Orthopedic surgeons often see patients with significant wound care issues that must be resolved before undergoing treatment for their orthopedic problems. Other times, patients are at risk for developing wounds as a result of orthopedic treatment. "There is a population of patients with risk factors that increase potential for wound complications, and those risk factors are occurring with more frequency than in the past," says Patricia Burns, a spokesperson and wound care expert with Smith & Nephew. "Sometimes healing wounds is a big challenge, so it's important to educate physicians on the challenges in wound care and about how they can minimize the risks before wound complications occur."
Here, Ms. Burns, along with David Young, MD, professor of plastic surgery at the University of California San Francisco, and Alexander Reyzelman, DPM, co-director for the UCSF Center for Limb Preservation, discuss the future of wound care management and how orthopedic surgeons can help their patients with wound issues.
Q: What factors are driving the wound care market today?
Patricia Burns: With healthcare reform, we are anticipating a great influx of patients into the healthcare system that are not there today. The approximately 32 million patients who will become insured and have access to care may need wound care. Those patients might have a chronic wound that was not managed well or an acute wound. There will be more patients with wounds in the healthcare system. The focus on early intervention and getting wounds closed as early as possible so they don't become chronic wounds will be key.
Q: How can orthopedic surgeons become more knowledgeable about wound management?
Dr. Alexander Reyzelman: I think it's important for them to take courses like this one, which was a simple one day course that really brought together an expertise of wound care physicians. It was run by surgeons and there is a lot orthopedists can get out of it. I think that's the best way and most efficient way for learning about wounds and taking care of patients who have them.
Dr. David Young: The purpose of our conference and my role is to alert orthopedic surgeons to the interactions they should have for patients with wounds and how they can contribute to treatment. Some orthopedic surgeons also do wound management, but wound management specialists can have a big impact on patient care. One of the things I think orthopedists understand, but it bears repeating, is there are a lot of patients whose wounds do not heal correctly.
A lot of it has to do with their underlying disease, such as diabetes. Diabetes is really on the increase in the United States and around the world; those patients' wounds have problems healing. When orthopedic surgeons or others operate on these patients, they are prone to problems. However, there are some things orthopedists can do to minimize those problems before they happen, or they can refer them to a wound management specialist after the wound breaks down.
Q: What are the steps orthopedic surgeons can take to minimize problems for patients with wounds?
DY: One of the big questions today is whether wound prevention really works or not. In all types of surgery, in all types of wound treatment, there are modalities like negative pressure wound therapy (NPWT) that can actually prevent some of the problems that occur in wound healing. That is something we were teaching at the course. It's still not 100 percent accepted by the surgical community, but in the hands of well-practiced surgeons, we can use negative pressure to prevent surgical wounds from breaking down or treat wounds after they open.
If the wound is infected, it breaks down and the narrow incision from surgery has broken open and now it's a big gaping wound. A lot of people will use negative pressure to help heal the wounds together. I go a step further and apply the negative pressure before the wound breaks down to prevent that from happening. The average surgeon might have heard about that but the majority of people don't practice it at this point.
There are a reasonable number of orthopedic surgeons using negative pressure wound therapy on areas that are prone to break down, such as around the ankle where the skin is tight, or the lower part of the leg or the foot itself. Those are areas where, because the skin is very tight, many orthopedic surgeons are applying negative pressure dressings to keep wounds from breaking down. We use the method on a lot of pressure ulcers on the buttocks and other areas that are prone to breaking down if the patient is moving a lot.
Q: Once the wound has occurred, how can surgeons direct their patients for the best care?
DY: Once the wound has occurred, there are a slew of things that can help them heal faster that weren't available five years ago. The negative pressure dressing helps heal wounds faster if they do break down than conventional dressings. When wounds get infected, that is another issue. Diabetics are prone to infection, so their immune system isn't very good. There are products you can put on the wound to kill bacteria, but what is new is that we are better at killing the bacteria without actually harming the cells that help the body heal.
In the past we could kill the bacteria but we would also kill the good cells that helped heal the wound area. One of the new things we can use is silver; there are a variety of different silver products that will kill the bacteria without harming the cells and that has been a big difference in how we treat wounds. Frequently, it will turn the wound around to the point where it will start healing and get them out of trouble that way.
Q: What options do orthopedic surgeons have if they are unable to help patients with wounds themselves?
DY: Every large population center in the United States has specialized wound care centers. If the orthopedist has trouble with the wound or the wound isn't healing, those become very complicated patients to deal with and something that requires several different specialists to treat the problem. If the orthopedist doesn't have the ability to coordinate all those different specialists, sending them to the center is good for the patients and the orthopedist can get back to practicing orthopedics.
If the orthopedic surgeon refers their patient to us, we are still going to have to deal with the underlying orthopedic problems they have. Once they are healed we send them back to the orthopedists. If they have a bone infection, I can treat them but I would much rather have one of my orthopedic colleagues help out with that.
Q: What exciting developments are there today in wound management?
AR: One of the exciting new developments has been hydrosurgery which is a form of debridement. For surgeons, it is especially exciting because it is more exact and one can control the depths of debridement. It is also much faster, which allows surgeons more time to see additional patients and achieve a faster turnaround time in the operating room.
Smith & Nephew has also come out with the negative pressure device PICO that is exciting and new. It's a very simple, battery operated negative pressure device which can be placed on surgical incisions in the operating room. The advantage is we could potentially put it on closed incisions after surgery and prevent dehiscence. It protects the wound and prevents sutures from coming apart by reducing edema and preventing skin retraction.
PB: The new technologies that have gained traction, particularly in orthopedics, are treatments for when the bone is exposed. If there are major reconstructions where surgeons are using hardware, one of the risks is developing an infection. The use of antimicrobial barrier dressing with silver protects the wounds from contaminants.
Today we really manage the physical environment of the wound and try to optimize it. Research is really focused on biologics and understanding what happens at the cellular and chemical level, as well as finding ways we can intervene.
Q: Where is the future of wound management headed?
DY: I think there are many pharmaceutical companies that have products they want to test that could accelerate healing, particularly in diabetics who have a difficult time healing. Some of these products may also be focused on preventing these wounds from occurring in the first place.
AR: The most influential factors in the wound care market right now are the new and improved versions of NPWT and new topical products that will be entering the market. These new products will expedite wound healing. The future of wound care will be focused on figuring out what is missing within the wound environment and being able to intervene more precisely. Most wounds may lack certain growth factors or simply get stuck in the inflammatory phase. Soon we will be able to take wound biopsies to figure out the missing ingredient and replace it with a topical cocktail which would jump start the healing process..
PB: We are working on increasing awareness of wound care and the interventions that can be done to promote healing. There is good education available about wound care, including from the American Diabetic Association. The serious consequence of diabetic conditions is limb loss. There is a lot of patient education around good foot care but there is not a national campaign around wounds.
It's not recognized as an independent specialty so it can get lost in the mix. It's a need, as we go forward in healthcare reform, and we are constantly trying to spread information about what can be done. People live with wounds and think there isn't a treatment; we need to get them into the system with wound care specialists sooner.
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Here, Ms. Burns, along with David Young, MD, professor of plastic surgery at the University of California San Francisco, and Alexander Reyzelman, DPM, co-director for the UCSF Center for Limb Preservation, discuss the future of wound care management and how orthopedic surgeons can help their patients with wound issues.
Q: What factors are driving the wound care market today?
Patricia Burns: With healthcare reform, we are anticipating a great influx of patients into the healthcare system that are not there today. The approximately 32 million patients who will become insured and have access to care may need wound care. Those patients might have a chronic wound that was not managed well or an acute wound. There will be more patients with wounds in the healthcare system. The focus on early intervention and getting wounds closed as early as possible so they don't become chronic wounds will be key.
Q: How can orthopedic surgeons become more knowledgeable about wound management?
Dr. Alexander Reyzelman: I think it's important for them to take courses like this one, which was a simple one day course that really brought together an expertise of wound care physicians. It was run by surgeons and there is a lot orthopedists can get out of it. I think that's the best way and most efficient way for learning about wounds and taking care of patients who have them.
Dr. David Young: The purpose of our conference and my role is to alert orthopedic surgeons to the interactions they should have for patients with wounds and how they can contribute to treatment. Some orthopedic surgeons also do wound management, but wound management specialists can have a big impact on patient care. One of the things I think orthopedists understand, but it bears repeating, is there are a lot of patients whose wounds do not heal correctly.
A lot of it has to do with their underlying disease, such as diabetes. Diabetes is really on the increase in the United States and around the world; those patients' wounds have problems healing. When orthopedic surgeons or others operate on these patients, they are prone to problems. However, there are some things orthopedists can do to minimize those problems before they happen, or they can refer them to a wound management specialist after the wound breaks down.
Q: What are the steps orthopedic surgeons can take to minimize problems for patients with wounds?
DY: One of the big questions today is whether wound prevention really works or not. In all types of surgery, in all types of wound treatment, there are modalities like negative pressure wound therapy (NPWT) that can actually prevent some of the problems that occur in wound healing. That is something we were teaching at the course. It's still not 100 percent accepted by the surgical community, but in the hands of well-practiced surgeons, we can use negative pressure to prevent surgical wounds from breaking down or treat wounds after they open.
If the wound is infected, it breaks down and the narrow incision from surgery has broken open and now it's a big gaping wound. A lot of people will use negative pressure to help heal the wounds together. I go a step further and apply the negative pressure before the wound breaks down to prevent that from happening. The average surgeon might have heard about that but the majority of people don't practice it at this point.
There are a reasonable number of orthopedic surgeons using negative pressure wound therapy on areas that are prone to break down, such as around the ankle where the skin is tight, or the lower part of the leg or the foot itself. Those are areas where, because the skin is very tight, many orthopedic surgeons are applying negative pressure dressings to keep wounds from breaking down. We use the method on a lot of pressure ulcers on the buttocks and other areas that are prone to breaking down if the patient is moving a lot.
Q: Once the wound has occurred, how can surgeons direct their patients for the best care?
DY: Once the wound has occurred, there are a slew of things that can help them heal faster that weren't available five years ago. The negative pressure dressing helps heal wounds faster if they do break down than conventional dressings. When wounds get infected, that is another issue. Diabetics are prone to infection, so their immune system isn't very good. There are products you can put on the wound to kill bacteria, but what is new is that we are better at killing the bacteria without actually harming the cells that help the body heal.
In the past we could kill the bacteria but we would also kill the good cells that helped heal the wound area. One of the new things we can use is silver; there are a variety of different silver products that will kill the bacteria without harming the cells and that has been a big difference in how we treat wounds. Frequently, it will turn the wound around to the point where it will start healing and get them out of trouble that way.
Q: What options do orthopedic surgeons have if they are unable to help patients with wounds themselves?
DY: Every large population center in the United States has specialized wound care centers. If the orthopedist has trouble with the wound or the wound isn't healing, those become very complicated patients to deal with and something that requires several different specialists to treat the problem. If the orthopedist doesn't have the ability to coordinate all those different specialists, sending them to the center is good for the patients and the orthopedist can get back to practicing orthopedics.
If the orthopedic surgeon refers their patient to us, we are still going to have to deal with the underlying orthopedic problems they have. Once they are healed we send them back to the orthopedists. If they have a bone infection, I can treat them but I would much rather have one of my orthopedic colleagues help out with that.
Q: What exciting developments are there today in wound management?
AR: One of the exciting new developments has been hydrosurgery which is a form of debridement. For surgeons, it is especially exciting because it is more exact and one can control the depths of debridement. It is also much faster, which allows surgeons more time to see additional patients and achieve a faster turnaround time in the operating room.
Smith & Nephew has also come out with the negative pressure device PICO that is exciting and new. It's a very simple, battery operated negative pressure device which can be placed on surgical incisions in the operating room. The advantage is we could potentially put it on closed incisions after surgery and prevent dehiscence. It protects the wound and prevents sutures from coming apart by reducing edema and preventing skin retraction.
PB: The new technologies that have gained traction, particularly in orthopedics, are treatments for when the bone is exposed. If there are major reconstructions where surgeons are using hardware, one of the risks is developing an infection. The use of antimicrobial barrier dressing with silver protects the wounds from contaminants.
Today we really manage the physical environment of the wound and try to optimize it. Research is really focused on biologics and understanding what happens at the cellular and chemical level, as well as finding ways we can intervene.
Q: Where is the future of wound management headed?
DY: I think there are many pharmaceutical companies that have products they want to test that could accelerate healing, particularly in diabetics who have a difficult time healing. Some of these products may also be focused on preventing these wounds from occurring in the first place.
AR: The most influential factors in the wound care market right now are the new and improved versions of NPWT and new topical products that will be entering the market. These new products will expedite wound healing. The future of wound care will be focused on figuring out what is missing within the wound environment and being able to intervene more precisely. Most wounds may lack certain growth factors or simply get stuck in the inflammatory phase. Soon we will be able to take wound biopsies to figure out the missing ingredient and replace it with a topical cocktail which would jump start the healing process..
PB: We are working on increasing awareness of wound care and the interventions that can be done to promote healing. There is good education available about wound care, including from the American Diabetic Association. The serious consequence of diabetic conditions is limb loss. There is a lot of patient education around good foot care but there is not a national campaign around wounds.
It's not recognized as an independent specialty so it can get lost in the mix. It's a need, as we go forward in healthcare reform, and we are constantly trying to spread information about what can be done. People live with wounds and think there isn't a treatment; we need to get them into the system with wound care specialists sooner.
More Articles on Orthopedic Surgery:
7 Spine Surgeons on Biggest Opportunities for Growth in Spinal Surgery
Developing an Orthopedic Spine & Neurosurgery Partnership That Works: Q&A With Dr. Edward Benzel and Adam Bartsch of Cleveland Clinic
10 Sports Medicine Surgeons With Medical Inventions of Patents