The wound care industry has produced and marketed a flurry of new options for clinicians in a very short period of time. Indeed, some experts wonder whether this has created confusion among clinicians, further widening the gap between academic clinicians and those who are in everyday community or office settings.1 As Professor Terence Ryan pointed out, “There is a difference between the ‘gold standards’ of the elite and the logistics of providing care in the environments of those with limited access to expertise.”2 A February 2002 survey of podiatrists in the United States offered some critical insights into wound care.3 Regranex and Silvadene Cream were commonly used by approximately 20 percent of the survey respondents yet some of the more recent wound care products were in the low single digits for common usage in practice. Another intriguing finding was the fact that 17 percent of those polled cited saline wet-dry dressings as their most common wound agent. Why are wet-dry dressings so prevalent? Studies have clearly identified how these dressings increase trauma to the wound; increase pain; increase the rate of infection; lower skin temperature on the site, enhancing wound chronicity; and are far more expensive than newer moist wound environment options.1 That said, let’s take a closer look at some of the more impressive wound care dressings that have emerged and how one can apply these technological advances in a clinical setting. Silver Dressings: Why You Should Consider Aquacel Ag And Acticoat Silver has long been known to be an effective antimicrobial agent with a broad spectrum of activity against bacteria, fungi and viral organisms. The silver ions in the dressings replace the sodium ions in the wound fluids, resulting in the antimicrobial activity of the dressings. However, not all dressings are designed the same so it’s important to be aware of key distinctions. Aquacel Ag (ConvaTec) is a silver impregnated dressing that is based upon the hydrofiber technology of Aquacel hydrofiber. The silver concentration is continuously available to the wound and delivers silver in an “as needed” fashion. Wound exudate activates the delivery of silver in a sustained manner. The backbone of this dressing is a carboxymethylcellulose base with 1.2% silver, which has been demonstrated to be an optimal concentration for antimicrobial activity without causing toxicity to the tissues.4 Aquacel Ag has impressed our team. When we have used this dressing, it has facilitated superb management of exudate, reduced pain at dressing changes and enhanced wound bed appearance with decreased slough and non-viable tissue.5 We use Aquacel Ag on wounds of various etiologies and we now cover donor graft sites with the dressing. One should change these dressings based on the amount of exudate, with 72 hours being the maximum time period you should leave the dressing over a wound. Acticoat (Smith and Nephew) is another silver dressing that we use in our center. This is a silver impregnated sheet that incorporates silver nanocrystals onto the layered dressing.6 With Acticoat, the silver is delivered into the wound based upon exudate interaction, with the nanocrystals being deposited into the wound in a rapid fashion. Our team presently uses Acticoat barrier dressings on burn injuries and burn and skin graft sites. One difference between the two dressings is that we have noted staining of the skin with the crystalline dressings that is similar to silver nitrate. Both dressings have shown broad spectrum of activity against pathogens, including MRSA, Pseudomonas and VRE. Assessing The Potential Of Oasis Oasis xenograft (Healthpoint), a naturally occurring extracellular matrix derived from porcine small intestinal mucosa (SIS), stimulates the extracellular matrix foundation. With meticulous wound management (debridement of necrotic tissue), the Oasis graft can help develop a scaffold upon which the cellular repair and response can formulate. This graft does not need special storage needs and is produced in a fenestrated and non-fenestrated format. Presently, I use the graft on various wounds and prefer to cover the graft with a hyrocolloid or silver impregnated dressing. Based upon graft/wound inspection, I will repeat the graft application until I see healthy granulation tissue at weekly or biweekly intervals. We will also use the Oasis graft as an adjunctive agent prior to STSG when our team believes closure with STSG is warranted. One should avoid using this graft over heavily exuding wounds as the exudate will prematurely deactivate the graft integrity. Key Points On Hyalofill Hyalofill (hyaluronan esterified) dressing continues to be an impressive adjunct for the difficult to heal wound. Hyaluronan (HA) is a naturally derived polysaccharide that has proven to be a critical aspect of the wound healing cascade from the wound’s onset to long-term reparative phases. Researchers have found HA to be a key regulator of the inflammatory phase of wound healing.6-8 Using Hyalofill enables one to deliver pure HA to the wound bed and this modality has demonstrated an excellent angiogenic response.6 One should leave Hyalofill on the wound for up to 72 hours. Covering it with a secondary dressing of your choice will help nourish a moist wound environment. With these dressings in mind, let’s consider their adjunctive possibilities in the following case studies of difficult wounds. Case Study One: Treating The Diabetic WoundOf A Non-Compliant Patient A 53-year-old male with insulin-dependent diabetes and an extensive history of ulceration on his right plantar first MPJ was referred by a podiatric colleague. The patient had a chronic ulceration since 1998. He had undergone multiple debridements and, in late 2002, had his sesamoids removed due to osteomyelitis, leading to wound chronicity and complications. Previous care after debridement included rotational flaps, STSG, Apligraf, custom inserts and extra depth shoes. The patient received excellent treatment by numerous vascular and podiatric clinicians. However, persistent non-compliance led to re-ulceration and the ultimate referral. The patient is obese, has uncontrolled IDDM, is neuropathic, hypertensive and has a bipolar psychiatric disorder. Consultation with the referring DPM revealed a patient who simply would not cooperate with instructions, leading to chronic wound complications. Our clinical exam revealed a grossly infected right first MPJ with exposed metatarsal joint and hallux on the medial aspect of the foot. A previous surgery resulted in removal of the sesamoids and part of the first metatarsal, leaving the joint in marked hallux varus. We admitted the patient to the burn/wound unit for medical and surgical management of the infected foot. His vascular status was adequate with no significant disease. Radiographs revealed marked osteomyelitis of the first MPJ proximally to the middle of the metatarsal and a pronounced hallux varus due to prior surgeries. We initiated broad spectrum IV antibiosis. When You Can Combine VAC Therapy And Acticoat To Get Results In the OR, we performed an amputation of the hallux and distal half of the first metatarsal. We also performed extensive debridement of soft tissue and probed the region for tracking or tunneling, which was nonexistent. We were able to create a clean wound with no devitalized tissue. In an attempt to achieve rapid wound closure and control post-operative drainage, we applied a VAC unit to the defect. (See “A Few Thoughts About The Impact Of VAC Therapy” below.) After 48 hours, an inspection of the wound revealed excellent edema control and minimal exudate. The large surgical defect was markedly reduced in depth with neovascular tissue. At this time, we initiated synergistic therapy, peeling off one layer of Acticoat dressing in the wound and applying the VAC over the top. The peeled layer was no obstruction to the VAC. When we inspected the wound three days later, we noted excellent granulation. There was no foul odor, maceration or slough. Significantly, the synergistic employment of the Acticoat dressing under the VAC eliminated nearly all of the drainage from the stump. Proximally, no bone was exposed from surgery and we proceeded to seek a plastics consult with a scheduled split thickness skin graft (STSG). Ten days after the surgery, the patient came back to the OR for the STSG on the defect of the medial foot. The graft was harvested from his lateral thigh and applied to the healthy wound bed. We stapled the graft in place and covered it with an Acticoat dressing. We proceeded to cover the harvest site in a petrolatum-impregnated gauze dressing and stapled it in place. Despite extensive noncompliance in the post-graft period, the patient was discharged from the hospital within two weeks of the STSG placement. In this case, our team determined that employing the VAC system over an antimicrobial barrier dressing resulted in enhanced wound bed preparation and expedited healing. We now employ Acticoat under VAC with no adverse problems and encourage clinicians to incorporate this synergistic practice into their regimens. Case Study Two: When There Is Gangrene In Both Feet And One Hand From Meningococcal Toxicity A 14-year-old female patient was referred from a children’s hospital with gross gangrene on both feet and one hand due to meningococcal toxemia. The patient experienced septic shock from pelvic inflammatory disease, was comatose for four weeks and had s/p cardiac arrest, ARDS, fungemia and multi-organ failure. The patient’s gangrene had previously been treated with topical antibiotic cream and gauze. Physicians recommended a follow-up visit in four weeks. When the nursing staff became concerned with the treatment plan, they referred her for evaluation of wounds. Our initial evaluation revealed dry gangrene of the left forefoot, necrotic ulcers on the left and right heel, dry gangrene on the right fifth toe, heavily exuding wounds in the midfoot of both feet and gross gangrene on all five right fingers. This patient was emergently admitted to the pediatric intensive care unit for a systemic medical workup and upcoming surgical planning for multiple wounds. Key Surgical Considerations While all wounds were impressive, they had remained stable with no progression of gangrene. The team decided to prepare the patient for surgery gradually, while her medical status was optimized. Prior to surgery, we utilized Accuzyme (Healthpoint) to debride the necrotic tissue. Enzymatic therapy did assist with removal of some necrotic debris and, more importantly, helped us delineate viable from non-viable tissue on her feet and hand. Concurrent treatment consisted of broad spectrum IV antibiotics, oral antifungal therapy and nutritional and emotional support, the patient underwent amputation of gangrenous digits and excision of exotic tissue from both feet. Simultaneously, our plastic surgery hand team amputated digits one through four on the right hand. Intraoperatively, amputation of the lateral three digits on the left foot was unavoidable due to the extent of gangrene to the level of the MPJs. In the OR, we also discussed whether we should remove the second toe to the MPJ and how to proximally address the first MPJ. After significant discussion, we opted to leave as much of the hallux and second digit as possible based upon clinical appearance, with the expectation that serial debridement would be highly likely due to the severity of the wounds. Biomechanical concerns for the first MPJ and long-term gait function were driving forces for removing less bone on the first MPJ. Essential Wound Care Treatment Pearls Inspection of the patient’s heels revealed full thickness, necrotic wounds. Based upon preoperative vascular studies that revealed healthy blood flow, we opted for complete excision of necrotic tissue en toto (based on wound bed principles of accelerating endogenous healing) as well as removal of senescent cells or cells which had ceased to function. Radical excision of necrotic heel tissue allowed cells to reorganize and begin to perform in a normal histocellular manner. Keep in mind that removal of this “necrotic burden” is significantly enhanced with scalpel excision versus other less aggressive options and is advisable whenever permissible.14 To manage exudate, provide antimicrobial protection and offer pain reduction, we used Aquacel Ag to dress the wounds. For the first week, we performed dressing changes every 48 hours and pre-medicated the patient with 5-mg morphine sulfate IVP 20 minutes before removing the dressing. After the first week, we discontinued analgesics. Thanks to the silver impregnated hydrofiber dressing, the patient didn’t have any pain. Additionally, the dressing absorbed exudate quite effectively, with no lateral wicking or maceration. After two weeks, we switched to a Hyalofill dressing as it has proven to be highly effective in enhancing angiogenesis and regulating cellular functions of wound healing.6 We proceeded with the dressing regimen for six weeks, changing the Hyalofill every 72 hours. In addition to experiencing rapid healing of all wounds on her feet and hand, this patient did not need to be taken back to the OR for additional surgery or debridement, something we all anticipated. The patient proceeded to undergo extensive rehabilitation with PT/OT for gait and hand function, and was cast for custom fitted shoe gear by our orthotist for biomechanical control. In 12 weeks, the child was fully healed and returned to a foster care family. She remains happy and healthy. In the management of this child, clinical coordination amongst multiple specialties minimized emotional and physical trauma, and facilitated healing in an acceptable timeframe. Significantly, our team approach reduced the odds of a proximal amputation, which had been discussed previously at the original hospital center. Case Study Three: Treating A Thermal Burn Of A Nonambulatory Pediatric Patient A 5-year-old male came in for evaluation and management of a full-thickness thermal burn to his left heel that was present for four weeks. The injury occurred when the patient’s foot froze to an oxygen tank that was leaking liquid oxygen. He was twice sent to a major academic emergency department. His family was instructed to apply topical antibiotic cream twice a day and to return to the plastic surgery clinic in four weeks. The child is a nonambulator due to gross motor disease, mental retardation, seizure disorders, chronic full body eczema and chronic oral candidiasis. He has a permanent tracheostomy and G-feeding tube in place. An examination of the wound revealed that his left heel had necrosis encompassing the entire majority of plantar skin. We noted black necrotic eschar and a cellulitic, hot, swollen foot. We admitted the patient to the pediatric intensive care unit and his admission CBC was 25.5. A broad spectrum IV antibiotic was initiated and would later be changed based upon bone cultures from the OR. Achieving Full Wound Healing In Three Weeks The child was brought to the operating room for radical debridement of necrotic tissue. We excised all devitalized structures, including exposed and desiccated tendon, and infected calcaneal bone. After inspecting the site, our team performed pulse lavage, using caution in directional spraying to avoid spreading infectious particles into healthy tissue. Satisfied that all infected tissue was removed, I used an Oasis graft to stimulate cellular response and applied a VAC unit over the xenograft to enhance wound bed status. Our intent was to stimulate granulation tissue formation and prepare the site for ultimate split thickness skin grafting. (Additionally, VAC therapy has been proven to reduce bacterial counts on wounds and has also been identified as a modality that will significantly reduce the cost of care by helping to secure rapid wound closure.11 We observed no problems in using the VAC unit over the fenestrated graft.) Within seven days, we observed excellent granulation tissue over the defect and our burn/plastics team noted no contraindications for STSG. The child returned to the OR for a STSG, which we harvested from his lateral thigh and applied to the plantar wound. We covered the donor site with an Aquacel Ag dressing. We selected this dressing for the antimicrobial benefit of silver, the ability of the hydrofiber to absorb exudate and for the reduction in pain on dressing changes at wound sites. We covered the graft site with the same dressing and secured it with surgical staples to avoid graft shearing. Our PT/OT service placed the left foot in a custom fabricated offloading brace to reduce disruption of the graft. After five days, we inspected the heel along with the donor site. The donor site was well epithelialized and there was minimal discomfort upon dressing removal. Inspection of the graft revealed the STSG to be inosculated, a phenomenon in which there is a reconnection of blood vessels from the graft to the recipient site.12 The patient was discharged fully healed three weeks after admission. IV antibiotics continued for six weeks and serial radiographs revealed no osteomyelitis. In this clinical case, our team agreed that immediate excision of necrotic or “toxic” tissue was paramount. This allowed a healthy wound bed to form, which facilitated closure and full healing of the wound. Studies have shown clinicians fail to appreciate the wound bed status as a measure of progress and instead look ahead to wound closure.13 Indeed, without recognizing the necessity of meticulous wound bed preparation, would closure is extremely unlikely. Final Words Team care is critical. While not all wounds are salvageable, we can obtain the best outcome for our patients when the DPM serves as the “gatekeeper of the wound.” By intertwining our expertise with appropriate consultations from other specialists, podiatrists will continue to make a substantial impact on the lives of our patients, while highlighting the critical role of the DPM in the world of modern wound medicine and limb preservation. Dr. Cantor is in private practice at Meadowbrook Foot and Ankle Center in East Meadow, N.Y. He is an Attending Surgeon within the Department of Surgery and is a member of the Burn/Wound Center Team at Nassau University Medical Center in East Meadow. Dr. Cantor is also a Consultant Podiatrist at St. Mary’s Hospital for Children in Bayside, N.Y., and a Faculty Member of the Oxford University Wound Healing Institute Summer School at Oxford University in the United Kingdom. He is a Fellow of the American College of Foot and Ankle Orthopedics and Medicine.
References 1. Ovington L. Hanging Wet-To-Dry Dressings Out To Dry. Advances In Skin And Wound Care 2002 15:2, 79-84. 2. Ryan T. Wound Bed Preparation, 2001 Royal Society of Medicine Press Limited, London, U.K. 3. Donoghue S. “The 20th Annual Survey: Capturing And Keeping What You Earn: PM’s Latest Success Story.” Podiatry Management, February 2003, pg. 72-104. 4. Bowler P. Poster presentation. 16th Annual Symposium On Advanced Wound Care. Las Vegas, April 2003. 5. Cantor AJ. Management of Complex Lower Extremity Wounds with New Silver Impregnated Dressing. Poster presentation. 16th Annual Symposium on Advanced Wound Care. Las Vegas, April 2003. 6. Cantor AJ. “Hyaluronan as a Treatment for Chronic Recalcitrant Wounds.” The Oxford University Wound Healing Course Handbook. May 2002. Postitiff Press. Oxford, UK. 7. Ballard K, Cantor AJ. Treating Recalcitrant Diabetic Wounds with Hyaluronic Acid: A Review Of Patients. Ostomy Wound Management 2003, 49:4, 37-49. 8. Cantor AJ. Management of a five year old venous ulcer with a Hyaluronic Acid dressing in an immunocompromised patient. Case History. Poster Presentation. 14th Symposium for Advanced Wound Care, Las Vegas, April 2001. 9. Arganta LL, Mory Kwas MJ. Vacuum-assisted closure: a new method for wound control and treatment: clinical experience. Annals of Plastic Surgery, 1997; 38(6): 563-77. 10. Teot L. Wound Bed Preparation: 109-114: 2001, Royal Society Medicine Press Limited. London, UK. 11. Armstrong D, et. al. Outcomes of Subatmospheric Pressure Dressing Therapy on Wounds of the Diabetic Foot. Ostomy Wound Management. April 2002: 48(4): 64-68. 12. Synder R, et. al. Applying Split Thickness Skin Grafts: A Step-By-Step Clinical Guide And Nursing Implications. Ostomy Wound Management. November 2001: 47(11): 20-26. 13. Goodacre T. Wound Bed Preparation: A Plastic Surgeon’s Clinical Experience. 73-79. Royal Society of Medicine Press Limited. London, UK. 2001. 14. Falanga V. Wound Bed Preparation and the Role of Enzymes: A Case for Multiple Actions of Therapeutic Agents. Wounds 14(2), 47-57, March 2002.