Closing Challenging Stage IV Heel Wounds With A Suture Retention Device

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Hello. My name's Alton Johnson. I'm a DPM and a wound care specialist. I'm currently an employee at the University of Michigan Healthcare System. I work as a professor, podiatrist, and wound care specialist at the institution here in Ann Arbor, Michigan. Been here going on about a year and it's exciting. And I do lots of wound care and lots of general podiatry as well, both inpatient and outpatient services at the institution.

So there's a multitude of challenges that clinicians and surgeons experience when it comes to wound closures. And that's the issue, right? So typically the issue is with a periwound, mainly because when you have a wound that you're trying to close that's a chronic wound, that should turn into an acute wound after aggressive debridement, whether it's osseous or a soft tissue debridement or a mixture of both. Typically, a periwound isn't healthy because it's been having multiple dressings on it over time and you're trying to put sutures through it. And one of the most common things that happens is that suture will rip right through it because it kind of acts as like a saucer or like a cutting tool through because that tissue is so soft and it doesn't have much integrity to it.

So of course maturation of that actual periwound to get the closure of the sutures, even if it's not a tight tension closure, it's just kind of tough to do. And then sometimes you'll use like a vertical mattress suture pattern to try to get it closed, but even then sometimes it's a challenge. And of course, just management of that actual incision once it's done is another challenge. Right? Because you get the closure, and then either... If the closure's too tight, you can start to get strangulation of the tissue and a lot of tension around it, which starts to lead to necrosis, and then wound dehiscence, then you're right back to where you started when it came to performing that procedure as to why you're doing it.

And then of course, when it comes to acute incision management, you got to make sure you're aware of that tension as well if you just doing like a elective C-procedure versus these chronic diabetic ulcerations that I'm going and doing aggressive debridement, osseous and soft tissue, then kind of closing it after I got the infection out or what I can see in a growth matter.

The novel adhesive suture retention device address these challenges because essentially it's now facing the stress and the strain of that suture material onto the device. And essentially, it has basically a plastic piece on it attached to an adhesive that you can put on the incision. You pace it out one centimeter away from the incision, which you typically would do depending on what type of closure you're doing, but you'll do for these wide excisional debridement closures for like your heel ulcerations ... whether it's lateral or plantar. You usually kind of take about a one centimeter gap from that incision anyways to get it closed because you're trying to just bump those tissues together and not try to have too much strangulation or stress on the tissue like that, which I spoke about earlier. It can lead to necrosis.

So the good thing about the adhesive suture retention device is you've now kind of made that device responsible for that tension restraining reduction. And now, you're not getting as much blanching of the tissues at the actual incision site because all of that strain the stress, not all of it, but the majority of it, is going to that device, which helps get better outcomes for patients. And the good thing is you get less dehiscence rates and less necrosis, which from my experience, especially when it comes to a transmetatarsal amputation or aggressive heel debridement closures. And then I also use it electively from when I'm removing soft tissue masses. And it was actually created for that reason. It was designed by plastic surgeons that do most closures and they couldn't get that tissue to close without too much tension. So they basically came up with that design.

So now, I kind of changed it and kind of made it into the podiatric application and start to use it in my closures for my chronic wound patients that don't have active infection, erythema drainage going on at the time of the closure. And then of course, typically I would perform a debridement to make sure I can get that biplanar direction so I can let the device do its work as in try to take off as much stress on the tissues that I'm manipulating when I'm closing. And have had good success with it so far. I think fairly simple design. I wish I had created it myself.

The poster was a case series with me and a couple other docs around the nation; about five or six of us. And so when it came to the study, I had talked to the manufacturers of this device and tell them, "Oh, I should use this to close these very tough heel closures," and "What you think about it?" And they said, "Oh, you not the only doctor that does this." I said, "Put me in touch with them." So I basically did a retrospective case study because this was before we got into using the product in my office, because I use it in office, in our procedural incisions as well to close soft tissue mass closures.

And I put these cases together and I started looking. And I was like, "This is amazing," because I had similar results with my first use of it. Actually, he had happened to be a physician. And he kind of encouraged me. He was like, "Do the research on it. Do it. Do it due diligence," He was happy that it changed his outcome because he had osteomyelitis that we had to fix. And so it's really cool to go through that with that particular case. But when it comes to my poster, essentially it's a case series of seven challenging cases of different etiologies. So some of them were pressure heel ulceration, or blisters that became infected and abscess. Some of them were just clean cases as in they didn't have bone involvement and were just soft tissue cases that needed to be closed, are cleaned out and closed, because of the type of wound that they had.

And some of them were plantar, some of them were lateral, and some were medial, but majority of the cases presented were bone resection cases. And those were ones that I definitely wished caught my eye because most of mine were in the procedural suite when I did them because I didn't really have to take them... They didn't have active osteo at the time. I didn't even get to put the x-rays in this poster, but if you see it, it was aggressive bone debridement and getting into these closures to try to manipulate this tissue.

So when I put them together, then I started looking at the timelines of how long it was taking them to heal, because sometimes especially with these heel ulcers that you're closing, or heel closures in general that you're closing, it usually go to a below-knee amputation majority of the time. So it's the last ditch effort. And to see... Most of the times, I'm seeing three to six weeks to complete healing, which is the same thing I had in my case. I think in my case the first time doing it was like four weeks. So four weeks after doing it, the patient was on, set back to their lives, back to their active life. I was like, "This has changed." You know? So I definitely got excited about it. You know? Everyone, I had to try to gather all the cases so we can write, so I can write them up so I could present it at a SAWC, which eventually end up winning first place for the practice innovation category. And I was excited about it.

So yeah, it's great technology. I definitely encourage people to look up the poster. And obviously, if they don't have it, I can send it out to them. But it's some impressive stuff. And like I said, definitely use this stuff, this material, this product in elective cases as well. And I've used it to excise soft tissue malignancies and to get closure, especially on the dorsal foot. But that's the summary of the poster. I definitely encourage the surgeons, providers, podiatrists, podiatric surgeons, foot and ankle surgeons to look into using this adhesive suture retention device. Even if you decide to use it for elective cases, like I said, I think you'll notice a difference in the outcomes. It definitely has changed the way I approach skin closures. And it's interesting because it's full thickness skin closures and I definitely recommend it. And I mean, for SAWC to recognize it and the blind judge test... So they didn't know I was writing this, who the authors were, or anything.

They just based it on the data that was presented. And obviously, there is some inherent bias in this poster because it's a retrospective case, the series. So obviously, when I recruited these patients, I'm only getting people that succeeded and I'm sure there's people that did not succeed. And that's why we want to do a larger study where we just kind capture everyone. But I definitely recommend it because I do think it decreases complication rates, especially when it comes to wound dehiscence to TMAs and heel closures. And that's where we kind of struggle because we get those tight tension closures and it starts to blanch, and that means it's not getting much circulation and we're strangling the tissues. And you don't get that blanching with this type of technology when you put it onto the wound incision.

So I just encourage, even if you don't reach out to the company to use it, just research about it and read more about it. I think as surgeons and as clinicians and as practitioners, you'd be impressed by it.