Atypical and Complex Wounds

Chronic and complex wounds of the lower extremity frequently recur. It is difficult to determine the precise recurrence rate across patients with different lower extremity wound types, including diabetic foot ulcers, arterial ulcers, pressure injuries, and venous ulcers. However, we know that recurrence rates are high; nearly 40% of patients with an ulcer will develop a recurrence within one year of healing. This percentage is 60% at three years after healing and 65% at the five-year mark.

Growth factors and cytokines are secreted by the cells and are essential to the complex wound healing and tissue regeneration process. This process involves the interplay of growth factors with chemokines, cytokines, and other signaling molecules. Although there have been numerous advances that have increased our understanding of wound healing, the exact tissue regeneration mechanisms following an injury have yet to be determined.

Angiogenesis: The complex process in which the growth of normal, stable, and functional vessels is critically dependent on the coordinated interplay in space and time of different cell types and growth factors. This process involves the forming of new blood vessels from preexisting vessels by invading the wound clot to organize in a microvascular network throughout granulation tissue.

Autologous cell therapy: A therapeutic intervention that uses an individual’s cells, which are cultured and expanded outside of the body and reintroduced into the donor as a bioengineered skin substitute to aid in wound closure.

Immunomodulation: Therapeutic interventions aimed at modifying the immune response. Healing in chronic and complex wounds can be enhanced with immunomodulating agents.

By Cathy Wogamon, DNP, MSN, FNP-BC, CWON, CFCN

A pilonidal cyst is a pocket located at the top of the cleft of the buttocks that usually results from an embedded or stiff hair. This area may remain dormant for years and cause no major issues; however, often the embedded or stiff hair may cause the cyst to become inflamed and infected, resulting in an abscess that requires an incision to drain the infected material. These abscesses can recur, causing the patient to require surgical intervention to remove the cyst. After surgery, some patients tend not to heal well, and the result is a chronic, tracking wound in an area that is difficult to heal.

By Temple University School of Podiatric Medicine Journal Review Club

One of the most severe complications of the diabetic foot is diabetic osteomyelitis. The diagnosis of diabetic foot osteomyelitis requires clinical suspicion of infection, and an associated soft tissue infection only increases the likelihood of confirming diabetic foot osteomyelitis. That said, there are still challenges in the diagnosis of osteomyelitis, such as a bone infection without the clinical manifestations of infection. This occurs in approximately half of all hard-to-heal osteomyelitis cases. Currently, the tests used to confirm a diagnosis of diabetic foot osteomyelitis include a probe-to-bone test, radiography, magnetic resonance imaging (MRI), and bone biopsy. Laboratory tests are also used to confirm the diagnosis of diabetic foot osteomyelitis, with the most important biomarker being erythrocyte sedimentation rate (ESR).

By Roshni Patel, BSc (Hons), MCOptom

The cornea, as we know it, is a complex and fast-healing tissue that provides protection from infectious and non-infectious defects. However, it can still be injured through environmental impacts or surgical procedures, such as cataract operations or laser-assisted in situ keratomileusis (LASIK), as well as traumatic injuries. Although most corneal wounds repair themselves without further drawbacks, possible complications may occur and delay the healing process. This blog outlines the natural healing process of corneal wounds and post-surgical wound healing, as well as the obstacles to healing that may occur in diabetic patients.

By: Dianne Rudolph, DNP, GNP-BC, CWOCN

What are some ways to achieve insurance coverage for fistula pouches or to use ostomy supplies for a fistula? We often run into the issue of supplies not being covered for Medicare or Medicaid patients.

Unfortunately, coverage is inadequate. CMS (Centers for Medicare & Medicaid Services) coverage for fistulas is limited for fistulas caused by or resulting from a surgical procedure, and even then, it may be difficult to get reimbursed. Spontaneous fistulas (15% to 25%) are generally not covered. The Wound, Ostomy and Continence Society is working on trying to effect a change in coverage. Some insurance companies may be more amenable to reimbursement, and it may require a case-by-case application or appeal. For patients being discharged home, it may be possible to secure a short-term supply of 10 to 14 days. The cost for the pouches may run $255 and up for a box of 10.

By Lauren Lazarevski, RN, BSN, CWOCN

As summer begins to wind down and we look ahead to Halloween, let’s discuss some “creepy crawlies” we may encounter in wound care that may cause apprehension in even the most seasoned health care staff.

By Temple University School of Podiatric Medicine Journal Review Club

An appropriate timeline to initiate biofilm-based wound care (BBWC) has been a topic of question since the incorporation of biofilm therapy was introduced. In hard-to-heal delayed wounds, it is largely agreed upon that biofilms are a significant barrier to healing, and that removal is essential. By definition, hard-to-heal wounds are wounds that have failed to respond to evidence-based standard of care and contain biofilm. Biofilms are polymicrobial communities residing in an extracellular matrix produced by bacteria, which is well-hydrated and resistant against antimicrobial agents and host defenses. Biofilm can form within hours, can reach maturity within 48-72 hours, and has the ability to regrow within 24-48 hours. A first critical step to BBWC is debridement, though it requires additional suppression methods, as well as considerations of a patient’s risk factors. Risk factors include peripheral vascular disease, infection, diabetes, and pressure off-loading, which encourage biofilm development by delaying wound healing. Risks and costs with early BBWC are most likely less than those associated with biofilm-related wound complications. Thus, in March 2019, a panel of nine experts met in London for an Advisory Board Meeting, where they developed solutions to barriers preventing early BBWC and methods of appropriate “wound hygiene” for all health professionals. They reconvened in the summer of 2019 to create a clinical consensus document published in the Journal of Wound Care supported by ConvaTec Limited.

Paula Erwin-Toth, RN, MSN, FAAN

Hello to my wound care colleagues around the world. As I write this blog, the news relating to the results of COVID-19 continues to provide evidence of the profound impact this pandemic has had on those suffering from the disease and the negative impact shut downs and quarantines have had on the health of people with chronic illnesses. We, as health care providers, are under tremendous stress as many of us have been re-deployed to maintain and support the overwhelming challenges of front-line health care providers serving patients with COVID-19. We, too, are on the front lines helping to maintain skin integrity in critically ill patients who are often intubated and placed in the prone position. The physical, emotional, and financial strains on patients, health care providers, businesses, and governments are going to affect us for years to come.