November 18, 2021

Cosmesis should never be an afterthought.

CREDIT: Sherwin S.W. Ho, MD
CLOSING TIME Administered properly, emerging wound closure techniques can not only boost efficiency in the OR but, more importantly, minimize scarring for patients.

In the name of efficiency, some surgeons let their assistants close an incision so they can quickly move to the next OR and the next case. Sutures and staples get used, sometimes out of nothing more than habit. The procedure itself was a success — but it left a significant scar.

That's not best practice, according to Jeffrey S. Freed, MD, MPH, FACS, a clinical professor in the department of surgery at the Icahn School of Medicine at Mount Sinai in New York City. "I tell all my third-year medical students the same thing: The scar is often the only thing patients remember about their surgeries," he says.

Surgeons who might believe there is no reason to stop using their tried-and-true wound closure methods should be made aware of new alternatives that provide plenty of benefits, including sending their patients home with a constant visual reminder of the cutting-edge care they received. A variety of wound closure products are now on the market that result in less scarring than what commonly occurs when sutures and staples are used. These products include adhesives, adhesive and tension-distributing combinations, external tissue expanders and technology that employs tiny hooks or micro-anchors that dig into the dermis.

This new generation of wound closure products can deliver other benefits beyond minimal scarring. They can save a facility money because they take less time to use. "You can save around three or four minutes in closure time at the end of a case, which really adds up," says Sherwin S.W. Ho, MD, a professor of orthopedic surgery and rehabilitation medicine and the director of the sports medicine fellowship program at University of Chicago Medicine.

The novelty of using innovative products can also help surgical practices on the patient satisfaction front. "When you tell patients about a new device you'll use to close their incision and explain how it works, they get excited," says Dr. Ho. "These are the people who will talk to their friends and family and spread positive reviews about your facility."

Proper wound care can prevent SSIs in foot and ankle surgeries.

HORROR STORY Poor would closures can lead to surgical site infections and devastating recoveries for patients.

Efforts to prevent surgical site infections (SSIs) don't end until wounds are properly cleaned, closed and covered, which prevents trillions of potentially harmful bacterial cells from entering patients. While that might seem obvious, wound closure sometimes isn't as "locked down" as it should be in the OR.

Tightly layered wound closures are vital because they don't leave open areas below the skin surface that can turn into abscesses and, eventually, infections, says Matthew Regulski, DPM, a foot and ankle surgeon and medical director at the Wound Care Institute of Ocean County in Toms River, N.J.

Closing methods must be strong enough to completely close each layer of the wound until it's completely healed, adds Jon Minter, DO, an orthopedic surgeon in Alpharetta, Ga. "Some of the sutures available now are antibacterial, which are fantastic because they inhibit bacterial growth," he says. Proper wound irrigation is another key component of SSI prevention in wound care. Dr. Minter has a catchy saying about it: "The solution to pollution is dilution."

Dr. Regulski likewise praises the benefits of proper wound irrigation. "We used to use saline, which has no effect on bacteria or biofilm, or a diluted betadine solution, which is toxic to healing cells and bone tissue," he says. "Newer irrigating options destroy biofilm, which is resistant to so many things, without harming good tissue. You can irrigate the wound as you're completing a layered closure to prevent infections in high-risk patients."

Both doctors note that applying wound gel and sterile adherent dressings to the incision helps to prevent bacteria from invading a wound. Many patients expect their surgeries will leave minimal or no scarring, so it's important to manage their expectations while also employing tight wound-closure techniques that lead to less scarring and help to reduce infections. "Surgical centers should call the patient the next day to see how they're feeling and to make sure the bandage is clean, dry and intact," says Dr. Regulski.

Dr. Minter notes that proper wound care is both good medicine and good business. "The outpatient setting is a competitive space," he says. "Making sure you're delivering the best possible results for your patients includes wound care management."

The use of a continuous external tissue expansion device aids in successful outcomes.

CREDIT: Synovis MCA
Surgeries in the lower extremities can benefit from DERMACLOSE to aid in wound closure.

Avoiding wound infections in any surgery is the focus of every OR team, but foot and ankles surgeries pose special challenges that specifically relate to wounds. Surgeons looking for solutions, such as a continuous external tissue expansion (CETE) device, know that it's imperative to safeguard the implant and contribute to postoperative recovery.

According to a study in which the authors who wrote about the use of a continuous external tissue expander in total ankle arthroplasty, "Despite major improvements in surgical technique and implant designs in total ankle arthroplasty (TAA), wound healing complications are still commonly encountered. Not only do these problems delay postoperative recovery and threaten functional outcomes, they also carry an increased risk of progression to deep wound infection, which can jeopardize ultimate retention of the implant."¹

A solution is the use of a CETE. They note, "In an effort to reduce the high frequency of wound-related complications after TAA, we have incorporated the use of continuous external tissue expansion (CETE) to augment our closures of the anterior ankle incision. CETE is an innovative technique that is currently being used to aid in the rapid closure of acute and chronic full thickness soft tissue defects, including fasciotomy wounds, high grade open fractures, and chronic foot ulcers."¹

This technique facilitates wound edge approximation of full thickness defects. It also helps take tension off tenuous incisions, allowing them to heal and reducing the chance for wound dehiscence. Wound dehiscence can become life-threatening — when part or all of a wound comes apart, it does not heal completely and can cause complications post-surgery.

The authors say, "Since introducing CETE to the closure of our TAA incisions, we have seen a decrease in the number of postoperative wound complications and time to wound healing. Based on our experience, we believe that the use of CETE for the prophylactic management of tenuous surgical incisions, specifically those used in the anterior approach to the ankle during TAA, is both safe and efficacious."¹

Orthopedic and foot and ankle surgeons use a special device (DERMACLOSE) to help them achieve primary closure, avoid skin grafts and donor sites, and also help them improve surgical outcomes. The DERMACLOSE Continuous External Tissue Expander reduces time to closure with no need to re-tighten or readjust. It provides delayed primary closure of full thickness wounds. This CETE can benefit successful outcomes for foot and ankle surgeries and avoid wound complications, keeping patients safe post-surgery.

Endovascular interventions tackling complications of peripheral artery disease.

Vascular surgeons trying to prevent lower limb amputations due to peripheral artery disease (PAD) are using outpatient interventions in the foot and toe to do so.

PAD, a chronic disease that affects circulation in the legs of approximately 12 million Americans, was once regarded as a precursor to amputation. The traditional vascular surgery treatment for PAD usually requires inpatient hospital stays of one or more days. There is a growing movement, however, toward an alternative treatment through minimally invasive outpatient procedures.

Steve Berkowitz, MD, chief medical officer at Modern Vascular in Overland Park, Kan., says that migration is accelerating. "The numbers are indisputable," he says. "More advanced endovascular revascularization using newer techniques is reducing amputations among PAD patients."

Outpatient PAD treatments include below-the-knee and below-the-ankle endovascular arterial reconstruction. Successful outcomes include patients reporting reduced pain, more rapid wound healing and a better quality of life. The interventions are also an important step in avoiding future limb amputation and longer life expectancies. "Specialists can extend that revascularization to the foot and toe, and the benefit to the patient multiplies," adds Dr. Berkowitz.

The rate of lower limb amputation due to PAD is high, as is the rate of death following amputation — nearly 50% after one year and 90% within five years, respectively. Yet thanks to these new outpatient techniques, Dr. Berkowitz and other surgeons now say up to 90% of amputations are preventable.

Patients report a high rate of satisfaction with using wheeled knee walkers during their rehabs.

A recent study found that more than 90% of unilateral foot and ankle surgery patients who fell while using wheeled knee walkers still reported satisfaction with using the devices during the non-weight-bearing periods of their recoveries.

Researchers conducted the study, published in The Journal of Foot and Ankle Surgery, to determine the safety of wheeled knee walkers and the level of patient satisfaction that accompanies their use. To their knowledge, say the authors, it is the first study reporting on wheeled knee walker usage in a clinical population.

Of the 80 participants in the study, most used a steerable, four-wheeled knee walker, with nearly half possessing no prior experience with walking aids of any sort, and none having ever used a knee walker before. Two-thirds of the patients reported that they had not received any instructions on how to use their knee walkers, which they used for an average of nearly seven weeks, and almost six hours per day.

Nearly half of the patients fell while using the knee walker, with nearly two-thirds of those reporting multiple falls — yet more than 90% of the patients who fell still reported satisfaction with their knee walkers. The study found no statistical association between the falls and the patients' ages, BMIs or number of comorbidities.