Faculty

Robert Snyder, DPM, MSc, MBA, CWS-P

Robert J Snyder, DPM, MBA, MSc, CWSP, FFPM RCPS (Glasgow)
Dean, School of Podiatric Medicine
Professor and Director of Clinical Research
Director, Fellowship Program in Wound Healing and Clinical Research
Barry University School of Podiatric Medicine

Dot Weir, RN, CWON, CWS

Clinical Staff
Saratoga Hospital Center for Wound Healing and Hyperbaric Medicine
Saratoga Springs, NY

Disclosures

• Dot Weir: Consultant — 3M Healthcare, Medical Solutions Division, Smith &

Nephew, ConvaTec; Speaker — 3M Healthcare, Medical Solutions Division, Smith &
Nephew, ConvaTec

• Dr. Snyder: Consultant — 3M Healthcare, Medical Solutions Division, Integra,

RedDress, Mediwound; Speaker — 3M+KCI, Integra, RedDress, Mediwound
 Disclaimer

• The faculty have been informed of their responsibility to disclose to the audience if
they will be discussing off-label or investigational use(s) of drugs, products, and/or
devices (any use not approved by the US Food and Drug Administration)
– Applicable CME staff have no relationships to disclosure relating to the subject matter of this
activity
– This activity has been independently reviewed for balance

• This continuing medical education activity includes device or medicine brand names
for participant clarity purposes only. No product promotion or recommendation
should be inferred.

Learning Objectives

• Recognize the critical importance of a holistic approach to chronic wound

management

• Review the mechanism of action of negative pressure wound therapy (NPWT)

• Examine case outcomes for the use of NPWT across a variety of wound types

Wound Bed Preparation

Wound bed preparation is

an important step in treating and
protecting against
wound infection

DIME

Sibbald RG, et al (2011) Adv Skin Wound Care. 24:415-36

Schultz GS, Sibbald RG, Falanga V et al. Wound bed preparation: a systemic approach to wound management. Wound Repair
and Regeneration, 2003;11:1-28
 Wound Bed Preparation: Restoring the Balance

• Integrates proven concepts to build a platform for the treatment of chronic wounds
• Organizes medical procedures into a holistic approach that can be used to evaluate
and remove barriers to the wound healing process
• Optimal management of a wound in order to accelerate endogenous healing, or to
facilitate the effectiveness of other therapeutic measures
• Aim is the formation of good-quality granulation tissue, leading to complete wound
closure

Falanga V. Wounds. 2002;14(2):47-57. Enoch S, et al. Wounds. 2003;15(7):213-229.

Wound Bed Preparation: TIME

Tissue (debridement) Infection/inflammation

Moisture balance Edge of the wound

Breaking the Barriers to Healing:

NPWT
Dot Weir, RN, CWON, CWS
 Confirm the Etiology and Provide Supportive Care

• Venous
– Compression
• Diabetic
– Offloading
• Pressure
– Pressure redistribution
• Arterial
– Protection from injury
– Possible vascular intervention
• Atypical
– Low threshold for biopsy
– Possible medical intervention

Break the Barriers to Healing

• Intrinsic barriers
– Diseases or conditions that interfere
– with healing
– Increased age
– Obesity
– Edema
– Nutritional status
• Extrinsic barriers
– Smoking
– Mechanical stress/pressure
– Moisture
– Bacteria
– System barriers

NPWT Mechanism of Action

Thermoregulation and moisture retention

Macrodeformation

Drainage of wound
exudate including:
• Excess fluid
• Inflammatory markers
Optimization of
wound bed
Macrodeformation, microdeformation,
fluid removal, and alteration of the
Microdeformation
wound environment

Images adapted from: Panayi AC, et al. World J Dermatol. 2017;6(1):1-16.

 Edema Reduction/Tissue Decompression

Tissue edema is at minimum,

perfusion is ideal

Normal tissue

Tissue volume ↑, vascular density ↓,

perfusion distance ↑, and blood flow decreases
Edematous tissue

Images adapted from: Panayi AC, et al. World J Dermatol. 2017;6(1):1-16.

Microvessel Density
5
Microvessel density (%)

3 Before V.A.C.® Therapy

V.A.C.® Therapy with 3MTM V.A.C.®

2 GranufoamTM Dressing contact
V.A.C.® Therapy without
GranufoamTM Dressing contact
1

Before 1 2
treatment week weeks

ROCF = reticulated open cell foam.

Greene AK, et al. Ann Plast Surg. 2006;56(4):418-422.

A Case-Based Look at NPWT

Robert Snyder, DPM, MSc,
MBA, CWS-P
Clinical Photo

Angiogram

Post-op 1
 Post-op 2

Tendon and muscle exposed NPWT applied

Follow-up

Cadaveric allograft

Surgical STSG

STSG = split-thickness skin graft.

 Follow-up

Necrosis in a Patient with Diabetes

Secondary to Trauma
• 54-year-old African American male
with IDDM presented with liquefactive
necrosis after an insidious injury from
a car door to his lateral foot
• Symptoms were present for 5 days
• The area was foul-smelling with frank
purulence and pain
• The foot was swollen and painful
despite diabetic neuropathy
• The patient was urgently admitted
to the hospital

IDDM = insulin-dependent diabetes mellitus.

 NPWT Was Utilized With Silicone Dressing

• After endovascular
intervention, the patient
required an extensive
debridement
• Due to copious drainage
and a H/O non-
compliance, external
fixation with a foot plate
was utilized for offloading
and NPWT was started

H/O = history of.

After a “pocket” was

discovered, additional
debridement ensued,
and a dermal skin
equivalent was
applied; powered
NPWT was continued

• NPWT and frame were

subsequently
discontinued in favor of
collagen/ORC and total
contact casting
• The wound went on to
heal without incident

ORC = oxidized regenerated cellulose.

Portable NPWT
Availability Was Huge
for Outpatient Care

There Was Still an Unmet Need

• Patient’s need to
– Work
– Go to school
– Be social
– Ambulate
– Therapy
• Fall risk
• Sleep disturbances

Then Portable Became Wearable

 Mechanically Powered NPWT

• Mechanical, non-motorized,
ultra portable, disposable
negative pressure wound
therapy device
• Its ability to function without
electricity in an inconspicuous
manner makes it novel in the
wound care space, filling an
unmet medical need
• NPWT delivered under an
There has been a 12%-11% increase in
advanced wound dressing Why
nontraumatic amputations in patients with
now? diabetes since the advent of COVID-19
COVID-19 = coronavirus disease 2019.
Rogers LC, et al. J Am Podiatric Med Assoc. 2020;20-248

Ischemic Foot Ulcer in a Patient with Diabetes

Wound Bed Preparation

• Endovascular intervention
• Extensive debridement in the operating room
• Application of non-adherent silver dressing x 1 week
• NPWT x 2 weeks
• Offloading with CAM walking boot
• NPWT utilized with silicone contact layer

CAM = controlled ankle movement.

 Rotational Flap with NPWT Incision Management

NPWT Incision Management

Actively manages and protects
surgical incisions
• Holds the edges of the incisions together,
reducing the risk of dehiscence
• Decreases lateral tension and edema
• Protects the operative site from external
infectious materials
Region H, Feb 2013

Completely Healed Flap

Necrosis Secondary to Infection and Compartment

Syndrome in a Patient with Diabetes
• 67-year-old White male with insulin-dependent
diabetes
• History of a small ulceration under the first
metatarsal head
• Returned from a business trip after walking
extensively and sitting for long periods
in an airplane
• Area was painful despite sensory neuropathy
• Recent history of distal bypass, which
was still patent
• Surgery was considered emergent
 S/P Open Amputation

• Cadaveric allograft was

fenestrated and applied to the
open wound
• NPWT was utilized for
approximately 2 weeks with a
silicone contact layer
• An angiogram revealed 3-vessel
run-off and vascularity was
deemed appropriate to support
healing

S/P = status post.

• Patient healed the TMA but

subsequently returned with necrosis
and infection secondary to lack of
adherence and a tight shoe
• Emergent surgery was undertaken, and
all necrotic tissue was removed

TMA = transmetatarsal amputation.

Extensive Wound Debridement

S/P debridement Application of acellular dermal matrix

 2 Weeks S/P Dermal Matrix, and NPWT

• A split-thickness skin graft

was performed and NPWT
was continued for 5 days
• A silicone dressing was
utilized as an interface
between the graft and
NPWT

TMA = transmetatarsal amputation.

How Do We Put it All Together?

 Quality
Measures

Snyder RJ, et al. Adv Skin Wound Care. 2016;29(5):205-215.

Diabetic foot ulcer evaluation

Comprehensive
history & physical

Vascular Neurological
evaluation evaluation VIP Dermatologic
evaluation
Orthopedic
evaluation

Assessment
Treatment

Moist wound Healing

Debridement Offloading Matrices Infection control
Biologics

Snyder RJ, et al. J Am Podiatr Med Assoc. 2014;104(6):555-567.

If the Only Wound Treatment You Have Is a…

Every Wound-Healing
Problem Will Be a…
 Utilizing NPWT
to Meet
Multiple
Needs…
Dot Weir, RN, CWON, CWS

The Need to Manage Exudate

• 71-year-old
• Venous leg ulcer
• S/P fem/pop bypass
• Venous wound: No problem
– Gelling fiber, foam, and 2-
layer wrap

• Thigh wound with copious

exudate, presumed lymphatic
• MP-NPWT x 3 changes,
6 days, exudate stopped

MP = mechanically powered.

The Need to Manage Exudate

• 75-year-old female, removal of

lipoma resulting in lymph leak
• Depth decreased from 2.5 to
0.6 cm
• Exudate from copious to
minimal
• 2 weeks, 4 MP-NPWT
changes
 The Need for Creativity

• 40-year-old Hispanic male

• Hx: Type 1 DM, ESRD on PD, sensory neuropathy, HTN
• Debridement of abscess
– 1.0 x 2.2 x 4.4 cm

Hx = history; DM = diabetes mellitus; ESRD = end-stage renal disease; PD = peritoneal dialysis; HTN = hypertension.

Curette to Smooth Out Surface

Prep and Protect Skin; Hydrocolloid Ring Added

 Foam Placement

Application of Bridge Dressing and

Transparent Film to Seal

Final View
 3 Weeks of Treatment

3 Weeks

At 4 weeks, cell therapy applied

Closed at 8 Weeks

The Need to Meet All Support Needs

3 Weeks
 Meeting All Support Needs

6 Years

At 4 weeks, cell therapy applied

 The Need for Edema Management

• 79-year-old female
• PMH: HTN, multiple sclerosis, lower
extremity neuropathy
• Lower extremity edema, pulses present
per palpation and doppler
• Moved from out-of-state to be near
daughter; dropped box on leg during move
• Daughter has original photos; clearly a
hematoma
• Initial measurements: 3.5 x 3.0 x 0.5 cm
– 3.5 cm undermining 8-1 o’clock
• Initial management: PVA gelling fiber,
foam dressing, 2-layer wrap
PMH = past medical history; PVA = polyvinyl alcohol.

• 10 days: Wound smaller, undermining

less, leg volume decreasing
• Sharp debridement
• Began MP-NPWT and continued 2-
layer wrap

• 4 days later: Improved granulation • 11 days: Undermining down

tissue, minimal slough; continued to 0.2 cm
reduction in leg volume
 • At 5 weeks: MP-NPWT • 1 month later: Closed, placed in
discontinued and began collagen compression stockings
dressing with silicone bordered
foam and 2-layer wrap

The Need to Work

• 43-year-old morbidly obese gentleman, works at theme park 1 shift per day, then
works at a convenience store another shift per day
• Deep ulcer to his lower extremity
• Powered NPWT initiated 3/26
– Was not doing well; when questioned, learned that he was removing suction while he worked
because neither employer would allow him to have it showing
– Not working was NOT an option; powered system discontinued 4/6; wound did not progress

Initial wound presentation 2.5 weeks: NPWT discontinued

 Patient was able to continue working 2 jobs; disposable MP-NPWT device
was run up his leg and he could slip the cartridge in his pocket undetected

5 weeks later: MP-NPWT initiated 28 days later: MP-NPWT discontinued

Parting Shot…

Sternal Wound: A Look Back in History

• 42-year-old male
• Morbidly obese
• Type 2 diabetes, fair control
• CABG 09/2010
– Post-op infection down to
wires
– Revision of wound with
removal of wires 11/30
– Began disposable MP-NPWT
while awaiting charity-
powered system

CABG = coronary artery bypass graft.

 Application

Summary

• An ongoing comprehensive evaluation of

the patient is imperative
• Edema is a significant problem in wound
healing
• Negative pressure wound therapy is a
critical component in our management of
chronic, hard-to-heal wounds

Thank You
Q&A
 Case Analysis
Now it’s Your Turn to Decide…

Case 1

• 53-year-old African American male with insulin-

dependent diabetes
• Non-palpable pedal pulses
• Cool right foot
• Foul-smelling wound right hallux with severe pain
despite diabetic neuropathy
• Duration 5 days with no previous treatment
• Febrile with a white blood cell count of 18,000/μL

What Would You Do?

1. Order an angiogram and vascular consult

before any local/surgical intervention
2. Take the patient to the OR urgently for
extensive debridement prior to vascular
intervention
3. Treat locally with outpatient wound
debridement and topical antiseptics

OR = operating room.
 After successful endovascular intervention,
a transmetatarsal amputation was performed; however,
patient had significant tissue loss at the site of the original
surgery, making complete closure challenging

IV antibiotics x
6 weeks
Multidisciplinary
approach

Now
what?

IV = intravenous.

Patient had the benefit of NPWT for 2 weeks, however,

still had an open wound
Collagen/ORC/silver x 2 weeks Collagen/ORC to closure

Mechanically
powered NPWT

Case 2

• 68-year-old Haitian male with insulin-

dependent diabetes
• Weakly palpable posterior tibial
(monophasic) with ABI of 0.3 mm Hg
• Necrotic right great toe
• Severe pain despite severe diabetic
neuropathy
• Crepitus
• White blood cell count and CRP WNL
• Afebrile
• 5 days duration
ABI = ankle-brachial index; CRP = C-reactive protein; WNL = within normal limits.
 What Would You Do?

• Order an urgent IR consult with potential

intervention prior to surgery
• Urgent OR debridement, including partial
first ray amputation
• Hospitalize for IV antibiotics and wait until
infection begins to resolve
• The patient has no constitutional
symptoms; after culturing, treat
empirically outpatient with oral antibiotics
and local wound care

IR = interventional radiology.

The patient undergoes successful distal endovascular

intervention and now has 3-vessel run-off; a multidisciplinary
approach is utilized

Now
what?

The patient has 3 weeks of NPWT with silicone dressing as an

interface; he will require a total of 6 weeks of IV antibiotics
 The patient is still exhibiting copious drainage and
increased bioburden
Silver alginate x 2 weeks Collagen/ORC/silver x 2 weeks

Now
what?

What Now?

Moist wound
healing to closure
(eg, hydrogel,
foam)

MP-NPWT?