Wound Care
(or better yet wound healing)
Pretty much everything you need to know about wound care:
Dr. Gitlin has been involved in the treatment of patients with foot and ankle wounds for the past 15 years. He was director of the St. Johns Medical Center wound care and tissue regeneration fellowship as well as medical director of their Hyperbaric and wound care program. During residency he trained under E. Douglas Newton, MD, in Pittsburgh and Christopher Attinger, MD at Georgetown.
Since then he has given hundreds of lectures nationally on the subject of wound care surgery, limb salvage, amputation, charcot reconstruction, bone infection among other topics in the field of wound care.
" Wounds always have a reason to be there "
So in order to treat and heal the wound we need to diagnose its reason for existence. There are a long list of systemic diseases that can cause wounds to appear on a persons body. However, in the lower extremity the majority of wounds occur due to pressure as in many diabetic foot cases; others occur because of lack of blood flow or the lack of blood drainage in the veins back to the heart.
We will address all of these causes.
First the most common that we see in the lower extremity practice - the diabetic foot wound. Just beacuse someone has diabetes does not cause the wound. Its peripheral neuropathy which makes loss of feeling in the foot occur, then since the body feels no pain indicators of a problem the skin simply breaks down and causes the foot ulceration. We use a grading system in wound care, the Wagner Classification System seen below on the left. On the right there is another classification system that is a bit more comprehensive but less commonly used called the University of Texas attached here for your knowledge.
After we understand the kind of wound we are dealing with, we look for the reasons, in the diabetic there may bone prominences like in cases of charcot foot ( if you want to know more about what CHARCOT is click here ) where the bones break down and form bulges in the skin which rub against the floor and since the patient has no protective sensation the skin ulcerates.
We also look at the tendons, how are they pulling the patients joints? or are these tendons and muscles not pushing enough are centain muscles overpowering others and creating imbalances and deformities that create the prominent areas that are prone to ulceration?
Many wounds in the ball of the foot can occur simply because the patients have a condition called equinus ( click to learn about EQUNUS ). This is where the achilles tendon is too tight for any reason and the ball of the foot bears most of the weight during walking and causes ulcers in patients without a protective sensation. ( peripheral neuropathy- yes click it if you are interested)
In other cases the wounds may occur because a joint does not have proper range of motion either from a prior injury, or arthritis, and this may cause undue pressure in other areas of the foot and casue wounds, again usually in patients with some sort of numbness in the feet and legs.
Now arterial wounds are a different story all together- these need to be addressed by a well trained vascular surgeon before we can render any care. Arterial wounds re ones caused by a lack of blood flow to the limb. Venous ulcers usually appear on the inside of the ankle where blood likes to move very slowly and happen because the veins are not working properly to deliver the blood ( which has now run out of oxygen ) away from the feet and back to the heart and lungs. These venous ulcers are treated by compression and debridement and should also be assessed by a vascular surgeon.
We take xrays to see the condition of the bones, we may order an MRI imaging test if necessary - why?
Xrays show us the bones, an MRI is our xray vision, it can show us the anatomy inside a bone and all the soft tissue structures like tendons, ligaments, cartilage and everything else in between. Some clinicians may order a CAT Scan or a PET scan, these are other imaging modalities we use to gather information.
Usually when we get these tests we are looking for hidden infections. If a wound has been present for a long time the bone beneath it may be infected. This creates a situation where the wound will never completely heal because the infected bone -osteomyelitis ( click to learn about it ).
Once we have all of the information about the wound we can begin treatment, we see most wound patients weekly although when they are doing well we can see them every other week. If you have a wound and are seen once a month find a new doctor.
During those weekly visits we perform wound debridements, we use instruments to clean the wound removing any dead skin and tissue as well as to remove any normal skin bacteria that is colonizing the surface of the wound ( that layer is called the biofilm there is a lot of research on that topic going on now. In some cases we also apply antibiotics directly to the wound.
WHY DEBRIDE A WOUND ?
A wound that did not just happen (acute) is one that becomes neglected by the body, we consider this a chronic wound. There are also cellular changes that occur as well. When we clean the wound we make it bleed again, this tricks the body into thinking that there was an acute injury and helps to restart the healing process. The body then sends blood to the area that contains all the cells necessary for healing an acute injury.
OFFLOADING A WOUND
After debridement we either place the patient off weighbearing of in a special cast called a total contact cast or a special boot or shoe made to take weight off the affected foot. Remember we said most of the common wounds in the foot and ankle come from weight on bony prominences. Offloading takes the weight off those areas and allows it to heal. The new very thin skin cells that form the first layer of healing skin are very easily damaged by shearing forces, these are the side to side rubbing forces that happen to the feet during walking.
WHO NEEDS SURGERY ?
If we make a diagnosis that something is resposible for pressing on the skin from the inside we act quickly to remove the bone prominence causing this. In some cases it is to shave down a piece of bone to more extensive bone wedges and realignments. when we do thses surgical deformity correction we often use external fixators ( to learn more about this technique click here ), it is an old technique but one that works extremely well to help hold bones together during healing from the outside just like a scaffold on a building being repaired ,see the case pictures below.
We also use skin graft and flaps-
Actually we are one of the few practices that uses flaps for wound closure, this is a science that is rarely taught today. There is noone else in the tristate area that is trained in some of these techniques.
When we talk about covering a wound surgically there are a few options. The simplest one is artificial skin substitutes, some are made from cultures baby foreskin, some from shark skin, others from plant fibers. Some advertise that the contain growth factors which are necessary for healing. their names include apligraft, dermagraft, oasis and now there are so many more advertised.
We do not prefer any of these fake skin grafts at all!!!!!!
WHY? "because the best skin is the skin next to it". What I mean is the best skin to close a patients wound is there own skin and when it comes to the bottom of someones foot that has very different skin from other places in the body if you could move skin from right next to it will heal a wound much better- see the cases below to understand this.
How about taking skin from another area in the body and using it to cover the wound?
This is called a split thickness skin graft and we do use these often. The way this is done is a machine called a dermatome is used to shave a thin layer of skin ( usually around .15 of an inch- very thin), the skin is then placed in a machine called a mesher that creates uniform holes in the graft that allow for wound drainage. These grafts are then staples or stitches to the wound. These skin graft can only be used in very shallow wounds that are already ready for top layer of the skin coverage.
This skin graft harvest is usually done in the operating room, we do however use an machine called an epidermal harvest system. this allows us to - in the office ' harvest very this layers of skin through gentle heating, then placing these small epidermal grafts onto the wound painlessly.
WHAT IS A VAC MACHINE?
another way to help get a wound more shallow for possible grafting is the vacuum assisted closure device, a company called KCI made the first one years back and its considered one of the most important skin surgery and wound care inventions in recent history. There are now many other companies that produce and sell a similar product bu nothing beats the original KCI VAC. This machine is a vacuum that attaches to the wound and keeps constant suction on it helping the skin to heal quickly. It stays on the foot and is changes every 3 days.
WHAT ABOUT HYPERBARIC THERAPY ?
We do use hyperbaric treatment on occasion but only in addition to our regular treatment and only in very specific cases. Many wound care centers at hospitals use these on anyone they can only because the hospital gets so much money for that treatment, ill explain later. So do you need hyperbarics or HBO for short- usually not, there is simply not enough research to show that even works.
What about deep wounds?
For deeper wounds we have two choices- we can do weekly debridement and get the wound to heal to a shallow level and then skin graft the wound. Or in some cases we can do a rotational flap. These graft are different because we take local skin many time just adjacent to the wound itself and shift it around to cover the wound.
Below is a case of a simple rotational flap, as you can see the skin next to the wound is mobilized to cover the wound, in this case we were able to close the 'donor' site as well.
Below is a more complicated flap for larger wounds in the middle of the foot called a medial plantar artery flap. This is more difficult since when it is made an artery must be kept alive in the flap
We believe that a longer a wound is present the more chance for infection so in many cases of large and deep wounds we now prefer to perform a flap surgery to quickly close the wound. below are some wound flap cases for your interest.
Below is a before and after pic, the wound was cut out completely and stiched closed. An external fixator was applied to the limb ( this is like a scaffold on a building, only in this case we attach it to the bones inside ) This technique of external fixation allows us to stabilize the wound and allow it to heal without movement. The healed picture you see is only 4 weeks after the initial surgery.
This case below is a diabetic male with severe infection after drainage of the abcess a large wound was created. In order to close the wound we used an external fixator scaffold to compress the foot together so as to get the ends of the wound close enough to stitch up. The picture on far right shows 5 weeks after initial surgery , all healed.
This novel technique above was presented by Dr. Gitlin at the American College of Foot and Ankle Surgery annual meeting.