INTRODUCTION

For the 35th anniversary of Advances in Skin & Wound Care, a variety of thought leaders have been invited to share their insight into a range of topics of current interest to the field. In this special installment of Practice Reflections, Dr James McGuire describes the history of podiatry and wound care, Dr Bharat Kotru reflects on the present state of podiatry and wound care, and Dr Anthony R. Iorio ponders how future advances will impact the intersection between the two.

Ancient Wound History

There comes a time in one’s life when you have to face your own mortality. For me, it was on a bus to the airport recently when a much younger man stood to offer me his seat. The second was when I was asked to write this history of wound care prior to 2000. I am sure it was because Advances wanted an eye-witness report as opposed to a mere recanting of writings from the annals of history. So, I will limit my review to the events within my lifetime and not a discussion of the use of poultices and potions, although during my time in Vermont it was not uncommon to encounter patients who had received advice from a “white witch” or backwoods healer.

My earliest memory of wound care was my mother, who—after listening to the advice of her mother-in-law, who assured her that without pain there was no gain and that direct application of alcohol, peroxide, and or mercurochrome was the only way to prevent bugs from entering a wound—applied myriad painful solutions to help heal wounds. As she did, she was doubtless remembering the words of her grandmother quoting Dr Joseph Lister, who in 1865 recommended the use of carbolic acid, another pleasant antiseptic used to fight infection.1 This explains the toughness of the greatest generation and whatever remnants of it remain in the baby boomers of today.

Bandages and dry gauze followed, with assurances that a nice dry scab was the way to go. By the time I went to physical therapy school in 1974, the concept of moist healing using Adaptic and saline-moistened gauze had taken hold to aid in dressing removal for patients with burns, as well as ease the pain and facilitate healing. The ghost of my German grandmother still pervaded society though in the form of the wet-to-dry dressing that ripped off slough and adherent tissues with each dressing change, assuring a nice clean, granular, painful surface and eventual healing. By the time I entered podiatry school in 1977, medicine had figured out that if saline wet-to-dry works well, then povidone iodine-soaked gauze had to work better. Besides, the new “safe” opioid pain relievers were much better at helping patients tolerate the dressing changes than the old “bite the bullet” technique.

After my residency training, in 1985, I was fortunate to fall under the tutelage of an icon in wound care, Nancy Faller, RN, to whom I owe my interest in wound care. She introduced me to hydrocolloids and a new concept in wound care, “moist wound healing.” Now, to be accurate, hydrocolloids were introduced in 1967, but took 18 years before their use began to influence clinicians in Vermont.2 This explains the continued use of wet-to-dry dressings, dry gauze, Betadine dressings, and even mercurochrome today. It also is a perfect example of the phrase “information travels quickly but acceptance lags behind”—way behind. When I left Vermont for Philadelphia in 1992, the local doctors still thought that hydrocolloids induced infection as evidenced by the “pus” that accumulated between dressing changes. The need to do daily dressing changes dies hard.

Alginates followed in 1983, and foams were not introduced by Fleichman until 1995.3,4 Negative-pressure devices were added in the early 1990s5 and, after many years of study, topical platelet-derived growth factor was introduced in 1997.6 I do not want to list the introduction of every dressing here, but these are examples of “ancient history” in wound care that have all become the standard of care today. In fact, this “history” really is not that ancient, and points to the fact that we are in the infancy of modern wound innovations.

I first entered full time wound care in 1999 when I became the Director of the Leonard Abrams Center for Advanced Wound Healing at Temple University’s School of Podiatric Medicine, right after the introduction of the aforementioned topical platelet-derived growth factor. In 1995, Cook Biotech Inc introduced a new wound healing bioscaffold, porcine small intestinal submucosa, that we were privileged to study. It is now marketed as OASIS Matrix by Smith & Nephew (Fort Worth, Texas). First studied as a wound healing material in 1989, this bioscaffold was first used clinically in 2002.7 One of the first artificial “skin substitutes,” this xenograft became the springboard for numerous other “slaughterhouse floor” wound products. Pigs, cows, horses, fish, and sheep all met their demise and contributed to the repair of human tissue. Vegans should not worry—there is still hope for vegetable proteins, just stay tuned. Needless to say, I entered wound care right at the birth of the modern era of wound healing; the ride has been fast and has not slowed down to this day.

The Present Role of Podiatry in Wound Care

Podiatry has become specialized in the past few decades to include everything from sports medicine and ankle surgery to wound care. The podiatry designation was introduced by MJ Lewi in 1917. In some countries, including Canada, practitioners are known both as chiropodists or podiatrists, depending on their training program and provincial regulatory authority. Podiatrists play major and impactful roles in wound care. Podiatrists manage diseases, disabilities, and deformities of the foot with procedures that include physiotherapy techniques, nail care, local wound care, and minor surgeries in addition to providing therapeutic footwear and orthotic devices.

Podiatry skills include gait assessments to identify biomechanic anomalies and pressures. When these gait abnormalities are diagnosed and treated in a timely manner, further foot complications can be prevented. Foot specialists are often the first to recognize the presence of limb- and life-threatening wounds. The role of podiatry in wound healing is essential, and emphasizes lower extremity preservation and limb salvage. Currently, the majority of podiatrists are trained in advanced wound care.

The prevalence of type 2 diabetes is increasing worldwide, resulting in foot complications that lead to poor quality of life and increased cost of living. In 2019, 463 million people worldwide were living with diabetes, a number that is estimated to increase to 700 million by 2045. Unfortunately, four out of five people with diabetes live in low- and middle-income countries, where podiatry services are usually lacking.8 There is a need to empower nursing or allied healthcare professionals with foot care and podiatry services in these countries because persons with diabetes can develop several foot problems, which can lead to serious complications. Up to 70% of all nontraumatic lower leg amputations occur in persons with diabetes.9 With the increase of diabetes and diabetic foot problems, many wound care programs now offer specialized lower extremity wound care by podiatrists.

Podiatry plays a major role in the prevention of many lower extremity ulcers: with early assessments, treatments, and timely referrals, amputations can be avoided. Podiatrists are trained to recognize the signs and symptoms of peripheral arterial disease. This knowledge facilitates timely referrals to the appropriate vascular specialists, but also cardiologists and internists to prevent catastrophic medical events including heart attacks, strokes, and other medical complications.10 In India, podiatrists employed within the public health system provide conservative sharp wound debridement to all patients with nonischemic diabetic foot ulcers (DFUs) as the predominant modality to remove nonviable tissue and promote healing.11 Advanced wound care centers offer a specialized level of care that is typically not available in a local healthcare system. These centers offer state of the art specialized equipment, up-to-date techniques, an interprofessional team approach, and evidence-based practice to manage complex diabetic foot cases.12 This approach enables providers to collaborate with one another for immediate care and is optimal in patients with diabetic foot infections to increase limb salvage.13

In addition to an interprofessional approach, advanced wound care centers offer a plethora of skilled services and advanced technological resources that may not be available in local centers. These resources may include hyperbaric oxygen chambers, digital thermography, transcutaneous oximetry, foot Dopplers, negative-pressure wound therapy, biogenic skin graft substitutes, and various pressure-offloading devices. Increased plantar pressure is a causative factor in the development of diabetes-related plantar foot ulcers. Plantar pressure redistribution can heal plantar foot ulcers and prevent their recurrence.14 Because they are well equipped and have the latest technology, wound care centers offer the best possible outcome for patients.

Specialized dressings are also impactful in the treatment of DFUs. With podiatric medical advancements, a paradigm shift away from conventional and traditional medical thinking is needed. The following are some recent innovations in podiatric wound care:

Biomechanical analysis systems Walking and running gait analysis with a light illuminator podoscope Foot scans, computer-aided design and manufacturing Orthotic devices with different specifications as per patient need Customized footwear Various wound care solutions including regenerating bone with innovative grafts

The podiatry profession proved its flexibility and adaptability during the pandemic, adjusting rapidly to ensure that patients could access treatment to reduce risk of infection, ulceration, and amputation. Many clinicians have offered virtual care supplemented with algorithms and enablers to ensure that patients are triaged appropriately. To support clinicians, the number of virtual continuing professional development webinars have increased. Podiatrists have also embraced remote technology to facilitate patient self-care.15

Although the fight against diabetes is an uphill battle, it is a battle worth fighting and winning. Healthcare providers must work as a team, communicate among all specialties, and know when and where to refer. Patients are the priority, and referring patients with diabetes to a podiatrist, especially individuals with a high-risk foot, is a good strategic move. Early referral can optimize foot care, wound care, and podiatry services in their settings.

Podiatrists can be “gatekeepers” for the prevention and management of DFUs. Successful collaboration between podiatry services will implement change to standardize the clinical assessment and management of DFUs. The interprofessional approach has demonstrated a reduction in DFUs and lower extremity amputations, with a heterogeneity of team members and interventions.16,17

The clinical and economic burden of lower-limb tissue loss should not be tolerated and must be reduced across the entire population with the help of podiatry.

The Future of Podiatry in Wound Care

Despite considerable advances in the past 25 years, DFUs continue to present a considerable healthcare burden.18,19 For a DFU without surgery, the median time to healing is 12 weeks; DFUs result in considerable suffering, frequently recur, and are associated with high mortality, not to mention enormous healthcare costs. The 5-year survival following presentation with a new DFU is around 50% to 60%: worse than that of many common types of cancer. Although national and international guidance exists, the evidence base for much of the routine clinical care is thin. It follows that many aspects of the structure and delivery of care are susceptible to the beliefs and opinion of individual clinicians. It is probable that these differences contribute to the geographic variation in outcomes that has been documented in several countries. Clinical outcomes vary widely even within the same country, suggesting that some patients are managed considerably better than others.

There is an urgent need to improve the design and conduct of clinical trials in this field. Specifically, the evidence base for clinical practice can be improved through randomized controlled trials. In addition, researchers should undertake systematic comparisons of the results of routine care in different health economies. Why is the current evidence base so poor? For one, diabetic foot care has traditionally been neglected. Also, there is a complexity to the pathogenesis that predisposes patients to ulceration. The care process is complex, in that caregiving and treatments are conducted by many different people, including physicians, surgeons, podiatrists, and other healthcare professionals. Some evidence suggests that appropriate changes in the relevant care pathways can result in a prompt improvement in clinical outcomes. The difficulties posed vary to some extent in each of the main areas of foot ulcer care; however, an attempt has been made to address them in a detailed summary written on behalf of the International Working Group on the Diabetic Foot and the European Wound Management Association. Other factors and pathways such as study design, study conduct, and study reporting all can be used as contributors to influence different outcomes.

Much has been achieved in the past 2 decades with major amputations occurring much less frequently, at least in some countries, but there are more advances to come. There are wide variations in outcomes, even in industrialized countries and those with nationalized health care systems. If communities embrace these initiatives, it will be possible to trigger substantial improvement in outcomes relating to DFUs. Care of the foot needs to metamorphose from a subspeciality to a “superspecialist” of diabetes.

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