Using Core Tenets of Wound Care to Guide Difficult Decisions

There are a few basic tenets that guide wound treatment, that, when fully met, greatly progress healing towards closure. Although comprehensive clinical checklists may improve efficiency and effectiveness, no matter how thorough or thoughtful, one must continue to emphasize these core tenets for the best outcomes.

In my experience, there is no mystery when it comes to the essential foundations of wound treatment. The team must eradicate acute infection, manage chronic bacterial colonization and biofilm, ensure or restore perfusion, and mitigate all forces externally acting on the affected site. This all seems extremely simplistic, and for the purposes of this column, I submit that nutritional and metabolic status, cardiopulmonary components, anemia, smoking, etc., all have a tremendous and important impact on healing and overall outcomes. Thus, they should be optimized when possible. Conversely, if one improves the aforementioned points and ignores infection, peripheral arterial disease (PAD), or offloading, the consequences become obvious.

We have all had patients for whom, despite all attempts, the risk is disproportionate, and the healing or prognosis is dire. A common cumbersome situation to patients and doctors alike is the scenario of inadequate distal circulation. Let us consider the following scenario: a 61-year-old male with well-controlled type 2 diabetes and a history of right transmetatarsal amputation previously successfully underwent right lower extremity bypass. He now presents with a left medial first metatarsophalangeal (MTPJ) blister, which quickly ulcerates and shows ischemic changes. Angiogram reveals single vessel run-off via a diminutive peroneal artery without a distal target for future bypass. On a subsequent visit, the hallux has completely mummified with definitive demarcation and no evidence of infection. Even without any further information, it is clear that there is a critical barrier to healing. Any attempt for a foot-level amputation is highly likely to fail.

I hear many questions from patients and doctors faced with similar circumstances. Is dry gangrene toxic to the body? Will this worsen over time or increase chances for infection? How long can I live like this before it becomes a problem?

To answer these questions, I find it is important to disclose to patients that the processes which predispose patients to develop PAD are progressive. That the disease process, in general, worsens with time, and thus, any acute or chronic changes to circulation will have a deleterious effect on the affected tissue. With that said, the primary goal still must focus on those basic tenets of healing. In such cases, the primary goal may not be healing per se, but rather to prevent worsening.

The answers to these questions are complex, personalized, and can vary. Recognizing that, I do my best to answer them in the best way for specific patients. However, focusing on the core tenets of wound care, I can guide patients, and myself, in making reasonable decisions in challenging situations.

Any patient with critical limb ischemia for which vascular intervention will not restore circulation, and who has complete ischemic necrosis, should be seen at reasonable surveillance intervals based on overall comorbidities and the status thereof. As with most pathologies, these intervals, I find, are fluid and should be modified as the patient’s condition changes. Assessment should include patient activities of daily living (ADLs), functional mobility, and overall quality of life. If the affected part is causing limitation to a degree that hinders the patient’s ADLs, poses a gross burden to the ability to navigate their home or important medical appointments, or causes intractable rest pain, these may be indications to discuss the scope of amputation options.

In the example provided, hallux amputation would likely lead to prolonged or even lifelong wound care. There may be just enough distal perfusion to the rest of the foot that no additional necrosis occurs, or the gamble may result in proximal gangrenous changes. Nonetheless, interval evaluations should be in line with patient expectations, with a strong emphasis on the risks associated with intervention or lack thereof. Ultimately, the long-term prognosis is likely poor. Perhaps, considering all factors, the most appropriate conclusion may be a major lower extremity amputation. While these are difficult discussions, they are not necessarily bad decisions. If the decision is in line with the basic tenets described above, solves important patient-related quality outcome measures such has performance of ADLs and improvement in quality of life, and simultaneously is in tune with patient expectations, the discussion is actually easier than one may think. As always, a comprehensive multidisciplinary approach should be instituted to provide patients with the best possible outcome.

In my practice, I strive for close podiatric and vascular follow-up at intervals that convey emphasis on infection control, activities of daily living, ischemic progression, prognosis, and patient expectations. I stress education on achievable goals based on the distribution of the arterial blockages. I encourage appropriate collaboration on timing of potential surgery, but clearly state that acute changes such as infection will alter this timeline, with full disclosure about risks and benefits. Some patients opt for a local amputation, which may result in an open ischemic surgical site, but this simply is a continuum of the same algorithm. We are all familiar with adjunctive care options, and the associated risks, benefits, and outcomes.

So, I leave you with my key advice to fall back on: always provide compassionate continuity of care.

Dr. Elmarsafi is a fellowship-trained foot and ankle surgeon with Vascular Surgery Associates, LLC, in Maryland.

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