What’s new in wound management??

Dr. Kevin Y. Woo PhD RN FAPWCA Assistant professor, Queen’s University

Wound Care Consultant, West Park Health Centre, Toronto

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Medical therapies

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! Pentoxifylline

! Horse chestnuts (Escin)

! Hydroxythylrutoside (HER) semisynthetic flavonoids

! Daflon

! Sulodexide (LMWH + dermatansulfate)

! NSAIDs

! Zinc sulphate

! Anticoagulation

! Diuretics?

! Cilostazol (vasodilator)

! Topical nitroglycerine

! Prostacyclin analogues

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Surgical intervention

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! Vein ligation/stripping

! Radiofrequency ablation (RFA)

! Endovenous laser therapy (EVLT)

! Foam sclerotherapy

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Evidence for compression! >21 RCT

! Compression better than no compression

! High compression better than low compression

! Use high compression system best suited to the patient ,provider and health care system (modified )

! NO difference between short stretch and long stretch

! Multi-component is not better 6

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Laplace’s Law-The interaction of factors that affect the pressure produced by a compression therapy system

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Assessment methods Comments

ABPI >0.5 sensitivity = 90%; specificity = 95%

Transcutaneous oxygen tension "

> 30 mmHg"sensitivity = 77% (increases to 100% post

exercise); specificity = 83%

Toe pressure >55 mmHgsensitivity =8%, the specificity =96%, the

positive predictive value 12%, and the negative predictive value = 94%.

Skin perfusion pressure SPP of 40 mm Hg sensitivity= 72%; specificity= 88%

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Foot ulcers (diabetes)

! 2–3% PWD develop a foot ulcer/ year ! 25% lifetime risk of developing a foot

ulcer ! cost of diabetic foot ulcers (not requiring

amputation): US$993 to US$17!519 (1998)

! Foot ulcers precede 84 percent of all nontraumatic lower limb amputations in PWD

! Diabetic associated lower-extremity ulcers are responsible for 92,000 amputations annually

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Diabetes Mellitus

Trauma

Neuropathy

MOTOR

WeaknessAtrophy

Deformity

Abnormal Stress

High plantar pressure

Callus formation

SENSORY

Loss of protectivesensation

AUTONOMIC

AnhidrosisDry skin, FissuresDecreased sympathetic tone(Altered blood flow

regulation)

Osteoarthropathy

Vascular Disease

MICROVASCULAR

Structural: Capillary BM thickeningFunctional: A-V shunting Increased blood flow Neuropathic edema

MACROVASCULAR

Atherosclerosis

Ischemia

Reduced nutrientcapillary blood flow

Impaired Response to Infection

Amputation DIABETIC FOOT ULCERATION Amputati

FIGURE 1 Contributing factors in the pathogenesis of ulceration.

TABLE 2 Risk factors for amputation

! Peripheral sensory neuropathy! Vascular insufficiency! Infection! History foot ulcer/amputation! Structural foot deformity! Trauma! Charcot deformity! Impaired vision! Poor glycemic control! Poor footwear! Older Age! Male sex! Ethnicity

Infection is a significant risk factor in the causal pathway to amputation,while it is not often implicated in the pathway leading to ulceration (9,15). Lackof wound healing, systemic sepsis, or unresolved infection can lead to extensivetissue necrosis and gangrene requiring amputation to prevent more proximal limbloss. This includes soft-tissue infection with severe tissue destruction, deep spaceabscess, or osteomyelitis. Adequate debridement may require amputation at somelevel as a means of removing all infected material (16,22,50).

Another frequently described risk factor for amputation is chronic hyper-glycemia. Results of the Diabetes Control and Complications Trial (DCCT) and theUnited Kingdom Prospective Diabetes Study (UKPDS) have supported the long-held

S10 Diabetic Foot Disorders: A Clinical Practice Guideline

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Ingrown nails

! pincer nail (overcurvature of the nail plate that may be genetic with an adult onset), subcutaneous ingrown toenail, and hypertrophy of the lateral nail fold.

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Nail care

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DFU prevention

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Transitional Approach to Tissue ProtectionDeep open

wound

• Total Contact Cast (TCC)

Shallow wound

• Removable Cast Walkers

• Felted Foam

Newly closed wound

• Carville Healing Sandal

• Diabetic Healing Shoe

Closed wound x 2-4 Weeks

• Depth Shoe with Rocker Sole

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Practical approach to biofilm management

Chronic woundStatic healing, moderate improvement with repeated rounds of oral antibiotics

Suspected bio!lm

Reduce bio!lm burden debridement/vigorous cleansing

Prevent recontamination with microorganisms barrier dressing AND

Suppress bio!lm reformation sequential topical antimicrobials

Healed

Reassess healing

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