Wound Care Center in Naples, Florida

(or better yet wound healing)

Pretty much everything you need to know about wound care:

Dr. Gitlin has been involved in the treatment of patients with foot and ankle wounds for the past 15 years. He was director of the St. Johns Medical Center wound care and tissue regeneration fellowship as well as medical director of their Hyperbaric and wound care program.  During residency he trained under E. Douglas Newton, MD, in Pittsburgh and Christopher Attinger, MD at Georgetown. Dr. Gitlin now treats patients with wounds that are difficult to heal in Naples, Florida.

Since then he has given hundreds of lectures nationally on the subject of wound care surgery, limb salvage, amputation, charcot reconstruction, bone infection among other topics in the field of wound care.

" Wounds always have a reason to be there "

To effectively treat and heal a wound, it’s essential to identify the underlying cause. Numerous systemic diseases can lead to the appearance of wounds on an individual's body. However, in the lower extremities, most wounds are primarily caused by pressure, particularly in cases of diabetic feet; other wounds may result from insufficient blood circulation or inadequate blood return through the veins to the heart.

We will explore all these factors.

The most prevalent issue we encounter in lower extremity care is the diabetic foot wound. The presence of diabetes alone is not the direct cause of the wound. Instead, it is peripheral neuropathy that results in a loss of sensation in the foot; as the body does not receive pain signals indicating a problem, the skin deteriorates, leading to foot ulcers. In wound care, we employ a grading system known as the Wagner Classification System, which is illustrated on the left. On the right, you will find another classification system that is more detailed but less frequently utilized, called the University of Texas, provided here for your reference.

After we understand the kind of wound we are dealing with, we look for the reasons, in the diabetic there may bone prominences like in cases of charcot foot ( if you want to know more about what CHARCOT is click here ) where the bones break down and form bulges in the skin which rub against the floor and since the patient has no protective sensation the skin ulcerates. 

We also look at the tendons, how are they pulling the patients joints? or are these tendons and muscles not pushing enough are centain muscles overpowering others and creating imbalances and deformities that create the prominent areas that are prone to ulceration?

Many wounds in the ball of the foot can occur simply because the patients have a condition called equinus ( click to learn about EQUNUS ). This is where the achilles tendon is too tight for any reason and the ball of the foot bears most of the weight during walking and causes ulcers in patients without a protective sensation. ( peripheral neuropathy- yes click it if you are interested)

In some situations, wounds may arise due to a joint lacking proper range of motion, either from a previous injury or arthritis, which can lead to excessive pressure on other parts of the foot and result in wounds, typically seen in patients who experience some degree of numbness in their feet and legs.

On the other hand, arterial wounds represent a completely different issue that must be tackled by a qualified vascular surgeon before we can provide any treatment. Arterial wounds originate from insufficient blood flow to the limb. Venous ulcers, in contrast, often manifest on the inner side of the ankle, where blood tends to flow very slowly, and occur because the veins are not functioning correctly to return the blood (which is now depleted of oxygen) from the feet back to the heart and lungs. Treatment for these venous ulcers includes compression and debridement, and they should also be evaluated by a vascular surgeon.

We take xrays to see the condition of the bones, we may order an MRI imaging test if necessary - why? 

Xrays show us the bones, an MRI is our xray vision, it can show us the anatomy inside a bone and all the soft tissue structures like tendons, ligaments, cartilage and everything else in between. Some clinicians may order a CAT Scan or a PET scan, these are other imaging modalities we use to gather information.

Usually when we get these tests we are looking for hidden infections. If a wound has been present for a long time the bone beneath it may be infected. This creates a situation where the wound will never completely heal because the infected bone -osteomyelitis ( click to learn about it ).

Once we gather all the details regarding the wound, we can start treatment. Most wound patients are seen on a weekly basis, although if they are making good progress, we may switch to every other week. If you have a wound and are only seen monthly, it's time to look for a new doctor.

During those weekly appointments, we carry out wound debridements, using tools to cleanse the wound by eliminating any dead skin and tissue, as well as reducing the presence of normal skin bacteria that might be developing on the wound’s surface (this layer is referred to as the biofilm, and there is ongoing research about this subject). In some cases, we may also apply antibiotics directly onto the wound.

WHY DEBRIDE A WOUND ?

A wound that did not just happen (acute) is one that becomes neglected by the body, we consider this a chronic wound. There are also cellular changes that occur as well. When we clean the wound we make it bleed again, this tricks the body into thinking that there was an acute injury and helps to restart the healing process. The body then sends blood to the area that contains all the cells necessary for healing an acute injury.

OFFLOADING A WOUND

After debridement, we either have the patient refrain from bearing weight or put them in a specialized cast known as a total contact cast, or in a special boot or shoe designed to relieve pressure from the affected foot. It’s important to note that most common wounds in the foot and ankle are caused by pressure on bony prominences. Offloading alleviates pressure on these areas, promoting healing. The new, very delicate skin cells that form the initial layer of healing skin can be easily harmed by shearing forces, which are the lateral rubbing forces that occur during walking.

WHO NEEDS SURGERY ?

If we make a diagnosis that something is resposible for pressing on the skin from the inside we act quickly to remove the bone prominence causing this. In some cases it is to shave down a piece of bone to more extensive bone wedges and realignments. when we do thses surgical deformity correction we often use external fixators ( to learn more about this technique click here ), it is an old technique but one that works extremely well to help hold bones together during healing from the outside just like a scaffold on a building being repaired ,see the case pictures below.

We also use skin graft and flaps-

In fact, we are among the few practices that utilize flaps for closing wounds, a technique that is rarely included in current teachings. No other practice in the tristate region has been trained in some of these methods. When discussing surgical options for wound coverage, there are a variety of choices. The most straightforward option is the use of artificial skin substitutes; some are derived from cultured infant foreskin, others from shark skin, and there are those made from plant fibers. Certain brands claim to include growth factors essential for the healing process. Their names include Apligraft, Dermagraft, Oasis, and there are many more that are now being marketed.

We do not prefer any of these fake skin grafts at all!!!!!!

The reason is simple: "the best skin for closing a patient's wound is their own skin." What I mean is that the most suitable skin for repairing a wound is the skin adjacent to it, especially when dealing with the skin on the bottom of someone's foot, which differs in texture from other body areas. If skin can be taken from nearby, it will significantly improve the healing of a wound—see the cases below for further clarification.

What about using skin from a different part of the body to cover the wound?

This procedure is known as a split-thickness skin graft, and it is quite common in practice. The process involves using a device called a dermatome to shave off a thin layer of skin (typically about 0.15 inches thick), after which the graft is treated with a machine called a mesher that creates uniform perforations to facilitate wound drainage. These grafts are then secured to the wound using staples or stitches. Such skin grafts are generally only applicable for shallow wounds that are prepared to receive the skin's top layer. The harvesting of skin grafts is usually performed in an operating room; however, we can also utilize a device called an epidermal harvest system. This enables us to gently obtain very thin layers of skin through the application of heat and then painlessly apply these small epidermal grafts directly onto the wound.

WHAT IS A VAC MACHINE?

another way to help get a wound more shallow for possible grafting is the vacuum assisted closure device, a company called KCI made the first one years back and its considered one of the most important skin surgery and wound care inventions in recent history. There are now many other companies that produce and sell a similar product bu nothing beats the original KCI VAC. This machine is a vacuum that attaches to the wound and keeps constant suction on it helping the skin to heal quickly. It stays on the foot and is changes every 3 days.

WHAT ABOUT HYPERBARIC THERAPY ?

We do use hyperbaric treatment on occasion but only in addition to our regular treatment and only in very specific cases. Many wound care centers at hospitals use these on anyone they can only because the hospital gets so much money for that treatment, ill explain later. So do you need hyperbarics or HBO for short- usually not, there is simply not enough research to show that even works.

What about deep wounds?

For deeper wounds we have two choices- we can do weekly debridement and get the wound to heal to a shallow level and then skin graft the wound. Or in some cases we can do a rotational flap. These graft are different because we take local skin many time just adjacent to the wound itself and shift it around to cover the wound.

Below is a case of a simple rotational flap, as you can see the skin next to the wound is mobilized to cover the wound, in this case we were able to close the 'donor' site as well.

Below is a more complicated flap for larger wounds in the middle of the foot called a medial plantar artery flap. This is more difficult since when it is made an artery must be kept alive in the flap

We believe that a longer a wound is present the more chance for infection so in many cases of large and deep wounds we now prefer to perform a flap surgery to quickly close the wound. below are some wound flap cases for your interest.

Below is a before and after pic, the wound was cut out completely and stiched closed. An external fixator was applied to the limb ( this is like a scaffold on a building, only in this case we attach it to the bones inside ) This technique of external fixation allows us to stabilize the wound and allow it to heal without movement. The healed picture you see is only 4 weeks after the initial surgery.