Charles Gilarski, DPM,FACFAS

Certified in Wound Care by CMET

Objectives Identify various types of wounds seen at a wound

healing clinic

Demonstrate understanding of current practice in the care of lower limb wounds

Identify wounds requiring a multidisciplinary approach to treat

Goals of a Wound Program Heal difficult wounds

Reduce amputations

Reduce patient health care costs

Improve patient quality of life

MGMC Wound Healing Center Established in 2009

Multidisciplinary

Certified Wound Care Nurses

Podiatrists

Infectious Disease

General Surgery

Vascular Referral

HBO Therapy Referral

MGMC Wound Healing Center

Interdisciplinary Team

Diabetes Educator

Nutritionist, Weight management Counselor

Orthotist

Compression Stocking Fitter

DME providers

Home Care Agencies

PT/OT

Types of Wounds Treated Venous Stasis

Pressure Ulcers

Arterial Disease

Diabetic Foot Ulcers

Mixed etiology

Other Chronic Wounds (Surgical Wounds, Trauma, Burns, etc.)

Post op complications

Wagner ulcer classification 0-Pre ulcer –skin intact

1- Superficial skin ulcer above fatty layer

2-Full thickness down to tendon or joint capsule

3-Deep ulcer that may or may not go to bone with abcess, osteomyelitis or joint sepsis.

4-Gangrene of a geographical portion of the foot.

5-Gangrene of the whole foot beyond salvage.

University of Texas (San Antonio) Diabetic Wound Classification System

Grade0 1 2 3

StageA healed tendon/ joint bone/

wound soft tissue capsule joint

B w/ infection “ “ “

C w/ ischemia “ “ “

D w/ infection & ischemia “ “

Venous Ulcers Venous return to the

heart impaired due to:

-Valve dysfunction

-Blockage

-Failure of calf muscle to pump

Causes venous hypertension, edema

and stasis ulcer

Venous Stasis: Factors Influencing Development

Obesity

Lower Leg Edema

History of Blood Clot/DVT

High Blood Pressure

Previous Surgery

Standing or Sitting for Long Periods

Family History of Venous Stasis Ulcers

Varicose Veins

Leg Trauma

Venous Stasis: Signs and Symptoms Occur on Inner Ankle or Lower Leg Shallow Irregular in Shape Wound Appears Dark Red or Purple Painful (due to exposure of nerves in epidermis) Large Amounts of Drainage Dry, Scaly Skin Swelling/Edema Dark Staining of Skin (hemosiderin staining)

Treatment & Prevention Manage Edema-Compression

Manage Drainage-Specialty Dressings

Manage Infection-Antibiotics, Topical Preparations

Prevent Recurrence-Compression Stockings

Debridement

Evaluation by Vein Specialists-Dr Salti

Evaluate for Lymphedema

Case Study 52 year old male

Occupation-Cook

Medical history:

Morbid Obesity-(454 lb.)

Obstructive Sleep Apnea

Essential Hypertension

Case Study 92 y/o female

Severe peripheral edema

Severe venous stasis

Morbid obesity

Poor compliance with compression hose, elevation

Continues to itch lower legs causing shin breakdown

Pressure Ulcer Occur in Areas of the Body That May Experience

Prolonged Periods of Pressure

Left Untreated-May be Life Threatening

Pressure Ulcer: Factors Influencing Development Ischemia to Bony Prominences-due to high pressure

gradient Hips

Elbows

Spine

Heels

Coccyx

Loss of Sensation-Neuropathy, Spinal Cord Injury, Aging

Time, Intensity and Pressure High Pressure, short time

Low Pressure, long time

Four levels of skin breakdown Hyperemia (seen within 30 min. or less)

Ischemia (after 2-6 hours)

Necrosis (after 6 hours of continuous pressure)

Ulceration (occurs within 2 weeks after necrosis)

Pressure Ulcer Stage I

Intact Skin

Nonblanchable erythema

Usually over a bony prominence

Stage II

Loss of epidermis and partial loss of dermis

May present as a blister or abrasion

Pressure Ulcer Stage III

Full thickness tissue loss, down to fascia

DOES NOT extend into bone, tendon or muscle

Stage IV

Full thickness tissue loss, extending to muscle, bone or tendon

Pressure Ulcer Unstageable

Obscured by slough or eschar

Full thickness tissue loss

Suspected Deep Tissue Injury Due to damage of underlying tissue

Presents as purplish discoloration or blood blister

May be painful, mushy, boggy, warmer or cooler than surrounding tissue

Plan of Treatment Offloading the foot

Prevalon Boot

Darco (Surgical) Shoe

Modify resting position and bedrest if necessary

Close monitoring of Achilles area

Vascular consult

Daily treat topically to decrease bioburden

Treatments for Pressure Ulcers OFFLOAD-

No matter where located on the body need to remove the source of pressure

Modify bedding

Vigilant nursing care

Depends on Staging

Stage 1-Monitor

Stage 2-Remove source of pressure, Add Xenaderm

Why is this in a wound care talk?

Stage III & IV Treatment May Include

Sharp debridement

Enzymatic debridement (Ex. Collagenase)

Autolytic Debridement (Ex. Medical Grade Honey, Hydrocolloid)

Mechanical Debridement (Ex. Wet to dry dressings)

Dressings-absorbent (Ex. hydrofiber, foam, gauze)

Negative Pressure Wound Therapy

Grafts-Autograft or Allograft

Flap

__________________________

Case Study 62-year old male

Disabled

Medical history

Diabetic

CAD

Previous smoker

Hyperlipidemia

Previous left AKA

__________________________

Diabetes by the numbers 9.3% of U.S. population has diabetes-29 million

7.5% of Story County has diabetes

11.1% Wapello County has diabetes

8.1 million in U.S. are undiagnosed

Medical costs for diabetes patients are 2x as high as for people without diabetes (3-4x higher if foot ulcer present!)

$245 billion in total medical costs and lost work and wages annually. (largest % was inpatient hospital care)

Partial amputations have a 34% chance of reamputation

Diabetic Foot Ulcer (DFU) Also called Neuropathic Ulcer Tri-Neuropathy

Often see a combination of all three types Sensory

Loss of sensation-Large fiber Type A Semmes-Weinstein fiber 10 gram pressure loss

Motor Loss of Intrinsic Muscles Clawed toes

Autonomic Absence of sweat and oil production-dry non-elastic skin where minor trauma causes ulceration

Diabetic Foot Ulcers cont. Blood Vessels Become Obstructed due to

Atherosclerosis(medial calcific sclerosis)

Macrovascular/Microvascular

Decreased Blood Flow

Can show islands of ischemia

Diabetics with DFU have more fatal CVA”S

Diabetics with DFU have more fatal MI’s

DFU –mixed etiologyWhich ulcer had the poorest healing rate?

0%

0%

0% 1. Ischemic ulcer

2. Neuropathic ulcer

3. Neuroischemic ulcer

Diabetes effects… On wound healing are multifactorial

Cause decrease in cell signaling

Cause decrease in cell migration

Causes increase in chronic inflammatory state causing a delay in remodeling

Diabetic Foot Ulcer- Signs & Symptoms Located on Pressure Points of Foot and Ankle

Skin and Wound are Dry

Base of Wound is often Pale Pink or Necrotic in Appearance

Often Calloused

May Start as a Fissure

Contributing factors-Ill-fitting Shoes, Prolonged Pressure, Mechanics of Foot and Gait

Treatment Options Surgical or Sharp Debridement Autolytic or Enzymatic Debridement Allograft-e.g. Collagen (bovine, porcine),

Bio-engineered Assessment and Revascularization of

Arterial Supply Assessment for and Treatment of Infection

(Osteomyelitis) Decrease bioburden if a stable eschar Offloading Total Contact Casting

__________________________

Case Study 61 year old male Employed full-time in Management Medical History-

Type 2 Diabetes Polyneuropathy Dyslipidemia Obesity Hypertension Psoriasis 8 trips to the OR for soft tissue/bone infections with

final result TMA

Arterial Ulcers: Factors Influencing Development Plaque Formation and Narrowing of the Lumen

Due to Arteriosclerosis May Become Occluded by Small Blood Clots

Inadequate Blood Flow and Oxygen to the Tissues of Feet and Lower Legs

Without Oxygen, the Tissue Becomes Necrotic

Area of Necrotic Tissue May Eventually Open & Create a Wound

Causative Factors Past and/or Present Tobacco Use

Diabetes Mellitus

Hypertension

Hyperlipidemia

History of Cardiovascular Disease

Local trauma

Signs/Symptoms Located on Tips of Toes, Pressure Points

Wound Bed Pale or Necrotic

Minimal Exudate

Painful

Absent Pulses

Dependent Rubor/Elevational Pallor

Treatment Options Referral to Vascular surgeon

Angiography

Stenting or Bypass

Pharmacological Antiplatelet

Vasodilators

Antilipidemics

Wound management/Topical Therapy Decrease bioburden

Identification & Management of Infection

__________________________

Case Study 54 year-old female

Disabled

History of: Diabetes Mellitus

ESRD (started on Hemodialysis)

Fibromyalgia

Neuropathy

Hypertention

Hyperlipidemia

Case Study

Antiphospholipid syndrome

Sjogren’s syndrome

Thrombocytopenia

Diabetes mellitus

Arteriosclerotic cardiovascular disease

Case Study 56 y/o male

Diabetic/vascular ulcers

A1C= 7.7

Previous Stroke

Non-adherence to plan of care

Case Study Pretibial ulceration to the base of a large scar where

patient had multiple surgeries and skin grafting from past trauma

Tried everything from wound dressings to wound VAC for 6 months.

ABI=0.9Rt, 0.81Lt

Continued smoker

Referral to HBO

Case Study Pyoderma gangrenosum

29 year old male

Employed as a mechanic

Medical history includes:

Ulcerative colitis

Celiac disease

Case study HgBA1C >16 on 1/2/2017

61 year old

__________________________

Case Study Y.H. 23 y/o Chinese foreign exchange student

AVM predominant dorsalis pedis right foot

First had alcohol ablation & sclerotherapy in China

Followed by transcatheter therapy with microembolization

Bleeding, painful

MSSA

Referred to vascular surgeon who suggested

U of Iowa, U of Minnesota.

Active intelligent student- Tough to keep down

Case Study 55 y/o Post op complication

Referred for possible Charcot fracture which was actually a TA tendon rupture

Had Left hemispheric stroke 2 years prior leaving dropfoot

Type 2 DM A1C 12.3 initially

Primary repair of TA

@ 2.5 weeks post op, family started to put vaseline on the wound for healing purposes

__________________________

Case Study J.P. 65y/o female with simple skin tear

Cancer patient at Mayo (chronic myelogenous leukemia)

Rheumatoid Arthritis

CKD Stage 3

Anemia of chronic disease

Hx heart failure

Bronchiolitis obliterans

Case Study 89 y/o severe venous disease

DM Type 2

Duplex showed superficial vein thrombosis from proximal to middle to distal calf

Dystrophic calcification lower leg

Started in 5/2015-Penrose by surgeon-healed

Reulcerated post op

Visible calcium in subcutaneous tissue

__________________________

Case Study 69 y/o male

DM, A1C-8.0

Venous stasis/decubitus heel ulcer currently @ 10 months of treatment

***Pearl***

Avoid these ulcers from starting in the first place!

Case study 82y/o male 7 months post op THR

Diabetes mellitus

Bone culture S. capitis

Retired M.D. referral for longstanding heel ulcer (pressure ulcer obtained following hip surgery)-had been treated in Iowa and Florida

Not much confidence in our treatment plan at first

Special Olympics

Thank you

Final thought The structure of the wound care process is a much

greater determinant of outcome of a diabetic foot wound than the choice of any wound care product.

-W.J. Jeffcoate