MANAGEMENT OF CHRONIC WOUNDS
Chronic wounds are a common problem, and are a major source of morbidity and expense in the healthcare system.
While standard care for chronic wounds is predicated on several fundamental principles, such as off-loading and compression, surgical approaches to these wounds are increasingly used to augment healing and increase the chances that a given wound will heal.
There is no clear guideline on the extent to which wounds should be surgically debrided, though debridement should be directed toward removal of nonviable tissue, including overlying eschar, periwound callus and fibrinous slough within the wound bed.
Multiple debridements are often necessary, as debridement frequency has been associated with greater healing benefit.
In skin grafting, donor site selection should be determined by its ability to be concealed, similarity to recipient skin, potential discomfort, and healing capability.
Prior to skin grafting or application of skin substitutes, proper wound bed preparation, such debridement and treatment of infection, must be achieved to ensure success.
Flaps should be properly planned and sized to maintain perfusion that may otherwise be restricted due to tension of wound closure.
To control exudate and prevent fluid buildup beneath graft skin and skin substitutes, absorbent dressings should be chosen to prevent graft elevation.
In most cases, surgical treatment does not correct the underlying pathophysiology of disease; thus patients should continue standard of care treatment, including compression therapy for VLU patients and maintenance of wound bed preparation and offloading for DFU and pressure ulcer patients.
Pitfalls and Cautions
In patients with skin graft or flap procedures, maturation may take over a month; careful follow-up and minimization of strenuous activity is required.
All surgical procedures entail risk, and any intervention designed to heal a chronic wound may risk further wound formation and exacerbation.
Patient Education Points
Surgical interventions for chronic wounds generally do not address the underlying etiology of disease; therefore, they represent a treatment, rather than a cure.
Given the lengthy process of healing needed postoperatively, patients should be highly motivated and educated regarding the planned procedure.
Most therapies for chronic wounds may be billed using the standard code sets for flaps and grafts.
These procedures usually have 90-day global periods; therefore, care should be taken when billing for additional procedures and visits in the postoperative period.
Chronic wounds are a common problem, and pose a significant economic and healthcare burden. All wounds develop from a variety of etiologies and mechanisms, including surgery, trauma, burns, pressure, and disease states such as venous insufficiency, diabetes mellitus, peripheral arterial disease, rheumatologic diseases, and autoimmune disease.1 Wound healing is a well-defined process comprised of four overlapping phases: hemostasis, inflammation, proliferation, and remodeling.2,3 It involves a highly regulated, ...