Transcription:
Limb Salvage Services and Advanced Wound Care Center

Bill Klaproth (Host):  Welcome to Aspirus Health Talk. I'm Bill Klaproth and today we're talking about chronic wounds and treatment and discussing the Limb Salvage Services and Advanced Wound Care Center at Aspirus. And joining us is Dr. Jonathan Brueggeman, Director of Advanced Wound Care at Aspirus. Dr. Brueggeman thank you so much for your time. It is great to talk to you. So, first off, what is the difference between a wound clinic and an advanced wound care center?

Jonathan Brueggeman, DPM, FACFAS, AAPWCA (Guest): For me, the big thing that distinguishes those two from each other is standard wound clinics would have the bare bones specialists involved in the care of patients with wounds. So, with the Wound Clinic, you've got your   standard care teams, whether it be a nurse or a different type of provider, but no other outside resources to round out, say a full team. With an Advanced Wound Care Center, you're doing all the same things, but I look at it more as a multidisciplinary approach to wound care, which actually gives you the best chance at decreasing wound healing rates and improving the outcomes.

Host: And then if you could, tell us about the Limb Salvage Program and how that fits in.

Dr. Brueggeman: Yeah. The Limb Salvage Program actually takes that a step farther and starts to deal with what things are involved with causing the ulceration and removing those risks that are causing the ulcerations that'll decrease the chances of it coming back. When I think of that, I think about the team that should be involved including, not only the primary care providers, nursing and dieticians who are kind of the first people to evaluate wounds a lot of times and help with self-care behaviors, diet modification, blood sugar control, and things like that when we deal with diabetics, but then involve foot and ankle surgery like myself, general surgery for wounds which are above the knee and then orthopedic surgery as well can be involved as well as that. On top of that vascular surgery and vascular consultations to help with blood flow and then infectious disease. And of course our actual wound care team, which does the local wound care itself.

Host: Yeah, there is a lot to this. So, can you discuss your goals then for the Limb Salvage Services Program?

Dr. Brueggeman: Yeah, for sure. Initially, since we're dealing with a large geographic area and actually a very rural area in the UP as well, we'll probably start more with a virtual limb salvage center instead of a brick and mortar, kind of this is where the limb salvage center is type of situation, which you would do in a larger city. So, in other words, I'd like to implement an algorithm that primary care doctors, urgent care and ED providers can follow to basically identify these wound patients immediately and try to get them in front of a specialist like myself within 48 hours. And that's kind of the ultimate goal. I do like to use this team care approach, which was coined by one of the people I trained under. It's called the toe and flow model, which really centers around vascular and Podiatry or foot and ankle surgery, and then surround it with all the other team members I mentioned previously.

Host: The toe and flow model.

Dr. Brueggeman: There you go.

Host: That's a good one. So, we're talking about chronic wounds. So, can you explain this to us? What is considered a chronic wound? Is this a wound that just won't heal?  

Dr. Brueggeman: Yeah, exactly. A chronic wound is a wound that doesn't heal in an unexpected way or in a predictable amount of time as most wounds do. They can be recognized by a number of different symptoms, including more loss of skin or tissue around the wound or by the amount of time you can do it by as well. For most of our wounds, a lot of times you're dealing with diabetics who don't have sensations. So, they don't actually correlate a wound as being bad as you or I would. If we had a big hole on the bottom of our foot, obviously, we'd pay attention and complain to everybody we know about it. Whereas a diabetic may not feel any pain associated with a deep wound and thereby doesn't prioritize it in their life as much as they should. So, usually, we'll see wounds that have been present for weeks, months, or even up to years.

Host: Right. What makes chronic wounds difficult to heal?

Dr. Brueggeman: There's a number of different things that make chronic wounds difficult to heal. And the hardest or the thing I see the most is one, a lot of bad tissue. That's the easiest, most layman way to put that out there, develops around the wound and within the wound itself. Not only bad tissue, but dead tissue can build up as far as callus around the wound, which covers over the wound and doesn't allow the wound to drain, like it would need to, as well as doesn't promote any new tissue from forming into that wound itself as well. On top of that, chronic wounds will develop something called a biofilm over the wound, which is actually, kind of a superficial infection of bacteria on the wound surface itself which just keeps perpetuating this chronic cycle of non-healing tissue.

Host: So who is at risk for this? You mentioned earlier diabetes and diabetics, is that who mainly is at risk for this.

Dr. Brueggeman: Honestly, the most common is diabetic, but we also deal with a good number of patients that have two other main conditions, which are both vascular issues, one being an arterial issue or a peripheral vascular disease, which is a lack of blood flow getting to the extremity. Which obviously, if you don't have any blood getting to the tissue, that's your main way of providing oxygen to your tissues, so, you're not going to form new tissue to heal a wound if you're not getting adequate blood flow. The other blood flow issue we have is called venous insufficiency, which is a backflow or a backup of fluid collecting in the legs which causes a whole different problem with wound healing with a lot of extra fluid in the legs. The body pushes that fluid out of the open wound which also slows down healing significantly and they're all treated differently.

Host: All right. So, you just mentioned treatment. I know there are several ways to treat chronic wounds. So, let's go through a few of those. Now let's start with debridement.

Dr. Brueggeman: Yep. Basically, that is the manual way of cleaning a wound bed and the wound periphery. So, if there's any bad tissue surrounding or within the wound itself, we actually use cold, hard steel or a scalpel to mechanically debride or take away that bad tissue. Now, the common misconception I hear from patients is all that doctor cut on my foot and made the wound larger. And it's a common misconception and usually on the first times I evaluate the patient and go over these things we explain it really well otherwise, that is a misconception. But you need to take away everything that is not healthy to promote the wound to heal. Likewise, we already touched on chronic and acute wounds. Literally when you take a scalpel to a wound, we are converting a wound from chronic to acute by physically traumatizing the tissue.

Host: And then one that we in the general public would probably think of first is some kind of a special dressing or dressings.

Dr. Brueggeman: That's right. It could be an entirely different podcast on someone regarding the actual names or the types of dressing. So, I guess the biggest thing for patients and the general public to understand is that the wound care professional who's seeing you, whether it be the physician or the nurse or physical therapist will evaluate the wound and pick the appropriate dressing based on how the wound looks that day. So, we have dressings that will address the amount of moisture the wound has, or lack of moisture. We have dressings, which will treat different types of bacteria within the wound bed itself, which is that biofilm we had discussed with debridement. And then we have dressings, which will actually promote wound healing and further the healing or speed up the healing as well. Those are kind of the main categories, I guess I would separate dressings into.

Host: So, as the wound heals, it will excrete fluids. Is that right?

Dr. Brueggeman: Correct. Wounds will excrete fluids, right from the very start. Different wounds even drain more, depending on the type of wound they are. So, again, a lot of us that are in wound care, like to say the wound tells us what to put on the wound to get it to heal. And that's very true. So, when you're dealing with things like venous wounds, you're already dealing with an abundance or excess of fluid in the legs. And I always paraphrase to my patients that water in your legs as kind of like getting water in your roof. It's the water's going to follow the path of least resistance and in your house it goes down the walls. And that's usually where it ends up or to the ceiling and one wall. But it's following a path of least resistance. In your legs, if you have a hole in your leg and an excess amount of fluid in your leg, most of that fluid is going to go out that hole. Okay. So, the reason a lot of venous wounds have a hard time healing is they have so much extra fluid flushing out of the wound that your body cannot lay down new cells to heal the wound. They're constantly being flushed away. So, the main treatment with venous wounds is compression. You compress the leg and keep that excess fluid from coming out of the wound, which gives the body a chance to do its normal process, which is heal.

Host: So, with this excess fluid coming out of the wound another way is to kind of use a vacuum then. Right? Vacuum assisted would be kind of like a negative pressure wound therapy. Is that how that works?

Dr. Brueggeman: Correct. And we use the wound vac for a number of different reasons, whether it be on our grafts or whether we use it on a wound itself, which is not improving with regards to the appearance of the wound or even the size of the ulceration as well. And the vacs work by creating negative pressure around the wound and also by removing fluid away from the wound bed itself. The wound care professional is taking and putting a special bandage over the wound, which includes a sponge going over the wound itself, and then attaching that to a vacuum pump, which is then connected to a canister to collect the fluid. So, that It is all being pulled away from the wound and then also creating negative pressure at the wound and sealing that area. So, that you can control basically the atmosphere within the dressing itself over the wound.

Host: And then Dr. Brueggeman, and you were talking earlier about putting pressure on a wound. And then another technique I know is taking pressure off of a wound. What is that?

Dr. Brueggeman: Yeah, correct. Offloading of a wound, or removing pressure from the base itself is ultimately one of the most important things you need to do to get a wound to heal, because if you're constantly walking on an area, where your body is trying to lay down new cells, obviously, it's not going to work. So, the best way to do that is to remove pressure altogether. You can do that initially with complete offloading, whether that is with crutches or wheelchair or a knee scooter or something of that order. Or you can do it through actual different modalities. One of those being the big cast boots that you see, and we have special ones within our wound program where we can actually take out areas to take pressure from the underside of the foot away and remove pressure from the wound base itself. Or we can actually apply offloading padding to the skin.

And then we have more advanced modalities, like total contact casting, where we're putting a short leg cast on somebody and transmitting the forces the foot would absorb and putting them up to the healthy part of the leg and offloading the entire foot. Beyond that, then there's even more specialized ways we could get into, but that's kind of the gist of it.

Host: And then how about rotational flaps and skin grafts?

Dr. Brueggeman: So, once you get into that, everything has to start at a certain place. So, that initial wound evaluation, you're getting the wound healthier in appearance, and you're decreasing that biofilm through debridement. And you're also putting the right dressings on to get the wound to a healthy appearance. Getting rid of all the non-healthy tissue over the wound and once the body is prepared, then we can move into other more advanced methods of getting a wound to heal. A lot of times, it could involve going to the operating room or sometimes in the clinic through skin substitute grafts or grafts not made from the person's own tissue. So, we're getting that from donors. Some of the newer grafts are made actually from STEM cells taken from an umbilical cord, so to speak.   Those too basically help increase the healing potential of the wound by putting some of those native cells or building cells like collagen to the wound base and allowing the body to have to do less work, to get the body to heal.

Once you've gone through those or have other options, then we can start looking into even more advanced methods of closure, which should be skin rotational or adjacent tissue transfers or flaps, where we can take tissue immediately adjacent to the wound, and we cut the skin and rotate that tissue to cover the chronic area. So, you completely surgically excise the wound and then move adjacent tissue over to cover that area. Then obviously there's other flaps or grafts as well, where we can actually harvest skin from a different part of the body, like the thigh or the back or abdomen and move and cover over tissue as well.

Host: These chronic wounds can be really perplexing sometimes. Right. And serious, if you're unable to get this wound to heal. It isn't like, oh, I've got a bandaid. My it's just not healing. It takes a little time. I mean, this can really be serious stuff. Is that correct?

Dr. Brueggeman: Oh, of course. I mean, a lot of people aren't aware of the diabetes related statistics on amputations and really, that's why when people get these ulcerations and diabetics are fearful of things, what they're really fearful of is amputation, that's the biggest thing that people hear of, and that's why we have, what's called a Limb Salvage Program is we are trying to prevent these higher level amputations. And the reason is because of these diabetes related statistics. For people on dialysis, receiving an amputation, meaning like a higher level amputation below the knee or above knee amputation, the two year mortality rate is 74%.

And that's huge compared to cancer, it's second only to lung cancer, which has an 86% mortality rate. So, you're dealing with a very serious problem. The relative five-year mortality rate is, after a limb amputation is 68%, which is high, just with a single limb amputation.

Host: Wow, that really is something. So, then again, this is a perplexing problem, but that's why people like you know what you're doing and fix these things. So, then what happens after a chronic wound is healed? What special care is needed to prevent it from returning?

Dr. Brueggeman: What I think really sets this team care apart from just having a standard wound clinic, you don't necessarily have a foot and ankle surgeon involved who can then take the patient the rest of the way to the end zone is what I always like to term, because I tell patients when they heal, that's not the end of it. I like the football analogy. I tell people healing the wound is like getting to the 20 yard line and dropping the ball. Because if you don't deal with the aftercare afterwards, they all inevitably ended up back in your office with a recurrent ulcer. That comes down to the right shoes, the right inserts, possibly the right bracing, or in the severe instances, that's when we get into the deformity correction part of my foot and ankle surgical specialty, where we look at what is the underlying etiology or cause of that ulceration? Is it due to a really tight Achilles tendon and associated calf muscles, or is it due to a musculoskeletal deformity like Cavus foot which is a high arched foot and hammer toes or a bad bunion, or, you know, whatever the case may be and diabetes, we go as a major condition called Charcot foot deformity, which leaves the patient with severe deformities with regards to bony prominences and a dysfunctional foot. So, you kind of have to take all of that into perspective, after you've healed the wound and then try to make sure the patient doesn't end up back in your operating room for an amputation.

Host: Wow. There is really a lot to this. And like you said, after it heals, you don't want to drop the ball on the 20 yard line. There's still a ways to go to get into the end zone. Obviously you really want patients to follow that advice and take it home all the way. Well, Dr. Brueggeman, this has really been fascinating, a really interesting topic. And thank you so much for your time. We appreciate it.

Dr. Brueggeman: Thank you. I appreciate speaking on the subject.

Host: That's Dr. Jonathan Brueggeman and thank you for listening to this episode of Aspirus Health Talk. Head on over to our website@aspirus.org for more information, and to get connected with one of our providers. And please remember to subscribe, rate, and review this podcast and all other Aspirus podcasts. And for more health tips and updates, follow us on your social channels. Thanks for listening.