Therapies and Diagnostic Tests
Assessing your wound is the first step to healing. Out team uses several techniques to learn about your individual wound care needs and provides a personalized plan for treatment.
Our diagnostic tests and therapies include:
Debridement - The physician will often remove (debride) devitalized, or contaminated tissue from the wound using a scalpel, scissors or an instrument such as a curette. Debridement removes unhealthy tissue, debris, bacteria, and other substances that accumulate in the wound that impede the healing process. These things can accumulate in the wound between visits and debridement is often performed on a weekly basis.
Studies have shown that wounds that are debrided regularly heal faster than those that are debrided less frequently. Debridement removes debris or a scab that forms a barrier between the wound bed and the prescribed topical treatment, limiting its effectiveness. Debridement converts the chronic wound to an acute wound, prompting the body to recruit substances to the wound to stimulate healing and it prepares the wound bed for more advanced therapies.
Prior to all debridement, the wound area will be numbed with either topical and/or injectable lidocaine. Chemical and enzymatic debridement are alternative options for the removal of unhealthy tissue and are used in some circumstances. This process is much slower however.
Wound Culture - Patients with wounds are often placed on antibiotics by clinicians who are not used to caring for wounds under the premise that it should help the wound heal, but there are no magic wound healing powers in antibiotics. If there is bacteria in a wound it may be causing an obvious infection or promoting inflammation that will prevent a wound from healing.
Treatment of the bacteria is then important to reduce inflammation and allow healing to move forward. As part of your treatment, we may culture your wound to determine if bacteria or infection is present and if so, allows us to identify the particular type of bacteria is present. We can then treat with an antibiotic or antimicrobial treatment that is appropriate for that type of bacteria. This could using a topical antibiotic or antimicrobial dressing instead of something taken by mouth, the preferred treatment, where appropriate.
We typically obtain a culture by removing a small piece of tissue from the wound after it is debrided. This is much more accurate than wiping a swab over a dirty wound bed.
Tissue Biopsy - Occasionally a biopsy is warranted to rule out cancer or to diagnose an atypical wound. Skin cancers can sometimes present as a wound or ulceration. If a wound harbors cancer, it will be unlikely to heal. If your wound has been present for a while or if we cannot determine why it is not healing, we may recommend that it be biopsied.
Compression therapy - This process uses elastic garments or wraps to promote the mobilization of fluid from a swollen extremity. Swelling, or edema, is one of the most common impediments to wound healing, regardless of the cause of the swelling, and controlling swelling is one of the cornerstones of promoting wound healing.
One of the most important treatments for extremity swelling is compression therapy. Compression therapy comes in many forms - compression stockings, graded compression wraps, Unna boots and multilayer compression wraps. It is becoming known as the main treatment option for venous ulcerations, as research and experience has demonstrated the effectiveness of multi-layer, stretch dressings that increase venous return, allowing the lower extremity tissues to recover from the effects of venous hypertension, thus decreasing swelling and promoting healing. Compression therapy is often needed long-term to prevent the recurrence of wounds.
Offloading of the Foot - The most important treatment for wounds on the bottom of the foot is minimization or elimination of the pressure, trauma and friction on the wound. Ideally, this would be completely eliminated by being off of the foot altogether (accomplished with crutches, knee roller, wheelchair), however this is not always feasible and other devices may need to be used to minimize pressure as much as possible. Otherwise healing is unlikely to occur.
- Total Contact Cast - Total contact casting is considered the gold standard offloading treatment for diabetic foot ulcers (Snyder, et al, 2010) and any ulcer on the bottom of the foot. A fiberglass cast is often used to promote the healing of diabetic foot ulcers (neuropathic ulcers) by redistributing the weight along the entire surface of the foot and up the calf. TCC-EZ® creates a natural healing chamber that allows active wound healing and provides a safe environment for the foot, halting the cycle of the diabetic foot ulcer. The mechanical effects: TCC-EZ is a total contact cast system that reduces damaging forces and promotes healing in the diabetic foot ulcer: a) Locks ankle at a 90-degree angle; b) Eliminates the propulsive phase of gate and reduces stride length and pressure on the foot ulcer; c) Transfers weight to the calf; d) Reduces shearing forces. For additional information see: TCC-EZ
- Other offloading devices - Alternatives to a total contact cast include walking boots, specialty shoes, specialty insoles, and protective foams placed around the wound. Although used commonly, these alternatives are inferior to the total contact cast and comparative studies routinely show inferior healing rates for these alternatives.
Assessment of Arterial Blood Flow - Wounds need blood flow and oxygen in order to heal. It’s often important to determine whether there is adequate blood flow for healing to occur.
Ankle Brachial Index (ABI) - Ankle brachial index is a non-invasive calculation of arterial flow using Doppler ultrasound. The measurement is achieved by using the highest systolic pressure recorded in the ankle and dividing it by the highest systolic pressure in the arm. The result in normal arterial flow should be an ABI of 1.0. This can be falsely elevated if the arteries are calcified (common in diabetics), in which case a TBI or Toe brachial index (pressure in the big toe) is more useful. An ABI can be obtained at the bedside or sometimes is done in a vascular lab for better accuracy.
Arterial Duplex - A non-invasive ultrasound examination of arteries looking for areas of narrowing or blockage. Flow velocities can be obtained as well.
CTA/MRA - Special CT scan or MRI to evaluate arteries for blockages or narrowing.
Angiography - An invasive procedure where a catheter is placed in an artery and dye is subsequently injected to get a “roadmap” of the arteries. If a blockage or narrowing is discovered, balloons or stents may be used to open up the area during the examination.
Assessment of Venous System - Problems with the venous system can contribute to leg swelling, development of wounds and poor healing.
- Venous Ultrasound - Examination of the venous system for blood clots and/or valvular reflux. Blood clots may require blood thinners. Venous reflux in the superficial venous system can sometimes be treated with minimally invasive procedures such as venous ablation.
- CT Venogram - CT scan evaluation of venous system. Often used to screen for venous compression in the pelvis.
- Venogram - Injection of dye into the venous system to better define the venous anatomy,
- Endovenous Ultrasound - Uses ultrasound on the end of small catheters inserted into the vascular system. Allows measurement of intravascular flow and more detailed evaluation for venous compression
Assessment of Tissue Oxygenation
- Transcutaneous Oximetry Measurement (TCOM) - Transcutaneous oxygen tension (PtcO2) measurements provide a direct, quantitative assessment of oxygen availability to the periwound skin and an indirect measurement of periwound microcirculatory blood flow. This technology allows objective determination of the adequacy of tissue oxygenation and serves as a screening tool to identify patients at risk for failure of primary wound or amputation flap healing. It can also be used during assessment of patients with lower extremity wounds as a screening tool for occult arterial disease. The testing involves the placement of cutaneous electrodes to the skin around the wound. UHMS
- Near Infrared Spectroscopy (NIRS) - A cutting edge, non-invasive, bedside evaluation that uses light in the near-infrared spectrum to determine tissue oxygen saturation, a key indicator of tissue health. As simple as taking a picture with a camera, this is a fast and easy way to test for adequacy of tissue oxygen and a potential screening test for arterial insufficiency.