Brock Linden - Sheridan Memorial Hospital

An Algorithm for the ManagementofLower Extremity Diabetic WoundsBased on UT Wound ClassificationUsing a Human Acellular DermalRegenerative Tissue MatrixBrock A. Liden, DPM,

Introduction• Most Common Reason of Hospitalization for Diabetics =Infected Foot Ulcers• Diabetic Foot Complications =Main Cause of Nontraumatic Lower Extremity Amputations• Most Common Pathway to Amputation =Diabetic Neuropathic Foot UlcerArmstrong DG et al., Clin Podiatr Med Surg 1998

Introduction• Up to 85% of diabetic footand leg amputations maybe prevented with:– Appropriate knowledgeof risk factors– Application ofevidence-basedmultidisciplinarytreatmentArmstrong DG et al., Clin Podiatr Med Surg 1998

Evidenced-Based Algorithmfor Management ofLower Extremity Diabetic WoundsBased on UT Classification

Algorithm Purpose• To develop an evidence-based algorithm for managingdiabetic lower extremity wounds based on theUniversity of Texas Diabetic Wound Classification System– User-friendly– Streamline management of wounds– Employ use of hADM grafts and calcium sulfateantibiotic delivery systemLavery LA et al, J Foot Ankle Surg 1996

Algorithm PurposeGradeWound Description0 Completely epithelialized pre- or post-ulcerative lesion1 Superficial wounds penetrating through epidermis only orboth epidermis & dermis2 Penetrating into tendon or capsule, but not bone3 Penetrating to bone or into jointStageA No infection or ischemiaB Infection onlyC Ischemia onlyD Infection & ischemiaLavery LA et al, J Foot Ankle Surg 1996

Algorithm Overview• Stratifies management according to:– Infection– Ischemia– Wound depth– Involvement of underlying structures• Adds additional factor for consideration:– Wound bed status

Algorithm Overview• Preliminary Work-Up for Diabetic Patientswith Lower Extremity Wounds• Step 1: UT Classification &Wound Bed Determination- Grade 0 Wounds- Grade I Wounds- Grade II Wounds- Grade III Wounds• Step 2: Treatment by UT Classification Grade• Dressing and advanced modality guidence

Wound ContinuumStalledHealingHealedInfectedSenescent CellsPVDNecroticEdemaWet or DryElevated MMPPressureWound edge statusColonizedImproving wound environmentImproved blood supplyMixed GranularControlled edemaMoist Wound bedBalanced MMP’sOffloadedReduced edge effectCleanEpithelizingBlood SupplyClosingSustainedmanagementMWHAccelerating WHLong term solutionCellular migration

Algorithm Goals• Revert Wound Progression to Maximize Healing Potential– First address infection and ischemia to convert:Stage B, C, & D wounds → Stage A wounds– Manage wound bed status to progress:Fibrinous & necrotic wounds → Granular wounds– Employ aggressive debridement to restore:Chronic wounds → Acute wounds

Preliminary Work-UpDiabetic Patient with Lower Extremity WoundPatient History/Clinical PresentationPhysical Examination• Complete Medical/Surgical History– Arterial or Vascular Disease– Level of Diabetic Control• Social History• Nutritional Status• Medication History• Wound History– Cause and Duration– Treatment History– Diagnostic Imaging History• Compliance History• Vital Signs• Physical Examination• Lower Leg Assessment– Vascular Status– Pain– Edema– Infection• Wound Assessment– Location– Measurement– Description

Preliminary Work-Up of DiabeticPatients with Lower ExtremityWoundsDiabetic Patient with Lower Extremity WoundLaboratory TestingDiagnostic Imaging• Laboratory Tests– A1C– CBC– Chem 8– Nutritional Labs• ABI• Wound Culture(if necessary)• RadiographsIf Osteomyelitis Suspected• CT• MRI• Bone Scan

Tests and Lab Day OneBlood Work• CBC• Chem 8• A1c• PrealbuminStudies• ABI with segmental andtoes• Reflux (if venous)• X-rays• Suspect osteo CAT

Step 1A: UT ClassificationDeterminationDetermine UT Classification: Stage & GradeGrade 0 =Completely epithelializedpre- or postulcerative lesionStage A =No infection or ischemiaGrade I =Superficial wound penetrating toepidermis and possibly dermisGrade II =Wound penetrating totendon or capsuleUTClassification(Grade/Stage)Stage B =Infection onlyStage C =Ischemia onlyGrade III =Wound penetrating tobone or jointGrade D =Infection and ischemia

Step 1B: Wound StatusDeterminationDetermine Wound Bed StatusG =GranularF =FibrinousN =NecroticWound Bed Status

Step 1:UT Classification & Wound Bed Status DeterminationUT Classification(Grade/Stage)+Wound Bed Status(G, F, or N)Treatment Priority1. Grade2. Stage3. Wound Bed

Step 2:Treatment by UT Classification Grade• For each wound grade, treatment steps areidentical:– Address infection &/or ischemiaStage B, C, and D wounds → Stage A wounds– Manage wound bed statusFibrinous and necrotic wounds → Granular wounds

Step 2: Treatment Algorithm by UT GradeWound GradeStage A =Non compromisedStage B =Infection onlyStage C =Ischemia onlyStage D =Infection and ischemiaGTreatFTreatNTreatTreat Infection•Mild•MildTreat IschemiaTreatInfection•MildTreatIschemia•Mild•Moderate•ModerateEdema•Severe•Severe•Severe•SevereTreat Edema

Step 2: Treatment Algorithm by Stage(Wound Stages B and D)InfectionMild InfectionModerate Infection•More Aggressive Imaging•Tissue CultureConservative Treatment•Oral Antibiotics•Antimicrobial TopicalsTreatment•Oral Antibiotics•IV Antibiotics•Advanced Topical TherapiesApplies to UT Stage B and D Wounds

Step 2: Treatment Algorithm by Stage(Wound Stages B and D)Severe Infection•More Aggressive Imaging•Tissue Culture•Abscess•Gangrene•OsteomyelitisTreatment•Oral Antibiotics•IV Antibiotics•I&D/Resection•Advanced Topical TherapiesTreatment•Oral Antibiotics•IV Antibiotics•I&D/Resection•Advanced Topical TherapiesAdditional Treatments•Wound VAC•hADM Application

Infection

Infected ?

Infection ?PallorRuborDolorTumorLoss of function

Infected ?

Step 2: Treatment Algorithm by Stage(Wound Stages C and D)IschemiaConservative Treatment•Oral TherapiesReferral for Possible Surgery•Vascular Surgeon•Endovascular Interventionalist

Negative Pressure TherapyProperties• Controls Heavy Exudate• Promotes Granulation/Fill Depth• Increases Blood Supply→ Oxygenate Region• Reduces InfectionUsage• Combine with Silver Dressing for InfectionControl HOCL• Combine with Enzymatic Debriding Agents• Use as Dressing Over Matrix– Different protocols depending on product

Advanced Topical TherapiesW/WO Negative Pressure• Calcium Sulfate– Beads– injectable• HOCl• Trivalent Silver• Doxycycline paste

Step 2: Treatment Algorithm by Stage(Stage D Wounds)Ischemia TreatmentFollowing aforementioned algorithm• Conservative• SurgicalInfection TreatmentFollowing aforementioned algorithm• Mild• Moderate• SevereWhen both issues are concurrent,management of dominant issue takes precedence.

Step 2: Management of Wound Bed AlgorithmStage ANo Infection or IschemiaG =GranularF =FibrinousN =NecroticTreatment•Exudate-Sensitive Dressings•Collagen•Advanced ModalitiesTreatment•Exudate-Sensitive Dressings•Enzymatic Debridement•Sharp Debridement•Negative Pressure•Select Advanced Modalities

Step 2: Management of Wound Bed AlgorithmAfter Treating Wound Bed…EdemaTreatment•Compression Therapy(if adequate blood flow)

Management of Granular WoundsWound Ointments & Dressings• Minimal Exudate– Collagen– Non-Adhering Dressing– Living substitutes / Growth Factors• Minimal to Moderate Exudate– Collagen– Foams– Alginates– Advanced Modalities• Moderate to Heavy Exudate– Collagen– PVA foams– Alginate– Hydrofibre• Heavy Exudate– Collagen– Cavity– Negative PressrureOverlapBetweenGroups

Management of EdemaCompression Therapy• Minimal to Moderate Exudate– Unna Boot w/ Coban– Self-Adherent Wrap or Ace-StyleWrapMultilayer providesbetter compression for– Multi-Layeredema management• Heavy Exudate

Management of GranularWoundsAdvanced Modalities• Living Grafts• Collagen Matrix• Growth Factors• Skin Grafts

Management of Fibrous and Necrotic WoundsWound Dressings• Minimal to Moderate Exudate– Hydrogel– Enzymes– Foams• Moderate to Heavy Exudate– Calcium Alginate– Foams– Cavity• Heavy Exudate– PVA foam– Cavity– Hydrofibre– Negative PressureOverlapBetweenGroups

Management of Fibrinous and Necrotic WoundsCompression Therapy• Minimal to Moderate Exudate– Unna Boot w/ Coban– Self-Adherent Wrap or Ace-Style Wrap• Heavy Exudate– Multi-LayerMultilayer providesbetter compressionfor edemamanagement

Management of Fibrinous & Necrotic WoundsEnzymatic Debriding Agents• Collagenase Santyl® OintmentHydrolytic Debriding Agents• Hydrogel• Hydrocolloids• Honey• Negative Pressure– Lower Pressure / Intermittent

Management of Fibrinous & Necrotic WoundsNegative Pressure Therapy• V.A.C.® with White or Black Foam, asAppropriate

Management of Fibrinous & Necrotic WoundsBioengineered Grafts• Collagen Matrix with abx beads• Stem Cell pucksDeep Wounds

Conclusions

ConclusionsSimilar Successful Results Found Between:• UT Wound Stages• UT Wounds Grades• Chronic and Acute WoundsLending Support to Algorithm Goals…

Algorithm Goals• Revert Wound Progression to Maximize Healing Potential– First address infection and ischemia to convert:Stage B, C, & D wounds → Stage A wounds– Manage wound bed status to progress:Fibrinous & necrotic wounds → Granular wounds– Employ aggressive debridement to restore:Chronic wounds → Acute wounds

Conclusions• This Evidence-Based Algorithm– Streamlines management oflower extremity wounds indiabetic patients– Provides predictable outcomes– May reduce lower extremityamputation incidence

Thank You!