Essentials of Diabetic Limb Salvage (Part 2)

In this episode of Wound Care Wednesday, Dr Johnson joins guest speaker Dr John Lantis, the Site-Chief of Surgery at the Mount Sinai West Hospital, Professor of Surgery at the Icahn School of Medicine, and Editor-in-Chief of Wounds: A Compendium of Clinical Research and Practice. This episode continues to explore diabetic and ischemic limb salvage, focusing on a multidisciplinary approach to wound care.

Sponsored by 

 

Dr Jonathan Johnson: Welcome everybody. This is Dr Johnson, also known as Dr Wounds, and we are back with another excellent Wound Care Wednesday at SAWC Fall here in 2024. And we are keeping with an excellent topic, looking at the multi-disciplinarian approach in diabetic and ischemic limb salvage. And we have the expert, the superstar vascular surgeon extraordinaire, Dr John Lantis is here with us today.

Now, during the time of this podcast the Mets are playing, and we don't know who the Yankees are going to play, and John, being from New York, we got to figure out who's his team. So, John, tell us a little bit about yourself and, more importantly, who's your favorite baseball team?

Dr John Lantis: So, the interesting portion is I'm born in New York City.

Dr Jonathan Johnson: Okay.

Dr John Lantis: Raised a little bit in Europe and a little bit in upstate New York, not too far away from Yankees and Shea Stadium, back when Shea Stadium was not Citi Field.

Dr Jonathan Johnson: Mm-hmm.

Dr John Lantis: But the weird portion is I started following baseball during the era of the big red machine.

Dr Jonathan Johnson: Ah.

Dr John Lantis: So, I met Johnny Bench…

Dr Jonathan Johnson: Reds fan, for those that don't know.

Dr John Lantis: …so going with the Reds, but…

Dr Jonathan Johnson: Mm-hmm.

Dr John Lantis: I married this really wonderful woman.

Dr Jonathan Johnson: Uh-oh.

Dr John Lantis: And she is a dyed-in-the-wool true Red Sox fan.

Dr Jonathan Johnson: What?

Dr John Lantis: A real Red Sox fan.

Dr Jonathan Johnson: Dr Lantis…

Dr John Lantis: Like knows– everybody's batting average.

Dr Jonathan Johnson: Wow.

Dr John Lantis: Her and her mom and her grandfather.

Dr Jonathan Johnson: Wow. Like, back in the day…

Dr John Lantis: Back in the day, the whole thing.

Dr Jonathan Johnson: Huh.

Dr John Lantis: Carl Yastrzemski signed shirt. Told him she wanted to marry him.

Dr Jonathan Johnson: The heyday of Mookie in his heyday.

Dr John Lantis: Yeah.

Dr Jonathan Johnson: Yeah, yeah, yeah, right.

Dr John Lantis: So, happy wife, happy life. I'm a Red Sox fan.

Dr Jonathan Johnson: So, you're a Red Sox fan. From… Okay guys, I think this is probably a first. A New Yorker that's a Red Sox fan. But it's okay, I was a Red Sox fan back in the day when they had Big Papi and– One of my good med school classmates was a Yankee fan, and we went back and forth all the time. And so, believe me, I understand, baseball is the sport.

So, we are super excited today to talk about an excellent topic: diabetic and ischemic ulcers and injuries, limb salvage, and a multidisciplinary approach on how we treat these effectively and make sure we can decrease the rate and incidence of wounds. And this is sponsored by PolyNovo.

So, Dr Lantis, tell us a little bit about, in your practice, how you approach taking care of diabetic foot ulcers and how you incorporate your practice with other specialties to make sure we look at the entire patient from a diabetic prevention standpoint.

Dr John Lantis: Yeah, I think it's a great question, and obviously a hot topic. So, how do folks get to us? And one of the things that happens is, I would say that in New York City, the referral patterns are maybe a little bit unique compared to the rest of the country. A lot of our foot and ankle surgeons who are more community-based, the reality is the overall amount of resources that are necessary for the diabetic foot ulcer are—maybe a simple diabetic foot ulcer, fine. But once it becomes more complex, involves a bone or joint capsule, tendon, they're going to send it to somebody at our center.

Dr Jonathan Johnson: Okay.

Dr John Lantis: And they tend to send most of those folks to me first for vascular assessment. Now, some of them are pretty simple, but everybody gets vascular lab testing unless they have clearly very good palpable dorsalis pedis and posterior tibial. Now, we may do something like near-infrared spectroscopy…

Dr Jonathan Johnson: Mm-hmm.

Dr John Lantis: …or something a bit more cutting edge, if you will.

Dr Jonathan Johnson: Right.

Dr John Lantis: But we make sure that everybody has the adequate blood supply. And then, that therapy bifurcates, right? We put out patients who are neuroischemic versus patients who are predominantly ischemic…

Dr Jonathan Johnson: Mm-hmm.

Dr John Lantis: …and then the patients who are just neuropathic. So, we have this almost trifurcation of how we're going to deal with them.

Dr Jonathan Johnson: Right.

Dr John Lantis: And it really depends then on what our reconstruction options are. So that's how it starts, but the things that we have to incorporate in this are obviously ongoing communication with the person who referred them, then possible involvement of our inpatient foot and ankle team…

Dr Jonathan Johnson: Okay.

Dr John Lantis: …who might do everything from needing to put in hardware or put them in an Ilizarov frame or do something for offloading, in conjunction with whether they just need soft tissue reconstruction, whether they need hard tissue reconstruction, or they need revascularization.

Dr Jonathan Johnson: Got you.

Dr John Lantis: So, you start to choose which category of help you need and you got to– We, to some degree, not everything's a pathway, not everything's an algorithm,...

Dr Jonathan Johnson: Right.

Dr John Lantis: ...but you want to make sure you've checked the boxes and you know which pathway you're going to go down.

Dr Jonathan Johnson: 100%. So, we want to make sure we're focusing on the surgical side, very, very important.

Do you guys work with the endocrinology team and the primary care doc as well? How do you guys work with them and incorporate looking at the fasting glucose, looking at issues with the hemoglobin A1C, and ischemic issues, right? ABIs, Dopplers, etc. How do you incorporate that entire process into your clinical practice?

Dr John Lantis: Well, I think this is a great question, and the thing that's interesting is the endocrinologists often have not been involved previously, right? These are paid, because we all know this, and it's not– Sometimes you have a patient who has a hemoglobin A1C of 6.7 and everything's going okay, and then all of a sudden they have a bad foot problem, maybe an acute infection or something. But the reality is that's not a whole lot of the patients who develop these foot ulcers. It is really disheartening when you see a patient who has done really good job of controlling their hemoglobin A1C and their fasting glucose, and they end up with an acute Charcot or something of that nature, which can occur.

Dr Jonathan Johnson: Right.

Dr John Lantis: But, a lot of times when we bring in an endocrinologist, it’s for the patient who has the hemoglobin A1C of 14,…

Dr Jonathan Johnson: Ah.

Dr John Lantis: …16.

Dr Jonathan Johnson: Okay.

Dr John Lantis: And once in a while a patient, maybe they're pump broke, and we certainly get people into the right realm or help bring them down with concordance with therapy.

Dr Jonathan Johnson: Right.

Dr John Lantis: So, we actually usually only ask the endocrinologist to help us with folks that we're having a management problem with.

Dr Jonathan Johnson: Okay.

Dr John Lantis: Outside, once they have a hemoglobin A1C over 12, we're certainly going to get them involved.

Dr Jonathan Johnson: Uh-huh.

Dr John Lantis: We try to get the primary care physicians involved, and it depends on, and this is unfortunately true, but to some degree, whether they're within our health care system or outside our health care system.

Dr Jonathan Johnson: Very true.

Dr John Lantis: And we use hospitalists a lot.

Dr Jonathan Johnson: Mm-hmm.

Dr John Lantis: So, if they're within our health care system, the hospitalists are going to help manage that.

Dr Jonathan Johnson: Right.

Dr John Lantis: But it's only for the patients who are recalcitrant.

Dr Jonathan Johnson: Okay.

Dr John Lantis: So, our surgical resident group and ourselves, the general blood sugar stuff that seems to be in a– They have an appropriate therapeutic plan and they just got a little out of whack or they had a bad week or whatever,…

Dr Jonathan Johnson: Right.

Dr John Lantis: …we don't seek as much help.

Dr Jonathan Johnson: Got it, got it.

Dr John Lantis: We do have a structured plan at the Mount Sinai Healthcare System, which is called the Preoperative Medical Assessment, which is basically requires the hospitalist to see the patient, assess them. It's more focused on their cardiovascular health though. So how are they going to be able to undergo minor/major reconstructive surgery, vascular intervention, vascular surgery? So that's got a much more of a cardiac risk stratification, preoperative stress testing, etc, type of structure.

Dr Jonathan Johnson: Very key.

Dr John Lantis: So, almost everyone who's going to go to the OR gets seen by the hospitalist.

Dr Jonathan Johnson: Got it, got it.

Dr John Lantis: If they need help, then in most cases they're going to call in cardiology, so it's almost invariable that those two things get initiated.

Dr Jonathan Johnson: Mm-hmm.

Dr John Lantis: On a tertiary side point is obviously ID on one side, and so for infectious disease, and then on the other side is endocrinology. So those the 4 things come together to try to maximize preoperative health prior to us taking to the OR, unless it's a…

Dr Jonathan Johnson: Right.

Dr John Lantis: …very severe diabetic foot infection.

Dr Jonathan Johnson: Mm-hmm. Definitely, and focusing on making sure we have the multidisciplinary approach is key. Like Dr Lantis is saying, we're focusing on the surgical side, but also we want to bring in the medical side, the endocrinology-based side.

So, practicing in New York, there's a lot of issues with comorbidities—diabetes, peripheral vascular and arterial disease. So, being in the New York system, how are you working with some of those patients that may not have the best resources to get in to see you? Are you focusing on some telemedicine-based approach? How is Mount Sinai focusing on some of those patients that may be marginalized, that don't have the access or the resources to get into the clinic?

Dr John Lantis: Yeah, so it's a great question. And one of the things, though, that is a little bit also different, as you know, in New York is everything's very close together.

Dr Jonathan Johnson: Yes. Great point.

Dr John Lantis: And so we have, in a way our health care system has the west side of Midtown and it has the east side of Midtown, but once you get further to the east side you start to fall into another health care system, and there's these rings of health care in different categories.

Dr Jonathan Johnson: Yep.

Dr John Lantis: But we actually have a fairly, we're fairly easy to get into, honestly. And of course, in New York, one of the things that's different too is actually our state Medicaid program is very robust.

Dr Jonathan Johnson: Mm-hmm.

Dr John Lantis: So, one of the things that's rare to hear is someone who's uninsured completely. Usually they're caught by our safety– We have a significant safety net in the state.

Dr Jonathan Johnson: Got it, got it.

Dr John Lantis: And we can see people, we can figure out how to see people for free if we need to.

Dr Jonathan Johnson: Okay.

Dr John Lantis: And, of course, our ERs are an access point for some of these folks that occasionally you direct someone to for an economic reason. But usually, we try to do that with planning. We tell them, we call the ER ahead of time and say, "This person's coming in. This is why they're..." We try to be honest about it.

Dr Jonathan Johnson: Right, right.

Dr John Lantis: We want to take care of the human being.

Dr Jonathan Johnson: Of course.

Dr John Lantis: We took oaths to take care of these people. We're going to take care of these people.

Dr Jonathan Johnson: Yes.

Dr John Lantis: So, we'll try to direct them. I think the biggest hurdle is actually education to the patient at times, saying that as a limb salvage program, we're open to you.

Dr Jonathan Johnson: Mm-hmm.

Dr John Lantis: If you have a problem, and it's not an acute emergency, make an appointment, and we'll see you.

Dr Jonathan Johnson: Right, right.

Dr John Lantis: We’ll call. We'll see you on– One of the, there's myself, they're actually 26 vascular surgeons within the Department of Surgery last time I counted.

Dr Jonathan Johnson: But only one John Lantis <laughs>.

Dr John Lantis: Well, there's some people like Mike Dudkiewicz, who's one of my junior associates who does a lot of this,...

Dr Jonathan Johnson: Right.

Dr John Lantis: …and understands the process. And, other people like Adam Korayem, who’s also a younger guy who understands the process. So, they can come in and they can see a surgeon.

Dr Jonathan Johnson: Okay.

Dr John Lantis: So, one of the things that you say is, “Why'd you go to the ER?” They go to the ER, they get an X-ray, the X-ray was negative, then they go home. And then they come to see you on an appointment 10 days later and they’ve had a hole in their foot for 14 days, and you're like, “You could have just called and come in on Monday 2 weeks ago.”

Dr Jonathan Johnson: Right, exactly.

Dr John Lantis: And they're like, “Well, we didn't think of that.” And you're like, “I've been seeing you for 12 years. How come?” And I'd say that's the other big difference is once we've operated—most of our group, I know this is true of me, and I try to train some of the junior guys and some of my fellows and residents—…

Dr Jonathan Johnson: Right.

Dr John Lantis: …is once I've operated on someone's foot, I tend to see them at least every 6 months.

Dr Jonathan Johnson: Okay.

Dr John Lantis: And of course, if they've had a revascularization schedule for that, then it's based on what type of revascularization they had, but there's nobody who I did a revascularization on who isn't getting seen or being invited to be seen—of course, if they've moved or something—but in general, at least annually.

Dr Jonathan Johnson: Okay.

Dr John Lantis: So, once you're my patient, it's not like, “Oh, I'll see you next...," you know, I'll see you…

Dr Jonathan Johnson: You're staying with me.

Dr John Lantis: “When you have a problem again, come back and call me.”

Dr Jonathan Johnson: Yeah! No, you're staying with me. Again, that’s…

Dr John Lantis: But once you've rebuilt their foot or reconstructed any portion of their lower extremity, I'm going to be checking in on them at least once a year.

Dr Jonathan Johnson: Right, and that's awesome. So, we know that there's quality access to care. We know we're looking at decreasing the rate of diabetic issues, injuries, etc. We know the cost.

Dr John Lantis: Yep.

Dr Jonathan Johnson: We know that the cost of taking care of diabetes is a huge issue in our health care system from a financial burden, but it also outweighs a lot of the cancer treatment issues and problems, and as well as the cost, as well.

So, from a surgical standpoint, from the vascular side, are you using any new technology to help increase your management style and your clinical speed of taking care of diabetic foot injuries?

Dr John Lantis: Yeah, no, I think this is a great question. And I think with vascular interventions, there has certainly been this huge push towards endovascular.

Dr Jonathan Johnson: Right.

Dr John Lantis: But in the last year, the trial came out that looked at, fundamentally, what was better, bypass or percutaneous intervention?

Dr Jonathan Johnson: Mm-hmm, mm-hmm.

Dr John Lantis: And to some degree, a randomized prospective trial trying to look at this. And of course, there are biases to this, etc. They're going to just be built in. I do think we have not taken bypass off of the table, right?

Dr Jonathan Johnson: Right.

Dr John Lantis: Bypass can be very, very effective.

Dr Jonathan Johnson: Mm-hmm.

Dr John Lantis: And we still do open bypasses, and they're not always from all the way up the groin to the toe, but sometimes they might be from above the knee. We do some hybrid stuff, and we've done that for years where we might revascularize the superficial femoral artery percutaneously, and then we use a vein to go from the knee to maybe sometimes even 2 vessels—the posterior tibial and the dorsalis pedis.

Dr Jonathan Johnson: Got it.

Dr John Lantis: It is still true that if you can get really good pulsatile flow into the foot, you're going to do best.

Dr Jonathan Johnson: Mm-hmm. That's key.

Dr John Lantis: And so, whatever we need to do to do that…

Dr Jonathan Johnson: Right.

Dr John Lantis: …is how we're usually thinking. We do think about the angiosome theory, that if you can get flow, if you’ve got a toe problem, but you can only get flow to the perineal,…

Dr Jonathan Johnson: Right.

Dr John Lantis: …if you do that percutaneously, it doesn't work as well as if you do it with an open bypass, depending on–

But the things that have changed dramatically are some of the endovascular techniques of revascularizing the entire arch of the foot. If you can go in and do a SAFARI, which is a retrograde procedure where you actually puncture the dorsalis pedis or the posterior tibial artery under ultrasound, and then work back up the leg. That sometimes allows you to get across blockages that you couldn't get across other ways.

Dr Jonathan Johnson: Right.

Dr John Lantis: And the other thing we explore a lot, and this is not ready for prime time at all, we've been involved in most of the stem cell therapy trials, whether those are autologous spun-down blood, bone marrow, using placental tissue that is incubated to make mesenchymal stem cells, and none of those to date.

Dr Jonathan Johnson: Mm-hmm.

Dr John Lantis: Now there's some very interesting technologies that are being re-ramped up. There's something going to be coming out, probably in New England Journal of Medicine in the next couple of months, that's a new technology, in this area again. But these are going to be injectables, because about 15% of patients who have ischemia you can't revascularize.

Dr Jonathan Johnson: Mm-hmm, okay.

Dr John Lantis: Mainly for anatomic reasons—they just have no vessels in their foot.

Dr Jonathan Johnson: Right.

Dr John Lantis: Or sometimes for comorbidity reasons. They're just too sick.

Dr Jonathan Johnson: Got it, got it. So I think the general concept here, for the folks that are non-clinical that may be listening, is blood flow, which brings oxygen to the extremities to increase the rate of healing in the wound. Would you say?

Dr John Lantis: Yes.

Dr Jonathan Johnson: It's very important to make sure that we have access, whether that's the lower extremity wounds, whether that's the upper extremity wounds. The key is to make sure we have adequate access and blood flow.

So, in that specific vein, Dr Lantis, we always like to ask our guests 2 questions. Number one: What makes you passionate about wound care? And number two: Tell us an excellent, or not so excellent, clinical outcome and how you worked with that clinical outcome.

Dr John Lantis: These are great questions. I think there's a– The first question's a great question, and for me, personally, it's a little bit of a long story, but I was very interested in tissue reconstruction, tissue repair, and actually plastic surgery.

Dr Jonathan Johnson: Okay.

Dr John Lantis: And so I changed from wanting to be a, way back in college, I changed from wanting to be a, basically a PhD in biomechanics to wanting to be a plastic surgeon.

Dr Jonathan Johnson: Ah, okay.

Dr John Lantis: And so I was very interested in that. But I love the actual technical portion of vascular surgery. So, I eventually, during my residency, morphed into doing vascular surgery and the technical portions. And I love carotid endarterectomies and I like open aortas. And endovascular is very interesting to me, but the technical open surgery portion is what really brought, what made me think, “This is really cool.” And the long, very detailed distal bypass operations were really, really interesting.

Dr Jonathan Johnson: I remember those during my vascular rotation. I remember those. You have the loops and you’ve got your vascular bands, I remember.

Dr John Lantis: And a lot of these, to be quite frank, some people don't want to do them. And they are morbid. There's no doubt about it. They're morbid. You do them maybe not as a last resort, because sometimes they're a very good first resort.

Dr Jonathan Johnson: Mm-hmm, mm-hmm.

Dr John Lantis: But, they often take 5 or 6 hours So you're there all, you're there concentrating for a long time.

Dr Jonathan Johnson: Yes.

Dr John Lantis: But I like that detail.

Dr Jonathan Johnson: Right.

Dr John Lantis: But, when things, you do a bypass, and it didn't make a lot of sense to me, and then you have to cut off the toe,…

Dr Jonathan Johnson: Yeah.

Dr John Lantis: …and then you gave it to someone else. Now some places, that's how it works, but for me, I was like, “The patient's not done until that toe’s healed.”

Dr Jonathan Johnson: Continuity. Got to have continuity of care.

Dr John Lantis: Personally, I always like– And most of the patients come in because their toe’s black.

Dr Jonathan Johnson: Mm-hmm.

Dr John Lantis: They don't come in because they need a bypass.

Dr Jonathan Johnson: Right.

Dr John Lantis: They came in, their heel has a hole in it. That's what they need fixed. So I'm like, “Oh yeah, you need a bypass.” And then they're like, “Okay, now I got a big cut in my leg, or I got some stents, and I still got a hole in my heel, Doc.”

Dr Jonathan Johnson: Mm-hmm. Right.

Dr John Lantis: “Oh, you can go see someone else.”

Dr Jonathan Johnson: Got to do something about that.

Dr John Lantis: Now collaboratively, I know that, but for me I was like, “I want to see that thing fixed.”

Dr Jonathan Johnson: Of course, of course.

Dr John Lantis: So, I got very involved early on, and we talked about this before when you and I  met.

Dr Jonathan Johnson: We have.

Dr John Lantis: But, very early on there was this suction device that you put on wounds, and it started filling tissue.

Dr Jonathan Johnson: Yeah.

Dr John Lantis: And that was just going through the FDA and doing these trials, and I got involved in all 4 of the early trials. So, I was like, this is interesting. I can do the cool stuff, and then I can feel the wound.

Dr Jonathan Johnson: And you can see them after.

Dr John Lantis: Yeah, so I kept–

Dr Jonathan Johnson: That’s the wound vacs, guys, there's the vacs.

Dr John Lantis: So, I kept on doing that. And that just remains interesting to me. And they are long battles, right?

Dr Jonathan Johnson: Yeah.

Dr John Lantis: They're wars, really. When you win them, after 50 weeks because, the bypass, if it works, it works, and that's your battle, right? You went, you had a battle, you won it, you lost it—you can figure that out usually out pretty quickly.

Dr Jonathan Johnson: Right.

Dr John Lantis: The war is when you get the wound healed, and those are very gratifying. They're hard.

Dr Jonathan Johnson: Very.

Dr John Lantis: Tedious, but they're– So, but that's what drives me. I still like winning those. Now, to that end, I'll give you an example, and I work with some very, very good vascular surgeons. But within our group, I do a significant amount also of the soft tissue and bony foot stuff. In conjunction, sometimes I revascularize them, sometimes my partners do.

Dr Jonathan Johnson: Okay.

Dr John Lantis: And then they just say, “The rest is yours, John.”

Dr Jonathan Johnson: Yeah.

Dr John Lantis: “I don't even,…”

Dr Jonathan Johnson: There you go.

Dr John Lantis: “…that's not my thing.”

Dr Jonathan Johnson: Multispecialty approach, team. Multispecialty.

Dr John Lantis: Even though we're all in vascular surgery.

Dr Jonathan Johnson: Right. Multispecialty. Right.

Dr John Lantis: But I also involve the foot and ankle surgeons and all the other people were talking about.

Dr Jonathan Johnson: The plastics guys…

Dr John Lantis: Plastics and all that.

Dr Jonathan Johnson: Yeah, doing flaps, yep.

Dr John Lantis: So, with that in mind, one recent one, I had a patient come in, and I actually got called after he'd been revascularized.

Dr Jonathan Johnson: Okay.

Dr John Lantis: I go see him, and he looks like a second- or third-degree burn on his foot. And his leg had been really swollen, and so a swollen leg that was ischemic, has all this tissue death. So, he has 260 centimeters, dorsum of his foot, ankle bone exposed, etc.

Dr Jonathan Johnson: Oh! Huh.

Dr John Lantis: So, I take him to the OR. He's now revascularized. Look at the angiogram. My partner did a great job. But I'm like, “Huh, what am I going to do with this?” And I don't even know what, and to this day, I still don't really know what happened to this guy. He's got wife, kid…

Dr Jonathan Johnson: What was the original injury?

Dr John Lantis: Well, that's the thing. He's like, “It got really swollen.” And I don't know if he just had uncontrolled edema with heart failure…

Dr Jonathan Johnson: Compartment syndrome or anything like that?

Dr John Lantis: No, no.

Dr Jonathan Johnson: Compartment pressures were fine when he came in?

Dr John Lantis: Yeah. I know. It really looked like a burn.

Dr Jonathan Johnson: Yeah.

Dr John Lantis: It looked like someone who had been burned and was edematous.

Dr Jonathan Johnson: But post-burn, you can have compartment syndrome sometimes, I’ve seen it.

Dr John Lantis: Yeah, all that was fine.

Dr Jonathan Johnson: Huh.

Dr John Lantis: And had arterial, he’s 82 years old.

Dr Jonathan Johnson: Oh, older.

Dr John Lantis: But ambulatory. So I just say, okay, I got to debride this dead tissue, let it demarcate for over the weekend or 5 days after revascularization. Took it in the OR, took off this 280 square centimeters involving lateral ankle, malleolus exposed, joint capsule exposed, all his tendons on the dorsum of his foot.

Dr Jonathan Johnson: Oh, wow.

Dr John Lantis: And I, family was a little shocked. “Oh, you should heal fine.” I said, “No.” So, I go out and tell them, “There's less than a 50% chance we're going to save this foot.”

Dr Jonathan Johnson: Right.

Dr John Lantis: So, I said, I need to get a good granular base on that.

Dr Jonathan Johnson: Mm-hmm, mm-hmm.

Dr John Lantis: So, we use a lot of tangential hydro surgery to cut away the tissue. We cleaned everything up, we got it down, but I got exposed to tendon and everything. So in that case, I took a polyurethane dressing and put that on with—the two-layer polyurethane dressing, put that on. Just, I just want to get some granulation tissue. I also want to get this guy, I don't really know what happened. I know he’s got the circulation, and I don't know if it's even going to work.

Dr Jonathan Johnson: Right.

Dr John Lantis: I don't want to be changing things every week. A lot of the tissues I use work really well, but you have to put a new one on every weekend, but you need 280 square centimeters.

Dr Jonathan Johnson: Yeah, that’s a lot.

Dr John Lantis: So, you're not going to be doing that outpatient.

Dr Jonathan Johnson: No, not at all.

Dr John Lantis: So, I want to put something on, just sit back, see, is this guy going to do well? And so we see him every week in the outpatient office. And you can tell he's granulating, right, under the polyurethane product. So, then we wanted some extra depth though before we were going to do any skin graft because– Actually in a month we take him back, took this off, and he had nice granulation tissue on his tendon…

Dr Jonathan Johnson: Wow!

Dr John Lantis: …and I'm like, "Okay."  

Dr Jonathan Johnson: Had a great base.

Dr John Lantis: Yeah, and the family of course, every time I see him, “Percentage gone up, Doc?” “Are we out of the woods?” I'm like, “No, we're not anywhere out of the woods.”

Dr Jonathan Johnson: Right.

Dr John Lantis: We're not. We're just starting. So, then I want to do, I need to rebuild some more thickness, right? So, I took him back to the OR, and I use actually another synthetic just, again, because of size. And again, I was, quite frankly, I was a little bit of experimenting on him. I got some algorithms for all these things, but I'm like, this is a weird one.

Dr Jonathan Johnson: Yeah.

Dr John Lantis: Do that, and actually got quite a good granular bed. And then we took him to the OR, and he's not the healthiest guy, so under regional anesthesia, etc, we end up doing a skin graft on the dorsum of the foot, which looked good, and up onto the shin, and we got 100% take.

Dr Jonathan Johnson: Great.

Dr John Lantis: Looks great. We still have the lateral ankle. I have some exposed Achilles. I've got some exposed malleolus, that deal with the bone, so we do a little bit more build up there with a biologic.

Dr Jonathan Johnson: Wow.

Dr John Lantis: And I’m just like getting tired here, but…

Dr Jonathan Johnson: It’s a lot.

Dr John Lantis: Yeah, a lot. And then that actually worked. And I'm thinking do I have to take him back for another skin graft? Oh my goodness, I don't want to do that. So, we used a little bilayer, living skin equivalent on there.

Dr Jonathan Johnson: Okay.

Dr John Lantis: And got the wound bed even looking better, and I'm just like, “Great.” And he's actually a conservative Jewish gentleman.

Dr Jonathan Johnson: Okay.

Dr John Lantis: And so, this is a Jewish New Year.

Dr Jonathan Johnson: Right.

Dr John Lantis: Actually, we're speaking during Jewish New Year.

Dr Jonathan Johnson: We are, yes.

Dr John Lantis: And he wanted to be able to get in the shoe for that. And I said, “Only way that's possible is another skin graft.”

Dr Jonathan Johnson: Oh wow. Right, yeah.

Dr John Lantis: They took him back and did another skin graft. And I said, “It's not going to have 100% take,” because there's still a little– The tendon’s covered, bone’s covered, but it's not the best cover. I mean, it's not perfect. You can say, why didn't it do a free flap or something like that? I showed him to plastics.

Dr Jonathan Johnson: I was looking at, I was thinking the rotational flap or some type of flap, right on that lateral mal, because it works really, really well.

Dr John Lantis: Yeah.

Dr Jonathan Johnson: Take the calf, the gastroc, and roll it over.

Dr John Lantis: But with him and his vascular, 83-year-old guy with a vas– But I agree.

Dr Jonathan Johnson: Yeah.

Dr John Lantis: I was thinking, could we do that?

Dr Jonathan Johnson: Rotational, yeah.

Dr John Lantis: I do my own rotational. Free flaps are done by plastics. I looked at both, and I'm thinking, with his edema and his heart failure, and his this, and his that. And plastics was like, “No way. We're not touching this.”

Dr Jonathan Johnson: Oh no, they're definitely letting vascular.

Dr John Lantis: Yeah, so I was really stuck with conservative things. So, we got him a shoe the other day. We got him in a shoe. He's not finished. He's still draining. He's got a little couple wounds.

Dr Jonathan Johnson: Okay, yeah. Alright.

Dr John Lantis: But we got his shoe for him and made it to his New Year.

Dr Jonathan Johnson: That's great. That's great.

Dr John Lantis: That was a lot of…

Dr Jonathan Johnson: That seems like that was a lot of work. Well listen, our main goal on Wound Care Wednesdays is to always chat with our experts. They have great cases, great knowledge, great experience. And we want to impart a lot of that knowledge on our audience because our experts are here to make sure we can continue to work clinically and make sure we have the best management choices out there and we can learn from their experiences.

So, we are super excited today and we thank Dr John Lantis, who is a vascular extraordinaire in the New York area, Mount Sinai. You can definitely go see him as needed. Again, we'd like to thank everyone for coming out for another Wound Care Wednesday. This is SAWC Fall 2024, sponsored by Polynovo, and we cannot wait to see everyone on the next Wound Care Wednesday. I'm Dr Jonathan Johnson, and we'll see you again on the next Wound Care Wednesday.