A surgical algorithm for sustainable healing in real-world complex wounds
Dean Meshkin1, Ersilia Anghel2, Kenneth L. Fan1, Karen K. Evans1, John S. Steinberg1, Paul J. Kim3, Christopher Attinger1
1MedStar Georgetown University Hospital, Washington, DC;2Oregon Health and Science University Hospital, Portland, OR;3University of Texas Southwestern Medical Center, Dallas, TX
Background: Complex wounds continuously challenge patients and healthcare systems globally. Reported wound outcomes fluctuate and often represent narrow study designs omitting influences of significant comorbidities and severe wounds amongst cohorts. This study aims to quantify the relative wound healing efficacy of a surgical algorithm for large, infected wounds requiring hospital admission.
Methods: All patients were admitted to a tertiary wound-referral academic hospital with infected wounds. No exclusions were set for demographics or wound characteristics. Outcomes were assessed at 30, 60, 90, 180 and 360 days after discharge for healing, complications, re-operations, amputations, loss to follow-up, and mortality using electronic medical records and an obituary database.
Results: 100 patients were admitted with neuropathic (31%), surgical (36%), ischemic (12%), decubitus (11%), venous (5%) and traumatic (2%) wounds. Average wound size and depth were 46.5 ± 59.4 cm2 and 2.7 ± 1.7 cm2, respectively with 62% of wounds involving bone. Wound healing at 30, 60, 90, 180 and 360 days was 65.6%, 49.3%, 65.6%, 55.6%, and 75%, re-operation rates were 6%, 20%, 11%, 27%, and 12%, and vascular interventions to maintain healing were 0%, 0%, 0%, 7% and 8%, respectively. There was 1 above-knee amputation, 2 below-knee amputations, 2 deaths, and 8 losses to follow-up over the study period, with significant associations observed within outcomes.
Conclusion: We observed a 75% wound healing rate at one year in a population with severe, multi-etiology wounds following an approach that systematically employs serial sharp debridement, negative-pressure wound therapy with instillation, vascularized soft-tissue coverage, and multidisciplinary follow-up care. As therapeutic modalities advance, uncensored evidence encompassing the full wound-care episode is necessary for the most pragmatic and effective wound healing algorithms for improving long-term patient outcomes.
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