Progress In Wound Care And Limb Salvage: Yesterday, Today And Beyond

Medicine is a field of continuous innovation, and limb salvage is no exception. Here the panelists discuss their observations and experiences over their years of practice regarding developments that have made an impact for patients, along with their thoughts on what the future will bring.

Q:What do you feel have been the most impactful developments in the field of limb salvage and/or wound care over the past decade (or more, depending on your length of practice)?

A:

Kazu Suzuki, DPM, CWS, in the field of wound care for two decades, says the most impactful events in his opinion include the expanding field of regenerative medicine, more specifically, various human cell tissue products such as Grafix (Smith + Nephew) and Epifix (MiMedx).

Andrew Rice, DPM, FACFAS agrees that innovations in biologics have also provided additional tools to heal difficult wounds in a wide array of challenging patients with multiple co-morbidities. He also feels that the collaboration and integration of podiatry with vascular surgery and many other disciplines such as trauma, burn and orthopedic trauma teams over the years facilitated recognition of the value of podiatry both at academic and community hospitals.

“This has led us in podiatry to lead in clinical limb medicine and clinical trials as well as excel surgically in high risk limb preservation and reconstruction,” he explains.

Barbara Aung, DPM, DABPM, CWS, FAPWHc cites new impactful technologies that allow her to determine to a level of confidence the presence of bacteria in a wound, or a camera that provides information about tissue perfusion to remote temperature or pressure monitoring devices such as MolecuLight i:X (Moleculight) and Snapshot NIR (Kent Imaging).

“But as with anything new, I don’t feel as though adoption has kept pace with the usefulness of the technology, and as always it has to do with reimbursement and cost,” she adds.

Q:How do you feel these developments impacted your overall wound care and limb salvage practice?

A:

Dr. Rice feels that milestones such as the collaboration with vascular surgery and the progress made in early recognition and intervention of the critical limb that he and colleagues are saving more limbs from major amputation, thereby improving quality of life.

Dr. Aung says she feels she tends to obtain cultures and vascular testing at perhaps a greater frequency than her colleagues, especially before utilizing any tissue substitutes.

“If I can’t use a newer imaging device, I will get cultures to make sure that there is very low bacterial count or no growth before I move forward with tissue substitutes, since they are so expensive for the medical system and for the patient as a whole,” she elaborates. “I want to save resources and also provide a more predictable outcome for the patient so that they feel confident if they have a greater cost share in their treatment.”

Dr. Suzuki believes, after 10 years of experience with them, that he is more discriminating and discerning with use of human cellular tissue products (CTPs).

“For the toughest and most difficult wounds to heal on more challenging patients, I believe they (CTPs) have made differences in closing the most difficult wounds,” he says.

Q:What do you think/hope the next decade will bring as far as advancements in wound care and limb salvage? What do you think needs to happen to continue to improve patient outcomes?

A:

Dr. Aung predicts the future will bring more bedside/chairside clinical support tools, such as cultures or identification of infection by use of “dip stick” or something similar to a pregnancy test. She also opines that there will bespecific or individualized solutions for wound therapies directed to a particular patient, possibly including topical medications or even modified tissues based on patient’s wound genetic expressions.

“We used to talk about being able to know what is missing in the wound or the patient and then directing the treatment plan based on this information,” she says. “I think and hope that is likely to happen over the next decade.”

Dr. Suzuki says he would like to see the adoption of remote patient monitoring products, such as “smart” and connected patient interfaces (smart bathmats, socks and insoles) which monitor the patient’s skin temperature and activity levels to predict or warn of recurring diabetic foot ulcers. He adds that he would like to see Medicare and other payors see their value and provide them free of cost to high-risk patients for limb loss.

“We will see most likely also see accumulation of medical evidence in using CTPs over the standard of care wound care in closing difficult-to-close wounds, and perhaps their cost effectiveness versus limb loss and subsequent loss of quality of life,” he adds.

Dr. Rice agrees that a greater number of clinical trials in the biologic space is likely to have an impact in the upcoming years. In his opinion, this will allow for podiatric and multidisciplinary limb preservation teams to develop widely adoptable algorithms to wound healing centered upon evidence-based medicine.

Q:Are there any other thoughts you’d like to add?

A:

Dr. Suzuki shares that he is most interested and excited about technology and how it may change practice for the better.

“For example, we now have a device that is a continuous glucose monitor (CGM) and insulin pump that actually communicate and work together,” he explains. “This technology will make the pancreas transplant (which involves organ procurement, complicated surgery and lifetime suppression drugs) obsolete. I do recommend CGM routinely as indicated to my patients and I would like to see them adopted and prescribed to all of our patients with diabetes for the sake of better blood glucose control.”

Dr. Aung adds that, as Dr. Suzuki previously mentioned, there are new technologies to help with monitoring for early warning signs of skin breakdown, which she feels are likely to become more sophisticated and more widely adopted in the near future.

“We do need our governmental leaders or payors to catch up to the technologies and see the global benefits of coverage,” she says. “While prevention may cost more at the front end, it may pay off in dividends at the back end. The payoff may not be in dollars and cents, but it is more likely to be human saving in that the quality of life for patients and families will improve when they are not seeing wound care physicians or clinicians every week for months.”

Dr. Rice concludes by saying he believes that it is of great importance to encourage more podiatry students and residents to make limb preservation surgery a primary sub-specialty of their practice and to participate in clinical research. 

Dr. Aung is Chief of the Podiatry Section of the Tenet Health System/St. Joseph’s Hospital in Tucson, Ariz. She is a member of the APMA Coding Committee, the APMA MACRA/MIPS Task Force and is on the Exam Committee of the American Board of Wound Management. Dr. Aung is also on the Editorial Review Board for Wound Management and Prevention.

Dr. Rice is a Fellow of the American College of Foot and Ankle Surgeons, the Co-Director of the Southern Arizona Limb Salvage Alliance (SALSA) and a Clinical Associate Professor of Surgery at the University of Arizona Health Sciences College of Medicine in Tucson, Ariz.

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.