Regenerative Medicine in Wound Care

What is regenerative medicine?

Regenerative medicine, in its most simplest definition, is using bioengineered products to accelerate the body's healing potential. In wound care, this refers to placental based tissues to heal wounds. The placenta is a magical piece of material containing loads of stem cells ideal for healing. After all, it nourishes and builds a baby for nine months.

The reason I love wound care of the lower extremity is that there are many components to understanding why a wound may not heal. The lower extremity is different from other body parts because of our dependency with weightbearing and walking for activities of daily living. The biomechanics of the lower extremity is complicated (have you ever tried to not walk on one foot for a day?) It's not so easy and yet this is what is required to heal a foot ulcer. 

When do I employ regenerative medicine in my practice?

To be honest, I am a firm believer of following basic principles of wound care so I tend to avoid most sales reps until I absolutely need them. My medical and surgical background allows me to dig around in my medical toolbox to solve wound problems. Many times, wounds can be healed by utilizing the following protocol that I just made up in these 2 seconds, pnuemonic OPENMIC:

  • Off-loading the pressure point (a biomechanical evaluation to determine source of pressure ie equinus, other foot deformities)
  • Patience (wound healing takes time, but you don't want an acute wound to crossover to a chronic state by waiting too long)
  • Edema control (probably the most underrated part of the puzzle, but critical to control, swelling impedes nutrients from getting to the wound and healing it)
  • Nutrition and medical management (in diabetics --> control of blood glucose; obesity --> protein intake, etc)
  • Maintaining a balanced moist wound bed (if it's dry, wet it; if it's wet, dry it --> FYI "wet-to-dry" dressing is not adequate)
  • Infection control (if present treat it appropriately prior to use of any grafts)
  • Circulation status (is there enough blood to heal? If not, refer to appropriate vascular interventionalist quickly)

If after a month, the wound does not improve in size and appearance (or the wound is grossly large in a compromised host), I escalate the treatment plan to using allografts that is rich in stem cells. The stem cells recruit the body's own cells to potentiate healing. Time is of essence so I employ this technique as soon as insurances approve of its use. 

Here's an example of a very sweet patient of mine who was close to having her leg amputated:

 Use of regenerative medicine in a nonhealing heel ulcer

Use of regenerative medicine in a nonhealing heel ulcer

The back of the heel poses the biggest challenge because it is a constant pressure point. I have found that being aggressive with these wounds using regenerative medicine to be highly beneficial on top of the OPENMIC principles of wound care. For patients unable or unwilling to undergo flap reconstruction for immediate wound coverage, this is a really nice option to get patients to heal and ultimately prevent major lower extremity amputation.

 

Venous leg ulcers

Working as a wound care specialist of the lower extremity, I see a variety of medical issues and will often require a medical team approach for complete care. For example, venous insufficiency of the legs where the valves of the veins are no longer functioning properly can cause pooling of blood, swelling of the legs and painful ulcers can develop. What I do as a podiatrist in this scenario involves referring the patient to a vein specialist who can address the underlying source of the ulcer. They will evaluate the competency of the veins and decide on the appropriate procedure to fix the problem. In conjunction, I provide local wound care that may include various therapeutic compression wraps, grafts and a holistic view of the patient. Can the patient tolerate the wraps? Do they have home support to assist them with transportation to their appointments? Caring for these types of patients commands a trusting relationship between the patient and doctor, which is why I love what I do. 

Here's an example of a venous stasis leg ulcer that did well with conservative measures. My wound care protocol:

- Wounds greater than 1 month old that does not change in appearance --> biopsy
- Biopsy demonstrated necrosis of vessels consistent with venous stasis
- Referral to a vein specialist
- Weekly compression dressing, using a hydrating product such as hydrogen plus Silvercel and 2 layer compression
- Skin graft if ulcer is not 40% smaller by 4 weeks
- For long term management, compression hose at 30-40mmHg daily for life
- Calf pump exercises daily have also proven to help decrease edema
- Monitor routinely for recurrence or new sites of ulceration

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Leg cellulitis and how a podiatrist can help

There are numerous reasons why a person may develop an infection to the leg, also called cellulitis. Some are obvious, such as drug injections using contaminated (dirty) instruments. While others are not so clear. 

  Left: initial presentation in the office. Right: 3 weeks after antibiotic treatment.

Left: initial presentation in the office. Right: 3 weeks after antibiotic treatment.

Here is an example of a patient I have been seeing for a long time because of multiple wound issues. The most recent problem he presented with is the development of a leg infection. He can only recall that he bumped the ankle against some furniture at home. He then developed general weakness and the leg became very red, swollen with clear draining fluid throughout. He came to see me in the office and I immediately sent him to the hospital for further medical management. 

With the help of the hospitalist and infectious diseases doctors, the infection was able to be controlled and eventually resolved. What I do as a podiatrist is assess the patient's condition and determine the urgency that is needed for hospital care. Then, I provide recommendations for wound care and continue to see the patient in the wound clinic, monitoring the progression. With that amount of swelling, seen in the picture, compression wraps are very helpful. Because I see the patient so frequently, he knows I'm only a phone call or text away to help him. 

Does everyone who gets a scratch on their skin get cellulitis? No, but some patients who are immune compromised or have a history of wounds and infections require a lot more medical attention, which I am attentive to. This particular patient has a baseline lymphedema (chronic leg swelling) that can be misinterpreted as a cellulitis. It requires a well-trained wound specialist who knows the patient well to determine what is their normal and what is not normal. 

Often times I see very "normal" leg redness from chronic lymphedema that is not cellulitis, while other times cellulitis gets overlooked or is mismanaged. A podiatrist well versed in wound care should be part of a medical team to help determine whether changes in the patient's legs are normal or unusual. A team effort helps patients heal faster. 

 

Did someone tell you that you needed a leg amputation?

The most difficult conversation I have as a podiatrist is telling patients they may lose their leg. My job and passion is to save every limb I possibly can. That's what podiatrists do, we keep people walking through palliative foot care, routine exams and educating on prevention. I love every part of my job and I've found a great deal of satisfaction helping people stay independent, pain-free and maintaining their "foot fitness."

However, a big part of my subspecialty is in wound care where people suffering from nonhealing wounds below the knee come to see me. I want to share with you this story about (consent obtained) a wonderful patient who found me. Let's call him Mr. Fish. 

Mr. Fish presented as a 70+ year old gentleman with multiple nonhealing wounds for at least 1 year on his leg. He suffered from type 2 diabetes, peripheral arterial disease, heart disease and is a chronic smoker and drinks alcohol regularly. He had seen at least 3 other specialists of a variety (vascular, general surgeon, internal medicine, other podiatrists, etc) who have all recommended a below knee amputation as a treatment plan. When I finally saw him, I have to say, I was in agreement. 

He says to me in sheer desperation, "is there anything you can do to save my leg?" I told him that with his current infection, medical co-morbidities and social history that I don't know for sure, but I can try. However, this will be a longterm treatment plan and he may still end up losing the leg. Think of wound care as a marathon, it will be a long stretch that requires dedication and commitment for success. It will mentally exhaust the patient and their caregivers including family members. There will be ups and downs, some setbacks, needed sacrifices (quit smoking and drinking), some achievements, and it won't be a smooth ride. Plus, we'll have to wrangle with their insurance company to pay for these treatments. He agreed to my treatment plan. 

Of course I wouldn't be writing this if there wasn't a happy ending but I don't want to mislead you to thinking that I can save everyone. Sometimes, patients come far too late for any viable intervention. This patient came at just the right time. Of course, sooner would have been better.

The photos demonstrate the progression from his initial presentation and then one year later where he is finally healed and walking independently. His leg is still attached to his body and he does not have pain. In the process, he developed multiple resistant infections, multiple hospitalizations were required, multiple attempts to establish an IV line because his veins were collapsing but we were able to deal with it right away. I have a wonderful cardiovascuar interventionalist who was able to help improve his circulation and his primary doctor to help with his medical management. I was attentive to any subtle changes and he trusted my expertise every step of the way. 

  Left  - exposed and dead Achilles tendon which had to be removed.  Middle  - first clean up.  Right  - multiple clean ups and eventual skin grafts leaving him completely wound-free and he is walking without complications.

Left - exposed and dead Achilles tendon which had to be removed. Middle - first clean up. Right - multiple clean ups and eventual skin grafts leaving him completely wound-free and he is walking without complications.

What's the lesson here? As a foot, ankle and wound specialist, I care about preventing amputations. If there is a glimmer of hope, physiologically speaking, and the resources are there (family support and medical doctors intimately involved), I feel a deep obligation to try before burning any bridges. Once you remove the leg, you can't go back. 

Could any of this have been prevented? Absolutely. Finding the right specialist who cares about you as a person and not just your disease and what insurance plan you carry is essential in long-term success. Preventive actions such as caring for yourself through diet, exercise and mental wellness is the utmost importance. Being proactive about your health, rather than waiting for something bad to happen to see the doctor, can sure save you a lot of trouble in the long run. 

My advice to you would be to have a podiatrist on your care team early on. If you need help finding a podiatrist in your area, visit the American Podiatric Medical Association. For more Feet Facts visit ACFAS.org.

 

 

Dry Feet? Here are some not-so-secret secrets

It's probably still winter in some parts of the world which means there's probably a lot more dry feet this season. Want to know how to deal with dry feet? Here are some home care remedies that has worked for my patients:

 I get zero dollars to promote any products but looks like the customers love this stuff. And it's affordable! And I also bought this for my mother-in-law. 

I get zero dollars to promote any products but looks like the customers love this stuff. And it's affordable! And I also bought this for my mother-in-law. 

- Daily moisturizing with a cream or oil based product. I emphasize daily because it's a maintenance issue, just like brushing your teeth. What products, you ask? People have done well with many products readily found at the drug store. My patients have particularly liked Amlactin (they give us tons of samples so our patients have more exposure to it) and products with urea in it (check out Amazon's urea 40% cream). You can also try Vaseline for tougher skin and recently a patient raved about Corn Husk lotion. 

- Avoid hot showers. I know this one is particularly hard for some but the increase in water temperature can strip essential oils from your body, increasing dryness. 

- Avoid barefoot or walking with sandals. This is another way moisture can evaporate.

- Dry feet with callus? Hydrate this skin at night time with Vaseline or coconut oil, cover with socks. The next morning in the shower, use a emory board or foot file to gently remove the hard skin. Do a little at a time so you don't damage the skin underneath. 

- Dry feet with cracks and open wounds? Visit your local podiatrist or dermatologist. They can evaluate if your dry skin is due to a bigger medical problem. You'll want to hold off putting on any creams in the mean time. We'll need to determine if there is an infection lingering around so you don't want to give it any yummies to stick around.  

Wishing you feet wellness!

Source: Photo by Clint McKoy on Unsplash

How'd I get here? Podiatry.

Have you ever wondered how your doctor became a doctor? I'll give you the scoop, the short, dry and honest version of course of this podiatrist's timeline in deciding on her career as a foot and ankle specialist. 

I have to admit, I didn't always have a passion for medicine. As a wee little nugget I had a Playskool doctor kit but I was more interested in playing cops and robber with my imaginary friend. Of course, my idealistic childhood waned with time and I realized a career is what's necessary to live a comfortable life. I had a knack for helping people, often missing class in elementary school to help file some papers in the front office. (Looking back, I don't know why they let me do that!) I preferred doing things rather than sitting around being lectured at. As I got older and witnessed people getting sick, I gravitated towards naturopathic medicine, often awed by nontraditional home remedies like Chinese herbal medicine to cure the sick. But I wasn't satisfied with the 'it just works' mentality, my curious nature needed to know how. This then pulled me into a yearlong training program to be a pharmacy technician, learning about western medicines. At the completion of my training, I couldn't find a satisfying job. 

 Through my journey I have met some amazing human beings like Dr. Chris Attinger (plastic surgeon from Georgetown). He's taught me some cool ways to heal a wound and his insights on limb reconstruction is just incredible. What an honor!

Through my journey I have met some amazing human beings like Dr. Chris Attinger (plastic surgeon from Georgetown). He's taught me some cool ways to heal a wound and his insights on limb reconstruction is just incredible. What an honor!

Then I thought, maybe pharmacy school? Or study pharmaceutical science? Or sell makeup? All these tangent paths from understanding medicine didn't light a fire of interest and I felt so lost. (Except selling makeup, I just needed a job.) Already into undergrad on the way to graduating, I had nothing waiting for me at the end of that painfully long and expensive journey. I supported myself through loans and it felt so heavy not knowing if I could ever pay it back. Then, someone suggested I look into medical school and I thought, "yea right!" Training is too long, too expensive, what if I didn't like it, what if I didn't make it, I don't have any connections, no one in my family even made it through college, and on and on with the self doubt. I had no mentors and it just seemed like a dark lonely dusty path that I had never put thought into...but what if I succeed?

I set some conditions before deciding to move forward. 1) Once you commit, you stick it through no matter what. 2) No kids. 3) Specialize right away so you're not dilly dallying into areas you have no interest in. 4) Be damn good. 

And that's it, I found podiatry school from a career fair at my last year in undergrad and 8 years of training later here I am making a great living doing what I love in expensive California. I learned to love feet, or least love to fix them, and all its intricate anatomy. It seems to get more complicated the more I learn about it. What fun challenges there are in podiatry!

If you asked me 10 years ago where I thought I would be, I didn't have an answer, I just knew it would be somewhere and at least it was moving forward. Even if you asked me 3 years ago, having lived across the country from Iowa to Michigan to Texas, I'd never thought I'd be back in my home state. I was on the go and on fire! I had the freedom to live in any state I chose to, even considering selected countries that accepted podiatrists. Buuut opportunity in California arose and here I am, enjoying every blissful minute of this great opportunity to continue my craft and eventually, be damn good at it. I'm not quite there yet but, finally for once, I know where I am going. 

Big Toe Arthritis - Variants of a Bunion

This is by far my most favorite topic to discuss with patients...bunion pain and its variety. What are the varieties? This is what I will focus on here.

Typical presentation: A patient presents with a bumpy joint pain by the big toe (hallux) and believes it is a bunion. States it seems to be getting bigger with time and that it hurts with walking and certain shoes. They'd like to know treatment options to alleviate the pain. 

An office consultation will consist of clinical exam and xrays.

 This patient had pain for many decades and what is shown is abnormal bony growth around the first metatarsophalangeal joint. Normal joint should look pearly and smooth, the above shows irregular ridges and loss of articular cartilage. 

This patient had pain for many decades and what is shown is abnormal bony growth around the first metatarsophalangeal joint. Normal joint should look pearly and smooth, the above shows irregular ridges and loss of articular cartilage. 

You can already see what option we went with in this particular patient. I call this the "bunion variant" because that's what most people will think they have in this area when in fact it is arthritis. The bumps in the first joint is really a build up of bone that occurs with long term use of wear and tear. Some people's anatomy are set up for this type of pathology as they get older, while many others will never have this problem. The biomechanics of the foot is incredibly amazing but that's not what I'll discuss here. I'm sure what you really want to know are what are the treatment options when you get arthritis in this joint, right?

Nonsurgical options (conservative):
- Activity modification
- Better supportive shoes
- Inserts (also called orthotics - can also get these custom made)
- Pain medication or steroid injections

Surgical management (when all else has failed to provide adequate relief):
- Shaving off the extra bone (cheilectomy)
- Cutting bone, shifting it and securing the new position with screws in a better anatomic alignment (shortening osteotomy)
- Joint replacement (like knee replacements but much smaller)
- Joint fusion (most definitive for end stage arthritis where the joint it already stiff, this procedure eliminates the pain - many people don't miss the motion in the joint anyway at this point)

As much as I enjoy performing surgery, many people do quite well with conservative management. But know that you don't have to live with pain forever. Consult your nearest foot and ankle specialist to discuss which option will be best for you.

New Year, New Shoes?

Welcome back my wonderful readers! It's been 2 months since I've blogged so there's a lot of catching up to do. Of course if you've already found me on Instagram (@drtea_podiatry), you'd see some updates about my personal and professional life and why I've been MIA. I have a growth in my uterus...

 Photo by  Emma Simpson  on  Unsplash

Photo by Emma Simpson on Unsplash

But onwards to an optimistic new year and I bet a new you perhaps? Which means a lot of people are looking to rev up their physical activity and get fit! Much kudos to you but of course you want to do it safely so that you can continue on with a healthy lifestyle. Too much too soon can de-motivate your efforts so here are some pointers to get you started on the right foot.

Things to keep in mind when starting to work out:

1. Looking at new shoes? Choose the appropriate footwear
- You want a sturdy shoe that does not fold in half, particularly if you choose running as your activity.
- Break into them before going full speed. That means go for a test run (short distance) before using them for a race or long distances.

2. Start slow
- Start at a level that is comfortable and gradually increase to a level that challenges but does not hurt you. A gym coach would be a safe start. 

3. Keep going!
- Establish a routine and schedule it like an important appointment. A scheduled "me time" will leave you feeling amazing and acomplished. Motivation will wane with time, but a habit will stick. 

4. No pain, no gain?
- Pain is essential to living and it is protective so know when to stop. If you push through the pain, injuries can happen that will put you out of commission longer than you desire. Small periods of rest and recovery is essential in optimizing your workout and your overall well being. 

Wishing you a happy healthy new year!

Complications of an ingrown toenail

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A lovely 70 year old female presented with a toe infection on-going for a few days. She relates having an ingrown nail causing her pain and was subsequently removed by a podiatrist. 

She is a diabetic and admits to going back to work after the procedure. Several days later I was called to see her in the emergency room. See far left image. There was increasing redness, swelling and purulent material draining out the nail bed. Her prognosis was bleak. 

I didn't know if the toe could be saved but I told her I would try. I worried that if we did nothing, the infection would spread affecting other parts of her feet. So we wheeled her into surgery right away. 

Paying close attention to the blood source to the toe, an incision was made down the middle and the infection was gently cleared out with a curette. The wound remained open to allow further drainage. She was admitted to the hospital for IV antibiotics and debridement was performed daily until I was comfortable that the infection was controlled. 

Several weeks later, she is doing quite well. 

Complications of an ingrown nail is rare but the risk is still present, especially in patients with diabetes. It is important for patients to feel comfortable in addressing any problems they have after a procedure immediately with their doctor and equally important for the doctor or their medical assistant to be available as well. Don't take any procedures lightly and as you can see here, complications are real but if dealt with in a timely fashion, prognosis can be good. 

 

"I think I have an ankle fracture. Now what?"

 XR of an ankle (fibular) fracture

XR of an ankle (fibular) fracture

Breaking any bone in your body is frightening. Not only does it hurt but fear of surgery and long term disability is on everyone's mind. My husband recently missed a step going down stairs, he was holding the dog's leash in one hand (and she was pulling) and his cell phone in the other (I don't see how this was a good idea to start with). His foot turned under him and ... SNAP! He heard and felt a pop, called me immediately and fortunately for him had concierge service from his favorite podiatrist. He told me "I think I fractured my ankle."

Luckily my office wasn't too far from where he was so I was able to drive him to the office and get xrays immediately, bypassing the emergency room. Of course, the whole time he was very scared that he would need surgery. He himself is a general surgeon and runs around all day and night going between patients traveling to different facilities and stands for long periods to operate nearly everyday. His job, like many others, requires him to ambulate independently without pain. So, what was next for him?

His xrays were negative for an ankle fracture. But what was that audible pop and the immediate bruising and swelling? He may have torn one of the lateral ankle ligaments but since he was not a professional athlete, I advised him to take the following protocol seriously so he can heal optimally without surgery, the acronym R.I.C.E. protocol is appropriate here:

1. REST - I realize many working people don't know how to do that. He was given a walking boot to protect the ankle and was instructed to wear it during working hours, then take it off when sleeping or driving. Functional recovery (continued protected movement) is important in ankle sprains. In the evening, he was to do passive range of motion exercises, drawing out the alphabet with his foot. Too much immobilization could stiffen the ankle and weaken the leg slowing down recovery. 
2. ICE - this will decrease the swelling
3. COMPRESSION - I applied an elastic ACE wrap to help with the swelling
4. ELEVATE - raising the affect leg above the heart while at rest will also decrease swelling

(or P.O.L.I.C.E. - Protect, Optimum Loading, ICE, Compression, Elevation)

He only took a few ibuprofens in the beginning but went straight back to work the following day taking it slow. Of course I'd occasionally find his boot laying around the house every now and then while he was at work, so you can say he was doing fine. After 6 weeks he felt pretty normal and went back to working out and running comfortably.

By the way, if it was an ankle fracture, that doesn't necessarily always mean surgery. Allow your surgeon to make the diagnosis and discuss treatment plans with you. The sooner you seek treatment, the better off you'll be.