Abstract:

All chronic wounds are colonized by bacteria. Increased bacterial burden or critical colonization can be deleterious to wound healing. In view of the ubiquitous presence of microbes, the clinician must discern whether bacterial balance (contamination or colonization) or bacterial damage has occurred. Silver is a common topical agent used to combat bacterial burden in chronic wounds. Given the wide array of silver-related wound care products, it is difficult to determine which product should be used. By reviewing relevant scientific evidence, we propose an acronym SILVER© to address the key contentious issues. These issues are summarized as SILVER: Signs of bacterial damage, the need for Ionic silver, Log reduction of bacteria, Vehicle (importance of moisture balance), Effect on normal cells, and Bacterial Resistance.

Authors:

Kevin Y. Woo, R.N., M.Sc., Ph.D. (C), A.C.N.P., G.N.C. (C), Clinical Scientist /Advanced Wound Specialist, Women's College Hospital, Toronto, Ontario, Canada; Elizabeth A. Ayello, Ph.D., R.N., A.P.R.N., B.C., C.W.O.C.N., F.A.P.W.C.A., F.A.A.N., Faculty, Excelsior College of Nursing, Albany, New York; President, Ayello, Harris and Associates, New York, New York, R. Gary Sibbald, B.Sc., M.D., F.R.C.P.C. (Med) (Derm), F.A.P.W.C.A, M.Ed., Professor of Public Health Sciences and Medicine, University of Toronto, Toronto, Ontario, Canada

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Abstract:

Traditional treatment of venous stasis ulceration has focused on compression therapy, debridement, and topical wound management. Prospective randomized studies have shown that only two additional treatment modalities are effective in healing venous ulceration: pentoxyphylline and bilayered living-cell therapy. Although initial healing rates of up to 75% can be accomplished, there is an unacceptably high recurrence rate that is thought to be due to patient noncompliance. However, recurrence of venous stasis ulceration is more likely secondary to uncorrected venous hypertension, a disease whose causes have been largely ignored in wound treatment. Few previous studies show improved healing rates of ulcers after surgical correction of venous hypertension with saphenous stripping. Venous pathology responsible for venous hypertension can now be easily corrected with new minimally invasive techniques. The purpose of this chapter is to define venous hypertension in patients with ulceration, and provide evidence that surgical treatment to eliminate venous hypertension combined with evidence-based treatment strategies will not only improve short-term outcomes but will also prevent recurrent ulceration.

Authors:

Randy Shafritz, M.D., F.A.C.S., Assistant Professor of Surgery, Division of Vascular Surgery, University of Medicine & Dentistry of New Jersey, Robert Wood Johnson Medical School, New Brunswick, New Jersey; Laura Lamb-Susca, R.N., R.V.T.; Alan M. Graham, M.D., F.A.C.S.; Norman Rosenberg, Professor and Chief , University of Medicine & Dentistry of New Jersey, New Brunswick, NJ

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Abstract:

Chronic venous ulceration is a common and important medical problem that causes significant morbidity. Venous ulcers are expensive to treat, have substantial economic effects in terms of days of work lost, and adversely impact the patient's quality of life. Relying on evidence allows for a rationale of clinical decision making. The objectives of venous ulcer management include the healing of the ulcer, prevention of recurrence, and improvement of edema. Compression is the cornerstone of venous ulcer therapy. Adjunctive modalities such as surgery, growth factors, grafting, biologic skin substitutes, dressings, and oral medication have differing levels of evidence supporting their use, and may also facilitate the healing process.

Authors:

Jordana Herschthal, B.A., Department of Dermatology and Cutaneous Surgery, Robert S. Kirsner, M.D., Ph.D.,Vice-Chairman and The Stiefel Laboratories Professor of Medical Dermatology, Miller School of Medicine, University of Miami, Miami, Florida, USA

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Abstract:

Chronic wounds with exposed bone present a challenge for clinicians. Without intact periosteum, cortical bone is relatively avascular and provides a poor base for wound healing and skin grafting. It has been shown that cortical bone fenestration and decortication can expedite wound healing in exposed calvarial bone. We present a case study where cortical bone fenestration and the subsequent application of human skin equivalent were used to heal a chronic wound of the lower extremity. We propose that this technique can facilitate the production of granulation tissue, and can aid the healing of chronic wounds of the lower extremities associated with exposed bone.

Authors:

Wayne J. Caputo, D.P.M., F.A.C.F.A.S., Director, Wound Care Center, Department Chair, Division of Podiatric Surgery, Clara Maass Medical Center, Belleville, New Jersey, Director, Department of Podiatry, Columbus Hospital, Newark, New Jersey, USA; Charles D. Ganime, D.P.M., F.A.C.F.A.S., Private Practice, Winchester, Tennessee, USA; George Fahoury, D.P.M., F.A.C.F.A.S., Department Chair, Division of Podiatric Surgery, Monmouth Medical Center, Monmouth, New Jersey, USA; Stephen Longobardi, M.B.A., D.P.M., Private Practice, Union, New Jersey, USA

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Abstract:

The steps to achieving a healthy healing wound include a correct diagnosis, ensuring a good local blood supply, debriding the wound to reveal a clean base, correcting the biomechanical abnormality, and nurturing the wound until it shows signs of healing. Debridement should be performed as often as necessary until the wound is deemed clean and ready for reconstruction. The repair is then dictated by how much of the foot remains post-debridement and how the foot can be closed in the most biomechanically stable construct possible. The subsequent reconstruction can then usually be accomplished by simple techniques most of the time, and with complex flap reconstruction in about 10% of cases. Wound healing adjuncts such as growth factor, cultured skin, and hyperbaric oxygen can be helpful adjuncts.

Authors:

Mark W. Clemens, M.D., Resident, Department of Plastic Surgery, Georgetown University Medical Center, Washington, D.C. USA; Chris E. Attinger, M.D., Director, Wound Healing Center, Professor of Surgery, Georgetown University Medical Center, Washington, D.C., USA

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Abstract:

Critical limb ischemia (CLI) is implicated in cases of between 220,000 to 240,000 amputations in the United States and Europe annually. Over the last five years, great technical strides have been made in both the surgical and nonsurgical endovascular treatments of CLI. This chapter analyzes and highlights those creative limb salvage strategies now used to treat CLI and save limbs.

Authors:

David E. Allie, M.D., Chief of Cardiothoracic and Endovascular Surgery, Cardiovascular Institute of the South, Lafayette, Louisiana, USA

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Abstract:

Keratinocytes are the major cellular component of epidermis, and they have several critical roles in the wound healing process. They are involved in the intricate mechanisms of initiation, maintenance, and completion of wound healing. The properties of keratinocytes vary depending upon their location and circumstances within chronic wounds. Keratinocytes at the non-healing edges of chronic wounds differ from normal, healthy keratinocytes. The cross-talk between healthy keratinocytes and other cell types participating in wound healing is critical for successful wound closure. This discovery provides the biological foundation for debridement: Removing "bad" cells from a quiescent wound edge and exposing or even replacing them with "healthy" cells with a high regenerative potential can enhance epithelialization and healing of chronic wounds. This paper will review the biological and pathological properties of keratinocytes as they relate to wound healing, and the ways in which they may provide highly efficacious therapy for patients with chronic wounds.

Authors:

Irena Pastar, Ph.D., Senior Postodoctoral Fellow, Tissue Repair Laboratory, Hospital for Special Surgery of the Weill, Cornell Medical College; Olivera Stojadinovic, M.D., Instructor, Tissue Repair Laboratory, Hospital for Special Surgery of the Weill Cornell Medical College; Marjana Tomic-Canic, Ph.D., Director, New York, NY, USA

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Abstract:

Diabetic foot ulcers (DFU) are a common co-morbidity affecting patients with diabetes. A variety of factors, including diabetic peripheral neuropathy, altered gait, and increased pressure on certain regions of the foot, can over time result in a diabetic foot wound. Reducing pressure at the site of the ulcer can promote healing and prevent further ulceration. Offloading is an evidence-based treatment modality for patients with DFUs and is part of the standard protocol for treatment. We discuss here the most common offloading modalities, placing them in the context of relevant medical and compliance issues that affect their use and success.

Authors:

Desmond Bell, D.P.M., C.W.S., F.A.C.C.W.S., F.A.P.W.C.A., Fellow, American College of Certified Wound Specialists , Director, First Coast Diabetic Foot and Wound Management Center, Wound Summit Outreach, and Wound Care Consortium, Jacksonville, Florida, USA

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