Volume 23 - Issue 12 - December 2011
Working Toward a Better Comprehension of Wound Healing
- Thu, 12/8/11 - 4:39pm
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Many of us who treat wounds spend the majority of our time in well-defined niches, whether it’s treating diabetic foot ulcers, venous leg ulcers, truncal pressure ulcers, or dermatologic conditions. In these areas we have numerous, although not always well designed, trials to supplement our knowledge. There are many commonalities in these wound types—necrotic debris, bioburden, hostile microenvironment, microscopic and macroscopic tissue perfusion—to name a few. Many of us believe that we are experts in many of these fields. However, it is in the area of revascularization that we are more likely to have to send a patient with ischemic issues elsewhere.
Additionally, data are scarce regarding ischemic patients’ actual wound healing, whether revascularized or not—in almost all randomized controlled trials they are excluded from enrollment. Many insurance providers, including Medicare, preclude patients with diminished circulation from certain treatments, such as bilayered skin substitutes. Once these patients return to the clinic, their procedure is deemed as successful or not successful based upon procedural criteria, not usually upon how the patient’s wound actually progresses. If deemed “non-operable,” we are then limited to arterial pumps, hyperbaric therapy, or possibly a “gene” therapy trial.
Mixed Arterial and Venous Ulcers
- Thu, 12/8/11 - 5:21pm
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Index: WOUNDS 2011;23(12):351–356
Abstract: The most common underlying etiologic factors responsible for chronic delayed healing among lower extremity wounds encountered in the outpatient clinic are chronic venous insufficiency (CVI), diabetic neuropathy, and arterial insufficiency (AI). One or more of these factors can be identified in more than 90% of chronic lower extremity ulcers, and treatment protocols have been designed to manage wounds of each type to maximize healing potential. It is important to remember that multiple factors may coexist in any individual patient with a chronic wound, complicating management and hindering the healing process. Recently, it has been reported that the neuroischemic diabetic foot ulcer is now more common than nonischemic neuropathic diabetic foot ulcers, as arterial insufficiency promoted by poorly controlled diabetes complicates already impaired healing present in patients with diabetes. This article will discuss the management of patients with leg ulcers and both arterial and venous insufficiency, including identification, diagnostic methods, and treatment protocols to maximize the potential for wound healing.
Endovascular Interventions for Limb Salvage
- Fri, 12/9/11 - 10:18am
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Index: WOUNDS 2011;23(12):357–363
Abstract: Although operative bypass is still considered the “gold standard” for treating peripheral arterial disease, over the last decade endovascular interventions have become more popular and now represent the vast majority of peripheral arterial treatments being performed. Open bypass is associated with an unacceptable morbidity and mortality that is not encountered to the same extent with endovascular techniques. However, outcomes of endovascular intervention are dependent upon the location and nature of the lesion, as well as possibly the technologies available to treat the lesion and the experience of the interventionalist. In correctly selected patients, endovascular techniques should be the primary management employed for critical limb ischemia. The group of patients that would benefit from endovascular techniques continues to expand with new data constantly emerging. This article will review the current endovascular techniques currently being employed, focusing on the indication for specific intervention.
The Role of Open Bypass Surgery for Limb Salvage in Patients With Diabetes
- Fri, 12/9/11 - 10:52am
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Index: WOUNDS 2011;23(12):364–368
Abstract: The pathogenesis of foot ulceration in patients with diabetes involves the interplay of neuropathy, vasculopathy, and immune dysfunction. Autonomic neuropathy results in loss of pain sensation, decreased sweating, and the development of brittle skin, which predisposes these patients to foot trauma. As a result, the traumatized tissue progresses to necrosis and subsequent ulceration. Once an ulcer is present, the vascular supply to the foot plays an integral role in healing. Foot ischemia in patients with diabetes may be attributed to atherosclerotic macrovascular disease and additional microcirculatory dysfunction. The following report will review the role of open bypass surgery addressing macrovascular problems for limb salvage.
Miraculous!
- Fri, 12/9/11 - 11:07am
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Dear Readers,
Christmas has been called “the season of miracles.” Miracle is defined as “an event in the physical world that surpasses all known human or natural powers and is ascribed to a divine or supernatural cause.”1 I don’t know if you believe in miracles, but I surely do! As a surgeon, I have seen patients recover from injuries and illnesses from which there was virtually no chance of survival and the medical personnel had given up all hope. On a more mundane level, just look around you. I think it is a miracle of nature that the deer in Alabama, even though they cannot read or write, know exactly when hunting season starts and ends. I see deer on my property for most of the year except during hunting season. I still consider it a miracle when two cells from unrelated persons (hopefully!) come together and form a relatively normal human being. Miraculously, these two cells do not immunologically react with each other, but after they unite and divide a few times, they react violently on contact with any other “foreign” cell.2,3 Most consider it a miracle that Christmas causes many people to act as they should all year long!
Evidence Corner
- Fri, 12/9/11 - 11:27am
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Dear Readers:
The Association for the Advancement of Wound Care (AAWC) recently updated its Venous Ulcer Guideline, accessible at www.aawconline.org/professional-resources/resources/. Summarizing the best available evidence through 2010, the AAWC Guideline Task Force found recommendations with little evidence for self-care interventions, such as leg elevation, walking, or exercise that may empower individuals with venous insufficiency to help reduce the likelihood of a venous leg ulcer (VU) or VU recurrence once healed. This seemed odd, considering the growing trend toward patient-centered care. Researchers in Australia and the Netherlands are providing evidence that these self-care interventions work. This edition of Evidence Corner summarizes two recent studies that support the efficacy of these self-care interventions in improving outcomes for patients with venous insufficiency. Why not put the patient on the wound care team by encouraging self-care that works?
Laura Bolton, PhD, FAPWCA
Adjunct Associate Professor
Department of Surgery, UMDNJ
WOUNDS Editorial Advisory Board Member and Department Editor
Our Holiday (and Wound Care) Wishes
- Fri, 12/9/11 - 11:37am
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On behalf of AAWC President, Dr. Terry Treadwell, the entire AAWC Board of Directors, members, volunteers, and staff, we wish you the most wonderful holiday season and look forward to your new or continued membership in 2012.
The AAWC is proud to have a niche family of nearly 1600 professionally educated, multidisciplinary practitioners, and other advocates of quality, evidence-based care, lay-caregivers, and patients who work hard to advance their knowledge, educate others, and support the mission of AAWC.
But it is not enough. As we all know, the impact wound care has on our nation and the world does not receive nearly the amount of attention it deserves. You may be a practitioner, teacher, researcher, or other representative for wound care. You may or may not support the AAWC with dues-paid membership, but you know at least something about wound care.
Subcutaneous Hematoma: An Emerging Problem
- Tue, 12/13/11 - 1:06pm
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- 500 reads
Dear Editor:
In the October 2011 issue, LaRosa and Fanelli “Successful Outpatient Treatment of Full-thickness, Necrotic, Lower-extremity Ulcers Caused by Traumatic Hematomas in Anticoagulated Patients” did a fine job describing their care of the four warfarin hematoma and necrosis patients. The use of layered skin substitute and negative pressure wound therapy (NPWT) has become more and more established for these wounds. It might be of interest to know that there is another use for NPWT in less severe cases of skin necrosis and slough associated with subcutaneous hematomas. In fact, if there is no necrosis at all, we have successfully managed these with aspiration (sometimes repeated) and light compression therapy. If there is necrosis, but it does not extend to the edge of the hematoma, then there is a cave-like space with a flue-like opening in the top where the eschar formed. After removing the eschar and the clot, NPWT has been very effective in closing the wound. Care is taken to put the foam in the opening, but not under the skin flaps. This has the virtue of coaxing the skin flaps to adhere down to the fat and, I believe, serve as a form of tissue expansion as well. The NPWT can draw the flap edges toward each other reducing the size of the wound by stretching the flap tissue centripetally from all directions.
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