My Scope of Practice: One Product Can Advance Your Practice

For tomorrow belongs to the people who prepare for it today. -African Proverb

     If Shoeless Joe from Hannibal, MO were alive today and had his stockinged feet created problems, he would have benefitted from knowing Edward A. Cline, DPM, FACFAS, and the medical staff of Hannibal Regional Hospital. Treating diseases and deformities of the foot and ankle is an integral part of Dr. Cline’s practice, where his ability to manage diabetic foot ulcers recently was enhanced with the introduction of Dermagraft® wound closure (Advanced Biohealing, Westport, CT). Dr. Cline’s views the addition of this product into care protocols a “breakthrough” in the management of these challenging wounds.

     A graduate of Des Moines University, College of Podiatric Medicine and Surgery, Dr. Cline trained for podiatric surgery at the College of Podiatric Medicine and Surgery in cooperation with Broadlawns Medical Center (Des Moines, Iowa). He became a member of the Hannibal Regional Hospital Medical Staff in 1997 and concentrated on private practice until 2007. He later joined the newly formed Hannibal Regional Medical Group (HRMG), a growing hospital-developed multispecialty group created to better serve the needs of the community. HRMG’s specialties include Podiatric Surgery, Family Practice, Internal Medicine, Occupational Medicine, Interventional Cardiology, Invasive Cardiology, Pain Management, Plastic Surgery, Urology, Pediatric and Adult Psychiatry, Emergency Medicine, and Anesthesiology. “Inpatient consultation at Hannibal, in cooperation with the local medical community, is a strong and vital component of my practice,” he says. Dr. Cline also serves outlying communities with a remote clinic and nursing home care.

      Addressing lower extremity trauma and reconstruction, as well as diabetes and wound management, is an important responsibility. “Hannibal Hospital’s Wound Care Center is designed to provide advanced wound care solutions to the patient with diabetes and lower extremity wounds and to help patients create a healing and healthy lifestyle,” Dr. Cline says. “The new product provides a way to take a chronic nonhealing foot or leg and heal it.”

     Dr. Cline’s new treatment utilizes a cryopreserved dermal substitute manufactured from human fibroblast cells derived from newborn foreskin tissue comprising fibroblasts, extracellular matrix, and a bioabsorbable scaffold. During the manufacturing process, the human fibroblasts are seeded onto a bioabsorbable polyglactin mesh scaffold. The fibroblasts proliferate to fill the interstices of this scaffold and secrete human dermal collagen, matrix proteins, growth factors, and cytokines to create a three-dimensional human dermal substitute containing metabolically active living cells.

     Preparation and application of the dermal substitute to a diabetic wound involve 24 steps. The product arrives frozen at approximately -70˚ C and must stay frozen until its immediate use. At application, it is thawed according to instructions and cut specifically to fit the patient’s wound. The area is dressed with an accommodative padded dressing, placed in an offloaded boot or shoe with further accommodation, and left intact for 1 week. The process is repeated on a weekly basis for approximately 8 weeks. Patient adherence to care protocols during the healing phase, including limited activity, is paramount. The application procedure is detailed in the product’s instruction manual; application can be performed in the physician’s office and does not require sutures or anesthesia.

     Dr. Cline says the hospital’s podiatric, diabetes, wound, and ostomy center offered the new alternative to patients with wounds in efforts to yield more efficient healing results. The initial patient population to receive dermal substitute applications has done extremely well. “The procedure helps wounds heal by rebuilding the first layer of skin,” Dr. Cline says. “Several of the initial groups of patients healed within an 8-week time frame. Wounds ranging in diameter from 1 cm to 8 cm and in depth from 0.5 cm to nearly 1.5 cm have responded quite well. This has dramatically improved chronic ulcer and wound care options for our patients.”

      “The new product is welcomed not only by [physicians] but also by the patient ultimately receiving the benefit,” Dr. Cline asserts. “Wound care has certainly evolved since I began private practice in the early 90s. The proliferation of wound care centers and advanced wound management treatments is leading to exciting and rewarding times in 2009 for the physician treating wounds.”

     Dr. Cline’s future plans for podiatric medicine and surgery in Hannibal and his ideas for the hospital diabetes, wound, and ostomy center are closely intertwined. “Of course I would like to continue to see my practice grow and succeed,” he says. “We will make full use of the treatments and modalities that we currently have available as we continue to search for new and exciting ways to close chronic wounds.”

     According to Dr. Cline, use of dermal substitutes, a seemingly simple medical technique, has resulted in monumental healing success. Dr. Cline and the Hannibal Regional Hospital staff view this approach as one of many great advances potentially on the horizon for patient care. His enthusiasm and faith should be central to every podiatrist’s scope of practice.

This article was not subject to the Ostomy Wound Management peer-review process.