Editorial
Clinics in Podiatric Surgery
Lesly Robinson and James McGuire*
Departments of Podiatric Medicine and Podiatric Biomechanics, Temple University School of Podiatric Medicine,
USA
*Corresponding author: James McGuire, Departments of Podiatric Medicine and Podiatric Biomechanics, Temple University School of Podiatric Medicine, USA
Published: 13 Jul 2017
Cite this article as: Robinson L, McGuire J. Clinics in
Podiatric Surgery. Clin Surg. 2017; 2:
1557.
Editorial
Significant changes have occurred in Podiatric Medicine in the past 20 years. Although the
profession has been primarily focused on expanding the surgical training to include a uniform
PSR 36, there has been a recent need to expand our capabilities in dermatology, lymphedema
management, and wound healing. We have also reenergized our interest in biomechanics and greatly
expanded our understanding of alternative therapies and nutraceuticals. The colleges, long invested
in expanding our surgical abilities, have not kept up with the profession’s need to know more and
more medicine and each school has had to make significant investment in training facilities in this
area. Nowhere is this change more obvious than in the area of wound care. Destined to become the
next recognized medical specialty, wound healing has embraced podiatric medicine as an equal to
allopathic and osteopathic medicine largely due to our expertise in diabetic foot management to
which we owe a great debt to the early pioneers in the field such as Harkless, Armstrong, Lavery,
and Frykberg.
Wound management has come a long way from the advent of moist wound healing, driven by
the nursing community in the late 80s through the nineties, to multiple therapeutic options from
negative pressure to cellular and acellular tissue-based products (CTPs) to enhance the rate and
frequency of wound closure. Research investment in podiatric medicine has also expanded greatly
from the days when 1 or 2 researchers received the majority of grants to today when Federal, State,
and Corporate grants are available to numerous podiatric researchers in the field.
At Temple University we have received grants to study antifungal medications, dermatological
preparations, compression dressings, offloading devices, and the effects of CTPs on wound healing.
Beginning with porcine small intestinal submucosa in the late 90’s the majority of our present works
in the wound center has been in the study of placental derived tissues both cellular and acellular.
Although significant improvement can be obtained with acellular materials whether porcine, bovine
or ovine, cellular materials appear to produce better outcomes with even the most difficult wounds.
Despite advances in dressings the best that standard of care in wound healing has been able to
achieve is approximately 49% closure at 12 weeks [1]. Sheehan demonstrated that percent change
in wound area after 4 weeks of care was a strong predictor of healing at 12 weeks [2]. In that study
the percent change in wound area at 4 weeks in wound healers was 82% (95%CI 70–94), as opposed
to 25% (15–35; P < 0.001) in those who failed to heal by 12 weeks. Sheehan demonstrated that early
intervention with advanced wound care products such as CTPs is recommended when 50% wound
closure is not achieved within the first 4 weeks of therapy. Several clinical studies of CTPs have
demonstrated various healing rates from 32% to 76.1% to date [3,4].
Continued research on new therapies to improve the healing process of stalled wounds has
demonstrated that we need not settle for that [5,6]. Placental membranes have been used to treat
wounds for over 100 years. The combination of growth factors, collagen-rich extracellular matrix
and in some CTPs live cells provide the clinician to a powerful healing modality. The preservation
of mesenchymal stem cells (MSCs), neonatal fibroblasts and epithelial cells in cryopreserved
human amnionic membrane provides a significant jump start for non-healing wounds. Multiple
growth factors and proteins including anti-scarring proteins (TGF-β3 and growth factor) [7], antimicrobial
proteins (neutrophil gelatinase-associated lipocalin and defensins) [8] and angiogenic
factors (vascular endothelial growth factor, platelet-derived growth factor [8] and basic fibroblast
growth factor) are present in the matrix [8-10]. The addition of live cells and MSCs has made a
significant difference in our ability to heal difficult to close chronic wounds. We have also been
impressed with both our clinical experience and the results of the studies that show superior healing
with cryopreserved human amnion that preserves the MSCs in the tissue over cellular dehydrated
versions of the same tissue. A recent study just published by Johnson et al. pointed this out. In this investigator initiated study of clinical outcomes, the authors compared two nonrandomized statistically equal homogenous patient cohorts
totaling 79 patients and 101 wounds. 63% of the patients receiving
the cryopreserved human placental membrane achieved complete
closure within the study period compared to 18.2% of that receiving
dehydrated amnion/chorion membrane. This clinical comparison of
two very different versions of the same tissue increased our confidence
in what had been demonstrated in controlled randomized studies and
what we had suspected from our clinical observation.
The study we have just closed and a new one about to open will
be to study this same technology. At the Foot and Ankle Institute of
Temple University we are also conducting trials of a cadaver skin
allograft, an offloading insert, a topical antifungal, and a competing
cellular and acellular tissue product. In the past several years we have
looked at fetal bovine tissue, compression systems, several antifungal
medications, and DNA microbial assessment of chronic wounds.
This is a far cry from the years when the only studies completed
were case studies, basic research in the gait lab, and surgical case
studies of materials and fixation systems. Wound care, dermatology,
biomechanics, and the medical aspects of podiatric medicine are
taking center stage again. Recently one of our clinicians was overheard
discussing the varied aspects of their practice. After reviewing all
their interests and the care they rendered the observer asked “I don’t
understand. Are you a surgeon, a dermatologist, a biomechanist, a
physical therapist, or a wound care specialist? The clinician replied,
“I am a podiatrist.
References
- Papanas N, Maltezos E. Benefit-risk assessment of becaplermin in the treatment of diabetic foot ulcers. Drug Saf. 2010;33(6):455-61.
- Sheehan P, Jones P, Caselli A, Giurini JM, Veves A. Percent Change in Wound Area of Diabetic Foot Ulcers Over a 4-Week Period Is a Robust Predictor of Complete Healing in a 12-Week Prospective Trial. Diabetes Care. 2003;26(6):1879-82.
- Marston WA, Hanft J, Norwood P, Pollak R; Dermagraft Diabetic Foot Ulcer Study Group. The efficacy and safety of Dermagraft in improving the healing of chronic diabetic foot ulcers: results of a prospective randomized trial. Diabetes Care. 2003;26(6):1701-5.
- Regulski M, Jacobstein DA, Petranto RD, Migliori VJ, Nair G, Pfeiffer D. A retrospective analysis of a human cellular repair matrix for the treatment of chronic wounds. Ostomy Wound Manage. 2013;59(12):38-43.
- Veves A, Falanga V, Armstrong DG, Sabolinski ML; Apilgraft Diabetic Foot Ulcer Study. Graftskin, a human skin equivalent, is effective in the management of noninfected neuropathic diabetic foot ulcers: a prospective randomized multicenter clinical trial. Diabetes Care. 2001;24(2):290-5.
- Hanson SE, Bentz ML, Hematti P. Mesenchymal stem cell therapy for nonhealing cutaneous wounds. Plast Reconstr Surg. 2010;125(2):510-6.
- Duan-Arnold Y, Alexandra Gyurdieva A, Johnson A, Uveges ET, Jacobstein AD, Danilkovitch A. Retention of Endogenous Viable Cells Enhances the Anti-Inflammatory Activity of Cryopreserved Amnion. Adv Wound Care (New Rochelle). 2015;4(9):523-33.
- Maxson S, Lopez EA, Yoo D, Danilkovitch-Miagkova A, Leroux MA. Concise review: role of mesenchymal stem cells in wound repair. Stem Cells Transl Med. 2012;1(2):142-9.
- Duan-Arnold Y, Uveges TE, Gyurdieva A, Johnson A, Danilkovitch A. Angiogenic Potential of Cryopreserved Amniotic Membrane Is Enhanced Through Retention of All Tissue Components in Their Native State. Adv Wound Care (New Rochelle). 2015;4(9):513-22.
- Johnson E, Marshall J, Michael GM. A comparative Outcomes Analysis Evaluating Clinical effectiveness in Two Different Human Placental Membrane Products for Wound Management. Wound Rep Regen. 2017;25(1):145-9.