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The Wound Healing Spectrum

The Wound Healing Spectrum

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Published by: davidarmstrong on Oct 13, 2009
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 The Journal of Diabetic Foot Complications Open access publishing  The Journal of Diabetic Foot Complications Open access publishing 
The Wound Healing Spectrum: A Timeline forthe Utilization of Advanced Technology
Ryan H. Fitzgerald, DPM
, Lee C. Rogers, DPM
, David G. Armstrong, DPM
 The Journal of Diabetic Foot Complications, Volume 1, Issue 3, No. 3, © All rights reserved.
The Journal of Diabetic Foot Complications, Volume 1, Issue 3, No. 3, © All rights reserved.
The Wound Healing Spectrum: A Timeline forthe Utilization of Advanced Technology
Ryan H. Fitzgerald, DPM
, Lee C. Rogers, DPM , David G. Armstrong, DPM
There is a clear relationship between thedevelopment of lower extremity diabeticulceration and subsequent non-traumatic lowerextremity amputation. Therefore, it is vital thatclinicians involved in the care of the lowerextremity manifestations of patients living withdiabetes mellitus have a thorough knowledgeof the pathophysiology as well as currentmanagement principles for diabetic foot ulcers.There are numerous advanced modalities andtherapies available in the management ofcomplicated lower extremity wounds. However,a search of the literature demonstrates nodiscussion regarding when each modalityshould be utilized to appropriately progress awound through the phases of wound healing.This paper presents the three phases withinthe continuum of wound healing: wound bedpreparation, promotion of granulation tissue,and wound closure. We seek to demonstratethe appropriate utilization along the timeline forwound healing for the numerous advancedwound healing modalities available.
Key words:
Diabetes, Wound, graft, collagen, stemcell, growth factor, Negative Pressure, Larvae,bioengineered tissues.
Address for Correspondence:
David G. Armstrong, DPM, PhD. Professorof Surgery, University of Arizona College of Medicine, 1501 N. CampbellAvenue, Tucson AZ 85724-5072 , United States of America+1 520 360 0044+1 520-423-3091 (FAX)Armstrong@usa.net
Hess Orthopaedics & Sports Medicine, Harrisonburg, Virginia.
Director, Amputation Prevention Center at Broadlawns Medical Center, DesMoines, IA.
Director, Southern Arizona Limb Salvage Alliance (SALSA) and Professorof Surgery, University of Arizona College of Medicine, Tucson, AZ.
With the incidence of diabetes on the riseworldwide, practitioners involved in the care of these patients have seen an increase in thesubsequent complications associated with diabetes.Among these, lower extremity ulcerations are verycommonly observed.
Numerous studies havedemonstrated that lower extremity ulcerations are amajor risk factor for amputation, and the morbidityand mortality associated with amputation in thispatient population is severe.
It is incumbent onthe physician participating in the care of thesecomplicated patients to be well versed in theprinciples of wound care. There are numerous basicand advanced wound care modalities and techniquesavailable to the clinician to promote wound healing.However, a search of the current literaturedemonstrates that there have been no clear attemptsto quantify a timeline as to when each techniqueshould be appropriately utilized until now.Prior to initiation of the wound healing timeline, itis necessary that those predisposing factors whichcontribute to wound development, progression, andchronicity be addressed. Vascular status, infection,and pressure are known as the “VIPs” of diabeticwound healing. These factors significantlycontribute to wound formation and therefore mustbe addressed prior to initiation of wound healingmodalities and progression through the continuumof wound healing.
Without appropriatediagnosis and management of these VIPs, woundswill not heal, regardless of the modalities that areutilized.
 The Journal of Diabetic Foot Complications Open access publishing 
Figure 1
Temporal sequence of Wound Simplification and modalities utilized.
64Debridement is a vital component of wound management, and it is the necessarystarting point on the spectrum of wound healing inthe treatment of lower extremity ulcerations.
 (Figure 1) Debridement provides for the removal of all fibrotic, necrotic, and nonviable tissue inaddition to any undermining that will impedewound healing and promote infection.
This tissuecan appear yellow, gray, black, or tan, and can bewet or dry. Removal of necrotic, nonviable tissuedown to a bleeding, base is necessary to allow forwound bed preparation and the formation of healthygranular tissue and neoepithelialization.
 Additionally, debridement is useful in stimulatingsenescent cells observed in chronic wounds.
Inthis way, debridement removes nonviable tissueswhile also stimulating the cells contained within thewound bed. In effect, it converts a chronic wound toa more acute, active wound.Studies have demonstrated that wounds respond tosuch maintenance debridement with decreasedhealing times associated with increasing numbers of debridements. In fact, Armstrong et al. found thatdiabetic foot ulcers that were debrided on each visithad a 5.3-times greater chance of healing in 12weeks than ulcers that were debrided less often.
 There are numerous methods of debridementavailable to the clinician and these will be discussedin detail below.
Mechanical debridement is one of the oldestmodalities that has been used by wound careclinicians to effect wound debridement.
The twomost common examples of mechanical debridementinclude whirlpool hydrotherapy and wet-to-drydressings. In hydrotherapy debridement, thepressure of water in a whirlpool is utilized toprovide tissue debridement.
 The Journal of Diabetic Foot Complications Open access publishing 
Wet-to-dry dressings provide mechanicaldebridement by essentially allowing a saline-moistened gauze to dry and adhere to the woundbed.
When the dressing is removed, all tissue thathas become adherent to the dressing is mechanicallyremoved as well.65While effective and inexpensive, these modalitiesare nonselective and can damage burgeoninghealthy tissue that is trying to form in the woundbed. In addition to being nonselective, mechanicaldebridement therapy can be very painful.Whirlpool hydrotherapy is generally less painful,but there is significant risk of skin maceration andbreakdown, in addition to risk of contamination andinfection with waterborne pathogens.
Attemptsto disinfect the circulating water utilized inhydrotherapy have yielded mixed results and oftenthe additives utilized for disinfection are cytotoxic.This can further damage the wound retard woundhealing. Considering the numerous disadvantagesof mechanical debridement, this method is notrecommended unless the circumstances necessitateits use.
Autolytic debridement therapy utilizes the body'sown enzymes and moisture to liquefy hard escharand slough.
Autolytic debridement is selective;only necrotic tissue is liquefied, and this modality isvirtually painless for the patient. Autolyticdebridement can be achieved with the use of occlusive or semi-occlusive dressings that maintainwound fluid in contact with the necrotic tissue.
 However, autolytic therapy may promote anaerobicbacterial growth if occlusive hydrocolloids areutilized and therefore the wound must be monitoredclosely for signs of infection. Autolytic therapy canbe used on its own after surgical debridement inconjunction with enzymatic or mechanicaldebridement. This is helpful for patients who cannottolerate other forms of debridement.
Enzymatic debridement utilizes topical ointmentswhich contain chemicals that actively breakdownfibrotic and necrotic tissue.
Some enzymaticdebridement agents are selective, such ascollagenase, while others are not.Often, this therapy is used in conjunction with othermodalities and, like autolytic therapy, enzymaticdebriding agents can be utilized in those patientswho are not candidates for more aggressive surgicaldebridement.
One enzymatic debriding agentavailable to the clinician is collagenase (Santyl
,Healthpoint Ltd, Fort Worth, Texas). This contains250 collagenase units per gram of white petrolatumbase, and the enzyme, produced by the fermentationby
Clostridium histolyticum
, specifically targets thecollagen in necrotic tissue while newly formed orhealthy tissue is not attacked.
In this way, onlynonviable tissue is removed thereby promoting theformation of healthy granulation tissue and neo-epithelization.
Surgical debridement is the most rapid means of removing the nonviable and necrotic tissuecontained in a wound. It can be performed in theoperating room or at bedside depending on theextent of the debridement required and theclinicians’ ability to manage the patient’s painlevel.
19, 32-35
There are multiple methods to effectsurgical debridement, ranging from sharpdebridement with a scalpel to newer advances intechnology that speed and improve efficiency of surgical debridement. Among these, hydro-surgicaland ultrasonic debridement devices are showingpromise in providing significant, selective softtissue debridement.
Much of this technologywas initially described in the literature regarding thesurgical management of full and partial thicknesswounds, and has now been incorporated into themanagement of complex lower extremityulcerations.

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