Wound Care: Back to the Basics

In this age of continual innovation and development of new wound care products and services, sometimes it makes sense to go back to the basics. In this column, the panelists share their new innovations of choice, along with tried and true options that continue to show results for their patients.

Q: Sometimes the volume of emerging technologies and options in wound care can become overwhelming. What, in your opinion, is the one most important and useful innovation in wound care in the past 5 years, and why?

A:

Kazu Suzuki, DPM, CWS shares that, in his experience, skin substitute grafts or cellular and tissue products (CTPs) are among the most impactful developments.

“They are expensive and limited in indication and coverage, but are valuable tools in healing the wounds that were unable to close before, or they meaningfully accelerate the wound healing in many chronic wounds,” he says.

Jayson Atves, DPM, AACFAS feels that judicious use of negative pressure vacuum devices have single handedly aided, although not rectified, a major area of wound care management.

“These devices help to deliver superior local wound care, especially in the acutely infected population,” he explains. “However, just as beneficial as these devices may be, their use is still riddled with the potential for complication if not used judiciously.”

Bela Pandit, DPM, agrees that the volume of innovation is tremendous and the choices are sometimes overwhelming.

“In my opinion, the Sanuwave Ultramist has been the most useful innovation,” she says. “Using ultrasonic debridement with energy waves has stimulated faster healing on chronic wounds in my patients. There is a CPT reimbursement code associated with the treatment which is very helpful.”

Q: Conversely, what “classic” wound care principle or product do you find continues to play a role in your practice despite advances in the field, and why?

A:

Dr. Pandit stresses, that in her experience, there is nothing more effective, in plantar wounds particularly, than off-loading. She finds, as many providers do, that the more a patient stays off their foot wound, the faster it heals after proper debridement.

Edema control is a standard intervention that Dr. Suzuki sees as continually important.

“I’ve seen so many cases … sent to me for chronic leg wounds not healing for many months and years, only to be healed quickly under my care, as I diligently apply multi-layer compression bandages (ie BSN Jobst Comprifore 4-layer bandage system (BSN Medical, an Essity company)) to control leg edema coming from venous stasis, lymphedema or any other causes,” he says.

Dr. Atves relates that although many other products exist to help manage wounds effectively, ease of use has emerged as one of the most important factors for his patient population.

“Honestly, my tried-and-true wound care product is topical povidone-iodine, he adds. “I feel it provides superior antiseptic properties that also aid in preventing exorbitant moisture, is easy to use, readily available, inexpensive and easy to use, especially since there is no remnant residue to manage.”

Q: When evaluating a new product on the market, what characteristics or types of data do you look for when deciding if it is worthwhile for your patients? How do you obtain this information?

A:

This is an important area of the world of wound care, as emerging technologies and products may create significant changes in the ways in which we view and treat complex wounds, says Dr. Atves. Most generally speaking, he says he looks for a product or technology to fill a need for a patient or population.

“Some of the greatest inventions and advancements for mankind have been born out of necessity, and in this way, emerging products should clearly offer a solution, in part or in full, for filling a distinct patient need,” he says. “Imitation products have no place for me unless they offer a distinct and identifiable advantage over the similar. In this light, I am continually assessing and reassessing both anecdotally and with the aid of peer-reviewed literature to distinguish the superior products from those with lesser efficacy or advantage.”

Dr. Pandit acknowledges that companies and their representatives do try to sell and highlight new products, but she relates that it is imperative for her to see peer-reviewed data or long-term studies provided by the company or in a reputable publication.

“Many products are very expensive to utilize, so I also ask for an explanation of benefits (EOB) from a practice in my state,” she adds. “I tend to steer away from expensive in-office grafts and will utilize them in the OR setting instead. It goes without saying, if reimbursement looks too good to be true, it probably is.”

Dr. Suzuki notes that he is willing to listen and try out just about any products that come out. He adds that in his observation over the years, new technologies often sound crazy at first, but later become part of mainstay wound care therapies (negative pressure wound therapy and amniotic membrane grafts).

“Have an open mind and try not to write off anything, while being conscientious in doing your due diligence and refuse anti-science schemes,” he encourages.

Q: When looking at the big picture of wound care, what do you feel are the tried and true “basics” of healing that podiatrists should focus on?

A:

Dr. Suzuki stresses that wound healing can be simple, as in increasing the blood flow, cleaning the wounds with debridement, or taking off the undue pressure. He adds that he finds methodically following those basic steps equals success.

“Also, please don’t forget the human factor, and be conscious and conscientious in listening to the patients figure out what they need and counsel them accordingly,” he says. “I’ve learned that listening skill and counseling skill is a huge factor in achieving good clinical success.”

When evaluating a wound, it’s important to obtain guidance from the wound itself, says Dr. Pandit. For instance, necrosis or fibrosis in a wound can indicate need for a vascular consult. A chronic wound may necessitate an infectious disease consult. She goes on to add that offloading after proper debridement and moisture management are key concepts, but that every wound may react differently.

Dr. Atves agrees that even the basics are multifactorial.

“As is the case with the vast majority of complex wounds, multiple factors play part in formation, stagnation and recidivism,” he says.

He outlines that he finds the basic tenants of wound management should aim to address the following:

bacterial burden, be it in the form of infection or merely bacterial presence;

tissue vascularity and healing potential, as with proper management of peripheral vascular disease and comorbid conditions such as diabetes mellitus;

biomechanical aberration, be it as requiring offloading in the instance of plantar wounds or those requiring surgical correction as with those necessitating osseous and/or tendinous procedures to rectify such biomechanical faults, and;

closure of the soft tissue envelope, either primarily, secondarily or with the use of advanced plastics types closures with local or free tissue flaps.

Q: Is there anything else you’d like to add?

A:

Dr. Pandit concludes by sharing that she thinks physicians should keep some guidelines in a time frame in order to treat wounds more effectively. She encourages providers to question, if a “healthy”-looking wound is not healing, what are we missing? At what point is surgical intervention or an outside consult necessary?

Dr. Atves says that wound care management remains a daunting, yet exciting field where attention should be yielded to the immensity of the complex patient and wound environments.

“Patients with complex wound formation require adherence to a dynamic multi-faceted management algorithm that affords the best healing potential by minimizing bacterial bioburden, maximizes local and systemic tissue perfusion and healing capabilities, and permits significant considerations for biomechanical aberration.” 

Dr. Atves is an Associate of the American College of Foot and Ankle Surgeons and a Fellowship-trained foot and ankle surgeon practicing at MedStar Georgetown University Hospital’s Division of Podiatric Surgery in Washington, D.C.

Dr. Pandit is a Fellow of the American College of Foot and Ankle Surgeons and practices in Evergreen Park, IL.

Dr. Suzuki is the Medical Director of the Apex Wound Care Clinic in Los Angeles. He is also a member of the attending staff of Cedars-Sinai Medical Center in Los Angeles. He can be reached at Kazu.Suzuki@cshs.org.