Wound Healing With a Dermal Regeneration Matrix: More Insights From Thought Leaders

For the original article the researchers are discussing, click here. 

Caitlin Hicks, MD:

My name is Caitlin Hicks. I'm a vascular surgeon at Johns Hopkins University School of Medicine.

Ronald Sherman, DPM:

My name is Ronald Sherman. I'm the surgical podiatrist. I am one of the principal providers at the Multidisciplinary Diabetic Foot and Wound Care Services at Johns Hopkins.

Caitlin Hicks, MD:

We performed a study of using a thermal regeneration matrix to treat very extreme diabetic foot wounds. We analyzed the outcomes of over a hundred wounds that were treated with this mechanism and looked at their ultimate outcomes. When patients come in with diabetic foot wounds, we give them a stage based on the wound, ischemia and foot infection score or the WIfI score, and depending on that stage, we can get a prognosis for the patient's likelihood of amputation within one year. Over 90% of the patients in this study had a WIfI stage of three or four, which indicates a major amputation risk of between 25 and 50% in one year.

These are also very high risk patients. They had poorly controlled hemoglobin A1Cs, extensive wounds and all of them were diabetics, and that is really not the typical patient population that most physicians are using these dermal regeneration matrixes on. However, we were able to show that in the multidisciplinary setting, using these dermal regeneration matrixes on these high grade wounds, we were able to get excellent wound healing rates reaching over 70% at one year and over 90% at 18 months, which is really completely beyond what we've seen in anywhere nationally.

Ronald Sherman, DPM:

I think that the utilization of the dermal template is a game changer. It's been around for over 20 years. There's so much literature about this. This is a proven CTP, and oftentimes people talk about costs and cost-effectiveness of these type of products. We think it's a game changer and we think it's actually a cost saver. What does that mean? The cost to have a major lower extremity amputation is huge, from the hospitalization to the placement in a rehabilitation facility, the construction of a prosthesis and the physical therapy training that's associated with it, the uses of this type of product dwarfs the cost compared to the large cost of getting a major amputation. As Dr. Hicks illustrated that the success rate of utilizing this dermal template is very, very high, which actually surprised all of us, especially because of the comorbidities that these patients had.

This article showed that patients not only diabetic, PAD, but also CKD and ESRD patients still had a fairly good success rate. And it's important to note that even with the great disparity within the comorbidities, they all seem to do pretty well. We used Integra also in cases with osteomyelitis. Now, you don't hear that too often, but we do the best we can to provide source control with these patients. And look, we can do that, but there's going to be organisms around, they're going to continue to be there. And as you know, we have a very strong and robust infectious disease regimen that we use on these patients, and yes, organisms may still be around, but even with that, we still have been able to prove that Integra has been very successful.

Caitlin Hicks, MD:

In fact, in that study, we were able to show that patients with osteomyelitis did better than patients who just had large soft tissue defects in terms of their wound healing after use of a dermal regeneration matrix, which really changed the way that we think about these wounds.

Ronald Sherman, DPM:

The other thing that we've also done is that we've trained our home health nurses. This is essential, and the reason is, because we can provide this type of service, but as soon as they leave the hospital, can we actually ensure that these patients will actually cross the finish line and have their wound healed? So what we do on an annual basis is that we train about 200 to 300 nurses in wound healing and our paradigms so that when a patient actually comes to them, they are now on the same page as we are, and we're very confident that these wounds will progress to heal. The other thing that we have is easy access to our home health nurses. Why not? Let the nurses reach out to us, let them send us an email, let them question what they should do to what they shouldn't do. That's why we're there to add, to fill in, to supplement any uncertainties in the care of these patients.

Caitlin Hicks, MD:

I will say now that we have that study showing such good results with the use of a dermal regeneration matrix, we essentially use that strategy on almost all patients that come through to us that have a tissue defect after their wound debridement that cannot be closed primarily. So Dr. Sherman can speak to this more, but a very large number of our patients are treated in this manner, and it accelerates their wound healing to the point of getting healthy granulation tissue in the wound where we can then get them either primarily closed or we can place a split thickness skin graft, which ultimately gets them to healing much faster than if we had let them heal by secondary intention alone.

Ronald Sherman, DPM:

At a recent wound care meeting, it was illustrated that nationwide CMS is expending about $30 billion on chronic wounds, $30 billion on chronic wounds. The most type of wounds that we see that expenditures on is on surgical wounds. So in other words, patients who come in to have surgery, they then have these wounds and they just continue and they continue, and that's where a lot of expense happens. So you have to have a plan, and the plan is exactly what I stated, that it has to be a plan where all aspects of that care has been focused upon and improved. There's no area for things to go bad. We have to make sure that everybody on the team understands what their role is. Not one physician, not one health provider, has all the answers for care of these diabetic patients. We realize that, and what do we do?

We take the expertise of each individual provider to add to the care of these patients. You have to give it up. You have to put your ego to the side. You have to realize that these home health nurses are very, very good in what they do, and you have to compliment them. You have to train them. You have to continue to provide feedback for them because without them, your procedure will fail. And I think it's important for all of us to understand that we all have to work together. We accomplish so much more as a team than individually. And once people actually grasp that type of focus, then it can only add to the success of the patient.

Caitlin Hicks, MD:

For me, I hope the takeaway is that you can think outside the box a little bit when you're treating patients. So the dermal regeneration matrix was typically contraindicated in patients with diabetes, particularly those with poorly controlled diabetes, those with vascular disease, exactly the types of patients that we're treating. And we were able to show that using that technology in a controlled setting with a very strong multidisciplinary team, we were able to get really good outcomes. So I think the importance here is to not rely on old dogma about what you cannot and cannot do with patients, but you can push the envelope a little bit as long as you provide the clinic and wound care support that you need to for the patients to get them across the finish line.

Ronald Sherman, DPM:

I think one of the things that's important that when a provider chooses what type of reconstruction efforts to utilize is that these CTPs that are on the market, they have to be validated. They have to be proven. You have to have multiple RCTs about their product to then use it and incorporate it into your practice. What we try to do is to base our paradigms on science and research, and I think that's the message I want to get out today. Take the research, review it, understand it, embrace it, utilize it to the benefit of the patient because chances are that the patient's going to succeed with their wound, and this is what we're all focused on, is to eradicate the devastating effects of diabetes.

Look, prevention is the key. That's a whole other subject, but if they actually come with a significant wound, you have to use specific paradigms, proven paradigms, utilizing a dermal template, this particular product has been on the market for over 20 years. Dr. Hicks, through her research, has been able to prove the validity of it. Yes, it may be a little expensive on the front end, but on the back end, you're saving so much money, you're not having the 30-day readmissions, you're not having further minor amputations, and you're preserving their limb. To me, I think that's the message that I want to get out to the community.