What Happens When a Wound Heals?

Created in partnership with the American Podiatric Medical Association.

Brian McCurdy, Managing Editor:

Welcome back to Podiatry Today Podcast, where we bring you the latest in foot and ankle medicine and surgery from leaders in the field. Podiatry Today Wound Care Q&A Podcast is a special edition created in partnership with the American Podiatric Medical Association. Our guests today are key leaders connected with the limb salvage tracks at this year's APMA held in Nashville, Tennessee. In this episode, we will hear from them on what happens after a wound heals and what clinicians should think about in this vital time period for patients. Welcome doctors, why don't each of you briefly introduce yourselves to the audience?

Alton Johnson, DPM:

My name's Alton Johnson. I'm a podiatrist, a clinical assistant professor at the University of Michigan Medical School in Ann Arbor, Michigan. I specialize in wound care. I see about 30 wound care patients weekly and also have a private practice as well that's affiliated with the university. Sometimes I see wound patients in there, but pretty much dedicated wound care clinic where I try to see most of my patients. Some of them, like I said, kind of squeeze in my private practice sector. But other than that, I'm excited about this podcast and I've been at the university since 2021.

John Steinberg, DPM:

Great, and welcome everybody. My name's John Steinberg. I'm based in Washington DC at Georgetown University School of Medicine, I'm a professor of plastic surgery and I'm also co-director at MedStar Health, MedStar Georgetown University Hospital of the Center for Wound Healing. So I've been there since 2004 and have a great passion for wounds and wound healing and particularly working with biomechanics and the great procedures that we can do in our specialty to try to prevent those wounds from coming back. So look forward to chatting.

Brian McCurdy:

In your experience, why is the concept of life after wound healing important?

Alton Johnson, DPM:

As a young physician I used to think once I healed the patient they kind of walk out the door and that's kind of it. And then you start to realize that those same patients eventually come back. Som I realized that I was missing that educational piece on once I healed the wound. So I was all kind of patting on the back, excited, ringing the bell, everything once you healed the wound, but there's a whole other caveat after healing the wound.

I would say the biggest thing is now we call it wound remission, so it's basically in remission because that wound area that's healed is not fully matured, the skin's not fully mature, especially on the plantar foot. So trying to educate the patients to let them know, yeah, you can't go back hiking because a lot of my patients, even though most of them have sedentary lifestyle, once they get their wound heal they're kind of happy to get back to going to go see their grandkids or going to the grocery store without having someone else having to do it, things like that. And you kind of have to let them know you got to ease into it.

But I know you get will go more into it in the podcast, but the biggest thing is the educational aspect, kind of making sure the patient's aware of what could happen after hearing in the wound. Always compare it to a cancer. It's like, you have that cancer that's dormant, but it always can kind of pop back up. Oftentimes with wounds unfortunately happens more often than not. And that's the biggest aspect I would say. And I sure Dr. Steinberg will elaborate on it as well.

John Steinberg, DPM:

Yeah, well said Alton, I certainly will. We used to always talk about diabetic limb salvage, diabetic limb salvage, and it was all about saving the limb, saving the limb, saving the limb, and whoever saved more of the foot and the ankle was the hero. And now we've realized it's about function. It's function, function, function. And sometimes that means getting quickly to an appropriate amputation level and get that patient back to activity. So Brian, exactly as you phrased the question there, it's all about life after the wound and life after healing of the wound. And even if that means an amputation, let's get them back to the activity level that they deserve and that they want to be at.

I'll always remember as a tangent to that, my partner, Chris Attinger, MD, who's a plastic surgeon, when he brought me to Georgetown, he is like, "Steinberg, I didn't bring you here to heal wounds." And I said, "What are you talking about Chris? I thought that's what I was here for." He said, "No, I'm a plastic surgeon. I can cover just about any wound and close any wound that I want to, but I need you here to help these wounds from coming back." So that's where we're really trying to get to now at limb salvage is to say, "Hey, let's look at the whole picture and the whole patient. Let's evaluate what function level they want to return to and let's get them there and keep them there."

So it's so important to really talk with the family and their caregivers to make sure that we know the true goals and the true realistic expectations of where we can get to with these patients. But it's all about function at this point is what I would close with.

Alton Johnson, DPM:

Agreed. Agreed. I missed that part about functional. It has to be a functional limb because you have patients, you save their limb and they're still bedbound because the limb, they can't actually get any type of prosthetics or anything to fit it or shoes to fit that limb. And now they have a limb, but they aren't actually be able to be functional. So I agree with the functionality of it.

Brian:

Should planning for these aspects of life after wound healing truly begin after healing, or is this best approached earlier in the process?

Alton Johnson, DPM:

Yeah, so as I alluded as a young physician thinking all it was about was healing, healing, yes, I definitely pre-planned. So once we get, I would say close to halfway point, I start to get them mentally starting to think about life after healing because it kind of happens really fast. You'll have a wound that's pretty large, then maybe the next two or three visits is healed because it's kind of like once that you got that proliferation going, the body just kind of ramps up and heals, then you're not like, oh, I didn't plan a certain shoe or offloading device or orthotic or something like that or have an appointment. Because, especially now since the pandemic, getting those orthotic and prosthetic appointments or a little bit longer than normal and then the turnaround time with the materials take just as long. So it's about two months, at least at our facility, to just even get that prosthetic fabricated.

So I got to start thinking about eight weeks out when I think this wound's going to heal to start letting them know maybe we need to have a visit with the orthotic prosthetics and with a pedorthist so we can start designing a certain device for them if it's a amputation or toe fillers or something like that, or actually custom shoes or extra depth diabetic shoes or multi density insoles. Because otherwise I already missed the boat if I wait until after I healed it and I haven't even had the conversation or I haven't even had an appointment set up with them.

And then also starting to think about actual physical therapy, because at our practice we have physical therapy wound care, which is a little bit different than they actually providing wound care, but actually start thinking about physical therapy to get their functionality up and get their mobility up and get their endurance and cardio up so they can actually be able to walk and be functional. So I start having those conversations around that halfway point because I have to start planting these referrals essentially around that time. Otherwise, like I said, if I wait till it's healed I've already missed that boat, then now the wound's going to reopen once I let them go about their life in a ill-fitting device or orthotics that haven't been updated, they're wearing in the old orthotics that probably even caused the ulceration or something like that.

You have to be very methodical because everyone's at a different timeline and like I said, I'm seeing 30, 40 patients in a day managing just wounds. So it's like I have to start thinking timelines and make sure take mental notes and document that I spoke to them about it and that we're going to do certain plans as a clinician.

John Steinberg, DPM:

Yeah, that's a good point. It's embarrassing that we're in an age now where we can 3D print a talus overnight and we can't get a pair of shoes and inserts made in less than two months. So we struggle with some of those same timelines, Alton. So we do start that early. But gosh, we got to do a better job here. Why is it that we can get an athletic insert scanned and made overnight in private practice, but we can't get prosthetics done that way. I'm sure we will be and the needle will get pushed. But it is an area you identified really well that these devices take way too long and the fitters always want to wait until the wound is completely healed before they'll take an impression before they'll do a scan. And then what do we do? We're healed and now we're stuck with some clumsy offloading device that the patient's not going to want to wear for another month or two until their device is ready.

So starting early is key. Pushing your prosthetist, orthotist and custom fabricator to do a better job and do a quicker job and be efficient and treat these patients with the same speed that we treat some of our athletic patients, we can do this, we just need to apply it to the right patient population.

And then my final thought is that Georgetown every year we run this large conference called DLS or Diabetic Limb Salvage. We have a patient panel every year and we just finished it a couple weeks ago. And listening to the patients talk about their story in a nonclinical setting, you really get the feel of what they're going through and what their family's going through and the tears come out and you start to realize just what an impact this has on patients' dignity and their family and their caregivers and their overall outlook on life.

So yeah, we need to continue to push the needle and do a better job for this and think about the patient as you would, as we all try to, as our family member and how could we possibly get things moving quicker by starting that timeline sooner, knowing that there will be delays along the way. So yeah, it has to start way before the wound is healed, Brian.

Brian McCurdy:

How much of this preparation takes place with the care team and how much falls to the patient?

Alton Johnson, DPM:

I would say it's a 50/50 split. Unfortunately sometimes it may be at 80% on the patient, 20% on us because we're not able to see them as often or make certain decisions to pivot when it comes to... And you're talking about in reference to actual when the wounds open and then once the wounds heal, it's almost like 90% on them because they're definitely not coming in as often as they should or as they could because the system is bogged down with other patients with new ulcerations. So they kind of get not put to the back burner, but they just don't get as higher priority time slots and as frequent visits. So it's kind of relying on the care team.

So basically my care team essentially is case management, which I already kind of consult before they heal, so they already kind of know what's going to happen because usually they're managing the transportation. Then like I said, we have physical therapy, we have occupational therapy as well to try to get them if they're have a certain aim to activity that they want to get to for whether it's trying to return to work. Like I said, we're in Detroit area, so I have a lot of factory workers working for the auto industry or even the steel industry as well. So those are one of the aspects. And then also having their primary care provider back into the fold because they not took a backseat on it, but they wasn't as aggressive because it kind of relied on me to manage them. And then of course the endocrinologist is involved so we don't get back into this whole situation where the A1C is out of control and the neuropathy's out of control and they end up with another ulceration. Because the biggest thing that happens always ends up... Because now they've been offloaded so long to heal this ulceration, especially on the plantar foot, they get an ulceration on the other foot or something like that because the devices that they've been having so much pressure.

So those are one of the biggest issues. So almost like a surveillance period of trying to monitor that other foot for any new callouses. And then of course as the podiatrist with the patient making sure we surveillance as well. Then of course infectious disease if it's dormant osteomyelitis, making sure we have the appropriate oral antibiotics for the patient to remain suppressed because otherwise it'll blow back up. It always happens, I'll get a wound healed and patient's like, "Oh, the wound looks so good, I stopped taking my antibiotics." And then of course the active osteomyelitis pops back up and then the sinus tracks out and becomes even worse than it was before. Now we're talking surgical intervention. So all of this kind of plays into it and I kind of update the entire team. Luckily we're all mostly in the same office when it comes to the wound center, which is why the wound center is always pretty good for these type of wounds. So we all kind of know what's going on and we can kind of tag team it and work on overlap and overlap coverage for the patient, whether it's after or during the actual ulceration.

So that's my biggest thing. And then of course sometimes we bring the pharmacist in too. Now we have all those new drugs like dalbavancin and all that to go in with it. So that's also another member of the team to help either prevent re-ulceration or help accelerate that healing for the patients.

John Steinberg, DPM:

Yeah. Brian, the part I would add is that I hope, and we're trying to do this now at Georgetown, it's slow, but I hope we can eventually graduate to almost like the dental hygiene model where at the same time I'm running an acute hallway with five or six rooms and seeing my wound patients I've got a nurse practitioner or two that are running hallways seeing all those folks that have healed two months ago, six months ago, eight months ago, and not letting that distance get so far. Because once we fall behind the eight-ball we know it's catch up and we know we're going to lose tissue, we know we're going to have another amputation.

So if we could get those patients in more often, which I know as Alton pointed out, we struggle with the same situation where everybody's busy and focusing on the acute care patients. But if we were doing that at the same time as a nurse practitioner or two were next door to us in the hallway and they could grab us and say, "Hey, room seven I think needs to be admitted, there's a problem." Or, "Room eight I think needs a new pair of shoes sooner than what you had prescribed." That would be so nice. But we haven't gotten there yet, but we're trialing it at one of our Baltimore clinics soon with a new nurse practitioner. So I think that would be a great model.

These patients are high touch and we can't let them get out too far. I know there's concerns about reimbursement and coding and what you can get paid for and not get paid for, but an E&M visit for these patients in my opinion is justified every two to six months, however often you want to do it. I mean, you're evaluating risk assessment for that patient and you're evaluating a high risk patient for future mechanical damage to their skin. So I think it's key to get these folks in.

Alton Johnson, DPM:

Agreed. Agreed.

Brian McCurdy:

What important clinical aspects of life after wound healing should physicians incorporate into their care plans?

Alton Johnson, DPM:

So physical aspects, I guess that's almost alluding to how we talked about devices, but sometimes I actually provide surgical prophylactic procedures. Whether it's osseous procedures or tendon procedures for the patients to actually relieve the pressure that's caused that issue. Sometimes I even do it while the wound's open, but most times if it's a chronic wound it's kind of tough because I like to go to a different site so I don't introduce any worsening infection or something like that if it's not infected. But I would say even tendon rebalancing, osseous versus soft tissue procedures, whether it's in office or surgical settings. Some of these you can do surgical settings, whether it's tendon releases or something. Actually did several last week in office with extensive tendon releases for distal tough ulcerations as well.

So those are little tool bags that you want to have, especially as podiatrists. And that's one aspect that we have over a lot of our other surgical colleagues because they just don't utilize them or fully understand the biomechanics behind it. So that's kind of my play in it and that's kind of how my position is, especially in a big system where you're trying to justify why I'd spent X amount of dollars on the specialty. So that's where I try to utilize it to show, okay, I heal this wound, now I'm performing these soft tissue procedures in office, didn't have to spend much OR, time things like that to get it done. And of course I still prophylactically have them on antibiotics or, like I said, if they're currently on antibiotics still from their previous regiment, then they're protected.

But I still treat it like a surgical procedure. So have them with the prophylactic antibiotics, then most likely even have them take an antibiotic a day or two after to kind of when I do those in-office procedures. But most times I try to, like I said, avoid the OR, but sometimes I do have to take them to the OR.

John Steinberg, DPM:

Yeah, whether you love biomechanics or you hate biomechanics, it's a big deal in limb salvage and diabetic wound healing. So what Alton just said about particularly the prophylactic procedures, that's what we're there for that again, that conversation I had with my partner Chris Attinger way back when it's like that is really what we bring to the playing field that's unique and that is not really taken up by many other specialties in the degree that we do. So bring that to the table, bring your best game to your patients that have diabetes and apply those same functional principles as far as mechanics that you would to the non-diabetic patient. Some of the patients with diabetes deserve surgery way more than your non-diabetic patients because you can actually help prevent future ulceration, infection, amputation in these patients rather than... Of course pain is a big deal for the folks with neuropathy and diabetes. But I love even more so the fact that we can use those same procedures and those same principles in the diabetic population and help not necessarily address pain because they're neuropathic, but help address their future ulcer risks.

So be aggressive, be appropriately aggressive, proper vascular screening. And I don't operate on everybody who comes in my door, but you need to be thinking about that and talking about that patient from day one when they have a plantar forefoot ulcer. Let them know they have Equinus, help them understand the fact that this is caused by your Achilles tightness and that's from diabetes and that's from glycosylation and we're going to try to get physical therapy for you and get you in the right shoes, but if that doesn't work, I'm going to take you to the OR and I'm going to do a tendon lengthening on you and that that's what you're going to need to help prevent future ulcers. So I talked to them about that from day one. When I see them for their onset ulcer. I help them understand what I'm looking at, that this is a mechanical problem. It's not just a random hole in your skin.

Alton Johnson, DPM:

Correct. Exactly. Yeah, because a lot of times they don't fully understand it, especially those neuropathic patients where their mechanics is totally different than a patient with sensation. Yeah, agree. That's goes back to the education aspect.

Brian McCurdy:

What are some of the important patient centered aspects of this concept?

Alton Johnson, DPM:

So we kind of touched on it a little bit earlier in the conversation. There's a new term, I think we use it, not the university called informal caregivers. So it's not a direct relationship. So it could be even be a neighbor or something like that. Bringing those people in to the fold to kind of educate them too on the patients and what what's going on helps because that also helps them red flag and kind of brings it to attention to the patient. Because a lot of times our patients, especially if we're referring to patients with diabetes, they have diabetic retinopathy, so they can't even see, let alone when it comes to neuropathy, when they can't feel. So even if you have someone who sees the feet for them, letting them know like, oh, something's weird or there's drainage or there's a callous, kind of bring it to the tension and them, kind of follow up with the specialists after that. That helps as well because it empowers the person.

At first the patient feels powerless, but then the person that's taking care of them also feels powerless because they can't intervene. So it also gives them a kind of, we call it, a ball in the game type of thing. So it kind of makes them more involved. But also the social determinants of health aspect. There's a lot of other issues that's going on with these patients. I got patients who insurance expire because they may be on emergency Medicare or Medicaid and they can't even get a follow-up visit with me. So it's those little things, trying to connect them with federally qualified health centers where it's actually affordable care if they can't get to a university, things like that because they don't want large bills. And those are the biggest things. But I always say connect them with the case management even after healing because usually they have resources that I have no clue about and grant money I have no clue about and that kind of helps them get more aspects.

There's a lot of different things that factor into it. We can spend a whole podcast on social determinants of health after healing itself.

John Steinberg, DPM:

For sure. And those situations get even more challenging when, what about the example of when a patient's family is completely against your care plan and they disagree with doing the transmetatarsal amputation and they want to do the quickest thing for their grandmother who's been a big burden on their family and just go do the BK and they want to the guaranteed healing. What if you ethically disagree with that? So don't be afraid to get an ethics consult to help navigate some of these difficult conversations.

And I just had one yesterday that was a real challenge. A gentleman who's a diabetes and end stage renal, but also a stroke victim. He is been facility bound for 10 years, never walked in the past 10 years, and he's at a distal transmetatarsal amputation now because of infection gangrene. And the only person I have to reach out to is his court appointed guardian. There's no family, no brother, no sister, no mom, no dad. And how do we make those decisions like ethically, if he hasn't walked in 10 years, should we just do through the knee amputation and not put him through multiple limb salvage surgeries and a revasc and plastic surgery to get the TMA covered because he is never going to walk on it? Those become tricky situations. Is that not the right approach and we should be giving the patient same limb salvage that others would have.

So those lines get a little blurry sometimes, particularly when sometimes family goes against or doesn't understand that the medical situation. Usually family's a great plus and a great advocate and helps the patient get the right spot. But I think we've all encountered situations where it becomes the opposite sometimes too.

Alton Johnson, DPM:

There's a saying that my residency director used to say, she was like, save a limb, lose a life. Because it's like you put them through so much anesthesia and repercussions. So it's a balancing act. It's weird.

John Steinberg, DPM:

It sure is. It sure is. We've all experienced that where sometimes you push it too far and it's too many trips to the OR and it's too much anesthesia and the cardiac demand and yeah, you can really push these patients to become critically ill from too much heavy duty antibiotics and too much surgery for sure.

Brian McCurdy:

Anything else you'd like to add?

Alton Johnson, DPM:

Biggest thing I would like to add is start, I think we didn't really get to discuss it, but even remote patient monitoring, there's different aspects, different companies, different surveillances, I think that could be one key aspect. Incorporating, what we call it, artificial intelligence or AI into predicting what these wounds would be reoccurring at, looking for certain hotspots. I think that's be it. And I think the fact that if we can get it into primary care providers hands more often, because those are people that are interacting with a lot of these patients and that could prevent these patients from even becoming wound care patients. As long as we can figure out a way to surveillance them before they even get to stage three, stage four ulcerations, that could change the whole entire paradigm of treating the diabetic foot and PAD of the lower extremity when it comes to chronic ulcerations.

So I know a lot of docs are kind of iffy about the AI and augmented reality involving in their patient care, but it may be something we may need to consider because, like I said, it's just so many wounds out there and my wait list for new patients with chronic wounds is even higher. It's just kind of sad. So I think maybe it's time for us to embrace technology to some aspects. Obviously I don't think it'll replace providers, but it'll help us, we call, augment or enhance our care and provide more expedited care for our patients. 'Cause otherwise, I don't know what's going to happen. It's kind of sad actually, because it's going to be a bottleneck effect very soon or it's already happening, honestly.

John Steinberg, DPM:

Yeah. Anybody who's still watching this podcast at this point must really care because if you really put that kind of passion into your patient care and you have this kind of interest to listen to our discussion here now, then you share what Alton and I do, which is just really you're doing this because of you're passionate about it and you feel like you're really making a difference. And I would say, hang on to that. Don't let the negativity of medicine and surgery and current practice dynamics get to you. There's lots of barriers. There's lots of walls. There's lots of challenges. You could sit in the doctor's lounge and complain all day or you could go and see patients and make a difference. So I think this is one of the best parts of our profession. It's one of the neatest parts of medicine. Yes, they're really sick patients. Yes, they're really high risk patients. A lot of folks don't like this area because they think it's too treacherous for malpractice causes.

But I would tell you, I have found these patients to be the most grateful and their families to be the most thankful. And I just love this. 80, 90% of my practice is what we've just talked about, and I just love it. I'm happy to make it 100% of my practice very soon if I start weeding out my appointments. But I just love it. I think it's great. Be passionate about it. If you're doing it for the right reasons, even if and when you have bad outcomes, if you're a good communicator and you're reaching out to the caregivers like we just talked about, and you're having a relationship with the family about goals and objectives and risks and benefits, they will understand those bad outcomes much better than your fifth digit hammer toe or bunion patient will when things don't go perfectly. I think it's a very forgiving group if they know you're doing it because you care.

So do it for those reasons. Obviously, like I said, if you're still listening to this podcast at this point, you must be passionate about this and I appreciate that and your patience will appreciate it. So keep at it and realize you're going to have bad outcomes. You're going to lose a lot of legs. You may lose some lives. And it's pretty high stakes medicine and surgery that we're talking about, but it's well, well worth it. I'll always remember early on when I used to have a bad outcome or tragically would have a patient that passed away soon after surgery and worry about whether some of the stress of surgery that caused that. I remember one of the vascular surgeons grabbed me. He is like, "Steinberg, if your response to this is that you're not going to do it anymore and you're not going to take that risk, then we're not going to save anyone's leg." So pick yourself up, get back on the horse and realized that, yeah, bad outcomes are definitely part of this aspect of medicine of surgery, but it's well worth it and you can help of course, many, many patients in the process.

Brian McCurdy:

Well, thank you so much to each of you for sharing your thoughts with the audience. Hopefully clinicians will be able to implement these ideas in their own practices and continue to improve patient care. And thank you to the American Podiatric Medical Association for their partnership and collaboration. For more podcast episodes, be sure to check out podiatrytoday.com, SoundCloud, Spotify, or your favorite podcast platforms.