Chapters Transcript A Pathway to Support Achievement of Definitive Closure: Solutions to Protect Surgical Wounds Live webinar presented by Dr. Vipul Dev, Dr. Mark Granick, and Dr. Hector Campbell Hello and welcome to today's E Plasty webinar. Today's presentation is a pathway to support achievement of definitive closure solutions to protect surgical wounds. My name is Cynthia Cooley, F for E Plasty and we're happy to have you joining us today. We'd like to thank organogenesis for sponsoring today's presentation. We encourage you to submit questions and comments for our speakers by using the question submission section on your screen at the end of the presentation. We'll try to answer as many of your questions as we can in the time allowed today, we are very pleased to welcome our featured speakers. Doctor Hector Campbell, Doctor Mark Granick and Doctor Vipul Dev. Doctor Hector Campbell is a board certified plastic surgeon and currently practices at True U in Grand Forks, North Dakota. He specializes in hand surgery and reconstructive plastic surgery within his current practice. Doctor Mark Granick is a professor of surgery and medical director of the uh wound center at Rutgers. He has a 40 year history of academic plastic surgical experience. He specializes in surgical wound care including chronic wounds, complex reconstructive surgery from injury, cancer, various deformities and treatment of skin cancers. Doctor Vipul Dev is a plastic surgeon in Bakersfield California with over 20 years experience. Doctor Dev is currently affiliated with Bakersfield Memorial Hospital and specializes in cosmetic and reconstructive plastic surgery. We're so happy to have them joining us today and with that, I will turn it over to our presenters. Thank you again for joining us. OK. So let's begin. Uh Today we're gonna talk about uh various ways to establish a viable wound. Uh I work as a consultant for organogenesis and a couple of other companies. Uh Most of you probably recognize the time principle. A time principle was developed around uh 20 years ago, I would say, and it stands for tissue infection, moisture and edge. Uh These are the components of of wound bed preparation. Uh tissue, meaning non viable tissue or deficient tissue needs to be corrected. Infection obviously interferes with uh a proper wound bed. Uh Moisture balance is uh very important. Uh We used to think that uh desk a wound helps but uh around uh oh about 23 decades ago, moisture was noted to be a very important aspect and the edge is the healing edge of not advancing or undermining tissue addressing the challenges. Uh uncontrolled bio burden can delay healing. Uh biop burden is becoming a very well known force in uh in the wound industry. I'll talk more about biofilm later on and protecting those that uh need it. The most comorbidities interfere with uh host uh defenses and increase the risk of post surgical complications and managing complex wounds. Larger, deeper wounds are slower to heal. So, let's uh just briefly go over this again because they're so important uh bio burden, uh particularly biofilm uh needs to be controlled. Otherwise, uh, wounds are delayed in healing. Wound depths is obviously, um have an important component and wound shape. Its interestingly uh circular wounds are slower to heal than uh linear wounds. Uh loss of subcutaneous tissue also interferes with healing. So as far as bio burden and biofilm go, let's talk a little bit about that, you need to have biofilm under control. The potential factors preventing wound progression include excessive bio uh bacterial bio burden and biofilm. Increased neutrophilic accumulation, pro cytokines, uh decreased T MP levels, increased M MP levels and proinflammatory macrophages. So this shows a picture of the wounds. It stall, the presence of biofilm can trigger an chronic inflammatory response and delayed healing. So, on the left, you see free floating bacteria that's basically planktonic bacteria. Uh they began to aggregate in colonies. Uh They have a uh uh method of communication referred to as form sensing where they respond to chemical signals in the environment and they can aggregate and when they form mature biofilm, uh they have a variety of different type of cells there which uh make uh intrusion by antibiotics and other means. Uh much more difficult. So, aggressive debris is essential to removing b burden uh biofilm does reform rapidly. I'll show you some experiments that uh uh actually show you why that happens. So basically, within 24 hours, biofilm begins to reform some cases. Actually, even earlier, it was able to grow biofilm uh within two hours and a lead uh within three days, it's well established in most cases. So take a look at these surfaces, these are slimy and these are covered with biofilm, but it can appear in many different forms when you look at it uh under a microscope or electron microscope, uh what you see uh is a bacteria that tend to aggregate in the most comfortable environment for them. So for instance, if you have an anaerobic bacteria, it's gonna tend to be deeper into the wound because there's less oxygen uh that turns off its metabolic process biofilm causes chronic inflammation. And that elevates proac which degrade PDGM. I often cause chronic inflammation and that also degrades matrix proteins. This picture shows fibronectin being degraded in a nonhealing ulcer. So why are bacteria in film so hard to kill? Well, the key really well, several keys but the ones highlighted in red are the big ones exo polymeric uh material E PM, uh which is a shell that these uh organisms produce. And uh it makes uh penetration uh through the E PM, very difficult. They have hydrophobic proteins in it and it reacts chemically and degrades micro biocides. It has negative charge uh and uh DNA within uh the biofilm and persist bacteria, the persist bacteria have a lower metabolic rate. So they basically go into hibernation as it were, but they can wake up and emerge from the biofilm. So they're constantly coming and going antibiotics only kill metabolically active bacteria. So the persistent bacteria are uh pretty much immune to those oxygen diffusion uh toward the center of the biofilm is limited. And that promotes the growth of anaerobic bacteria. Much as the depth of that within the uh entire structure of the womb synergism between the different bacteria is also uh noted uh they feed off of each other and MRS A uh secretes resistance proteins. Pseudomonas secretes catalyst that destroys uh gen proxy. So what are the ways to address biofilm? Well, you can do it by frequent sharp debris, cutting away the surface of the wound. You can use enzymes. And this person b which I've worked with in the past, it's just actually coming onto the market now and they've seen it at the sewc Syme has been around for a while. That's used primarily in uh kids with uh cystic fibrosis to break up the biofilm uh in the lungs, uh surfactants uh which are becoming uh you know, the common now uh have a lower surface tension between liquid and solid uh or other liquid and that uh disperses biofilm. Uh negative pressure with irrigation has become a big presence on our marketplace, biotherapies or maggots. Uh I was very good at digesting biofilm and surgical excision. I take this as something different than frequent sharp debris. Surgical cision is something that's done in an operating room. And uh that includes uh hydro surgery, direct contact, low frequency ultrasound and scalpel excision. So, let's talk first about the uh little jet technology, high velocity streams of saline are used. Uh the one that is commercially available now basically consists of a uh hair sized uh stream of water uh forced uh through a hole uh and it becomes uh you know, cohesive and uh very high powered. You can get a stream of uh saline in this machine to go up to about 15,000 pounds per square inch. In industry. They have machines that can produce uh 100,000 pounds per square inch and uh can be used for extracting iron ore from the inside of the help. So they're very powerful. Uh When the stream passes by tissue, it tends to hold it in place and uh implode the tissue and removes the waste. It's a pretty ingenious system. So you have a jet tube, the water or saline is forced through a little hole, uh creates a relative vacuum using the venturia effects and evacuates through uh an evacuation tube. Uh The machine currently as it is used as additional suction, I generally don't use that aspect of it and it just makes it more difficult to use it. It has a tip frequency of over 20,000 Hertz in amplitude of about 100 20 microns. And uh well, this is the ultrasound uh direct uh contact low frequency ultrasound. Uh We've transitioned into that now. It is just above human sound perception, but don't bring your dog to the or because uh they will respond to it. It requires a fluid interface to transfer uh ultrasonic energy. Any time you're using ultrasound, it requires a fluid medium to be transmitted and it works by micro cavitation. Micro cavitation is because there are oscillations within the ultrasound uh which create vacuum bubbles and the bubbles collapse ultimately and release mechanical energy. A fair amount of that acoustic micro streaming are basically sound pressure waves. And these two are very important. Uh They actually can cause uh uh transmission of chemicals through cell membranes and they also stimulate cells, which is why ultrasound uh in some forms has a positive impact uh on healing. So direct contact, low frequency ultrasound uh of a sickle ulcer. This is a patient that has a sickle ulcer, uh extremely painful. Uh This was done under anesthesia. It took about 34 minutes of treatment uh to get a perfectly clean wound. Uh That is the difference between doing a surgical debris and doing a uh uh chemical debris uh or some other forms of debris at the bedside. Uh Surgery gives you great control and things move very quickly. Uh This is uh situation with a uh venous leg ulcer, uh venous leg ulcers are not just surface debris. If you look at this ulcer on the left, it looks like a fibrous exit, but you need to get down about four or five millimeters. Uh If you look at the next picture on the right, you can see that the wound actually looks excavated. That's because the ultrasound will get down to fashion uh very quickly and get things clean, but it gets rid of all of the junk. Uh Back when I was working with uh uh the fluid jet quite a bit. Uh We did uh punch biopsies of tissue before and after. And uh we were surprised to find that even though uh very superficial wounds were completely clean, the deeper wounds uh were not and they grew out a lot of bacteria. And basically what was happening there was that whole concept of bacteria living in different environments within the womb. The deeper bacteria are not as affected uh by a surface uh treatment. And uh the uh direct uh of the uh uh fluid jet really just works along the surface. So for deeper ones, the ultrasound seems to be better radical surgical excision is another way of getting rid of biofilm. Uh If you look at this wound on the left, it's a pressure ulcer, sacal ulcer and it looks pretty nasty. Uh But uh to approach this using a standard uh traditional surgery requires a fairly extensive excision because uh you're not just getting rid of the biofilm per se, you're getting rid of all the aquatic uh material and sometimes it can be quite extensive. This is what a properly the breeding wound looks like just prior to his Cambridge. So here are some studies that I did uh when I was uh studying some of this instrumentation uh for the direct contact, low frequency ultrasound. I was really uh fascinated by the uh the fact that industry uses uh ultrasound to clean biofilm uh off of metals. Uh And we had uh some sporadic reports of uh orthopedists uh treating the wounds of patients who had infected prostheses and having the infections uh resolved. Uh So I was able to get uh pellets of uh metal that were made out of the same materials as uh pros prosthetic devices and titanium and stainless steel discs in various all forms uh coated them with staph epidermitis, which is the primary bacteria in human skin and uh is a very strong biofilm form. Uh We were able to grow biofilm on it. So these are shiny metal discs and here you see it with biofilm and notice that the biofilm has a uh sort of a velvety look over the top of these disks. So we treated it with a direct contact low frequency ultrasound for 10 seconds. Uh We used uh either saline or hypo chloric acid as an irrigation through the uh device. Uh And the control was to do with and without ultrasound. And uh this is a stain with crystal violet, which is picked up by a biofilm. So, on the left, you see uh the controls, these are uh metal discs that have bio on them. On the right, you see uh shiny disks because all the bio has been removed, completely removed. Uh There've also been reports that the ultrasound kills bacteria and in fact, uh you can put an ultrasonic probe into a broth of bacteria and it'll kill all of them, but it's gotta be of sufficient strength and it has to be in for a sufficient duration. And even though the ultrasound energy that's produced by the direct contact, ultrasound uh is pretty powerful, it's not there long enough to kill the bacteria. And what we showed here was that the effluent um after treatment uh produced a lot of bacteria, so sing was great uh to irrigate it. Uh But if you culture that out, you just got a sea of bacteria. So it was releasing bacteria from the biofilm, but putting them into a planktonic form. And that's very important because if you have a wound, that's a dirty wound and you clean it off with a Debre device, you may be getting rid of the biofilm, but you're leaving plenty of bacteria behind and they will reform. So typically you wanna wait a few days, five days a week before you go ahead and put a graft on change dressings and so forth. But what you really need to do is you need to control the biofilm and that's where purify purely SX comes in. SX is their latest product which is made specifically for surgeons. It's pretty much the same as purely a MP. Apply AM is a collagen matrix and, uh, embedded within the collagen, uh, is HMB. And, um, may I interrupt you for just a moment? II, I have a question regarding uh your take on a couple of things. Um What's your take on um fungus and wounds? MRS A, what's been your experience as of late with uh the polymicrobial uh kind of things that we get from wound cultures as well. And then along that line, uh what's your take on actually obtaining tissue culture? Do you prefer to do that in a wound care setting or do you prefer to do that in a surgical setting since we're all surgeons on, on, on the line right now? Uh What's your take on that, please? Well, I think if you, uh if you do a wound culture in a wound clinic, you're gonna get what's on the surface. So I'm not big on it. I don't think it's all that accurate. So when I want cultures I'll do a punch biopsy or I'll just culture the material that's being surgically debrided, but you can easily do a punch biopsy in the clinic. It's not a problem. So if you're really concerned about culture in the wound for whatever reason. Uh That would be the best approach as far as uh polymicrobial infect microbial infections. Most of them are polymicrobial, particularly diabetics. And uh I think you need to be prepared for that and treat the patients for that. Uh You also need to wear uh eye protection and a mask. If you're Debre a wound, even if it's uh scraping a wound with a surgical Tourette in a clinic, you still need to wear a mask, you still need to wear eye protection. And in the, or if you're gonna use uh either the water jets or the direct contact ultrasound, then eye protection and a mask are even more important. Uh because you've got fungi, uh you've got all kinds of uh bacteria, uh nasty stuff in the wound and you just don't want to spread those uh those items. So we did a number of things, uh a number of different studies in terms of how to control uh uh spray dispersion with both of those devices. And I don't wanna waste too much time on that. But basically, if you use the proper technique in the proper speeds with the uh hydrogen, you can control uh spray uh formation uh during the treatment of the patient. And if you're using direct contact ultrasound, we've developed uh hoods that essentially surround the head uh of the device where the spray is emanating and it will recapture the spray and cycle it away from the wound and that almost eliminates it. If again, you use the uh proper technique in degrading wounds with cold steel doesn't really matter. You don't get much spray unless you're irrigating it. Um On the other hand, I've been in many rooms where 5 L of uh irrigation fluid or sprayed on the wound in the room, you gotta wear your high water boots. So again, in, in those situations, you need to wear a mask and uh uh eye protection. Well, thank you. Uh You know, I've uh I've had a, a biased approach because I've known you for so long and I've had a different approach ever since I've met you regarding uh M MP S and bio burdens and so on. So I just feel that everyone else needs to, needs to hear what you have to say. So I think uh we, we, we, we're privileged to hear what you've had to say today. Uh Sorry for the interruption. No problem. Thanks. So, lets see. Uh I was talking a little bit about uh SX uh the pure applied product. Uh the difference between pure apply SX and what you get. Uh We use in a, a patient uh setting. Uh The SX has got like four layers. Uh It's much thicker, it lasts a lot longer. Uh What you do with these things since they don't really adhere to a wound is you have to fix them in place in a variety of ways. You can staple it, you can sew it, uh you can tape it, you can put it back over it or some other negative pressure device. Uh but you don't want it floating around. So you need to stabilize it in some fashion. Uh Really the key uh is that you've got this nice uh cross length uh po uh collagen and that acts as a matrix and uh but the PHMB is a really powerful uh antimicrobial agent and this will kill all the negatively charged bacterial cells. That's what it targets. So, real world cases, solutions to protect surgical wound. Uh Now we're getting over to Hector's uh expertise and I'll let him take it away. There you go. Uh Thank you so much, Doctor Grant uh for a very comprehensive overview on just the science behind biofilm. Um So I'm uh just gonna go through a few uh real world cases utilizing uh pure apply AM and also SX and, and you'll also see just other products in the portfolio uh for organogenesis. I'm a consultant for organogenesis. So, in terms of just a principle and approach to patients, and uh my thought process is that I I approach any patient by, by thinking on systemic factors which are both are patient related factors and then local or wound factors. And for you to re um a patient, you have to optimize both. Um and in terms of optimization, which would be more about or talk today showing cases. Um the approach in terms of what's etiology of the wound. Um what's the location, size depth um um debridement? And as doctor um grant had mentioned, the, the different modalities of debri is a cornerstone for wound healing and preparing the wound wound care support. And that's where our pre apply am and sex come in and from my perspective, mostly from an inpatient um I'm showing cases. Um My overall philosophy and approach is utilizing a purely AM or sx with respect to supporting a wound, protecting the wound and also um preparing the wound. And so we wanna support the wound in terms of healing. We wanna protect the wound from by controlling biofilm and we wanna prepare the wound for definitive soft tissue closure reconstruction. So our first case is a 24 year old. Uh one second here is a 24 year old left hand dominant male uh who presented with a self inflicted gunshot wound to his left hand. Um The picture on your left shows the entry um um wo sorry, the exit wound. And uh and the the entry wound was uh on the palmer aspect of his hand. Uh the patient had a composite soft tissue injury, including skin tendon, nerve and bone and of course, just assessing this patient. Um uh But before going to the or we discussed all the various options including amputation. Um And so this picture is showing on your left, just the entry um gunshot wound and then the, the uh x rays on the right side showing a segmental bone loss with a over three centimeter um uh segment of missing bone. And so, obviously a uh a complex injury um throwing not only soft tissue loss, but also bony loss. So the principles of course, is to establish some form of temporary bony stabilization. And we did this using um just a mini X fix. And this is I always call it a woman's way of actually providing a mini X fix with K wires and a three CC syringe. Um And then we're able to partially close some of the wound. But then we have an area open when particular on the dorsal and some aspect of the palmer aspect of the hand. And so it comes to how do we establish soft tissue uh support for this patient? Um because that in itself is a critical step before we are able to have definitive bony stabilization. So my choice for this patient was purely am and this is the purely AM applied just before hydrating the product. Uh And just as doctor Granick mentioned, there are various ways in terms of stabilizing and keeping the product in the wound. And I opted for using the stereo strips. Um and then afterwards um hydrating the product before putting on uh dressing in this place and he was in a splint. So why triple I am in this instance, there's an open fracture. And of course, I'm uh my concern is for infection, but the thought is to support the wound, protect the wound, right? And also prepare the wound for definitive reconstruction. And purely am provided the part of the plus, it was able to provide a native cross link ECM Gaff fold along with that plus with the PHMB, a broad spectrum antimicrobial. And so after six applications of pure apply AM we're about to get just about some uh good uh soft stabilization. Um followed by definitive reconstruction. We're able to place a bone and allo graft along with an iron uh metacarpal uh nail. And I also did a dorsal uh hand uh rotational flap and a back graft of the uh secondary donor site with a skin graft. And so again, in this case, um illustrates just the the use of a purely AM and being able to support and prepare a wound um for definitive reconstruction. The second case is a uh patient um that uh came in with a de globing traumatic injury to her left upper extremity um from a motor vehicle accident. And uh this patient was initially seen by her orthopedic colleagues and underwent uh multiple debridements and washouts and was referred for uh uh soft tissue coverage. This is also uh showing the wound to her uh left forearm along with the wound to her um left axilla. And uh and I think that there's a slide with Doctor Granick when you, when you mentioned, what is this slimy stuff? And I I'll put it to you, you know, what is this slimy stuff? Um You know, this is obviously con some concern for, for biofilm. And so the patient was referred for soft tissue uh uh uh uh coverage. But in my opinion, this one was not fully optimized for us to proceed directly to soft tissue coverage. And so we performed an excision, the br um and wash out and wound does look better. I'm not seeing that uh that slimy stuff again, particularly to wound to the forearm. But even after this debridement, um we need to have somewhat of a granulating wound bed. Um And, and uh so I I still thought that this wound is not optimized to proceed with selfish reconstruction. So opted to apply to reply m again, with the principles of being able to further support, protect and prepare the wound place of duoderm just to help to be able to protect the permanent skin. And also to illustrate that after applying the ply AM at this point, the patient was discharged home. And so this patient didn't need frequent debridements in the or washout to need to be able to get this one ready in my opinion. And now this has changed my practice. Once I'm able to do a a definitive agreement of this wound, please reply. I am. I'm oftentimes able to get patients discharged out of the hospital, thereby providing value of care and decreasing costs in terms of frequent debris and wash ups. This is one week after debris and application of trip I am and this is the wound of the axilla. That's the wound to the left forearm and just to illustrate the pre debree until the left axilla compared to the post debree wound after one week of application of pre apply, am you can see that now we have a granulating wound bed and in my opinion, a wound bed that is more optimized for soft tissue coverage. And so we were able to proceed with uh split fitness game graft. And so again, I think this, this case illustrates not only the utilization of pre apply, am in being able to optimize a wound for definitive self issue closure, but also being able to add value care in having this patient discharged from the hospital in an acute setting, then being followed up in more for surgery a week afterwards. And so not keeping up in a bed in the in the hospital and also increasing costs. Hector, this is a great case. Uh um I I mean, really good work. Uh What's your take on using uh negative pressure therapy along with this? And uh what what kind of value do you think um your use of purely product adds to other modalities in getting the patient out of the hospital quicker? So I think length of stay does really matter, especially nowadays. Um And, and the number of surgical procedures. So if, if you can answer those two questions for me, uh give us an idea of what your take is on that. I, I think that's tremendous. Absolutely. So uh yes, I do use negative pressure um wound therapy for patients. I think there is um uh great utilization for negative pressure uh therapy even. So uh these days um with insulation, um however, um I still think negative pressure with therapy on its own um may not be able to, to fully optimize the wound uh uh necessarily because there is that biofilm that is still present in these wounds. Uh And so my, my uh philosophy is in terms of wound uh preparation is being able to um adequately control bio as much as I can to, to facilitate the granulating wound bed. Um uh I've been so oftentimes when I apply a prey, if I can, I don't, I wound back over it often times, most of the times that's what I'm doing. Um um And so uh uh generally speaking or um um so other colleagues, whether it be orthopedics, um or my general surgery colleagues, um they're fine putting in the wound back. But I think once um um uh I take over the wound, I'm thinking more of is it ready? And is it ready for definitive reconstruction? And if not, how do I get this wound ready? Um how do I support, protect um and prepare this wound and sometimes it's for defined reconstruction and sometimes it's by giving my secondary intent. Uh But I'm always using something um to get this wound prepared and I added something uh as well. Absolutely. OK. Thanks. Uh purely was developed as a tool for outpatient management in a wound center. So the original pur applies were very effective, but they came in small pieces. And uh as a surgeon, I was extremely frustrated by that. I'm sure you all were as well because it's a great product. But uh recently they came out with SX, the SX is essentially the same as purely, although it's thicker, it's got more layers and uh it's frate and you can use it in your because it comes in big pieces and that makes things a lot easier for it. So you don't have to mosaic, you're ruined in order to get it covered and it also lasts longer. Mark, that's a great comment. And I think as surgeons, you know, we're always worried about it. Uh We don't see the small ones, let's face it. Uh And let's be honest. Uh I mean, in our hands, we always need something that's more definitive. And I think the answer to that, or at least in my practice is the X product. Um You know, all three of us have practices that are very similar and mark you being at an academic institution, you're doing a lot of the, a lot of the heavy stuff just like we do in private practice. And I think that definitive treatment is kind of what we're after. And uh this certainly answers that question uh in, in, in my practice, it certainly answers that question. And your, your, your case is very right now, Hector Drive, drive home a very valid point to me because, you know, you're working in an area where their vital structures, uh both uh vascular and uh from a functional perspective as far as tendons go. So I think that uh that, that really helps uh helps me kind of provide insight to my patients on the type of care that I'm going to give as far as definitive closure. Absolutely. So, uh this is a case of a 62 year old female who underwent uh bilateral breast reduction and um uh a common thing that we uh we see in our patients with T junction deist and uh she is uh diabetic immunosuppressed. I've watched it for a while and then it's stalled. And then, you know, my thought was, you know, let's get ahead of this uh in turn, be a little bit more aggressive in, in, in uh in performing a debridement. And so it comes to debridement and how do we support this wound afterwards, right. Um And, and so still utilizing the same principles in our previous cases, how do we support? How do we protect right and how to prepare this wound. Um And so this patient was degraded um apply purely AM. And then this is 11 week after uh uh agreement with the application of purely uh am. This is two weeks afterwards. And you can see we're having uh a significantly more granulating bloom bed and also some wound contracture as well. And this is four weeks post agreement and four applications um with a significant reduction in size um um um and healing of the the wound near healing of the wound. I apologize. I do not have AAA final photo for this patient searched far and wide. But you know, in this case, this illustrates that even as surgeons experiencing these uh very common in his sense, um we can still be thinking of how do we support this wound, uh these wounds um uh if not being able to, to breed and do um uh a different closure, then how do we support? And so having a consideration of ply I am I've also utilized of course, uh the product in this way for my patients. Hector II, I like this case, Hector. Uh because of the fact that one sometimes, you know, when we do these kinds of procedures on the breast, it's hard to do a debridement, especially when you see them in the office, right? I mean, that's not what they're expecting and it's kind of meeting patient needs, but I'll tell you uh for me when I use a pure, purely am product, I use it in this kind of thing because I know that I'm going to get less bacteria growth over time, less bacteria growth allows the granulation bed to form. And I think our friend Mark would probably agree. The bio burden decreases it from there. So I think that helps, but that's how I would use it in my practice. So I think, I, I mean, I'm a little biased about your use there. But I think that's uh that, that to me is a spot on use for. Absolutely. And I, and I think, you know, we just, we're, we're thinking on uh applications, right? And, and, and as surgeons, I said, you know, we will have cases where we have a innocent. And so it's just thinking, you know, how do I support this wound? Would I reduce the, the bio burden or do I, you know, um facilitate healing uh by uh definitively healing by secondary tent or even if you're planning on um some definitive closure, the support of that wound still becomes important, right? And so, you know, that's kind of my philosophy and I'm happy we, we, we share uh kind of the, the, the same uh uh uh uh uh thoughts in terms of how we can support our patients. Uh so superficial sternal wound in a sense. Yeah, these are kind of some of the wounds that are problematic and this is a 52 year old, uh poorly controlled type two diabetic smoker and she, and she was that but a cabbage. Um she was worked up uh by our card thoracic surgeon. There was no uh deep collections, um uh no um exposed hardware, um no concerns uh for uh uh sternal osteo and so um act to help with the cure of this patient. My thought was uh let's keep it simple, right. Uh You know, we could try to close this primarily, however, that will lead to undermining the skin edges, creating um uh skin flaps, advancing them, obviously, not being sure of the uh the vascular supplied. Uh My thought was uh uh uh as simple as is is better. Um And so, uh after debridement, I use that to reply MZ uh which is just a micronized um um ported form of the crossly native uh collagen um to really be able to pack that wound um particularly in areas that she had a bit of uh um tunneling and then um a pre apply em um over that because what I wanted was this that support from her, from her PHNB um which is not present in our MZB. And then we placed the wound vac and, and this was a patient two weeks afterwards. And at this point, y was excited, the wound at this point seemed as if it was like at the Kentucky Derby, it was racing along towards healing, right? And then this is the patient, uh uh four weeks after for applications. And so, um, uh, with this patient, we were able to uh support, uh uh protect uh uh uh this wound uh for secondary healing without needing any, uh a major reconstructive surgery. Um, uh, and it worked well for her. Um, so, uh, next case and this is kind of uh one of the cases that, um, you get in your career that teaches you a lot. Um So it's definitely an instructive case for me. He's a 26 year old male. Uh I saw him after 2.5 years of this chronic nonhealing wound to his right groin period, you know, region, sacred oxy region and also his, his right posterior thigh. He had failed multiple flaps including in my hands. Uh It's e everything that I did just failed. Uh And, and, and so, um this is one of the cases where you, you pump the brakes a bit and you start thinking to yourself, am I optimizing the patient? You know, we think of the wound? But what about the patient? Something is going, something is going on. So, um going back to the drawing board bar, get the a team on board a lot of the times the approach to the cure of the patient is multidisciplinary. And so that was what we did in doing a series of tests, getting uh my internal medicine colleagues in um getting a a uh a lower G I work up um autoimmune work up, something was going on that I, we needed to find out what, and, and, and, and, and then this case pretty much was one of those cases that, you know, led me to Oregon, led me to pure reply. And uh uh in terms of using everything else in my arsenal at the time, that was not helping the patient, of course, we're able to make a diagnosis that something systemic was going on. Hydro orgy Reynosa, right? And, and typically this patient would be uh would do well just with immunosuppression, predniSONE, you know, infliximab um which was being managed by dermatologists. But even with that, we found that the porting was also very critical. And so just like uh Margaret Celia said, you know, whatever stands in the way it becomes the way, so to speak, this case stood in my way. But it became my way, it became, you know, my, my step in considering organo AAA as, as as options to help this patient. And so, um this is pretty much the wound after we started, you know, using organic products, heel to the groin, heel to the thigh, uh uh almost heel to the thigh. Um And so we went down from a 200 square soom room uh with using six applications of pim and then switching to to New Shield, which is um uh or AAA placental membrane product in the P of a Gyno Genesis um um um to significantly decrease the size of the wound by to 30 square centimeters and all the wounds have healed except the one to the posterior thigh, which um is steadily, of course, uh healing. And this has been months since I've seen the patient, he's likely healed by now, uh since I left that institution. But, um, again, this, this case was significant for me because as I said, it's that Sentinel case that led me to in terms of start using organic products considering that. Um but also, you know, uh you know, the taking the entire patient into consideration there is patient and there is a wound optimize both. Uh This case is a traumatic uh uh injury to the uh distal leg, um deputed multiple times by orthopedics. And uh when I saw the patient, I the patient was kind of optimized at that time, I use an a sl product. And uh it, it looked well and, you know, for a skin graft, uh you know, there are other options, free flaps, of course. Um I'm a, I'm a, I'm the type of person that surgeon takes things simple. If we can reconstruct the patients uh with uh sim a simpler uh modality reconstruction, then I'll try it out first. And so skin graft is good until two weeks afterwards. And uh you, you me with this, you have lost your graft, you know, uh the patient was in a eb there was a lot of friction. Um um There's the next question was the wound properly optimized, right? You know, was there still a bio burden that could have caused this uh a possibility? Right. And so our options for flap redrafting in an organogenesis in terms of using a pre apply m uh to support this wound um to, to, to decrease the body burden um um and to prepare this wound, either for defined reconstruction or healing by second intent. And so we Deb bred it. Um And after three applications of pre apply M we saw a granulating wounded, the contractor is getting smaller. And uh the patient basically had a definitive uh wound uh closure by secondary intent after through application of pre apply and, and uh used also some new shield uh as well. And so the patient was very happy that she didn't require a, a significantly larger reconstructive procedure and being able to heal um uh uh definitively after uh extra time. But uh she uh she was elated. So my last case is uh it shows my, my progression in uh from uh utilizing a pure apply am to know a purely sx. Um And this is a 60 year old female uh left and dominant infected elbow um and elbows are like ankles to me, you know, they're tough areas. Um She had serial debris by orthopedic colleagues attempted uh a closure twice the his became infected. He's been on an IV antibiotics uh significantly her last work up and it's negative for any osteomyelitis. Um And uh cultures are also negative at this point, but you look at the wound and you, you know, you see that slimy stuff again, you know. So um is this one ready for any defective reconstruction? You know, my opinion? No, I my opinion is that this one needs to be further optimized. Uh uh and so read a breed it and uh and uh place a purely sx covered with a wound uh wound vac. And the goal was to optimize this wound prepared for definitive reconstruction and we have exposed on Larena. But, you know, I think this wound looks better a week after a purely sx, right? And so we went on for uh she's a flexor carpi Aris uh muscle flap along with uh uh a sp in a skin graft uh for this patient. And I was able to give us good coverage over the bone uh uh uh as uh uh along with the skin graft. And this is a patient um five days uh post up and uh went on to, to full healing. Um And so again, this shows my progression in terms of utilizing a purely SX in a, in a similar philosophy as a purely am. But I think that the thicker uh product more with uh no, with a four layer. Um I think it adds value. Um It's much more robust and uh and uh if after a week you take a look, uh and it's incorporating it. Well, I mean, you could continue with the pure ply sex on the wound, necessarily change it. It's optional for me, but it adds value in my opinion um uh for, for these cases. Um And so I thank you. Fantastic. Thank you so much for that wonderful presentation. Um Looks like we have time for maybe a few questions here. Um This is a question for all of our speakers. Typically. How long do you wait between the first application and the next follow up? Is that different than the duration between debridements without the use of the product? Uh Let me go first. Ok. Well, I, I typically, you know, wait a week um before you re evaluate the patient um after debris and applying a purely PM RSX. Um III I think, you know, we need to give the product time to, to, to, to really work. Uh And so, um on average, I'll wait a week and um and I, I, I've, I've had instances where applying to IMRSX and um having my orthopedic colleague be asking me. So, um are you taking the patient back uh in two or three days? And I'm like, well, well, no, um um uh it, the product I'm utilizing uh needs time because of course, the overall um practice is always to go back every two or three days after for another debris and for another look. And so I'm, I'm, I'm looking at the patient a week afterwards after and then, and then, and reassessing to see. Oh, well, the wound is being optimized Hector. How do you deal with uh cavitary wounds like a single pressure ulcer or initial ulcer? Uh For those? Uh I, I debree, I um I utilize uh sometimes a lot of the, the flow. Um And I've oftentimes also uh utilize it to apply AM as I just started using SX. Um but I do think, you know, these patients, it's a, it's a, it's a particular and peculiar population where we have to approach a patient in such a multidisciplinary type way, pressure of offloading, et cetera. But um with palpitation, I, you know, there is this is where a lot of the times um using a purely MZ also may be helpful in getting into a lot of these um undermined areas. You know, I, I have tried the same thing. Uh I have difficulty using P apply AM in these wounds and a back because it just doesn't stick. And uh next thing, you know, the thing falls out clumps up. So I found that the MZ is extremely helpful because uh if it's configuration, you can get into the entire surface area and around and covering everything. So for me, that works pretty well, fantastic. And with that, it looks like we are out of time for today. So Again, I would like to thank our sponsor Organogenesis for today's presentation. And thank you all to our attendees at home and our wonderful speakers. We hope you have an amazing rest of your day. Thank you so much. Published August 6, 2024 Created by
