation and with the patient s identification band. The nurse has the patient explain what procedure is planned and then confirms the proposed procedure with the surgical consent form and the OR schedule. The circulating nurse notes the results of any abnormal laboratory studies, in particular the patient s hemoglobin and hematocrit levels, and, if the levels are decreased, discusses this with the surgeon and anesthesia care provider. The circulating nurse confirms that blood typing and cross matching have been completed and ensures that two units of packed red blood cells are available at the time of surgery. After completing a history and physical examination, the circulating nurse documents all pertinent information acquired from the patient and the records, including a social history and whether the patient is taking any over-the-counter medications, has medical or food allergies, or has had previous surgical procedures or complications. The nurse then develops a nursing care plan. (See the general care plan for patients with diabetes who are undergoing surgery [page 940]). Table 1 provides additional nursing diagnoses, interventions, and outcomes for patients with diabetes who are undergoing plastic surgery reconstruction of the foot. INTRAOPERATIVE CARE The anesthesia care provider and circulating nurse transport the patient to the OR. Typically, the patient is placed in the supine position. 954 AORN JOURNAL

5 Zgonis Stapleton Rodriguez Girard-Powell Cromack MAY 2008, VOL 87, NO 5 TABLE 1 Nursing Care Plan for Patients With Diabetes Undergoing Plastic Surgery Reconstruction of the Foot Diagnosis Impaired physical mobility related to reconstructive surgery and placement of an external fixator on the lower extremity Nursing interventions Assesses the patient s understanding of the external fixator (eg, bone alignment, faster healing) and cautions against tampering with the nuts and clamps. Addresses the patient s concerns regarding prolonged hospitalization and rehabilitation. Explains the need for modified activity after surgery (eg, elevating the extremity while seated or lying, lifting the external fixator to move the extremity) and ensures understanding of complete non-weight bearing until instructed. Assesses the patient s support system and the need for additional therapy or assistance with activities of daily living or the use of ambulation devices. Ensures that the patient understands symptoms to be reported immediately (eg, redness, elevated temperature, alterations in neurovascular status). Interim outcome criteria The patient verbalizes his or her understanding of the appearance of the external fixator and the need for modified mobility and observation. Outcome statement The patient does not experience impaired mobility during the perioperative phase. The patient exhibits the ability to use assistive devices as needed before discharge. The circulating nurse places a pillow under the patient s lower legs to ensure that the patient s heels do not touch the table and then places the safety strap over the patient s thighs. If debridement of the patient s heel region or posterior lower leg is required, the patient is placed in the prone or lateral decubitus position after anesthesia induction. After patient positioning is complete, the circulating nurse places a pneumatic sequential compression device on the nonsurgical lower extremity to further prevent the incidence of deep vein thrombosis and pulmonary embolism in the postoperative period. The circulating nurse helps the surgeon apply a tourniquet as far proximal from the surgical site as possible. The tourniquet is placed on the thigh of the patient s surgical extremity if the patient is undergoing general anesthesia or receiving a spinal anesthetic. An ankle or calf tourniquet is used if an ankle block is being performed. Tourniquets usually are inflated after the initial surgical debridement and irrigation have been performed and intraoperative cultures have been obtained. The tourniquet is deflated after the surgeon has finished meticulous flap dissection, which allows the surgeon to further assess flap viability and provide adequate hemostasis before closure. The circulating nurse ensures that topical thrombin and gel foam are readily available if needed for additional hemostasis. SURGICAL PROCEDURES Soft-tissue reconstruction of the diabetic foot begins with adequate surgical debridement. The surgeon must resect all devitalized and infected soft tissue and bone to create a wound bed suitable for closure. 2,15,30,31 Typically, the surgeon performs initial surgical debridement without the use of a tourniquet so he or she can effectively distinguish viable from nonviable soft tissue and bone and better evaluate the presence of sinus tracts or pus in the deep tissues and muscle layers (Figure 1). If a tourniquet is needed, as in the case of a patient with questionable hemodynamic stability, it should be released after debridement, which allows the surgeon to evaluate the viability of AORN JOURNAL 955

6 MAY 2008, VOL 87, NO 5 Zgonis Stapleton Rodriguez Girard-Powell Cromack the remaining tissue and adequately achieve intraoperative hemostasis (Figure 2). The surgeon obtains deep intraoperative cultures in a meticulous manner. The scrub person opens the culture tubes just before their use and ensures that deep soft-tissue or bone specimens are taken. The surgeon also may order a gram stain to initiate appropriate antibiotic coverage. In addition, the surgeon obtains aerobic, anaerobic, and fungal cultures and as well as bone cultures for histopathology and microbiology analysis. Definitive antibiotic coverage is based on clinical results of the intraoperative culture and susceptibility results that determine which antibiotic will be the most cost-effective, safest, and easiest to administer. This is particularly important because antibiotic administration for as long as six to eight weeks may be warranted postoperatively. 30,32 After surgical debridement, the surgeon irrigates the wound with copious quantities of saline using a pulse lavage system. The goal of pulse lavage irrigation is to eliminate any debris remaining in the surgical wound and to further decrease the bacterial count. Although the addition of an antibiotic to the saline has not been proven to be clinically advantageous in irrigating these wounds, some surgeons prefer to add antibiotics. 33 Use of high-pressure versus bulb-syringe irrigation also is controversial. Some believe that the high pressure systems can seed bacteria deep into soft-tissue crevices. 33 Typically, the surgeon positions the patient s leg so that the patient s foot can be placed inside a large basin and covered by an x-ray cassette cover to eliminate aerosolization of bacterial particles (Figure 3). The scrub person passes all instruments used during the initial debridement to the circulating nurse to reduce cross contamination. The circulating nurse also assists all scrubbed personnel in removing their outer gloves and regloving after irrigation is completed. The surgeon then achieves meticulous hemostasis with electrosurgery and suture ligation to prevent hematoma formation and further hemodynamic instability that can impede wound healing. The surgeon also may use hemostatic agents before closure or if the wounds are left open for a delayed closure. Figure 1 Intraoperative picture of an open partial first ray amputation five days after the original surgery. Figure 2 Wound with clean wound margins after debridement and adequate hemostasis achieved. 956 AORN JOURNAL

7 Zgonis Stapleton Rodriguez Girard-Powell Cromack MAY 2008, VOL 87, NO 5 The surgeon may choose to use antibiotic-impregnated beads or cement spacers to manage dead space and prevent osteomyelitis. 15 If used, the scrub person fashions the antibiotic-impregnated beads or cement spacers while the surgeon irrigates the wound. This maximizes surgical time while also allowing sufficient time for the material to set. An exothermic reaction is to be expected so only heat-stable antibiotics, such as vancomycin, tobramycin, or gentamycin, may be used. Spherical-shaped antibiotic beads offer the advantage of increased surface area, enhancing the elution (ie, extraction) of antibiotics x-ray cassette cover. to a localized area. Antibioticimpregnated cement spacers have a decreased surface area but are advantageous in maintaining stability of osseous segments after large osteomyelitic bone resections. Typically, the initial inspection and dressing change of the wound is performed 48 to 72 hours after surgical debridement, pending the results of the clinical examination. The clinician should evaluate the surrounding soft tissues for maceration or tissue necrosis and should closely monitor the patient s vital signs and laboratory studies in the early postoperative period. Earlier inspection of the wound may be warranted for patients who continue to show cardinal signs of infection. Team members should coordinate the timing of dressing changes to avoid repeated dressing changes or any unwarranted wound handling. If negative pressure therapy is used after the initial surgical debridement, it is recommended that the dressing be changed on the third postoperative day. After removing the initial dressing and examining the wound, the clinician may irrigate the wound with sterile saline for further debridement. When the wound appears viable and free of infection, the surgeon determines how and when soft-tissue coverage can be achieved. If vascular surgery is needed to enhance arterial perfusion, the plastic surgery reconstruction is Figure 3 Wound is irrigated using pulse lavage irrigation inside a basin with an delayed and appropriate timing is coordinated with the vascular surgical team. SPLIT-THICKNESS SKIN GRAFTING. Skin grafting is tissue transplantation that requires the adherence and formation of budding vessels from the recipient wound bed. The ideal recipient bed for a skin graft is a healthy, granular wound bed with no clinical evidence of bacterial contamination, maceration, infection, or ischemia. Split-thickness skin grafts (STSGs) offer many advantages for closing a diabetic foot wound. 14,34-36 An STSG can provide excellent soft-tissue coverage for large dorsal and non-weight bearing diabetic foot wounds, help close local- and pedicle-flap donor sites, and be applied directly over well-vascularized muscle flaps. An STSG should not be applied to wounds with greater than 5 mm of exposed bone, tendon, fascia, adipose tissue, or hardware. 15,34 Skin grafts applied on these avascular areas will not survive. The circulating nurse and scrub person ensure that required surgical instruments and supplies are available, including a power air-driven dermatome with a 1- inch to 3-inch blade, depending on the size of the wound; AORN JOURNAL 957

8 MAY 2008, VOL 87, NO 5 Zgonis Stapleton Rodriguez Girard-Powell Cromack a dermal carrier; a mesh set at 1:1.5 ratio; mineral oil; povidone-iodine solution; 1% lidocaine with 1:100,000 epinephrine; topical thrombin; adaptic gauze; and materials for a stent dressing. Common donor sites for the STSG include the buttocks, thigh, lower leg, and medial arch of the foot. 34,37 Harvest of the STSG from the lower leg offers the advantage of including the dressings for both the donor and recipient site in the same splint or cast, minimizing irritation to the donor site because the dressings are covered and not changed until later postoperative visits. According to the thickness of the dermis, STSGs are described as thick, intermediate, or thin. The scrub person checks the dermatome before the STSG is harvested to ensure that it is set appropriately for the required depth. Often, the depth is set at of an inch for a diabetic foot wound. After the surgeon surgically debrides the recipient wound bed and achieves hemostasis, he or she measures the size and dimensions of the skin graft required and marks the donor site accordingly with a sterile marker. If an oversized STSG is harvested, the circulat- ing nurse can store the excess skin in saline in a tissue refrigerator for later use if needed. The surgeon then infiltrates the donor site with a mixture of lidocaine and epinephrine to reduce postoperative pain while simultaneously providing hemostasis. The surgeon lubricates the area with mineral oil to facilitate smooth passage of the dermatome and thus prevent irregularities of the graft during the harvesting procedure. The surgeon maintains constant tension on the skin distally with his or her opposite hand while advancing the dermatome. Tension placed in this manner prevents the dermatome from skipping on small, uneven surfaces that could create irregularities throughout the graft and could result in a painful hypertrophic scar or keloid formation that could increase the risk of further skin irritation or breakdown. The scrub person places the harvested skin graft on a dermal carrier and runs it through a commercially available mesher. The surgeon then secures the graft in place with skin staples (Figure 4). The surgeon may choose to use topical thrombin or autogenous platelet-poor plasma to provide appropriate hemostasis if needed, thus preventing hematoma formation under the STSG or at the donor site. The surgeon Figure 4 A split-thickness skin graft secured to the recipient site with skin staples; a hemostatic agent is applied to the donor site. 958 AORN JOURNAL

9 Zgonis Stapleton Rodriguez Girard-Powell Cromack MAY 2008, VOL 87, NO 5 also may choose to use centrifuged blood and platelet-rich plasma before setting the graft to provide growth factors to the recipient site to stimulate the healing process. The scrub person covers the donor site with a nonadherent sterile dressing or uses a fibrinogen agent or platelet-poor plasma. Next, the surgeon and scrub person apply a stent dressing over the STSG to prevent shearing forces while simultaneously applying compression at the graft interface until the skin graft has completely incorporated (Figures 5A through 5D). The stent dressing is created by applying an impregnated, nonadherent dressing directly over the Figure 5A The surgeon places an impregnated, nonadherent dressing directly over the graft. Figure 5B The surgeon places a layer of moistened sponges over the nonadherent dressing. Figure 5C The stent is secured with multiple skin staples to the graft and around the border of the graft. Figure 5D A final postoperative bulky dressing with a posterior splint is applied. AORN JOURNAL 959

10 MAY 2008, VOL 87, NO 5 Zgonis Stapleton Rodriguez Girard-Powell Cromack graft and then again over a layer of moistened sponges that are secured with multiple skin staples to the graft and around the border of the graft. This method represents a simple, cost-effective, stent dressing that is easier to apply and remove than traditional stent dressings. 15 The stent dressing is not removed for several weeks to avoid unintended loss of the skin graft during dressing changes. The surgeon may remove the stent dressing to evaluate the graft site if signs of infection are believed to be present. Negative pressure therapy also may be applied over a hydrogelimpregnated gauze. To prevent hematoma and seroma formation at the recipient site after surgery, the patient should be limited to strict non-weight bearing with elevation of the affected extremity above the heart level when the patient is at rest. In addition, showering should be restricted to prevent inadvertent soiling of the dressings that could compromise graft incorporation. LOCAL RANDOM FLAPS. Local random flaps are used for closure of diabetic wounds located along the plantar surface of the foot. These flaps provide coverage to diabetic foot wounds with exposed bone, tendon, or underlying adipose tissue and provide excellent durability as the plantar wound is replaced with analogous, durable, adjacent tissue. 15,31 Local flaps include the epidermis; dermis; subcutaneous tissue; and, in certain circumstances, the deep fascia and underlying muscle. Local flaps are vascularized by a random intradermal or a subdermal plexus penetrating through the flap. The local random flap usually requires no greater than a 1:1 length-towidth ratio to ensure sufficient vascular supply to the flap. The blood supply is derived from a cutaneous, musculocutaneous, or a septocutaneous perforating artery, which tend to perforate from fixed areas to more mobile areas. 38 These perforators can be identified intraoperatively with a sterile, hand-held Doppler probe. 38 Local flaps are categorized by geometric design, the elasticity of the soft tissues, the nature of movement, and the angiosomes of the foot. The surgeon advances, transposes, or rotates the local flap to cover adjacent soft-tissue defects. Resection of exposed bone often creates the soft-tissue laxity necessary to allow movement that would otherwise be unavailable. Local flaps commonly used for the diabetic foot are determined by the size and anatomic location of the soft-tissue defect. For this reason, the surgeon initially dissects and raises the flap after the tourniquet has been inflated, whereas insetting of the flap is performed after tourniquet deflation to ensure proper hemostasis and flap viability. The flap is then sutured with a nonabsorbable suture; deep sutures are used minimally to prevent local tissue ischemia and possible necrosis. Various types of local flaps are used to cover wounds depending on where the wound is situated (Figures 6A through 6D). Wounds confined to the forefoot are covered by a single or bi-lobed, toe fillet, rhomboid, double-z rhomboid, or V-Y advancement flaps. Midfoot and rearfoot soft-tissue defects are covered by larger designed rotational, transpositional, or advancement flaps. 15 Atraumatic tissue handling must be implemented throughout any of the surgical procedures. Retraction of the flap should be performed only when needed and with delicate instrumentation to further prevent inadvertent cell death and tissue necrosis that occurs with extensive or prolonged tissue retraction. 31 Postoperative care of a local random flap requires frequent vascular checks by nursing team members. The postoperative nurse should check the flap every three to four hours for ischemia or venous congestion during the first 48 hours after surgery. Limb and bed position are important postoperative considerations. In most cases, the nurse ensures that the patient s surgical extremity is elevated to minimize edema unless signs of ischemia are present or suspected, at which time the nurse places the patient s leg in a more dependent position to improve blood flow. In addition, the surgeon may use external fixation devices in conjunction with local or pedicle flaps that are covering weight-bearing 960 AORN JOURNAL

11 Zgonis Stapleton Rodriguez Girard-Powell Cromack MAY 2008, VOL 87, NO 5 surfaces (Figures 7A and 7B). 39,40 External fixators offer the advantage of off-loading the flap, load sharing, and proper positioning of the extremity while allowing exposure of the surgical site for frequent postoperative assessments. 39,41 The postoperative nurse should ensure that medicinal leeches are available postoperatively if needed for the management of venous congestion. If medicinal leeches are administered, the surgeon should order appropriate prophylactic antibiotics with gram-negative coverage to be administered 30 minutes before application of calcaneal ulcer. the leeches (Figure 8). 42 INTRINSIC MUSCLE FLAPS. Muscle flaps are used for soft-tissue defects localized to the plantar, medial, or lateral areas of the diabetic foot. These flaps provide bulk and increased blood supply to wounds with exposed hardware, tendon, or bone, making them effective in the treatment of osteomyelitis by enhancing the delivery of antibiotics and white blood cells to the wound. 15,43 In general, muscle flaps are classified as having one of five patterns of blood supply, which often determines the degree of mobility that a surgeon can obtain from a particular muscle. These patterns include type I one major vascular pedicle, type II one dominant vascular pedicle entering at or near the origin with minor pedicle vessels entering the muscle belly more distally, type III two major vascular pedicles from separate regional arteries, type IV segmental minor vascular pedicles Figure 6A Preoperative picture of a chronic, nonhealing, posterior Figure 6C Wound after the surgeon has completed closure with a local double-rhomboid flap. Figure 6B Intraoperative marking and resection of a calcaneal osteomyelitis. Figure 6D Postoperative picture at the patient s six-week follow-up appointment. along the entire length of the muscle, or type V one dominant vascular pedicle at the origin with several smaller secondary segmental pedicles at the insertion. 43,44 Intrinsic muscle flaps in the foot are classified as type II intrinsic muscles supplied by one AORN JOURNAL 961

12 MAY 2008, VOL 87, NO 5 Zgonis Stapleton Rodriguez Girard-Powell Cromack Figure 7A A circular external fixation device used to offload the sural neurofasciocutaneous flap. dominant vessel at its origin and several minor vessels entering distally. 43,44 Type II muscle flaps are advantageous because they can be mobilized easily while maintaining their vascularity. The most common muscle flaps harvested from the foot are the abductor hallucis brevis, flexor digitorum brevis, and abductor digiti minimi. 43 The surgeon covers the muscle flaps with an STSG, and the patient receives the same postoperative care to ensure adequate blood flow to the reconstructed foot as patients who receive other types of flaps. Strict non-weight bearing during the initial postoperative period is crucial for minimizing postoperative complications of the muscle and ensuring graft incorporation. LOCAL AND DISTAL PEDICLE FLAPS. Pedicle flaps require the surgeon to isolate an identifiable neurovascular bundle that supplies a composite block of tissue intended to be transferred. The creation of a pedicle flap requires separation of either the source vessels or septofasciocutaneous perforating vessels. A pedicle flap may be fasciocutaneous, adipofascial, or musculocutaneous depending on the circumstances. Pedicle flaps Figure 7B A hybrid external fixation device. Figure 8 Application of medicinal leeches on a local random flap with venous congestion. 962 AORN JOURNAL

13 Zgonis Stapleton Rodriguez Girard-Powell Cromack MAY 2008, VOL 87, NO 5 The medial-plantar artery flap, used for soft-tissue defects around the dorsal-medial or plantar-lateral midfoot and heel, is the work horse for soft-tissue reconstruction in patients who have a wound in conjunction with a diabetic Charcot neuroarthropathy rocker-bottom deformity. may be raised adjacent to a soft-tissue defect, much like a local random flap, or from a site distant from the soft-tissue defect, much like a free flap. This offers the surgeon many options for addressing soft-tissue defects around the foot and ankle. The pedicle flaps most commonly used for diabetic foot wounds are the great-toe fibular artery flap, medial-plantar artery flap, and reverse-flow sural artery flap. These provide soft-tissue coverage of the forefoot, midfoot, and rearfoot regions, respectively. 28 The great-toe fibular artery flap is an adipofasciocutaneous flap that can provide coverage to defects of the plantar distal forefoot. 35 The surgeon raises the flap from the lateral aspect of the big toe and includes the digital artery from the first dorsal metatarsal artery and the accompanying vein and nerve. This flap offers the advantage of covering defects as lateral as the fifth metatarsal head. Typically, the donor site is closed primarily if the surgeon performs a bone resection or is closed with a small STSG. 45 The medial-plantar artery flap is useful for soft-tissue defects around the dorsal-medial or plantar-lateral midfoot and heel. This is the work horse for soft-tissue reconstruction in patients who have a wound in conjunction with a diabetic Charcot neuroarthropathy rocker-bottom deformity. 15,28 Often, this flap is used in conjunction with skeletal reconstruction of the Charcot foot. Flaps raised from the instep of the foot are supplied by two vessels: collateral flow from the dorsalis pedis and perforators off the superficial branch of the medial plantar artery. 46 Dissection required for raising the medial-plantar artery flap offers the surgeon a direct approach from the plantar aspect of the foot to address any underlying osseous deformity. 28 Reverse-flow sural artery neurofasciocutaneous flaps are useful for covering defects around the heel, ankle, and lower leg. 15,28,47,48 These flaps can be of various sizes and shapes, offering soft-tissue coverage to areas that previously required free-tissue transfer with microvascular anastomosis. Using the noninvasive vascular laboratory preoperatively helps mark the course of the lesser saphenous vein and determine the diameter of the vein. 15 This allows precise incision and donor site placement, thereby minimizing unnecessary dissection and reducing surgical time. Another key step is to mark the level of the most distal peroneal arterial perforator, which usually is found 5 cm proximal to the distal tip of the lateral malleolus between the fibula and Achilles tendon. 15 The surgeon confirms the location using a hand-held Doppler ultrasound probe on the surgical field before dissection. The surgeon then designs the flap based on the size of the defect. The surgeon dissects the flap under loupe magnification, dissecting from proximal to distal to ligate and include the median superficial sural artery and the lesser saphenous vein with a composite block of tissue; the surgeon also identifies the sural nerve. These structures have great variability in their relationship to one another, and great care should be taken to identify and include each structure to limit potential complications. The surgeon raises the flap either suprafascially or subfascially. At this point, the surgeon dissects from distal to proximal, isolating the easily identifiable pedicle components. The tourniquet, if used, should be released to allow the surgeon to evaluate the viability of the cutaneous and adipofascial portions of the flap before the surgeon insets the flap. The surgeon then insets the flap without torsion or tension of the AORN JOURNAL 963

14 MAY 2008, VOL 87, NO 5 Zgonis Stapleton Rodriguez Girard-Powell Cromack The goal of diabetic limb salvage is to improve the patient s overall health and to provide the patient with a limb that is stable, mechanically sound, and resistant to further breakdown while he or she resumes ambulation. pedicle components and secures it using skin staples and sutures. The surgeon achieves closure over the pedicle components primarily or, more commonly, via STSG. The surgeon primarily closes the donor site if it is smaller than 5 cm; he or she closes larger defects using an STSG from the ipsilateral extremity. 15 Studies have shown that using external fixation to off-load this flap decreases the likelihood of complications and flap failure. 15,49,50 The surgeon positions the foot in slight plantar flexion in an external fixator, minimizing tension across the pedicle component. The surgeon may employ one or more techniques, including the use of medicinal leeches, to prevent complications associated with reverse-flow sural artery flaps to achieve successful soft-tissue coverage of the most challenging wounds of the diabetic foot. 15,49,50 Postoperative nursing care includes close monitoring for ischemia or venous congestion. Pre - venting ischemia or venous congestion is paramount for ensuring a successful outcome. POSTOPERATIVE RECOVERY A multidisciplinary approach continues throughout the postoperative period to ensure a successful outcome. All team members work cooperatively to establish a protocol with guidelines so that everyone has a mutual understanding when providing postoperative care. The postoperative nurse assesses and documents the patient s vital signs, laboratory studies, culture and sensitivity results, and clinical status daily. The nurse observes and relays information regarding the patient s demeanor, mood, and obvious problems to the physician and other team members. The surgical team then can enter the room during postoperative visits better prepared to interact appropriately with the patient. Emphasis on the patient s dressing changes, wound care, physical therapy, limb position, shower privileges, and laboratory tests are discussed at the bedside with the patient. These patients need ongoing support and validation throughout the postoperative period to ensure a functional recovery and to prevent related complications. 16 Discharge from the hospital should represent an accomplishment for the patient. The surgical team should ascertain the patient s prognosis and discuss the remaining postoperative course. The postoperative nurse should give the patient instructions for follow up and daily or weekly monitoring of the surgical procedure results, medications, ancillary services, ambulatory status, work and social restrictions, and bathing. The nurse should ensure that any postoperative patient with diabetes mellitus and dense peripheral neuropathy is given instructions on identifying infection and ways of contacting the surgical team if problems arise. SUCCESSFUL DIABETIC LIMB SALVAGE The goal of diabetic limb salvage is to improve the patient s overall health and to provide the patient with a limb that is stable, mechanically sound, and resistant to further breakdown while he or she resumes ambulation. A proactive, surgical approach is essential for long-lasting, soft-tissue coverage of a diabetic foot wound. A multidisciplinary team consisting of surgical, medical, and nursing personnel who are knowledgeable and experienced in caring for patients with diabetes mellitus is needed to adequately manage the diabetic foot wound. Understanding the timing of surgery, the staging of surgical procedures, and the rationale for performing nontraditional plastic surgery techniques as they pertain to the patient with a diabetic foot 964 AORN JOURNAL

15 Zgonis Stapleton Rodriguez Girard-Powell Cromack MAY 2008, VOL 87, NO 5 wound are paramount for achieving a successful outcome throughout the perioperative management of the patient. REFERENCES 1. Lipsky BA; International Consensus Group on Diagnosing and Treating the Infected Diabetic Foot. A report from the International Consensus on Diagnosing and Treating the Infected Diabetic Foot. Diabetes Metab Res Rev. 2004;20(Suppl 1):S68-S Zgonis T, Roukis TS. A systematic approach to diabetic foot infections. Adv Ther. 2005;22(3): Crane M, Werber B. Critical pathway approach to diabetic pedal infections in a multidisciplinary setting. J Foot Ankle Surg. 1999;38(1): Dargis V, Pantelejeva O, Jonushaite A, Vileikyte L, Boulton AJ. Benefits of a multidisciplinary approach in the management of recurrent diabetic foot ulceration in Lithuania: a prospective study. Diabetes Care. 1999;22(9): Edmonds M. Infection in the neuroischemic foot. Int J Low Extrem Wounds. 2005;4(3): Leichter SB, Allweiss P, Harley J, et al. Clinical characteristics of diabetic patients with serious pedal infections. Metabolism. 1988;37(2 Suppl 1): Pinzur MS, Sage R, Abraham M, Osterman H. Limb salvage in infected lower extremity gangrene. Foot Ankle. 1988;8(4): Tan JS, Friedman NM, Hazelton-Miller C, Flanagan JP, File TM Jr. Can aggressive treatment of diabetic foot infections reduce the need for above-ankle amputation? Clin Infect Dis. 1996;23(2): Scher KS, Steele FJ. The septic foot in patients with diabetes. Surgery. 1988;104(4): Kanuck DM, Zgonis T, Jolly GP. Necrotizing fasciitis in a patient with type 2 diabetes mellitus. J Am Podiatr Med Assoc. 2006;96(1): Lipsky BA, Berendt AR, Deery HG, et al. Diagnosis and treatment of diabetic foot infections. Plast Reconstr Surg. 2006;117(Suppl 7):212S-238S. 12. Wieman TJ. Principles of management: the diabetic foot. Am J Surg. 2005;190(2): Sumpio BE, Aruny J, Blume PA. The multidisciplinary approach to limb salvage. Acta Chir Belg. 2004;104(6): Frykberg RG, Zgonis T, Armstrong DG, et al. Diabetic foot disorders: a clinical practice guideline (2006 revision). J Foot Ankle Surg. 2006;45(Suppl 5):S1-S Zgonis T, Stapleton JJ, Roukis TS. Advanced plastic surgery techniques for soft tissue coverage of the diabetic foot. Clin Podiatr Med Surg. 2007; 24(3): Roukis TS, Stapleton JJ, Zgonis T. Addressing psychosocial aspects of care for patients with diabetes undergoing limb salvage surgery. Clin Podiatr Med Surg. 2007;24(3): Wallace GF. Indications for amputations. Clin Podiatr Med Surg. 2005;22(3): Panneton JM, Gloviczki P, Bower TC, Rhodes JM, Canton LG, Toomey BJ. Pedal bypass for limb salvage: impact of diabetes on long-term outcome. Ann Vasc Surg. 2000;14(6): Lepäntalo M, Biancari F, Tukiainen E. Never amputate without consultation of a vascular surgeon. Diabetes Metab Res Rev. 2000;16(Suppl 1):S27-S Searles JM Jr, Colen LB. Foot reconstruction in diabetes mellitus and peripheral vascular insufficiency. Clin Plast Surg. 1991;18(3): Steed DL, Donohoe D, Webster MW, Lindsley L. Effect of extensive debridement and treatment on the healing of diabetic foot ulcers. Diabetic Ulcer Study Group. J Am Coll Surg. 1996;183(1): Frykberg RG, Armstrong DG, Giurini J, et al. Diabetic foot disorders. A clinical practice guideline for the American College of Foot and Ankle Surgeons and the American College of Foot and Ankle Orthopedics and Medicine. J Foot Ankle Surg. 2000; (Suppl 5):S1-S Frykberg RG, Wittmayer B, Zgonis T. Surgical management of diabetic foot infections and osteo - myelitis. Clin Podiatr Med Surg. 2007;24(3): Eneroth M, Larsson J, Apelqvist J. Deep foot infections in patients with diabetes and foot ulcer: an entity with different characteristics, treatments, and prognosis. J Diabetes Complications. 1999;13(5-6): Adam DJ, Raptis S, Fitridge RA. Trends in the presentation and surgical management of the acute diabetic foot. Eur J Vasc Endovasc Surg. 2006;31(2): Pellizzer G, Strazzabosco M, Presi S, et al. Deep tissue biopsy vs superficial swab culture monitoring in the microbiological assessment of limbthreatening diabetic foot infection. Diabet Med. 2001;18(10): Roukis TS, Zgonis T. The management of acute Charcot fracture-dislocations with the Taylor s spatial external fixation system. Clin Podiatr Med Surg. 2006;23(2): ,viii. 28. Zgonis T, Roukis TS, Frykberg RG, Landsman AS. Unstable acute and chronic Charcot s deformity: staged skeletal and soft-tissue reconstruction. J Wound Care. 2006;15(6): Zgonis T, Roukis TS, Lamm BM. Charcot foot and ankle reconstruction: current thinking and surgical approaches. Clin Podiatr Med Surg. 2007;24 (3): Zgonis T, Jolly GP, Buren BJ, Blume P. Diabetic foot infections and antibiotic therapy. Clin Podiatr Med Surg. 2003;20(4): Jolly GP, Zgonis T, Blume P. Soft tissue reconstruction of the diabetic foot. Clin Podiatr Med Surg. 2003;20(4): Kosinski MA, Joseph WS. Update on the treatment of diabetic foot infections. Clin Podiatr Med Surg. 2007;24(3): Wallace GF, Stapleton JJ. Transmetatarsal amputations. Clin Podiatr Med Surg. 2005;22(3): Roukis TS, Zgonis T. Skin grafting techniques for soft-tissue coverage of diabetic foot and ankle AORN JOURNAL 965

16 MAY 2008, VOL 87, NO 5 Zgonis Stapleton Rodriguez Girard-Powell Cromack wounds. J Wound Care. 2005;14(4): Levin LS. The reconstructive ladder. An orthoplastic approach. Orthop Clin North Am. 1993;24 (3): Donato MC, Novicki DC, Blume PA. Skin grafting. Historic and practical approaches. Clin Podiatr Med Surg. 2000;17(4): Attinger C. Use of skin grafting in the foot. J Am Podiatr Med Assoc. 1995;85(1): Roukis TS. The Doppler probe for planning septofasciocutaneous advancement flaps on the plantar aspect of the foot: anatomical study and clinical applications. J Foot Ankle Surg. 2000;39 (5): Zgonis T, Roukis TS. Off-loading large posterior heel defects after sural artery soft-tissue flap coverage with A stacked taylor spatial frame foot plate system. Oper Tech Ortho. 2006;16(1): Shmueli G, Nahlieli O, Baruchin A, Herold HZ. External fixation for fractures and pedicle flap immobilization: a convenient and inexpensive substitute. Plast Reconstr Surg. 1985;75(4): Roukis TS, Landsman AS, Weinberg SA, Leone E. Use of a hybrid kickstand external fixator for pressure relief after soft-tissue reconstruction of heel defects. J Foot Ankle Surg. 2003;42(4): Bickel KD, Lineaweaver WC, Follansbee S, Feibel R, Jackson R, Buncke HJ. Intestinal flora of the medicinal leech Hirudinaria manillensis. J Reconstr Microsurg. 1994;10(2): Attinger CE, Ducic I, Zelen C. The use of local muscle flaps in foot and ankle reconstruction. Clin Podiatr Med Surg. 2000;17(4): Attinger CE, Ducic I, Cooper P, Zelen CM. The role of intrinsic muscle flaps of the foot for bone coverage in foot and ankle defects in diabetic and nondiabetic patients. Plast Reconstr Surg. 2002; 110(4): Roukis TS, Zgonis T. Modifications of the great toe fibular flap for diabetic forefoot and toe reconstruction. Ostomy Wound Manage. 2005;51(6): Bhandari PS, Sobti C. Reverse flow instep island flap. Plast Reconstr Surg. 1999;103(7): Jolly GP, Zgonis T. Soft tissue reconstruction of the foot with a reverse flow sural artery neurofasciocutaneous flap. Ostomy Wound Manage. 2004; 50(6): Costa-Ferreira A, Reis J, Pinho C, Martins A, Amarante J. The distally based island superficial sural artery flap: clinical experience with 36 flaps. Ann Plast Surg. 2001;46(3): Price MF, Capizzi PJ, Watterson PA, Lettieri S. Reverse sural artery flap: caveats for success. Ann Plast Surg. 2002;48(5): Noack N, Hartmann B, Küntscher MV. Measures to prevent complications of distally based neurovascular sural flaps. Ann Plast Surg. 2006; 57(1): Thomas Zgonis, DPM, is an assistant professor in the Department of Orthopaedics, Podiatry Division, and the director of the Reconstructive Foot and Ankle Fellowship at the University of Texas Health Science Center at San Antonio. Dr Zgonis has no declared affiliation that could be perceived as a potential conflict of interest in publishing this article. John J. Stapleton, DPM, is an associate of foot and ankle surgery at VSAS Orthopaedics, Allentown, PA, and a clinical assistant professor of surgery at Penn State College of Medicine, Hershey, PA. Dr Stapleton has no declared affiliation that could be perceived as a potential conflict of interest in publishing this article. Roberto H. Rodriguez, DPM, is a reconstructive fellow and clinical instructor in the Department of Orthopaedics, Podiatry Division, at the University of Texas Health Science Center at San Antonio. Dr Rodriguez has no declared affiliation that could be perceived as a potential conflict of interest in publishing this article. Valerie A. Girard-Powell, RN, is a perioperative nurse at the University Hospital, San Antonio, TX. Ms Girard-Powell has no declared affiliation that could be perceived as a potential conflict of interest in publishing this article. Douglas T. Cromack, MD, is an assistant professor in the Department of Orthopaedics and Plastic Surgery at the University of Texas Health Science Center at San Antonio. Dr Cromack has no declared affiliation that could be perceived as a potential conflict of interest in publishing this article. 966 AORN JOURNAL

17 Examination 3.6 Plastic Surgery Reconstruction of the Diabetic Foot PURPOSE/GOAL To educate perioperative nurses about caring for a patient with diabetes who is undergoing plastic surgery reconstruction of the foot. BEHAVIORAL OBJECTIVES After reading and studying the article on plastic surgery reconstruction of the diabetic foot, nurses will be able to 1. identify comorbidities that are common for patients with diabetes, 2. explain how a multidisciplinary team manages a patient with diabetes who is undergoing plastic surgery reconstruction of the foot, 3. discuss the perioperative care of a diabetic patient undergoing plastic surgery reconstruction of the foot, 4. describe plastic surgery reconstructive procedures available depending on the extent of the infection present, and 5. describe the postoperative recovery of a diabetic patient who has undergone plastic surgery reconstruction of the foot. 1. Urgent or emergent surgery is necessary if a patient with a diabetic foot ulcer also has 1. ascending cellulitis. 2. evidence of compartment syndrome. 3. gas gangrene. 4. necrotizing fasciitis. 5. systemic toxicity with metabolic instability. a. 2 and 3 b. 1, 4, and 5 c. 2, 3, 4, and 5 d. 1, 2, 3, 4, and 5 2. The should be the gatekeeper for addressing the type, extent, and timing of the surgical procedure. a. endocrinologist b. perioperative nurse c. reconstructive surgeon d. vascular surgeon 3. The ability to probe to the bone along QUESTIONS with clinical and radiographic assessments may indicate the presence of a. gas gangrene. b. Charcot foot. c. osteomyelitis. d. cellulitis. 4. If debridement of the patient s heel region or posterior lower leg is required, the patient is placed in the a. lithotomy or lawn chair position. b. prone or lateral decubitus position. c. sitting or reverse Trendelenburg position. d. supine or Trendelenburg position. 5. The circulating nurse and surgeon apply the tourniquet as close to the surgical site as possible. a. true b. false 6. The patient may have to take antibiotics for as long as postoperatively. AORN, Inc, 2008 MAY 2008, VOL 87, NO 5 AORN JOURNAL 967

18 MAY 2008, VOL 87, NO 5 Examination a. six to eight weeks b. eight to 10 weeks c. 10 to 12 weeks 7. Spherical-shaped antibiotic beads offer the advantage of 1. decreased surface area. 2. enhanced elution of antibiotics to a localized area. 3. increased surface area. 4. maintaining stability of osseous segments. a. 1 and 4 b. 2 and 3 c. 2, 3, and 4 d. 1, 2, and 4 8. A split-thickness skin graft should not be applied to wounds with greater than of exposed bone, tendon, fascia, adipose tissue, or hardware. a. 5 mm b. 10 mm c. 15 mm d. 20 mm 9. A local random flap usually requires no greater than a length-to-width ratio to ensure sufficient vascular supply to the flap. a. 1:1 b. 1:2 c. 2:1 d. 3:1 10. The postoperative nurse gives the patient instructions regarding 1. ambulation and bathing. 2. ancillary services. 3. daily or weekly monitoring of the surgical procedure results. 4. identifying infection. 5. medications. 6. work and social restrictions. a. 1, 3, and 5 b. 2, 4, and 6 c. 2, 3, 4, 5, and 6 d. 1, 2, 3, 4, 5, and 6 The behavioral objectives and exam ination for this program were prepared by Rebecca Holm, RN, MSN, CNOR, clinical editor, with consultation from Susan Bakewell, RN, MS, BC, director, Center for Perioperative Education. Ms Holm and Ms Bakewell have no declared affiliations that could be perceived as potential conflicts of interest in publishing this article. This program meets criteria for CNOR and CRNFA recertification, as well as other continuing education requirements. AORN is accred ited as a provider of continuing nursing education by the American Nurses Creden tialing Center s Commission on Accredit ation. AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP Check with your state board of nursing for acceptance of this activity for relicensure. 968 AORN JOURNAL

19 Answer Sheet Plastic Surgery Reconstruction of the Diabetic Foot 3.6 Event #08038 Session #1904 Please fill out the application and answer form on this page and the evaluation form on the back of this page. Tear the page out of the Journal or make photo copies and mail with appropriate fee to: AORN Customer Service c/o AORN Journal Continuing Education 2170 S Parker Rd, Suite 300 Denver, CO or fax with credit card information to (303) Additionally, please verify by signature that you have reviewed the objectives and read the article, or you will not receive credit. Signature 1. Record your AORN member identification number in the appropriate section below. (See your member card.) 2. Completely darken the spaces that indicate your answers to examination questions 1 through 10. Use blue or black ink only. 3. Our accrediting body requires that we verify the time you needed to complete this 3.6 continuing education contact hour (216-minute) program. 4. Enclose fee if information is mailed. AORN (ID) # Name Address City Phone number RN license # Fee enclosed State Zip State or bill the credit card indicated MC Visa American Express Discover Card # Expiration date Signature (for credit card authorization) Fee: Members $18 Nonmembers $36 Program offered May 2008 The deadline for this program is May 31, 2011 AORN, Inc, 2008 A score of 70% correct on the examination is required for credit. Participants receive feedback on incorrect answers. Each applicant who successfully completes this program will receive a certificate of completion. MAY 2008, VOL 87, NO 5 AORN JOURNAL 969

20 3.6 Learner Evaluation Plastic Surgery Reconstruction of the Diabetic Foot This evaluation is used to determine the extent to which this continuing education program met your learning needs. Rate these items on a scale of 1 to 5. PURPOSE/GOAL To educate perioperative nurses about caring for the patient with diabetes who is undergoing plastic surgery reconstruction of the foot. OBJECTIVES To what extent were the following objectives of this continuing education program achieved? 1. Identify comorbidities that are common for patients with diabetes. 2. Explain how a multidisciplinary team manages a patient with diabetes who is undergoing plastic surgery reconstruction of the foot. 3. Discuss the perioperative care of a diabetic patient undergoing plastic surgery reconstruction of the foot. 4. Describe plastic surgery reconstructive procedures available depending on the extent of the infection present. 5. Describe the postoperative recovery of a diabetic patient who has undergone plastic surgery reconstruction of the foot. CONTENT To what extent 6. did this article increase your know ledge of the subject matter? 7. was the content clear and organized? 8. did this article facilitate learning? 9. were your individual objectives met? 10. did the objectives relate to the overall purpose/goal? TEST QUESTIONS/ANSWERS To what extent 11. were they reflective of the content? 12. were they easy to understand? 13. did they address important points? LEARNER INPUT 14. Will you be able to use the information from this article in your work setting? 1. yes 2. no 15. I learned of this article via 1. the Journal I receive as an AORN member. 2. a Journal I obtained elsewhere. 3. the AORN Journal web site. 16. What factor most affects whether you take an AORN Journal continuing education examination? 1. need for continuing education contact hours 2. price 3. subject matter relevant to current position 4. number of continuing education contact hours offered What other topics would you like to see addressed in a future continuing education article? Would you be interested or do you know someone who would be interested in writing an article on this topic? Topic(s): Author names and addresses: 970 AORN JOURNAL MAY 2008, VOL 87, NO 5 AORN, Inc, 2008