By Janet Wolfson, PT, CLWT, CWS, CLT-LANA
Reflecting back on "In the Trenches With Lymphedema," WoundSource's June Practice Accelerator webinar, many people sent in questions. I have addressed some regarding compression use here.
Temple University School of Podiatric Medicine Journal Review Club
Editor's note: This post is part of the Temple University School of Podiatric Medicine (TUSPM) journal review club blog series. In each blog post, a TUSPM student will review a journal article relevant to wound management and related topics and provide their evaluation of the clinical research therein.
Article title: Major Histopathologic Diagnoses of Chronic Wounds.
Authors: Turi, George; Donovan, Virginia; DiGregorio, Julie; Criscitelli, Theresa; Kashan, Benjamin; Barrientos, Stephan; Balingcongan, Jose Ramon; Gorenstein, Scott; Brem.
Journal name and issue: Advances in Skin and Wound Care, 2016
Reviewed by: By Tanvi Kadakia, Class of 2018, Temple University School of Podiatric Medicine
Chronic wounds are clinically defined as wounds that have failed to proceed through a healing process in a timely and biologically efficient manner. They are easily identified due to their presence of a raised, hyperproliferative, and non-advancing wound margin. They often are not responsive to initial therapy, and still continue to exist even with adequate wound treatment and sharp debridement.
Wound healing is a multistep process that includes three stages of varying time involvement. The first step is the inflammatory phase, which consists of the body’s natural response to a traumatic event. In this phase, blood vessels begin to constrict and a clot is formed. The second phase is the proliferative phase in which the wound begins to rebuild itself with new healthy granulation tissue. In order for granulation occur, the blood vessels must be supplied with adequate nutrients and oxygen, and be free from any signs of infection. The last phase is the maturation phase, in which the wound begins to remodel. The dermal tissue enhances its tensile strength and the wound is replaced with functional fibroblasts.
A study was conducted by Turi et al. to clarify the histopathology of acute osteomyelitis, chronic osteomyelitis, primary vasculitis, and secondary type vasculitis. The presence of a chronic wound can result in major morbidity and mortality, which makes understanding the pathological alteration of the wound tissue essential in managing standard wound therapy. The study took place at a tertiary care hospital in Mineola, New York, where 1392 wound operations were analyzed over a 24-month period. The specimens varied from lower extremity, sacrum, trunk, and buttocks. The wound debridements were based on standard indication, which included superficial wounds, soft tissue infections, and non-healing deep wounds. The tissue samples from the debridement were sent to the pathology laboratory for a histopathologic evaluation. Each specimen was placed in 10% neutral phosphate buffered formalin.
Acute osteomyelitis is histologically defined as a bone tissue infiltrated with polymorphonuclear leukocytes and osteoclast bone resorption with scalloping to the bone edges. Some clinical signs of acute osteomyelitis include bone pain, erythema, and drainage around the infected area. Only one histology from a bone biopsy and microbiologic analysis were found definitive for accurate osteomyelitis. The diagnostic sensitivity for osteomyelitis has been found to be as high 95% sensitive and 99% specific. While chronic osteomyelitis is defined as bone tissue that has a significant amount of fibrosis around the tissue, there is also a predominance of lymphocytes and plasma cells.
Without effective debridement, chronic osteomyelitis does not respond to an antibiotic regime. In chronic osteomyelitis, there is a draining sinus tract, limb deformity, and local signs of impaired vascularity. In primary vasculitis, such as granulomatosis with polyangitis (also known as Wegner granulomatosis), there is an injury to the vessel wall and necrosis of the blood vessel wall. Pathology from patient’s initial debridement showed evidence of cutaneous ulceration with numerous inflammatory granulomas in the papillary dermis. The granulomas had coalesced around the dermal vessel, and the greatest presence was found near the dermal vascular plexus. In secondary vasculitis, the blood vessel walls were found to be infiltrated by inflammatory cells and necrosis of the small vessel wall. Some etiologies of secondary vasculitis include infection disease, neoplasms, and drug-induced diseases. The clinical manifestations of secondary vasculitis are solely defined by location, type, and size of the affected vessel, while the clinical criteria for small vessel vasculitis and muscular vasculitis include perivascular infiltration and fibrinoid necrosis.
In the study, Turi et al. described the pathological findings of the four types of wounds that may complicate and alter the sequence of diagnosis and treatment of chronic wounds. These diagnoses are less commonly found and harder to diagnose clinically. They believe that complete yet thorough history and physical examination with accurate diagnosis of these wound specimens is the best means to target a successful wound treatment regimen.
Knowledge of histopathologic alterations present in wound tissue is essential to successful treatment and healing of chronic wounds. Pathologic evaluations can distinguish healing from non-healing wound edges, but for chronic wounds, the standard debridement and treatment is the guide for intervention and healing. Regardless of whether clinical signs and symptoms of osteomyelitis are present, histological findings of the bone tissue are crucial to treatment and effective cure of chronic wounds.
About the Authors:
Tanvi Kadakia is a third year medical student at Temple University School of Podiatric Medicine (TUSPM) in Philadelphia, Pennsylvania. She graduated from Loyola University Chicago in 2013 with a Bachelor’s of Science in Biology and Psychology. She is currently the President of the Forensics Club and the Secretary of the TUSPM Journal Society. She is also the Marketing Chair of Student National Podiatric Medical (SNPMA), where she volunteers at homeless shelters and athletic events in the Philadelphia community. Tanvi is interested in wound care, reconstructive surgery, and diabetic foot care.
Dr. James McGuire is the director of the Leonard S. Abrams Center for Advanced Wound Healing and an associate professor of the Department of Podiatric Medicine and Orthopedics at the Temple University School of Podiatric Medicine in Philadelphia.
The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.