Biopsy in Wound Care

Welcome back to Podiatry Today podcasts where we bring you the latest in foot and ankle medicine and surgery from leaders in the field. I'm Brian McCurdy, the managing editor of Podiatry Today, and today we're going to be talking about biopsies in wound care.

Anthony Tickner, DPM:

Yes. Hi. I am Dr. Anthony Tickner. I'm the medical director of the St. Vincent Hospital Wound Healing Center in Worcester, Mass. We are a 350-bed hospital, and we have about 17 providers on our panel, vascular, podiatry, infectious diseases, plastics, you name it. And we have our nursing staff and four hyperbaric oxygen chambers. So we do it all, we see it all, and we're glad to be here today.

Brian McCurdy:

Okay. When do you choose to incorporate biopsy into your wound care diagnostic pathway?

Anthony Tickner, DPM:

So that's a great question about when to biopsy a wound. We typically, if we have a new patient and they're coming to us with a chronic wound that hasn't responded to other therapies and they're coming to us with a referral of another look at their wound, I will routinely biopsy that wound on the first visit.

And the reason being is that they've tried everything, they've done everything, and they're coming to us for answers. So we want to make sure we're not only biopsying it to see what's in there, what microorganisms are in there, but to also check for other things such as malignancy or carcinoma or other types of things that could be going on that could be halting the progression of the wound healing.

Brian McCurdy:

What method of biopsy do you typically choose and why?

Anthony Tickner, DPM:

So we're a teaching hospital. We're a residency program, and I tell the residents try not to do swabs, try not to do anything superficial, because what happens is you'll get a lot of the normal flora, the bacteria that's supposed to be there that's on the skin, so you don't want to cross-contaminate or get anything that's a normal type of bacteria for that environment. And what I will typically do is we will do a deep-tissue biopsy of either a deeper tissue or a tendon or muscle, or we will try to get bone if there's a bone exposure. And that's going to be your best bet if you can get bone, but you typically want to stay away from anything superficial or any type of swabbing.

Brian McCurdy:

Do you have any pearls you recommend for getting the most out of the biopsy?

Anthony Tickner, DPM:

Absolutely. I would recommend that you do a thorough debridement beforehand. And the reason for that is that you don't want to biopsy tissue or a deeper type of structure from, say, a diabetic foot ulcer where the person's got a lot of dirt, a lot of contaminants in the area, because ultimately, you're going to get some of that into your microbiology or your pathology. So you really want to get that wound as clean as possible and you want to get a piece of tissue or a piece of muscle or bone that the area around it has already been cleaned.

Brian McCurdy:

One last question. Can you share a brief case example where incorporating biopsy was an important step in successful treatment?

Anthony Tickner, DPM:

Absolutely. Like I said, we routinely try to biopsy chronic wounds early on, but we've had many cases of non-healing wounds that have come to us, and also cases of patients that have been with us for a while. And for some reason or another, the treatment is kind of stalled regardless of what type of dressing, what type of fancy types of things we're putting on the wounds. So in those cases, if somebody's got a non-healing wound, a chronic wound, a nice pearl would be to obviously biopsy that early on. And we've had a specific cases where one gentleman had a non-healing wound along the bottom of his foot, the plantar heel area, and we decided to biopsy that and send it for microbiology and pathology, and we were able to get some bone out of there. And that was actually very helpful because the antibiotics he was on were actually not specific enough for that type of resection of bone that we took out.

Once we had those results and we knew it was actually growing in that environment, we were able to pinpoint it with the exact type of antibiotics, with the exact type of duration of therapy. And we were actually ...that's helpful because it's less pressure on the patient's kidneys, on their liver, on their internal organs when you can lessen the amount of antibiotics you're giving your patients.

And if you can, bone biopsies is basically the gold standard because you're getting it right from the source. That's better than any type of imaging, that's better than x-rays, that's better than MRIs, that's better than bone scans. If you can actually get a good sample of bone, that will be your best bet.

Brian McCurdy:

Anything else you'd like to add about biopsy?

Anthony Tickner, DPM:

Like I mentioned before, just try to biopsy. When you have those chronic non-healing wounds and you're trying to get a definitive course of treatment with your antibiotics, it's very, very helpful. Stay away from swabs or anything superficial. And the more tissue you can get, the more microbiology and pathology, the laboratories in your facility will like that. So if you're able to get a good robust piece with a Ron and other type of device, that is always helpful as well.

Brian McCurdy:

Okay. Well, I want to thank you very much for sharing that with us today, Dr. Tickner.

We really appreciate that, and I hope the listeners will too. And I hope you'll join us again for future episodes of Podiatry Today podcast, which you can find at podiatrytoday.com and on your podiatry favorite podcast platforms.