More on the Prepare to Repair Paradigm

Welcome back everybody to Podiatry Today podcasts where we bring you the latest in foot and ankle medicine and surgery from leaders in the field.

I'm Dr. Jennifer Spector, the Assistant Editorial Director for Podiatry Today. This episode marks the second part of a two-part series from Matthew Regulski, DPM, on his comprehensive prepare to repair paradigm in wound care.

He'll continue to discuss this with us today about how a clinician can go about properly preparing to repair a wound. Dr. Regulski has multiple certifications in wound healing and lectures across the globe, and we're so grateful that he has agreed to continue to share these details with us today.

What about the role of imaging?

Matthew Regulski, DPM:

Well, I think it's very important that when you have somebody that you're seeing first with a diabetic foot ulceration, no matter where it is, and if when you're debriding, I'm just using diabetes, diabetic foot ulcers as an example, and when you're feeling and you're probing the wound bed and looking, and particularly if it's over a bony prominence, it's good to have an x-ray. Whether it's a hammer toe, whether it's over a bunion, the back of the heel, if you think that you can feel bone or structures that are under there, tendon or something. What do you lose by getting an x-ray? You gain everything. What if there is gas in the tissue? What if there was a... What if they have a fracture? What if there are signs of osteolysis indicative of a bone infection? A nice easy x-ray lets you see what is going on.

Looking at the foot type of patient, they have a high arch. Do they have a low arch? They have a lot of bony prominence. Do they have accessory bones in the particular area? If it's over the malleoli, let's get an ankle x-ray and just see what the bone is looking like in that area. Is there an evulsion of bone? Is there some kind of sequester? Who knows what you can find? I always tell my residents, let's get an x-ray, let's see what's going on actually in the deeper tissues. And then of course, when it is a deeper tissue, if you're getting close to fascia or bone, let's get an MRI. Somebody that's had a chronic wound for an extended period of time, let's look inside there and see what is going on within the bone and in those deeper structures. If they can't get an MRI than you talk about Serotec white blood cell scans, which are better than bone scan because a bone scan is going to light up positivity even when there's turnover bone. Maybe they had previous surgery in that area, maybe they had a fracture, who knows? But at least we get some type of imaging so we can see and rule out any possibility that is occurring to the deeper structures or those structures contributing to the pathogenesis of that ulceration.

Now, even people that have venous wounds that are close to fascia or they have big scalved areas, what if it's over the anterior tibia? I always like to get x-rays too, looking for soft tissue calcifications. Or if there's some type of a chronic process that is going on inside or close to that bone, you lose nothing by getting these things done and you gain everything, you gain lots of information and it gives you a better concise understanding of what is going on so that you can formulate better treatment plans for your patient. So I think that imaging is really critical for patients.

Jennifer Spector, DPM:

Next we have nutrition. What can you tell us about that?

Matthew Regulski, DPM:

Nutrition? Now, nutrition plays a huge part in healing. There are hundreds of thousands of pages of information on nutrition having an effect upon wound healing. As we all know, especially in the diabetic population, that the diabetes for itself causes dramatic reductions in vitamin D and vitamin D is critical for everybody where we live here in New Jersey, and if you live above Atlanta, you make no vitamin D from November to March. And in the summertime we're all sunscreen. Vitamin D is critical. It controls 3% of your genome. Every cell in your body, just about every cell has a vitamin D receptor. And that's for a specific reasons. It helps your immune system to function normally. That's why we tend to get sicker in the wintertime. We're not getting enough vitamin D and you need to supplement that and you need to check that on these patients. And if it's a low, we don't want that low end of normal 30. We want to keep these people in the 50 to 60 range.

But at the same time, vitamin A is a critical one for healing, and I like to use two to three weeks of vitamin A and 10,000 units, for these people with chronic wounds. And if they're on steroid chronic use, they need to be on vitamin A, it helps to make your collagen stronger and negate the negative effects of steroid. Vitamin C is are critical crosslinker for collagen, great antioxidant to use. Protein supplementation, we use a lot of Expedite, which comes in a nice little bottle, looks like a five-hour energy, but it's a two ounce bottle equal to 16 ounces of protein. So instead of taking two or three protein premieres or Ensures a day, then you can do one two ounce bottle of Expedite.

We use that a lot in our hospital system and now you're able to get that on the outside. Diosmin hesperidin, that I talk about is a tremendous isoflavonoid that has over 30 years of rock heart science in the treatment of chronic inflammation and effects upon the endothelial glycocalyx and all that good stuff. And diosmin hesperidin is a micronized, purified flavonoid fraction helps you with your lymphatic and veno tone, reducing microvascular permeability and edema. But in chronic inflammation occurring in the endothelial cell, that's another good thing to take.

So nutrition is a huge part of the wound healing process and a lot of patients need to avail themselves of a dietician because they don't understand what is going on. If you're Medicare and you have a diabetic foot ulcer, I can write a prescription and you get almost 10 visits a year with a dietician and another thousands of wound patients, I treat you, how many take advantage of that? Maybe two. And that's a shame because there is so much information about what you are putting into your body fueling your type two diabetes or leading the obesity that you have. You need to have good strict requirements of these and a dietician is critical that can help you figure out a good eating plan for you to follow, to help in the healing and the maintenance of your good nutrition for the wound healing cascade. So I think nutrition plays a huge part in the wound healing paradigm.

Jennifer Spector, DPM:

Does a patient's medication list play a role?

Matthew Regulski, DPM:

Well, medication is very interesting because there's lots of medications that can contribute to chronicity of wound or impeding the wound healing process. And I've labeled a bunch of those. Prednisone, we have a lot of people that are on... Organ transplants, I see a lot of kidney transplant patients on cell set prednisone and Prograf and those anti-rejection medications also slow down your immune system and we need immune system for proper pathogen reduction as well as healing because people don't... You have to remember, white blood cells after they engulf pathogens through that process of inferior cytosis and your apoptotic neutrophils, they're going to secrete and they become polarized. Especially macrophages more into that M2 phenotype. So they start secreting anti-inflammatory and regenerative different types of growth factors and cytokines to help them. So your immune system is slowed with that. People that are on anticoagulation or you don't make a clot, you slow down that process and we need a clot to form provisional matrix to move on into granulation tissue.

How about people that are on NSAIDs? I don't know how many times, especially in venous leg ulcers, people are on NSAIDs because they can get painful. Well, we know that NSAIDs cause vasoconstriction, raise their blood pressure, and affect their kidney flow and can affect wound healing. So I just wanted, especially for my resident physicians to think about the different medications that people are on and they seem to overlook the medication list. And this just gives you a reference to remember to look at those medications because there's particular medications that can slow down the wound healing process considerably.

Jennifer Spector, DPM:

I think next we have labs.

Matthew Regulski, DPM:

Well, the labs are critical because a lot of patients out there haven't had blood work in ages. And I think that it's very important. And even on your diabetic people that are supposed to be getting their blood work every three months, but when somebody gets a new wound or they come in and they have a wound that looks acutely infected, I usually discuss with them when they had their blood work and if not, then I give them a full panel of doing things. We want to look at the hemoglobin A1C, we want to see their CBC, what's their hemoglobin? Maybe they are anemic. What is their kidney function? What's going on with their vitamin D? Maybe they need a blood culture done or if they are that sick, maybe they just need to be into the hospital.

But it's important for us to look at labs that they've had done, get new ones if it's necessary for it, but look at those levels because that gives us a better understanding of what is going on inside the patient. Vitamin D levels, you can look at folic acid, B12, and folic acid for patients. I tend to do a lot of blood work if they haven't had it done in a reasonable amount of time because it just gives me, again, more information that I need so that I can formulate the proper treatment plan.

Jennifer Spector, DPM:

So I think we're then moving on to biopsy.

Matthew Regulski, DPM:

Well, I think biopsy is another underutilized tool that we have. And listen, I have been fooled too. When you think somebody comes in with a wound around their ankle, oh, this is a venous ulceration, they have inverted champagne bottle appearance to their legs, varicosities, hemoacidosis, lipodermatosclerosis going on, family history of varicosities, parents had leg swelling and such. They may have AFib, they might have had a knee or hip replacement that can contribute to venous reflux and lymphedema. But if you do all these good things that you have been taught to do in this prepared to repair paradigm and you're not seeing that appreciable healing or the wound looks funny to you, it's scalloped, it's raised, elevated purple borders, or they have a history of inflammatory bowel disease, rheumatoid arthritis, autoimmune problems and may have that livedo reticular appearance to the leg or to the surrounding skin or something.

I think it's very important that we have a very low index of suspicion and we do biopsies for this because again, we lose nothing by doing that. But we gain more information, we gain a lot of insight of what is going on. And as I said, I've been fooled a couple of times, things that look like, oh God, this is a venous ulcer, turned out to be a squamous or a basal cell. And also the biopsy of that wound then gives you the definitive evidence if it is a venous legal ulceration with the hemosiderin deposits and the expansive neutrophil migration into the wound. So we can see that chronic inflammation.

So biopsy. If you suspect anything, somebody's had a wound for a very long time that coming to see you and you went through the whole prepare to repair paradigm. And if something just doesn't look right or not adding up, I highly recommend that we do biopsies so that we can get a lot of information and get definitive diagnoses of what is going on within that microvasculature.

Jennifer Spector, DPM:

So when does surgery become part of the picture?

Matthew Regulski, DPM:

Surgery is a critical part of these things. When you see, for instance, somebody that has a nice hammer toe and they got a wound on the tip of the toe and you do all those things, you through prepare to repair and get these patients squared away. Nice little tenotomy goes a long way to straighten, let that digit come up, take the pressure off the tip and on nice pad of the toe to help it to heal. People that have wounds over bunion prominences over bony prominences that may need to have some things that are shaved down and removed so that we can allow these wounds to go on to heal. People that have equinus deformity may need achilles tendon lengthening. Now obviously if you have exposed bone and purulent drainage that's coming out and things of that nature, you're going to require surgery. You're going to require hospitalization.

But also we know if you have areas that you may need to biopsy to get a little piece of bone out that you may have to use a Jamshidi needle or make a little incision and do something as a little in the minor room and a little local anesthetic just to get... Surgery does play a part into treatment of a chronic wound when it calls for that. So I just don't want people to think that we're always just looking at this hole in the patient and we're not looking at the whole patient that there is going to be times when you're going to need to do IND and bone resections and tenotomies and tendon balancing and those things to help mitigate that wound healing process and prevent future recurrence because of these biomechanical abnormalities that are happening. And a lot of times I tend to do that once we've done all those steps in prepare to repair as part of the treatment algorithm is to do some different type of surgical procedures that can have a long-lasting effect for your patient.

Jennifer Spector, DPM:

And the last point you have is evaluation after four weeks.

Matthew Regulski, DPM:

Well, that is from the FDA that we're looking at that if you don't have that 50% healing in four weeks, you start thinking about more advanced therapies. But sometimes it can take a long period of time to do all those things and prepare to repair. For instance, if you had somebody in the hospital and you had to do big I&D and resections, TMAs, midfoot, Chopart signs, amputations and things of that nature, and you had to leave it open in wound vac and do all those types of stuff. But after we don't see that 50% healing rate in four weeks. And when you look at those retrospective data, people generally don't go on to heal. 9% only went on to heal at 12 weeks, didn't reach that 50% mark. But when you look at a lot of that data, only 53% of people went on to heal at 12 weeks would actually achieved the 50% healing at four weeks. And they use that as a surrogate marker now in a lot of clinical trials is that if you get to that 50% healing at four weeks, then you will go on to heal at the 12 weeks. That's looking at some of this retrospective data.

It just, it's something for physicians and for my residents to think about that we've been treating this patient for this long. We went through the whole prepare to repair paradigm. Now do we move into doing a skin graft using a skin substitute wound vacing, advanced oxygen, topical oxygen, HBO, just something to think about. If we've already done all those good things we have done and we haven't seen that appreciable reduction, what can we do next? How do we move into these advanced therapies? And again, these advanced therapies can only work if you have done all of your prepare to repair paradigm.

So I think that's why the last one of putting that there is just to think about once you've done all of these good things, now let's move into those advanced therapies to help move this along to the proliferative phase. I just don't want people to think about just continuing to doing the same thing over and over and over again. But you have to start thinking about advanced therapies once you have done all of those guys before it in the prepare to repair paradigm.

Jennifer Spector, DPM:

And what resources would you recommend for clinicians to learn more about each of these steps? Are there any landmark studies or resources that you like?

Matthew Regulski, DPM:

Well, I mean I think there's 11 societies that put forth treatment guidelines for chronic wounds. I think it's very easy for people to research and go to these different societies, the APMA, the Society of Vascular Surgeons, the Wound Healing Society, AWC, and all of those have guidelines put forth. If you're not sure, then you can go and look those up. But that's why I did make the prepare to repair so that you have something that you can follow I think that's quick and concise. But there's multiple societies that you can look up and if you're not very well versed in it or you haven't been doing it in a long time, then it's easy to do, to look up these guidelines. But I think prepare to repair gives you a good framework so that you can cover all of your bases. And if there is deeper questions that you have, then you can certainly research and go to these various societies and look at those guidelines as well. Infectious Disease Society of America, even the ADA has some treatment guidelines on there. So I like the prepare to repair because it's just years of my experience thinking about all of these things that I go through in my mind each and every time I see a patient. And hopefully people can utilize it for their practice as well.

Jennifer Spector, DPM:

And lastly, what do you hope that wound care professionals will apply in their practices right now as a result of learning more about this algorithm?

Matthew Regulski, DPM:

I think it's important is to cover these basics because each and every time I see a lot of these patients, whether it's a consult in the hospital or somebody comes from far away to see me, is that something in this paradigm has been missed. The offloading, they haven't had a vascular study, their nutrition is terrible, their vitamin D is low, they're not any protein supplement, they're big, swollen leg, they're draining all over the place, they have this patient changing it at home and these environments. I think the thing with wound healing especially, it takes a lot of time. It can be very time-consuming for these patients. They have a lot of comorbidities. There's lots of things to go over to discuss with family members and to patients. It's very time-consuming and you need to devote your time to that. And I think that is as critical. So my hope is that prepare to repair gives physicians this paradigm and easy to follow paradigm so that they cover all of these bases and be able to treat patients more effectively and more concisely.

Jennifer Spector, DPM:

Well, thank you so much Dr. Regulski for sharing this with our audience today. And thank you to the audience as well for tuning in. Be sure to check out these podcasts on podiatrytoday.com specifically for more information on the specific steps involved in the prepare to repair paradigm, along with our May Diabetes Watch column.

You can find this and other episodes of Podiatry Today podcasts on all of your favorite podcast platforms, including SoundCloud, Apple, and Spotify.