The Center for Wound Healing, a division of MedStar Georgetown University Hospital in Washington, DC, has a 75% success rate in healing wounds and preventing subsequent amputations. According to Christopher E. Attinger MD, FACS, a plastic and reconstructive surgeon in the Center for Wound Healing, the reason for this success is the center’s team approach to wound healing.
“Our chief focus is a team approach, and we have everyone there on site to handle the problem expeditiously,” Attinger told O&P Business News. “We essentially have a whole team so whenever a patient comes in, we have the capacity to have them seen by the most qualified person for the problem that they have.”
The team of physicians and clinicians at the Center for Wound Healing includes a podiatrist, plastic surgeon, rheumatologist, vascular surgeon, orthopedic surgeon, infectious disease specialist and a certified orthotist and prosthetist on call at all times to deal with patients. When a patient comes in, he or she is examined and a treatment plan is put into action almost immediately.
“When a patient comes in, they go through a thorough intake for all of the potential problems, so we can call on all of the relevant specialties that need to be involved to handle that one problem,” Attinger said. “That way the patient gets seen by the most qualified person who is actually interested in that particular problem.”
Having all of the necessary professionals in one location hastens the treatment process and ensures that a patient will not have to travel between offices or wait long between treatments.
Along with the team approach, Attinger and his colleagues focus on the potential functionality of the foot as they formulate their treatment plan.
“Depending on the patient’s physical ability and ultimate function that he or she wants to achieve, we try to determine with the patient what kind of foot we can give them so that he or she doesn’t come back every 3 months with a breakdown,” Attinger said. “We have a conference every week where we go over all of our cases and discuss what is going to give the patient the best functioning foot and then design, plan and proceed accordingly. It might involve one to five different specialties.”
© Shutterstock
Wound closure
When a patient enters the Center for Wound Healing, the first thing that is assessed is blood supply. If there is not enough blood supply, the patient will visit with the vascular surgeon and eventually undergo revascularization of the foot.
“The big mistake usually is that the vascular supply is not adequately assessed. Without blood flow, nothing happens,” Attinger said. “If we think that there is not enough blood supply, then the first thing we do is perform a procedure that can allow enough blood supply to get to the foot.”
After a patient’s foot is revascularized, the next symptom that is addressed is infection. According to Attinger, many facilities do not have the necessary resources to adequately debride an infection and close the wound.
“We know that we can close any defect that exists provided that there is good blood supply, so we have no fear in debriding radically and getting rid of anything that is suspected to be infected,” Attinger said. “We can also get rid of infection more effectively because we have the capacity to close the wound.”
The Center for Wound Healing also utilizes hyperbaric oxygen therapy in particularly resistant wounds to promote healing. Hyperbaric oxygen therapy involves the delivery of 100% oxygen at 2 atmospheric pressure in a controlled chamber, the equivalent of diving 33 feet into water. Depending on the severity of the wound, the patient spends anywhere between 1 hour to 2 ½ hours in the chamber.
“This stimulates stem cells to mobilize from the marrow of the bone and come to the area of the wound,” Attinger said. “The [wound is then] repaired by stimulating formation of the vessels and cleaning the wound. And that can take anywhere from 20 to 60 sessions, depending on what you are treating.”
Once an infection has been sufficiently managed, Attinger and his colleagues plan the closure of the wound and reconstruction of the foot, focusing on biomechanics and functionality.
“First we focus on biomechanics. We don’t just fix the ulcer, we try to correct the problems that led to the ulcer in the first place,” Attinger said. “You might need to correct the Achilles tendon if there is a forefoot ulcer, or it might be a bony correction. But this has to be done in conjuncture with healing to lower the recurrence rate.”
According to Attinger, once a patient develops an ulcer, he or she has an 80% chance of developing a new one within 2 years if his or her biomechanics are not addressed and corrected. However, even if the patient’s biomechanics improve, the chances of an ulcer recurrence are still around 40%, so it is also important that he or she has adequate orthotics or prosthetics to mitigate the risk.
Amputations
Despite the Center for Wound Healing’s vast resources, they are not able to salvage every limb.
“Our overriding goal is function. So if a patient is young, he or she might be better served with an amputation than someone who is less active,” Attinger said. “But we do a lot of work with amputees to restore function, because we want them to walk.”
If a wound necessitates an amputation, Attinger said they are also very careful about limiting the number of transfemoral amputations performed.
“We try to avoid above-knee amputations, and our ratio of below-knee to above-knee is 4:1. We managed to preserve the knee most of the time,” Attinger said. “We also use plastic surgery to taper the stump and create a stable stump which is biomechanically active because we reattach all of the muscles.”
Because of this, most of the patients at the Wound Center who receive an amputation are walking again within 6 weeks, and the Center boasts an ambulation rate of approximately 78% for amputees.
In addition to Georgetown’s wound clinic, there are only a limited number of similar facilities across the country. If a clinician does not have access to a wound healing center, Attinger encourages them to develop their own network of professionals in their local area.
“Figure out who can help you. You have to build a team, whether it’s local or regional,” Attinger said. “If you don’t have immediate access to a vascular surgeon or orthopedic surgeon, but there is one 100 miles away, it’s worth sending the patient over to get revascularization and then bringing them back and taking care of the foot. Ninety percent of our patients are tertiary referrals from a center where they have tried to heal the wound but couldn’t do it.”
Attinger also emphasized that diabetic patients, especially if they have already had one limb amputated, must be monitored closely. Their sugar intake should be maintained, and orthoses and properly fitting shoes should be replaced every 3 months to 4 months to prevent breakdown. Patients should also engage in other forms of exercise besides walking or running, such as swimming, biking or rowing, to reduce the amount of time spent on their feet.
“Make sure you follow the basics and know when you cannot do something, because no one person can do everything,” Attinger said. “All of these things are critical for preventing recurrences.”
Disclosure: Attinger has no relevant financial disclosures.
