Further Insights on Prepare to Repair™

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Matthew Regulski, DPM:

Hello, I'm Dr. Matthew Regulski. I'm the Director of the Wound Institute of Ocean County, New Jersey. I'm a partner with Ocean County Foot and Ankle Surgical Associates in Toms River, New Jersey. I'm fellow faculty for the Royal College of Physician and Surgeons in Velasco, Scotland, and Triple Board certified by the American Board of Multiple Specialties in podiatry. I treat over 10,000 chronic wounds a year, and it's a pleasure to be here.

Well, I think that it's important that we peruse that because there are several medications that can impede wound healing, and one of the big ones are NSAIDs. People are on a lot of anti-inflammatories because they may have pain, and most of my diabetic population are also on [inaudible 00:00:49] medications for high blood pressure. They may have kidney disease. All of those can be affected by anti-inflammatories, and anti-inflammatories themselves cause vasoconstriction.

So, we're slowing down blood flow getting to the wound. So, it's imperative that we look at that and look at all the people that are on blood thinners. Blood thinners impair wound healing because they impair the formation of a clot, which you need to start that provisional matrix, which matures that into granulation tissue for epithelialization. Aspirin is another one that people are on. That's the same way, as that can impede healing, as well as the other injectable anti thrombolytics.

So, I think from that standpoint, those two are big ones that people are on, but also prednisone that people are on, have a multitude of autoimmune problems. People on biologics as well, and chemotherapy. So, it's very important that we look at that list and try to rectify your medication list as part of the wound healing paradigm.

Edema is critical for wound healing process. As you swell, you pull the arterials farther apart in the skin, so it's a greater distance oxygen has to go to diffuse to get into the wound. So, edema is critical. Obviously, in venous ulcerations, we do multi-layer compression bandaging after we know how their blood flow is from doing doppler. That's another part of the Prepare to Repair, to make sure we've adequate flow coming in.

But at the same time, we have to sequester that edema because it is pathologic. So, multi-layer compression bandaging not only for venous wounds, but look at your patients who are diabetic, who can have co-commitment gravitational edema. We need to have control of all that as well, and I've done that several times, particularly under total contact cast, because people have lymphedema, they have venous disease, or they just have a big swollen leg. We can press that down, put a total contact cast as well.

So, edema is pathologic. You have to look at it, you have to monitor it, and you have to treat it so that you improve oxygenation getting to the wound.

If it's a diabetic foot ulceration and it's a new patient, I always try to get an x-ray so I can see the topography, the mechanics of their foot, the architecture. It gives me a better idea of understanding what is going on. What do you lose by doing an x-ray? You can gain a lot of information.

Now, if that wound is probing down to fascia, there's a lot of undermining, maybe there's some tendon exposed, I can feel bone in there, then I always send them for MRI without contrast, because diabetics usually have some type of problem with kidney. Even those that don't, they're still at risk for it, so I like to use an MRI without contrast too.

So, I have a very low threshold for doing an x-ray. I get a lot of those because it just gives you good information about the architecture of the foot. And if there's any deeper structures or it probes deeper, I always send for an MRI as well, in that setting. So, I think it's important because you lose nothing by doing that and you gain lots of information to help a better treatment plan.

If I can, I try to do a weight-bearing film. I want to know how that arch is lying, how are the bones splaying? But there are some people that are in wheelchairs, if they can't, I get it. So, we kind of just have them extend the foot out and we take a picture of that, just trying to get something. But I always try to do a weight-bearing film. It gives you just a better attitude of how positions of things are, particularly in the Aquinas field.