Health matters

Conway McLean, DPM, Journal columnist

Readers who regularly frequent these pages are probably familiar with the topic of wound care. These chronic skin lesions occur for a host of different reasons, from clogged arteries to vein disease, injury to aging.

Another common cause for these challenging entities is iatrogenic, a term referring to man-made, generally the result of a surgery, often an incision that won’t heal for some reason.

This article is about Pete, a hard-drinking, fun-loving kind of guy. He presented to my office with an obvious concern: a hole in his foot. To be more precise, what remained of his foot. Pete had been diagnosed with a circulatory disease and some years earlier had developed gangrene of some toes (although the specifics of his condition and the treatment provided at that time are unknown).

As is generally the case, when a part becomes gangrenous, it is dead and needs to be removed (or allowed to fall off which is not uncommon when it’s just a toe). Pete had all his toes removed, including most of the adjoining metatarsals (except the first).

Apparently, the incision had not healed well, and when it did, the skin was of poor quality. Pete is not certain these many years later, but his recollection is of minimal care being provided to heal the wound.

Wound care is a relatively new field of medicine, meaning the “best” practices, how best to heal these stubborn but common problems, have only recently been discovered.

Many providers continue to utilize older, outdated methods since the more effective techniques haven’t made their way out to community providers. Research is on-going, and exciting discoveries and developments are made daily.

Pete’s surgical wound became a chronic wound. It did eventually heal but took many months to do so. Unfortunately, the skin that is grown by the body in the process of healing these open sores is never as good as it was prior to the injury. Recurrence is always a concern, always a possibility. Indeed, the wound reappeared about a year ago, apparently as a result of some mild trauma, the proverbial “stubbed toe” (although he didn’t have any).

Naturally, Pete saw several physicians for care of the skin breakdown but was told amputation of the foot and lower leg was indicated. This is a common proposal, especially since wound care takes time and patience. An amputation is definitive, one and done, absolute. This appeals to many surgeons while, in contrast, wound care is protracted and time consuming. Depending on the medications applied and technologies brought to bear, these frequently resist closure, lending to the onset of infection. After all, our skin is our most important barrier to bacterial invasion. When older methods of wound care are utilized, the results are less satisfying, leading to a higher amputation rate.

Our protagonist was not excited with this prospect and consequently sought another opinion. When assessing these wounds, it is critical to identify obstacles to healing. Why has this defect in his skin not healed? My evaluation identified the chronicity of the wound as an impediment but, maybe more significant, the challenge of his impaired blood flow.

His arterial supply was of critical importance since, as we say in wound care, “we are held hostage by the blood flow.” It doesn’t matter what fancy medication we apply or treatment we use, if there is not sufficient blood getting to the tissues of the ulcer, it will not heal. But vascular surgeons have many new technologies available to open clogged vessels through tiny openings, using endovascular techniques. Yet these procedures can only be used on vessels of a certain diameter.

To aid in blood flow into the tissues that were part of his wound, a unique form of electrical stimulation was employed. Unlike many forms of electricity, this technology helps to open the tiny vessels, improving the amount of blood getting to the defect. In addition, we performed photobiomodulation treatments, more commonly referred to as cold laser. This fascinating technology improves the health and viability of those tissues treated and its benefits to wound healing are becoming better established. Plus, there are no possible side effects or complications from its application.

When an ulcer remains open, numerous types of bacteria will “set up shop,” colonizing the surface of the lesion. These often don’t invade the tissues of the host, which would mean infection was present. Instead, multiple types of bacteria will form a cooperative colony, encased in tough, thick gelatinous material produced by the microorganisms. These colonies are referred to as biofilm, a common concern with implanted hardware as well as chronic wounds. Biofilm is a frequent obstacle to healing, altering the chemistry of many wounds, making it difficult for the body to grow tissue to fill the defect. Fighting biofilm is challenging. It’s also the reason many ulcers fail to heal.

A newer weapon in the battle against biofilm formation is a specialized medication, applied in a sheet of collagen, whose sole purpose is the killing of biofilm. Due to the longevity of Pete’s ulcer, significant biofilm had formed, preventing healing no matter the medication applied. When able to persist, biofilm can ruin the best wound care plan.

Along with the biofilm fighter, Pete underwent a series of treatments to the surface of the wound, utilizing an ultrasonically charged mist. Studies reveal the benefits of this therapy are many, including killing bacteria, improving blood flow, even breaking up debris. The ultrasonic therapy, along with the two already mentioned, began to cause visible changes to Pete’s wound. The surface was healthier, with less debris, and new tissue developing. Just as importantly, Pete’s ulcer pain, once formidable, was lessening.

Following the application of a short series of lab grown skin, a section of Pete’s own skin was applied to the wound, eventually resulting in complete healing. Pete gets to keep his foot and is out enjoying his freedom. Modern technology and bioscience have provided numerous exciting new ways to encourage healing of these common complications of life. If you or a loved one suffer from one of these, take comfort in knowing scientific research has provided exciting and effective options, with more of these healed than ever before. The fascinating world of modern wound care.

EDITOR’S NOTE: Dr. Conway McLean is a physician practicing foot and ankle medicine in the Upper Peninsula. Dr. McLean’s practice, Superior Foot and Ankle Centers, has offices in Marquette and Escanaba, and now the Keweenaw following the recent addition of an office in L’Anse. McLean has lectured internationally, and written dozens of articles on wound care, surgery, and diabetic foot medicine. He is board certified in surgery, wound care, and lower extremity biomechanics.


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