Overcoming The Challenges Of Offloading Neuropathic Plantar Foot Ulcers

Posted on Feb 19, 2019

We all have had the challenge of trying to determine the best way to offload patients who are either non-adherent or unable to have appropriate offloading. I have been treating a young male who has neuropathy and an undiagnosed neurologic disease. The left lower extremity with the plantar ulceration is the “good” foot. This extremity allows him to continue to ambulate. The other lower extremity is weak and has limited function. He cannot tolerate any type of restrictive offloading device, such as a total contact cast, controlled ankle motion (CAM) walker or surgical shoe. The patient cannot even tolerate a sneaker. He has a high risk of falling. Alternately, if you attempt to put this patient in a wheelchair, his lower extremities will become so weakened that he may not walk again. As you can see, it is a challenge. I recently went to the Symposium on Advanced Wound Care (SAWC) Fall in Las Vegas in September and heard a presentation on offloading. The speaker mentioned a type of offloading dressing called a football dressing. Rader and Barry discussed this football dressing previously in the journal Wounds.1 The search for a repeatable, inexpensive and efficacious dressing that addresses the need for non-removable offloading of the neuropathic plantar forefoot ulcer is what led the authors to propose this model. It is a well-padded dressing using cast padding, gauze and Coban. In our version of this dressing, we use foam, abdominal pads, Kerlix and Ace wraps. We were already using this modality for this patient but were not aware that there was research on it. I have been treating this patient for several months. I always had an uneasy feeling as if I could be doing more to offload his plantar ulceration. After hearing the presentation, I felt I was offering the patient something that physicians had used before and that research had proven to work. Obviously, this was not as aggressive an offloading device as some others but often we need to think outside the box for our patients. I am sure you have had similar scenarios. It is not only about the ulcer. It is the greater picture that we must also consider. Every patient’s situation is different. In this case, we have continued to use this offloading method with good success and expect wound closure soon. Reference 1. Rader AJ, Barry T. Football dressing for neuropathic forefoot ulcerations. Wounds. 2006;18(4):85-91. Original Posted on Podiatry...

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A Closer Look At Venous Insufficiency And Wound Healing In Women

Posted on Dec 2, 2018

The American Association for Women Podiatrists executive board members recently had a panel discussion on special considerations when it comes to surgery, biomechanics and wound care in the female patient. My topic was women and wound healing. When I initially approached this subject, I did not think I would find any significant differences between wound healing in women and men. However, I would like to share with you some of my findings in regard to venous insufficiency and ulcerations in women. Approximately 50 to 55 percent of women will develop varicose veins in contrast to 40 to 45 percent of men who will develop this condition.1 Women are more prone to venous stasis/insufficiency than men due to heredity, shoe style, pregnancy and menopause.2 Shoe style. Normal walking coordinates the foot and calf pump. When the foot is off the floor, the veins in the foot fill with blood. As the heel and arch of the foot contact the floor, the blood flows into the relaxed calf veins. The calf muscles subsequently contract, which propels blood up the deep veins. High heels change the natural walking motion, shifting the weight to the forefoot and toes and causing the calf muscles to remain contracted. This results in a decrease in the filling of the foot and calf veins, and a less forceful calf muscle pump. This lost efficiency causes the pooling of venous blood in the leg. Pregnancy. As the uterus grows during pregnancy, it puts pressure on the inferior vena cava on the right side of the body. This in turn increases pressure in the leg veins. During pregnancy, the amount of blood in the body also increases, adding to the burden on the veins in pregnant women. Estrogen. A clear correlation exists between estrogen levels and the rate of wound healing with retarded cutaneous healing in post-menopausal women.3,4 Decreased healing ability correlates with a reduction in post-menopause steroid use.3,4 Topical estrogen application treatment to some degree reverses three age-related skin conditions: atrophy, dryness and wrinkles. 1) Skin atrophy. Topical estrogen stimulates keratinocyte proliferation, reduces apoptosis, increases dermal collagen production and inhibits matrix metalloproteinase (MMP) expression. 2) Skin dryness. Topical estrogen alters keratinocyte function, increases dermal water holding capacity and increases sebum production. 3) Skin wrinkles. Topical estrogen increases dermal water holding capacity, increasing the number and orientation of elastin fibers. Postmenopausal females taking systemic hormone replacement therapy reportedly heal standardized acute wounds more rapidly than age-matched controls, which is in agreement with animal studies.5 References 1. Chicago Vein Institute. Varicose vein statistics. Available at http://chicagoveininstitute.com/varicose-veins-statistics/ . Published May 5, 2014. Accessed Aug. 18, 2015. 2. American College of Phlebology. Available at http://www.phlebology.org/patient-information/faq . Accessed Aug. 18, 2015. 3. Wang...

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Keys To Diagnosing And Addressing Hypergranulation Tissue

Posted on Aug 12, 2018

Last week, I had a medical representative come into the wound care center to see the use of one of her company’s products on a patient I was treating. While I was examining the patient, she expressed curiosity at the proud flesh granulation tissue she saw on the venous stasis ulcer. After telling her that it was hypergranulation tissue, she went on to ask why it develops. Accordingly, for this blog, I thought it would a good idea to review and discuss the underlying etiology, treatment and prevention of hypergranulation tissue. Hypergranulation, which is also known as overgranulation, exuberant granulation tissue or proud flesh, usually presents by secondary intention in the wound healing process. Granulation tissue is comprised of new connective tissue and tiny blood vessels that form on the surfaces of a wound during the healing process. Prolonged stimulation of fibroplasia and angiogenesis results in hypergranulation, which can be a potential problem for the wound healing process. Hypergranulation prevents epithelialization and the healing process may be arrested. The point at which hypergranulation tissue replaces normal healthy granulation tissue has not been clearly defined but we can speculate that epithelialization stops and the healing process is halted. This is a result of the nature of the hypergranular tissue, which impedes epithelial migration. Hypergranulation physically impedes epithelial cell movement (raised rolled overgrowth) or, as a result of changes in extracellular signaling, switches off the movement of epithelial cells. This exact mechanism is unclear. The wound generally will not heal when there is hypergranulation tissue because it will be difficult for epithelial tissue to migrate across the surface of the wound and contraction will be halted at the edge of the swelling. In regard to clinical recognition, hypergranulation has a friable red, sometimes shiny and soft appearance that is above the level of the surrounding skin. While there is limited research on the cause of hypergranulation tissue, clinicians have identified a few common characteristics. These characteristics include: • moist areas from exudates or bleeding • prolonged physical irritation or friction with continued repetitive minor trauma or pressure • excessive inflammation • bacterial bioburden or infection • a new scenario of negative pressure suction with microdeformation, particularly applicable to large pore foam dressings • low oxygen levels Additionally, patients with diabetes are very prone to clinical wound infection due to the inadequate delivery of oxygen and nutrients to the wound bed, which increases the potential for abnormal tissue such as hypergranulation tissue. Also keep in mind that overuse of occlusive dressings is thought to have an influence as it creates a hypoxic environment that causes the body to produce more blood vessels but some of those are immature blood vessels to compensate....

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When Should You Refer Patients For Venous Ablation?

Posted on Aug 10, 2018

I often have patients at the wound center who get referrals to me for care after a venous ablation procedure. I researched the procedure to explore what is involved and when we should be referring patients to a vein clinic or a vascular surgeon. In order to understand what venous ablation entails, we need to review the nature of venous insufficiency. Chronic venous insufficiency is the cause of many chronic ulcers in the lower extremity. The venous system is made up of both the superficial and deep vein system. These systems are connected by perforating veins as well as the great saphenous vein and lesser saphenous vein. Failure of the one-way valves separating both systems can lead to high pressures in the superficial systems, causing aching, which can lead to skin changes and ulcerations. As the valves are damaged, blood leaks and flows backward, causing the increased pressure in the vessels. Ulcerations occur in areas where blood collects and pools. As swelling occurs, this can interfere with the movement of oxygen and nutrients into the tissue. The most common cause of ulceration in the lower extremity due to venous disease is the great saphenous vein area (medial ankle area). This problem is the cause of 60 to 80 percent of chronic leg ulcerations.1,2 The incidence of these ulcerations increases with age. Risk factors include: family history, sedentary lifestyle and jobs that require people to stand for an extended period of time. The easiest way of treating venous insufficiency or reflux is compression therapy. If this does not help, venous ablation may be a good option. Venous ablation is a non-surgical technique that has replaced vein stripping in most cases.3 Using only a local anesthetic, vascular surgeons can eliminate the abnormal refluxing vein by sealing it closed. The surgeon makes a small incision at the knee and places a small tube into the saphenous vein. Then he or she passes a laser or radiofrequency fiber through the tube into the vein. Once this fiber is in place, the fiber activates and delivers very localized heat to the vein wall. In response, the vein closes down and becomes permanently blocked. If you have been seeing a patient for a venous wound and have been using conventional compression therapy without seeing wound healing in a reasonable timeframe or significant progress in four weeks, I suggest you consider a vascular consult or refer the patient to a vein clinic. References 1. Whiddon LL. The treatment of venous ulcers of the lower extremities. Proc (Bayl Univ Med Cent). 2007;20(4):363-366. 2. New York-Presbyterian Hospital. Venous insufficiency and venous ulcers. http://nyp.org/services/venous-insufficiency-ulcers.html 3. Dotter Interventional Institute, Oregon Health and Science University. Venous ablation. http://www.ohsu.edu/dotter/venous_ablation.htm.   Originally posted...

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How Measuring Transcutaneous Oxygen Can Help Evaluate Wound Healing Potential

Posted on Jul 24, 2018

I recently referred a patient who has a chronic ulceration for a vascular consult. Non-invasive testing included ankle/brachial index (ABI), toe/brachial index (TBI), pulse volume recordings (PVR), skin perfusion pressure (SPP) and transcutaneous oxygen (TCOM or TcPO2). Macrocirculation in the lower extremity occurs through the posterior tibialis artery, anterior tibial artery and the peroneal arteries, the three main arteries that supply the limb. The ABI, TBI and PVR studies evaluate macrocirculation. The SPP and TcPO2 examine the microcirculation or skin capillaries within the skin layer. All of these tests analyze for peripheral vascular disease. I wanted to take a closer look at measuring TcPO2 and how it can help determine the healing potential of a wound. A transcutaneous oxygen measurement assesses the oxygen level of tissue beneath the skin. This an indirect measure of blood flow because the blood supply carries oxygen and the TcPO2 is a useful test for predicting wound healing and whether the patient would benefit from hyperbaric oxygen therapy (HBOT). We also know that hypoxic wounds will benefit from HBOT. The TcPO2 test is painless and takes approximately 45 minutes with the patient in a supine position. Place electrodes on the affected limb and a control site. Ask the patient to breathe oxygen through a mask to see if there is an increase in the oxygen level around the wound. Electrodes in the sensors heat the area underneath the skin to dilate the capillaries so oxygen can flow freely to the skin. The first step of the test measures the tissue oxygenation at room temperature. If the normal oxygen tension is greater than 30 mmHg in a patient without diabetes or greater than 40 mmHg in a patient with diabetes, then the wound should heal and the cause is due to some other factor such as poor nutrition, smoking, elevated blood sugar, suboptimal wound care, etc. If the patient does not have normal oxygen tension, then one would measure the oxygenation of the tissues while the patient breathes 100 percent oxygen. An increase of tissue oxygenation indicates that the tissues are getting enough blood flow so HBOT should enhance wound healing. An inadequate response to oxygen usually indicates the patient has some form of arterial insufficiency and may benefit from a further vascular workup with intervention. If this second stage of TcPO2 testing is inconclusive, one can have the patient try breathing 100 percent oxygen in an HBOT chamber. If there is an increase in tissue oxygenation, this will indicate that HBOT may be of benefit. We cannot forget the importance of non-invasive testing, especially TcPO2, in patients who have chronic wounds in order to help evaluate the underlying peripheral vascular disease and the possible use of HBOT. Suggested Reading...

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The Importance Of Assessing Risk In Patients With Diabetes

Posted on Jul 10, 2018

In a recent blog, David G. Armstrong, DPM, MD, PhD, discussed an article he co-wrote in the journal Diabetes Care.1 Unfortunately, I did not see this article when it was originally published but came across it while reading his diabetic foot care blog. The article discusses the importance of stratifying our patients with diabetes into categories depending on their risk factors. During podiatry school and in residency, I recall the emphasis on learning classification systems for fractures, injuries and especially wounds when it comes to describing the wounds and classifying them. It would have been useful to learn a risk assessment for patients with diabetes that would help provide continuity of care for our patients but also help the patients better understand what their risks are and further guide other clinicians. We can discuss the risks with patients but they often see these as abstract unless these risks are associated with a number, the same way we can check people’s blood pressure and show them a visible number. The patient understands this. As I read this information, I thought, wouldn’t it be nice if every clinician used this risk assessment guide so it could immediately guide other medical professionals when treating these patients? It would also help patients immediately know where they stand with their diabetes and risk of complications. You can find the risk assessment table at http://care.diabetesjournals.org/content/31/8/1679/T4.expansion.html .1 You should complete the risk classification for every patient with diabetes annually and change it as needed. Include this assessment in your notes and charting, especially if you are connected to an electronic medical records system with multiple specialty groups. It is an easy way for the other clinicians to understand these risk factors immediately. The goal would be to include this in the chart of every patient with diabetes. This will also be a good referral source from primary care physicians if they recognize that they should assess this information in every patient with diabetes. I intend this blog post to show the importance for every clinician of classifying patients with diabetes into a risk category. The same way patients should know their daily blood sugar levels and HbA1C, they should also know what their risk classification is for diabetes. I encourage others to start using this risk classification system. I would like to hear the thoughts of others on this topic. Feel free to comment below. Reference 1. Boulton AJM, Armstrong DG, Albert SF, et al. Comprehensive foot examination and risk assessment. Diabetes Care. 2008; 31(8):1679-85. Originally posted on Podiatry...

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