Wound care can be complex and challenging, and a wide array of treatment modalities are used to aid in the healing process, with management options ranging from simple wet-to-dry dressings to more complex biologically engineered tissue products. For O&P practitioners, a broad understanding of wound care dressings and techniques can be helpful in providing comprehensive patient care.
With wet-to-dry dressings, saline-soaked gauze is placed on the wound first and dry gauze then is placed over the wet gauze. As the water evaporates and is absorbed in the outer dressing, the bottom gauze sticks to the wound. When the gauze is peeled off the wound, any loose debris also is removed with the gauze.
Although wet-to-dry dressings can be effective in treating wounds, several limitations are associated with this type of dressing. Such dressings must be changed several times a day, which precludes home wound care by visiting nurses, and inpatient care is not covered by insurance unless patients are septic or have medical problems. In addition, gauze wet-to-dry dressings are bulky and cannot be packed into a prosthesis. These drawbacks have led to the development of other dressings and techniques that treat wounds in the same way, said Christian Ertl, MD, FACS, private practice surgeon and clinical instructor at University of Connecticut.
Negative pressure wound therapy
One such technique is negative pressure wound therapy, which uses continuous negative pressure suction in a sealed environment to pull fluid from the wound and thereby promote healing. Used in the past as a therapy of last resort, negative pressure wound therapy has been proven to speed the healing process and its use has become more widespread in recent years.
“The system is a pump, tubing and foam dressing placed in the wound,” said Nancy Elftman, CO, CPed, an orthotist and wound specialist with Hands on Foot Inc. “It removes fluid, reduces edema, increases blood supply and decreases bacterial colonization, which encourages cell growth and division.”
With negative pressure wound therapy, the dressing requires less frequent changing, generally once every few days rather than several times daily. Several negative pressure wound therapy systems are available commercially. Portable systems are available and can operate on a battery. Moreover, the devices can be incorporated into a wound shoe, splint or neuropathic walker, enabling patients to remain mobile, Elftman said.
Wound gels also are used in wound care to promote a moist environment and encourage healing. Hydrogel dressings, which are cross-linked polymer gels, are used to increase the moisture content in the wound bed.
“Hydrogel is just a wound gel that promotes wound healing because wound beds need to be moist to encourage epithelialization,” said Kathy Pfleger, BSN, RN, CWOCN, a wound care nurse at Underwood-Memorial Hospital’s Wound and Skin Healing Center in Woodbury, NJ. “It just provides a good moist environment as opposed to a dry wound bed, which will not heal.”
Hydrogel can be left on the wound for several days without changing the dressing. Some wound gels that contain silver, known to have antimicrobial properties, can be left on the wound even longer, Pfleger said.
Saline gels also can promote healing by providing a moist environment. However, saline gels require daily dressing changes.
“We can put in a saline gel. It looks like a gelatin, like a clear toothpaste, and that will keep the wound moist,” Ertl said. “It is saline, so the bacteria do not like it and do not grow as much. Then you change it once a day because the saline only lasts about a day.”
Calcium alginate dressings
Calcium alginate dressings are nonwoven fiber dressings derived from seaweed. These dressings have the appearance of floss or angel hair. When wet, the calcium alginate dressing absorbs some of the wound drainage yet still maintains a moist environment for healing.
“Calcium alginate takes the drainage from the wound and draws it up into the dressing. Basically it turns into a good wound gel,” Pfleger said.
Calcium alginate dressings generally need to change daily or every other day. Like wound gels, some calcium alginate dressings contain silver to inhibit bacterial growth, and as with silver-containing wound gels, silver-infused calcium alginate dressings can be left on the wound for several days and sometimes for up to a week.
Hydrofiber dressings, which act similarly to calcium alginate dressings, also are available, both with and without silver. Rather than being derived from seaweed, hydrofiber dressings are made from nonwoven sodium carboxymethylcellulose fibers.
Cultured tissue products
For wounds that are not making any progress, cultured tissue products represent an option to aid healing. Derived from human tissue cells in a culture, these products also can be infused with growth factors.
“Basically, when you put a cultured tissue product on a wound to act as a synthetic graft, it dissolves, and the idea is that it stimulates the wound bed to do what it naturally would do. Anything with a growth factor should theoretically work if you paste it in a wound,” Ertl said. “However, sometimes it works, and sometimes not.”
Cultured tissue products are expensive, and there is uncertainty regarding how long any added growth factors remain in the wound. In addition, some products have a short shelf life, whereas others must be used immediately or soon after being opened.
“They are useful in a situation where you have a small wound and you do not want to do a skin graft because you do not want to make a hole on a patient and have the graft not take and fail,” Ertl said. “The problem is they are very expensive, and you have to put them on and cover them up for about a week, so patients may not be able to wear a prosthesis.”
Experimental products and therapies
Other experimental wound care products and therapies are constantly evolving and being explored. One product currently under study for wound healing is a honey dressing.
“Right now there is a focus on honey dressings, going back to an old-fashioned dressing type that dates back to the Egyptians,” said Jennifer Gardner, DPT, CWS, manager of wound care services at Underwood-Memorial Hospital’s Wound and Skin Healing Center. “There is a company that is marketing a product called Medihoney, and they are looking to get FDA approval for controlling infection with that dressing.”
Gardner noted another modality for wound care that recently has emerged is mist therapy.
“Basically, it is a noncontact ultrasound that helps with infection control, but it also helps debride the wound and helps promote the healthy tissue to grow, so that is a real promising up and coming new approach to wound care that is going to be seen more frequently in wound centers,” Gardner said.
Another strategy that can maximize wound care healing is to use a multidisciplinary collaborative approach. To that end, an emerging trend that has occurred in the past 5 to 10 years is an increase in the number of wound care centers.
“More and more centers are opening up, and community hospitals are realizing that this is a need for patients in the community,” Gardner said. “More facilities are offering either just a wound center or a wound and vascular center for people who need vascular work-up.”
The increase in patients with skin and wound issues can be attributed to the aging of the baby boomers as well as the sharp rise in the incidence of diabetes, Gardner noted. Many of the patients with wound issues need more help than their family practitioner or their general physician can provide, and wound care centers offer a collaborative approach to wound healing under one roof.
“At our facility, we have general surgeons, vascular surgeons, plastic surgeons, podiatrists and a physical therapist, and then we also have two certified wound ostomy continence nurses,” Gardner said. “We work closely with the primary physician. The primary physician continues to medically manage the patient, and we are managing the wound, but we do not just look at the wound – we look at the whole person.”
By having a team of health care providers in one center, care can be coordinated, and patients do not have to travel from one facility to another for appointments with different specialists. In addition, health care providers in a wound care facility can look at treatment from all angles and focus on helping patients get better.
“If we think patients need a vascular workup, we will send them for vascular studies, or if we think they need infectious disease, we will send them to the infectious disease doctor,” Gardner said. “We are able to do a more collaborative intense approach, not just looking at what can we do topically for the wound, but what can we do for the whole person to give that wound the best opportunity to heal.”
Treatment plans are individualized based on the appearance of the wound. For wounds with necrotic or dead tissue, a topical ointment may be used to help debride the dead tissue and get to a healthier wound. In patients with a venous ulcer and edema, a compression dressing may be used to help aid the venous system in getting the blood back to the heart. For diabetic wound or pressure ulcers, the foremost focus is to eliminate the pressure causing the wound and then proceed with topical treatment to aid in healing.
“The best way to decide how you are going to treat a wound is to actually look at the wound and then decide what is going to work best for that wound because each wound is different,” Pfleger said. “What is good for one person is not necessarily what is good for another person.”
Underlying reasons for wound problems
A collaborative approach also can help identify any underlying reason for a wound problem. For patients with ulcers who are prosthetic users, the wound may be caused by any of a number of problems.
“It is always a question of where is that ulcer? Where is the wound problem?” Ertl said. “Is it mechanical, or is it medical? Is it physiologic? Are they just rubbing the wrong way because now they have not been walking as much and they have hip problems or they have back problems?”
In cases in which the cause is mechanical, an adjustment to the prosthesis may solve the problem. As patients age, physiologic changes occur in their residual limb over time. Loss of muscle mass and atrophy can occur, creating friction and causing pressure ulcers to form. Patients’ personal habits also change over time, and they can become more active or less active, or they can gain or lose weight – all of which affects the way a prosthesis fits.
“I see this a lot 10 or 20 years later, the residual limb changes shape because now this patient is 40 or 50. They are not as active, and it is hard for them to walk,” Ertl said. “You see a patient walk down the hall and they are leaning one way or the other, and it is because they are not walking on their prosthesis very well. Their pelvic girdle and their bone structure have shifted, and they are going to get an ulcer in their leg. They are going to get a wound problem.”
Sometimes underlying conditions, such as vascular disease, atherosclerosis or diabetes, can be the source of the wound problem. In such cases, adjustments to the prosthesis may not solve the problem, and patients may need further medical evaluation, Ertl said.
“When you start asking yourself the question, ‘What am I missing?,’ then it is time to get on the phone and say, ‘I do not know what else to do with this patient,’” Ertl said. “Never be afraid to wave a flag or throw up a flare and say, ‘Hey, I need a little help here.’”
Mary L. Jerrell, ELS, is a correspondent for O&P Business News.
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