Inside Insights On Emerging Wound Care Modalities
Which emerging treatments show promise in treating lower-extremity wounds? Our expert panelists detail their usage of various wound care modalities, including topical antimicrobials and negative pressure wound therapy. They also take a look at what the future may bring for wound healing. Q: What new modalities do you use in the treatment of lower extremity wounds? A: When foot ulcers are complicated by impaired microcirculation and secondary infection, Steven Kravitz, DPM, uses the Circulator Boot™ (Circulator Boot Corp.) to help treat patients for whom revascularization is not a viable option. As Dr. Kravitz explains, the Circulator Boot assists distal blood supply and provides a mechanism to deliver perfusion and antibiotics to pedal and digital infected lesions. While there is no panacea in this area, Dr. Kravitz says using the device “definitely prevented” limb loss for some patients. While the boot has been around for 15 years, it has not received the exposure that he thinks it deserves. However, Dr. Kravitz believes the boot therapy may gain more statewide recognition in Pennsylvania as Medicare recently modified local carrier provisions to provide broader patient access to modalities like the Circulator Boot. Dr. Kravitz, as well as Lawrence Karlock, DPM, and David G. Armstrong, DPM, MSc, PhD, cite the benefits of Vacuum Assisted Closure therapy (VAC, KCI Inc.). Dr. Karlock uses the negative pressure wound therapy on deep draining wounds. Dr. Armstrong notes that VAC therapy simplifies deep, complex wounds. He says the VAC, along with some of the more promising acellular matrices available, such as GraftJacket (Wright Medical) and Integra (Integra Life Sciences), is “quite effective” in the subset of patients that could benefit from such treatment. For a stagnant wound that is healing slowly by conventional means, Dr. Karlock will use a living skin substitute. He believes these products can be employed earlier in the treatment of wounds. Dr. Karlock notes only 25 to 30 percent of diabetic neuropathic wounds will heal with standard care at 12 weeks. For large, non-healing wounds, Dr. Karlock has been utilizing autologous platelet rich plasma. Q: Is there any literature that supports the use of these modalities? A: Some literature reports cite positive outcomes as high as 90 percent for the Circulator Boot, according to Dr. Kravitz. In a soon to be published randomized study, Nelson indicated an average increase in perfusion of 43 percent by the end of the fourth week.1 According to Dr. Kravitz, Carlson, et. al., concluded that therapy with the boot is associated with improved outcomes in limb ulceration resulting from peripheral vascular disease. These authors indicated most patients can achieve complete ulcer healing and limb preservation.2 On the other hand, Dr. Armstrong concedes that the overall data for wound care modalities has been “exceedingly disappointing.” He attributes this to the fact that there is not much incentive for the industry to innovate. In addition, he says most wound healing dressings and devices are marketed with FDA 510k predicate approval. “Since devices or dressings only have to match up with prior approved devices, the bar is set very, very low to support their actual efficacy,” says Dr. Armstrong. “This has stifled innovation.” However, Dr. Armstrong notes that clinicians are demanding more evidence, “not just pretty pictures,” before beginning expensive therapy. He notes there are more partnerships between industry and academia for research and development. Dr. Armstrong also sees greater federal funding on the horizon as well as more promising studies. As an example, he cites the recent Lancet study, on which he was a principal author, which supports the use of negative pressure wound therapy on complex wounds.3 Such robust models will move the field forward and each randomized study brings the profession closer to standardizing research in wound care, offers Dr. Armstrong. Q: Do you have any experience with Versajet (Smith & Nephew) debridement? A: Dr. Armstrong has been using Versajet more in the OR and says it is an effective device for adjunctive debridement. However, he notes the Versajet’s per use price virtually limits the modality to use in the OR. Dr. Kravitz adds that many of his colleagues have used Versajet in the OR setting.