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Lecture Hall Wound Care | Treatment
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Advanced Technology in Wound Healing

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John Steinberg
John Steinberg, DPM
Assistant Professor
Department of Plastic Surgery
Georgetown University School of Medicine
Washington, DC
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Lecture Transcription

Author: John S. Steinberg, DPM, FACFAS

Associate Professor, Department of Plastic Surgery

Georgetown University School of Medicine

Let�s go real quick into advanced technology and wound heeling. What I want to accomplish here is to give you some ideas on what we do and how we do it and how you separate these different technologies. One word of caution, this product just came out. If you get Parade Magazine in your Sunday newspaper, you�ll see that Cozy Toes is now available for $997, you can 50% off the actual catalogue prize, free shipping and handling. And if you look, this actually puts an end to bunions, hammertoes, toe cramps, ball of foot pain, plantar fasciitis. I mean, look at this amazing device. This picture here, bunion, hammertoe and all this pain into a foot that has sparkles on it. So if you�re wondering why I do wound care, it�s because this product has completely ruined my reconstructive surgical business because Cozy Toes will fix everything else. So be careful about that, you may want to either sell these through your office or you may want to just buy them all up so no else can get it. These people make millions in these magazine ads with the bunion fixers and the bunion splints and the night splints in the Cozy Toes ad. It�s kind of scary what kind of finances those folks make.

This is one of my patients who has a nonhealing midfoot ulceration, Charcot deformity, diabetes, neuropathy, kidney transplant, and I asked him as I was filling out his handicap parking permit, I asked him how much driving he did and he was very proud of showing me a picture of his vehicle and his motorcycle that he actually drives.

Diabetes care, March 1999 � Gayle Reiber pointed out to us a very important fact of the diabetic foot and the diabetic foot ulceration, and that it is that it is very expensive to not heel a diabetic foot ulcer. You heard Bob Frykberg talk about that somewhat with us in the sessions prior, and the reality here is that in $1995, so 15 years ago, the reality is it costs $30,000 a year to not heal a foot ulcer, just to maintain it. So, the reality here is that you have to realize the fact that this is probably $60,000, $80,000, $90,000now in today�s dollars and this has to be dealt with and has to be realized. This is where we talk about with the insurance companies and other payers that �hey, it�s may be $1200 for this graft today, but we�re going to heel the wound in six weeks rather than have the same situation persist for three or four of a nonhealing ulcer.�

Wound Bed Preparation � this has become a highly academic subtopic now in the field. The concept here is that we want to actually have an optimized wound bed to receive your graft, whether it�s an autogenous skin graft, whether it�s a wound vac that you�re putting on, whether it�s some type of a bioengineered living or nonliving tissue or scaffold, you need to optimize the wound bed to receive that, otherwise you�re throwing away resources time, effort, and money.

Peter Sheehan helped us with this data and that was published in Diabetes Care in 2003, to understand that at three to four weeks if this wound is showing a nonhealing trajectory�so if at four weeks you haven�t healed by 50% with debridement, offloading, and moist wound healing, that wound will also remain nonhealing at 12 weeks, 24 weeks, 48 weeks. We can predict these non-healers very early. So there is no need to wait three months to declare a wound to be chronic. The chronic wound can be defined that way at the three to four week range.

Bioengineered Alterative Tissues � the concept here�this all started with kind of Procuren and Regranex, and what we�re looking at is the reality that these technologies are actually interacting with the wound. And when you actually interact with the wound and change the biology of the wound�when you interact with the biology of the wound, what you�re actually accomplishing here is that you are actually going to change the outcome of the wound. We�ve done a lot of dressings, we got a lot of topical wound care, we�ve got a information from previous. But, what we�re doing here with these categories and these products is that we actually are interacting with the wound bed itself and we�re creating an actual biologic stimulation to the wound bed.

So let�s start out with Procuren and Regranex. We�re now using these biologic scaffolds, these nonliving acellular products, we�ve seen a lot of this presented already. This includes items like graft jacket, Integra, Unite Biomatrix, MatriStem, Oasis. These all fit into this subcategory, and then is a final category here of the living tissues. We heard Lee Rogers talk about some of these technologies earlier, the Apligraf and the Dermagraft. These are living cell technologies where you actually are in somewhat transplanting a living human cell that�s has been cultured and grown in a cell bank on to the recipient graft site of your patient.

The science here that we�re delivering actual cell therapy, you have a barrier function and a dermal matrix for these patients that you receive from these various products. And what this all centers around is the human fibroblast. So you have to keep in mind that this biology that we�re delivering from the fibroblasts is actually creating the growth factors and creating the stimulation of the wound and the healing.

Characteristics of Bi-Layer Cell Therapy � highly proliferative healing capacity, production of cytokines and matrix proteins, and even producing antimicrobial peptides. So these grafts, these living tissues grafts and the fibroblasts that persist inside of them are actually producing their own antimicrobial, their protective peptides that are preventing infection of these wound beds.

This is actually a piece of Integra. The concept with Integra here is that we�re using this in some of these deeper tissue defects. It started off in burn patients because we�re trying to regenerate or replace a human dermis, and in these particular cases we�re actually regenerating this tissue over potentially exposed tendon, bone, capsule, and joint so that we can actually then move on to a secondary graft. So this type of a scaffolding product, that middle category, the nonliving acellulars, these are stepping stones to get to where you want to be. These are not going necessarily be the wound closure products.

The concept here in the application, as you can see, this is generally an operating room procedure if we�re dealing with a deep wound. Many of these can be applied at the bedside if it�s a superficial wound and a lot of living tissues are routinely done in the clinic for these individuals.

A couple of cases here for you to look at � a patient who required a partial calcanectomy. This was actually an X-fix pin site that was neglected, went on to an infection, ended up calcaneal osteo from a pin which is fairly rare, of course, but it can happen, and in the complication of diabetes and history of Charcot foot. When we resected this, we had a large soft tissues defect. So we covered that with an Integra graft along with negative pressure wound therapy. At two weeks we removed the silicon layer of the graft and at five weeks we applied the skin graft. So moving this patient rapidly from a deep defect exposing bone, covering that bone in a couple of weeks, after the bone is covered we come behind that and put on a skin graft.

This is a patient who was transferred into Georgetown, another hospital had been working on a patient, was not responding, still had a high white count, still was having difficulty with infection, and in fact this was a dorsal and plantar I&D already done but has significant osteo with the fourth and fifth ray including abscess of the joint. So the septic joints were resected, the corresponding toes were amputated, and we reconstructed this though a ladder by using first negative pressure and appropriate antibiotics and surgical debridement. Then we move on to rebuilding the tissues and we used Integra in this particular case. We then went on to a living bioengineered tissue, in this particular case Apligraf and then follow that a couple weeks later with a skin graft. So this kind goes into the wound bed preparation. We were using all these other products as wound bed preparatory products to get us to the skin graft phase where we could actually cover and close this.

A 70-year-old gentleman who�s already lost his other leg, came in with an exposed necrotic tibials anterior tendon, positive MRSA wound here at the distal TMA site. And if you look at the other aspects of the same leg, he�s got a posterior heel ulcer, exposed Achilles tendon with tissues necrosis, a lateral malleolar ulcer, and a fifth met base ulcer. So this is pretty ugly when you look at this and this certainly would be a recipient for amputation. However, this patient has already lost his other leg, so in this case we�re actually getting and go ahead and do what we can at his discretion to try an actually salvage this extremity. So he was first admitted, Infectious Disease, revascularized by vascular surgery and then moving on to debridement by our service. So the challenge would be that if you debride the patient first without revascularizing first, you are going to end up with more necrotic tissue and a dead foot.

We moved on to a Chopart�s amputation. We did an Achilles tenotomy. We used a non-layered graft anteriorly, we used Integra followed by Apligraf on the posterior aspect, and we had rapid coverage and closure of this challenging problem wound. So even in some of these extreme cases we can salvage the extremity and leave the patient with at least a biologic prosthesis that they can pivot from bed to chair and from chair to commode with.

Another challenging example, this is a patient who had a crush injury. Of course, in crush injuries we have to be aware of and be mindful of compartment of syndrome, which was indeed a factor for this patient. So there was dislocation and fracturing with avulsion of the distal pulp of the toe. What you�re looking at here is exposed distal phalanx bone right here. This is fasciotomy that was performed for compartment syndrome and a medial fasciotomy performed for compartment syndrome. You see this, obviously has edema continues and you leave this open for a few days, the skin will retract. We eventually brought this patient back for revision, debridement, and closure of the fasciotomies. We put some bioengineered tissue, in this case Integra, over that exposed bone in hopes that we could avoid an amputation, but I was certainly very skeptical and I was planing on doing most likely a revision to a partial hallux amputation.

The dislocation at the MPJ was managed with a MiniRail external fixator to keep that stable, and we actually got lucky on this case. We removed X-fix when the joint was stable and we just allowed this to continue to granulate in with appropriate wound care, keeping the wound environment moist and then eventually getting actual epithelization over a period of about three months.

A 49-year-old male, diabetes, history of an injury to his toe, required an amputation, and now he�s got a nonhealing wound. You can see this is a fibrotic nonhealing wound base. You can see the foot itself has an atrophic appearance. We talked on Thursday afternoon about intrinsic minus. This is definitely an intrinsic minus foot. He�s got autonomic neuropathy. Allen Jacobs talked about that earlier for today that this dry peeling cracking skin, nails fungal changes, you can see the soft tissues atrophy, you can see the loss of intrinsic musculature, and in this case you can see what appears to be an ischemic foot as well.

So before you go in and play hero and debride and revise and do some type of surgery for this patient, you�ll obviously have to get your vascular workup, and the vascular workup for this patient was that he needed a revascularization. After that was completed, now we can come in and safely do our debridement, get down to a granular healthy wound bed, move on to tissue grafting, and eventually on to complete closure.

What I would challenge you about these two slides, in followup to the discussion about autonomic neuropathy, is that look at what the revascularization did for this patient. Now the wound healing had something to do with it, but I would give way more credit to the vascular surgeon and what they were able to do in changing this foot. You�ve now got supple healthy looking skin, even got improvement, there is no more dryness, even got improving to the nails themselves looking at this in a long-term postop. So, the reality is that blood flow is, of course, in this particular patient was the rate limiting factor.

The concept here again is a stepwise approach, just like what we talked about dealing with infection on Thursday with a diabetic foot. If you are systematic about this and stepwise about it, for the boards of course you have to somewhat think about what answer is that they want me to give, because it�s not always necessarily what you�re doing today in practice and residency, but for the most part it does make sense in conjunction with what you�re doing clinically. So, think about this from a common sense perspective, be systematic about your approach to it, and realize that they�re looking for the comprehensive thought process here, not sometimes just the absolute memory of a particular fact.

Any questions you guys can think of?

Dr. Steinberg discusses the use of advanced technologies in wound healing. He reviews the indications for several therapies and presents case studies to illustrate the appropriate use of advanced technologies in wound healing.
Goals and Objectives
After participating in this activity, the viewer should be better able to:
1. Distinguish the difference between good wound care and advanced wound healing.
2. Choose when to transition from good wound care to advanced healing modalities.
3. Assess appropriate uses of advanced wound healing methods.

Estimated time to complete this activity is 22 minutes.
Target Audience
Physicians, diabetes educators, and other health care professionals who treat patients with diabetes.
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Advanced Technology in Wound Healing
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Advanced Technology in Wound Healing
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Disclosure Information
Advanced Technology in Wound Healing
It is the policy of PRESENT e-Learning Systems and it's accreditors to insure balance, independence, objectivity and scientific rigor in all individually sponsored or jointly sponsored educational programs. All faculty participating in any PRESENT e-Learning Systems programs are expected to disclose to the program audience any real or apparent conflict(s) of interest that may have a direct bearing on the subject matter of the continuing education program. This pertains to relationships with pharmaceutical companies, biomedical device manufacturers, or other corporations whose products or services are related to the subject matter of the presentation topic. The intent of this policy is not to prevent a speaker with a potential conflict of interest from making a presentation. It is merely intended that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts.
John Steinberg, DPM has no relevant financial relationship(s) to disclose.
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