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Dr. Christopher Bromley: So now, we go on to the next presentation and that's me. So, I'm not going to bore you with all the details about me. I'm just going to get started in the presentation, okay? If you want the details, come talk to me afterwards. I'll give you all the details, not a problem. Okay. So, the title of this presentation is going from months to weeks in closing chronic wounds. And what I'd like to discuss is a different way of closing wounds. It initially started as a surgical application, and you'll be interested in the surgical application, many of you because it has some definite impact on what you do. But I have taken this and I've moved it into the chronic wound field. Of course, I have, right? That's me, I would do that. And have discovered some ways that we can advance wound closure so that we can move a little bit more quickly than we're used to.

So of course, we have the disclosure slide, very common. And we have the learning objectives, which we'll get these learning objectives met no problem, very quickly as we go through this presentation. So, let's get started. We worked on the foot and ankle and that comes with some interesting issues in terms of how we close incisions and wounds in that area. It can be very challenging, we all ready know that. Poor vascularization and tissue perfusion, very common. Limited subcutaneous fat and thin tissue, especially in our diabetic patient and our elderly patients. We have lots of joints, lots of high wound indentation whether we're doing surgery or whether we're trying to heal that wound. Of course, in diabetes, we are face with the vascular insufficiency and the associated neuropathy. These wounds have a high distance rate so we want to find a way to stop that, and we also have poor patient compliance, what a surprise.

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These are the current structures that we're used to closing wounds with, both surgical wounds and sometimes ulcerative wounds. Well, sutures, we know that we've been suturing since our first year in school, right? First year in podiatry school, we've been practicing our suturing and make sure that we can do all that correctly. But along with learning how to suture both quickly and efficiently, we also have to understand what we're doing to the skin structures as we throw those sutures. And oftentimes, there's a high local force along the suture thread. And many times, and we've been taught this, and we teach others about the strangulation factor. When we tightened down that suture a little too snuggly, or make it a little too tight, or put a little too much tension.

So, tension and destruction force are something that we have to be aware of. And it's a learned technique, it's a feel when we throw that suture. But it's also problematic, especially because after we make an incision and we suture it, there's postoperative edema. And so, we haven’t planned for that when we threw our suture necessarily. And now, there is this high tension on the suture line that we have to be concern about. And oh yeah, those sutures have to be removed, and how many times has your patient cringed two or three weeks after that surgery when you go to remove those sutures? It happens all the time, right? Now staples, something that isn't really big in podiatry is using skin staples for closure, but it's very common elsewhere. So, staples represent a quick way to close, they also represent a percutaneous insult to the skin. There is also the chance of immune strangulation of the tissue, and sometimes they can be more painful than removing stitches or sutures.

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So, what would be the ideal product if we had it, if we had the ideal product to close a wound, what would that one be? Well, it would be something that would be nonabrasive, ease of use, cost effective for sure. It would provide pain relief from edge tension fast, in other words really easy to apply. We don’t want to spend forever applying this product because sometimes as we know, it takes longer to suture a wound than it is to do the procedure they created that wound. Has to be reliable, repeatable, and of course safe.

So, there have been a few therapies for mechanical closure, there's mechanically assisted delayed primary closure, there's retention sutures and - but we're going to talked about locking constant tension devices. Now of course, we're in a see-me lecture, so we can't use the trade names, but you'll understand as we go forward what we're talking about.

Let's look at the mechanically assisted delayed primary closure device, specifically we'd use this on a wound or a wound that has dehisced a suture that - an incision line that has dehisced, we would use a product like this. It's been around for a while, and it forms a constant contraction from a spring mechanism. It is tension line anchors along the periwound tissue. It's little bit bulky as you can tell by the picture and it doesn’t produce wound size, but it also causes new wounds around the original wound. And depending on the fragility of the tissue, you could end up beginning to close your original wound and end up with new smaller wounds around your original wound. I've seen that happen, that's been a problem. We have retention sutures, which we call arts and crafts because you have to be very creative to throw the right retention suture in the right direction, and with the right amount of tension.

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And many times, as we're throwing retention sutures, we throw one, and then we throw another one, and then we throw another one, and realize the first one we threw is now too loose. Because we're trying to bring the wound edges closer together, and we have to cut that one out, re-insult the surrounding tissue and throw another suture. So, we work by trial and error when we throw retention sutures. And then, will they close the wound, or do we have to add negative pressure to the wound, what else has to be done with this, and are they long lasting? So, they present an interesting set of difficulties and problems all by themselves. And you need the appropriate type of wound when you're going to use retention sutures.

Now, we have the locking constant tension device for wound closure. It's noninvasive, uses a hybrid of hydrocolloid and acrylic skin as an adhesive that attaches on either side of a wound. The device acts as cage or a scaffold, more like a scaffold, I think. Protecting the wound edges so it doesn’t interfere with the edge. And it gently pulls the wound together. It's totally adjustable, so you can use a lot of tension or a little bit of tension depending on the condition of the wound and the wound edge itself. You can still work on the wound itself, applying the products you would normally apply to that wound base. Because this product is - well, it adheres to the skin edge, the bands are totally detachable. So, it gives us a new way to close a wound and to treat a wound. Let's give you some pictures of what we're talking about here. There're two products, one is the original skin closure product. And it's been used primarily on orthopedic surgery for a very long time. It's now coming to us to used in a smaller version, and you'll see by the pictures what I mean and what's available.

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The first is like I said, for incisions. That's the picture on the left. It's a very narrow device, and you put it on either side of your incision, and you can lock it down, and push the skin edges together without having to throw a stitch. You can do your typical subQ closure, subcuticular closure if you'd like. Then you apply this device, bring your skin edges together and after a week, you can pull it a few more millimeters to bring those - make sure those skin edges are together. If there's edema present post operatively and you need to release a little tension from the skin edge, you can also do that. But it's measurable and predictable as to how much tension or lack of tension you put on that incision line. We've taken that product and we've changed it around a little bit so that the gap between the two ends is wider so that we can put it around the wound and bring the wound closer together. So, we’ve changed it so that we have now this big gap, and we'll show you in the case studies exactly what we mean by this large gap.

Interesting, there's been quite a bit of work done on this from the scientific point of view. Remember, we always like to see some science in these things. So, we know that it's noninvasive. If you don’t have to re-insult the skin by using staples or suture, you're way ahead of the game, that helps. It's less bacteria contamination by chance that can get into the wound. You still have tissue perfusion because you haven’t strangulated any tissue at all. There's no strangulation of any of the tissues along the incision or along the wound edge when you used this product. Studies tell us that it's stronger wound protection than sutures, which is really nice, and it's applied much, much faster.

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If you look at the video in the exhibit hall, you will see how quickly this can be applied, and how quickly it can be unapplied or taken off at the end of the healing of the suture line. As a result, we have fewer dehiscences, fewer wound complications, so that's really nice. So, as we begin to take a closer look at this product, it's totally adjustable. And this is a product that comes with four lines of closure. If you have a smaller wound, you can cut this in half. And only used those two lines of closure, which is really nice. So, everything is elastic, the hydrocolloid is very elastic and moldable. So, if you need to go around a bony prominence, you can go around the bony prominence. A hydrocolloid, and because we're familiar with hydrocolloids because we used them in wound care, we know that when they're applied and they're warmed just by your hand, a little pressure, they mold and adhere to the skin very, very nicely. So, that makes them perfect for this kind of situation.

So, this is the theory, the unique mechanism of action if we need to get into theory on this. As we go through, we apply it to the wound and then we gradually pull the little ties closer, and closer, and you can go down in succession. You can go every other one, any methodology you want and you can do this on a weekly basis. So, this can be week one, week two, week three, and then week four. And this remains intact and you just change the amount of compression that you place on the wound edge, which is really nice. Now, it doesn't - in wound care because these wounds drain, it doesn’t always last that long. It typically last seven to 14 days, but many times you might have to replace. I've had some last four weeks, so that's been really great.

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So, it's totally adjustable and each click is measured at one millimeter. So, if you really want to take very, very detailed notes, you can actually measure the number of clicks at each successive visit to measure how much closure to measure how much closure you are indeed getting. So, now for the fun part, the case studies. Case studies are always the fun part, they're the best part. So, here is a 58-year-old male with of course type 2 diabetes, history of right foot Charcot, full thickness plantar ulceration present for over a year. Status post plantar exostectomy performed 10 months ago and gastroc recession on the same side performed two months ago. Two years ago, on the left side, he had a forth and fifth ray resection. Oh by the way he's also on dialysis.

So, you have some picture of the patient that we're dealing with here, very comorbid, very diabetic, end stage renal disease, yeah, we got to take care of this quickly or he's going to breakdown. He's being offloaded for this plantar ulceration with an Aircast because his tissue quality is such, he cannot tolerate a TCC, which to me is crushing, but that's just the way it goes. So, this is what it looks like, the picture on the left. Right here is the initial presentation, this is the ulcer that's been there for a year, and it won't move. So, this is the device that we applied, this white are actually paper tabs that are attached similar when you used a vac for negative pressure. It's got the plastic sheeting on there that you peel away. But you can hang on to it so it's not - you don’t get the stickiness on your gloves, and then you peel everything away, and it adheres right to the skin.

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Same idea here, this is paper so that you can apply it, and then you just peel this off the top, and the hydrocolloid, which is right underneath here, adheres to the skin. Now, on this particular patient, we're using combination therapy. So, on the wound itself, we have applied in the middle here an amniotic membrane product, a piece of ADAPTIC, and kept that in place with a Steri-Strip. So that's what this is here in the middle, that's what we applied right to this wound. We have then applied the product without any tension, very loosely. And then in this picture, you can see that we've started pulling these tabs on either side to apply some compression to that wound edge. So, we're now squeezing that wound edge and locking it down, and we put them back in his Aircast.

Two weeks later, that's what that looks like. In two weeks, he closed 85% after one year of barely moving. So, we did the same thing, we apply an amniotic product and Steri-Strips. And then reattached a new locking mechanism because the other we actually took off here. After two weeks, it was with a little bit of drainage, it was starting to peel off anyways. So, we went from this over here to this that was week two, locked it down. This is what it looks like at three weeks. So, at three weeks, he's had 70% closure in the past week, 96% total closure since we originally saw him. And that's due to this device.

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So, we reapplied it again, locked it down, and in four weeks it was closed. So, we've taken this ulcer, Charcot arthropathy ulcer that had been open for a year and closed it in a month. Now, even with really amazing product used and amazing care, maybe we could get this closed in three months. And in my experience, that's about how long this would take. So, we've gone from several months to weeks to get this closed. It was pretty remarkable, we are very happy with it. Here's another patient, this patient is 70 years old with diabetes, history of venous insufficiency, hypertension, stage three kidney disease, all the usual things that these folks have, all these comorbidities. He has osteomyelitis on the second digit, second metatarsal, underwent a second ray resection.

So, it was the typical pie-shaped resection from the foot, where there's a piece of - a whole piece of pie tissue missing from the foot. He also had a plantar ulceration, sub first metatarsal that was I&D'ed at the time of surgery. And he was placed on negative pressure therapy, two weeks. So, here we're seeing him two weeks after his ray resection. And that's the picture, right here, this is two weeks. That's as far as we could get with negative pressure. So, we decided here's his plantar ulceration, it was communicating at one time. Because of the surgery and the negative pressure, these no longer communicated. So, we decide he would be a great candidate with this type of presentation to use this locking device. So, we again used an amniotic membrane product to fill this void. We put Adaptic over the top, and we applied the locking mechanism on top, and we did the same thing on the bottom.

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Now, granted, the bottom does not have the plantar aspect of foot, does not have the flexibility and tissue mobility that we have on the top. But we figured why not? He's got this ulcer on the bottom, status post I&D, let's try it and see what happens. So, after one week, he presents with this, this is what it looks like. And there were some drainage, which is pretty typical. The mechanism however, remains intact. On this picture, we just simply pulled out the Adaptic. This is the area that we need it to debride. But again, the uniqueness of this product, we simply unlocked it. You can unlock it, so you can leave all of this adhered. And here we are pulling back the little tie mechanisms so that we can go ahead and debride the wound, which we did here, just like this, and then reapply our amniotic product and are Adaptic. And re-insult and lock down this, but now we locked it down tighter.

So, in one week, he had 47% closure. That's is remarkable for a patient in this condition. 47% closure in a week, that's really awesome. So, after two weeks he comes back to see us. Again, here we unlocked the mechanism, pulled it over to the side, did a debridement. The plantar wound by this time had closed by 88%, it was almost closed. So, we did not put a locking mechanism on at this point, but that was getting ready to just fill in. So, we did pretty well, we're doing really good on this wound. Again, same thing after three weeks, the dorsal wound is 68% closed. This is how he looks, filling in distally, that's already closed. That's already closing distally.

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Here we are unlocking the mechanism and reapplying the things that we need. Five weeks, at five weeks, he's 75% closed. This should take a lot longer than five weeks. This should take a couple months easily, maybe longer maybe three months to close this type of an insult. So, we're well ahead, here we are, you can tell on this picture - oops, let me go back. This picture, how we've locked it down because we've scrounged the Adaptic there. So, we've locked it down quite a bit. You can tell by these little ties that we've put a lot of force on there. You can tell by the tension lines over here, and the tension lines here, that we've definitely put some tension on that hydrocolloid to lock down that wound. So, this is how he looked this past Monday. Very interesting, the bottom now is completely closed. The bottom is closed. So, we'll see what it looks like this Monday, and I think we're just about done. So, we've done some remarkable work with this patient, healing this traumatic wound that he had.

One last one, this is a 60-year-old male with type 2 diabetes, he had a first ray amputation with osteo, two months prior to this picture. His status posts two months of IV antibiotics, so he had osteo. Two months ago, he's been on an IV PICC line for two months, just got off. But the amazing thing is, is that he still has this big wound, and it hasn’t progressed. Even though his been offloaded, even though he's been on IV antibiotics, that hasn’t progressed very far. It stopped, so we said, "Well, it looks barely linear, I think we can go ahead and see what we can do about closing this patient."

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You see the measurements there, you see the application of the product and you can see how once we applied the mechanism here, we actually tie it down. You can see the length of the ties on the bottom picture after we lock it down, and how we lengthened them from the top picture. So, we put quite a bit of tension on this, right off the bat. After one week, the reduction was 93% in one week. This is a wound that wasn’t going anywhere that was problematic. So, what we did is we cleaned this up, reapplied it, you can see that's much narrower, and really tightened it down once again. Let me go back, there we go. Two weeks and three weeks, he's closed, wow.

So, what we've come across here, we stumbled across this. What we've come across is a product that will allow us to close many types of wounds with greater frequency and quicker than they usually can be closed. Now, we can do the same thing on surgical incisions because with no skin tension, you get a much better healing incision with less scaring, less hypertrophy, and cosmetically is going to look a whole lot better. So, something that we can use in our surgeries as well. So, some pearls of course, avoid using on patients with sensitivity, tape or Band-Aid. I forget the ID, adhesives. Avoid deep sutures, okay, avoid touching the adhesive. There're all sorts of way to avoid touching the adhesive. They put all kind of tabs on this so you don’t have to touch the adhesive as you apply it. And then pinch the wound close.

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Of course, you put pressure on that wound to close as much. And you move the little tabs to where they lock and then you're in great shape. And then we usually put something over the wound to make sure that we don’t use any adhesives to touch the device. Or you put some gauze over the wound, that works out really well. So, something else that you can use when you go to the OR, when you go to the surgery center for your incisions. If you have wound care patients, this might be something that you might want to give a try. So, by all means, they are in the exhibit hall. Stop by, take a look, see what they have to say. And I'll take any questions that you might have at this point.


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