On a daily basis, I am reminded of the travails of modern medicine. Having been in practice for over twenty years, I can speak with some experience of the changes that have been wrought in the American health care system. The obstacles to care created by insurance companies, the diagnoses provided by a 5 minute Google search, or the costs of running a practice, all these and more can make the practice of medicine sometimes aggravating. The hours required, and the demands of our patients, make it a 24 hour a day vocation for many physicians. Regardless, I continue to enjoy the practice of podiatric medicine, and the many challenges and rewards that come with it.

One of the greatest joys I experience is in the treatment of chronic wounds. This is an underappreciated aspect of medical care of the foot and lower leg, which is surprising since the majority of chronic wounds occur below the knee. The abilities of a podiatric physician well-versed in wound care has the potential to significantly impact the healing process when it does not proceed in an appropriate and timely fashion.

So that I might better help those individuals with a non-healing ulcer, I became board certified in wound care. These problems are commonplace in our society: chronic wounds affect about 6.5 million people. According to estimates, 25 billion dollars are spent annually on the treatment of these, and the burden is growing rapidly due to the aging population, and the sky-rocketing incidence of diabetes and obesity.

Chronic wounds impose a significant and intimidating burden to the individual, the healthcare system and society as a whole. They are rarely seen in individuals who are otherwise healthy. In fact, chronic wound patients frequently suffer from “highly branded” diseases such as diabetes and obesity, since the wound is considered just a component of their primary disease.

Fortunately, this is slowly changing, reflected by the growth of wound care research, and journals devoted to this topic.

Indeed, new techniques and products are developed almost daily. Sometimes research reveals that methods and materials we already have do provide significant benefits to the healing process. Unfortunately, when these are not reimbursed by health insurance, they become more challenging to provide.

Health insurances are primarily looking to cut costs, so providing coverage for some, supposedly new technique is challenging. The research must be irrefutable, and beyond question, for Medicare to add it to the list of “covered” services. (Like many others, I am of the opinion it is no longer the doctors who are practicing medicine, but insurance companies.)

The challenges of insurance reimbursement holds true for wound care, as in most other fields of medicine. For example, I utilize a cold laser device for the treatment of various injuries and musculo-skeletal conditions, and to great benefit. Apparently, because of the ability of this device to boost the metabolism and the health of the cells that are treated, cold laser therapy seems to be extremely helpful in speeding wound closure. But this is a new technology, and a new use. Studies are expensive, and difficult to construct when it comes to the multiple variables that exist in any wound care study. Should this lack of reimbursement prevent a physician from utilizing this device for the treatment of some particularly resistant ulcer?

Sometimes the “old standards” remain highly effective. Many new skin substitutes have been developed, but nothing works quite like one’s own tissue. Skin grafting is one of my favorite techniques since I am using the individual’s own skin to cover the deficit. Often, I am able to use only a very thin section, which means healing of the donor site is usually a simple process. Yet the graft provides living cells to the recipient site to aid in tissue repair, and thus healing.

Some amazing new techniques are being studied, with one of the most exciting being the use of fat cells for transplantation. This is a hot topic because of their potential for differentiation. Some adipose tissue (fat cells) have the ability to become different types of cells, so this type of tissue is being moved to various areas of the body, including the skin, where the new cells contribute to repair. The adipose cells can be harvested from any area of the body (the lower leg, in my case), and implanted with minimal trauma to the wound site.

One of the keys to successful care of these is determining why the body has not gone through the normal, orderly process of healing. When there is an insufficient blood supply, healing will always be delayed. A variety of techniques are available when the limitation in supply is due to clogs in some of the larger vessels, but there have been few options for the smaller vessels. I utilize a new form of electrical stimulation that improves blood flow through these tiny vessels, thus increasing blood supply to the area of the wound, where more blood is needed for the creation of new tissue. Again, another wonderful, new tool to aid in the closure of a chronic wound.

Some of these sores won’t heal because of the development of something called a biofilm. This is a tough layer produced by certain bacteria, although this is not a typical infection. The bacteria aren’t actively invading the body, but merely using the bed of the wound as a place to “set up shop.”

Unfortunately, the biofilm does result in a blockade of the healing process. An established technique called photo-dynamic therapy uses a special light, which in turn activates some type of topical medicine to treat some strange skin infections. I have been finding this method to be of benefit in healing up these stubborn wounds after recent studies demonstrated PDT to be helpful in eradicating biofilms.

Many diabetics suffer the needless loss of a foot or leg, often due to an infection that results from having an open wound. Because of the loss of normal sensation (a condition called neuropathy), these individuals don’t feel pressure appropriately, and, too often, this leads to skin breakdown. It is essential to remove those excessive forces to the wound to get it to heal.

This can be much more difficult than it sounds. (Hopping is hard!) As many studies indicate, the use of a special casting technique, called a “total contact cast” is the gold standard for treating this type of wound. Although it is labor intensive, I too have found it a wonderful technique for treating this kind of wound, therefore allowing the body to rebuild the protective layer that is the skin.

I continue to be amazed at the wonders of the human body. But when problems develop in healing of the skin, our barrier to the outside world, many amazing devices and procedures help us to heal more of these wounds than ever before (regardless of whether they are covered services). Often, amputations performed as a result of these wounds are unnecessary, and can be avoided with the use of an effective, appropriate treatment.

This goes beyond quality of life measures, and into the realm of life-saving measures. Wound healing continues to be a crusade of mine, protecting the body against the ravages of the outside world, and keeping people mobile and walking.

Editor’s note: Dr. Conway McLean is a podiatric physician now practicing foot and ankle medicine in the Upper Peninsula, having assumed the practice of Dr. Ken Tabor. McLean has lectured internationally on surgery and wound care, and is board certified in both, with a sub-specialty in foot orthotic therapy. Dr. McLean welcomes questions, comments and suggestions at drcmclean@penmed.com.