What is the best course of action for a patient with a complex or non-healing wound, such as a diabetic foot ulcer, venous or arterial ulcer, or pressure ulcer, who may have underlying conditions like diabetes, vascular disease, or mobility issues?

Advanced Wound Care Center Referral for Complex Wounds

Patients with complex or non-healing wounds—including diabetic foot ulcers, venous/arterial ulcers, and pressure ulcers—should be referred to a specialized multidisciplinary wound care center or diabetic foot service, as management by a coordinated team significantly reduces major amputation rates and improves limb salvage outcomes. 1, 2

When to Refer to an Advanced Wound Care Center

Immediate Referral (Within 24 Hours)

• Severely complicated wounds with signs of necrotizing infection, wet gangrene, or systemic sepsis 1
• Critical limb-threatening ischemia (CLTI) with rest pain, new areas of necrosis, or signs of acute arterial insufficiency 1
• Rapidly progressive infection despite initial antibiotic therapy, with spreading cellulitis, abscess formation, or gas in tissues 1

Urgent Referral (Within 48-72 Hours)

• Complicated diabetic foot ulcers showing signs of infection (hyperemia, cellulitis, purulent drainage, edema, fever) or ischemia (new necrosis, rest pain) 1
• Unstable wounds that are progressing in size or depth despite standard care 1
• Wounds with underlying osteomyelitis requiring surgical debridement and prolonged antibiotic therapy 1
• Arterial ulcers requiring vascular assessment for potential revascularization 1

Standard Referral (Within 1-2 Weeks)

• Non-healing wounds after 4 weeks of appropriate standard care 1
• Diabetic foot ulcers requiring specialized offloading devices (total contact casting, irremovable walkers) 1, 3
• Wounds requiring advanced therapies such as negative pressure wound therapy, hyperbaric oxygen, or biologic dressings 1

Why Multidisciplinary Wound Centers Improve Outcomes

Opening of an outpatient wound care center affiliated with vascular surgery has been shown to reduce major amputation rates from 8.8% to 5.5% at one year, representing a 59% reduction in amputation risk. 2 This benefit stems from:

• Coordinated revascularization and wound care: Adequate perfusion must be restored before or concurrent with wound healing efforts 1
• Regular expert debridement: Serial sharp debridement at each visit removes nonviable tissue and biofilm 1
• Specialized infection management: Prompt antibiotic therapy, surgical drainage, and culture-directed treatment 1
• Advanced offloading strategies: Total contact casting, custom orthoses, and pressure-relieving devices 1
• Access to adjunctive therapies: NPWT for post-surgical wounds, hyperbaric oxygen for select cases 1

Core Components of Wound Center Management

Vascular Assessment and Revascularization

Revascularization is the foundation of CLTI wound healing and must precede other interventions. 1 The wound center team should:

• Measure ankle-brachial index (ABI), toe pressures, and transcutaneous oxygen pressure (TcPO2) 1
• Perform urgent vascular imaging when ABI <0.5, ankle pressure <50 mmHg, or toe pressure <30 mmHg 1
• Coordinate endovascular or surgical revascularization before wound closure attempts 1

Infection Control

Foot infections in CLTI patients can progress rapidly to amputation and death, requiring prompt diagnosis and aggressive treatment. 1 Management includes:

• Immediate broad-spectrum antibiotics for moderate-to-severe infections 1
• Surgical debridement for abscess, gas, or necrotizing fasciitis 1
• Culture-directed antibiotic therapy for 2-4 weeks depending on severity 1

Wound Bed Optimization

After revascularization, wound care should optimize the healing environment through repeated debridement and appropriate dressings. 1 Key principles:

• Serial sharp debridement of nonviable tissue and callus at each visit 1
• Simple, cost-effective dressings (gauze, non-adherent) that maintain moist wound bed 1, 4
• Foam or alginate dressings for high-exudate wounds 4
• Avoid antimicrobial dressings (silver, iodine) as they do not improve healing outcomes 1, 4

Pressure Offloading

Non-removable offloading devices are superior to removable devices for diabetic foot ulcer healing. 1 Options include:

• Total contact casting for plantar ulcers (fastest healing rates) 1
• Irremovable cast walkers as alternative to total contact cast 1
• Custom therapeutic footwear to prevent recurrence after healing 1

Medical Optimization

Systemic factors profoundly impact wound healing and must be addressed concurrently. 1 Essential interventions:

• Mandatory smoking cessation (smoking causes vasoconstriction and tissue hypoxia) 1
• Glycemic control targeting HbA1c <7% in diabetic patients 1
• Cardiovascular risk factor modification 1
• Nutritional optimization 1

Adjunctive Therapies Available at Wound Centers

Negative Pressure Wound Therapy (NPWT)

NPWT should be used for post-surgical wounds and after minor amputation when primary closure is not feasible, with studies showing 100% limb salvage at 3 years when complete healing achieved. 1, 5 However:

• Do not use NPWT for non-surgical diabetic foot ulcers (no proven benefit) 1
• Reserve for post-debridement wounds requiring granulation tissue formation 1, 5

Hyperbaric Oxygen Therapy

Hyperbaric oxygen may be considered for non-healing diabetic foot ulcers after revascularization, though evidence is mixed. 1 Consider when:

• Standard care has failed after adequate revascularization 1
• Resources and expertise exist to support this intervention 1
• Patient has neuro-ischemic or ischemic ulcers 1

Note: One RCT showed decreased ulcer area at 6 weeks but no difference in complete healing or amputation rates at 6 months. 1

Advanced Biologic Therapies

Most advanced dressings and biologics lack strong evidence and should not be used routinely. 1, 4 Exceptions:

• Sucrose-octasulfate dressing for neuro-ischemic ulcers failing standard care 1, 4
• Autologous leucocyte-platelet-fibrin patch where venepuncture expertise exists 1, 4

Common Pitfalls to Avoid

• Referring calf ulcers to podiatry: Podiatry manages foot and ankle pathology only; calf ulcers require vascular surgery or wound care specialists 3
• Attempting wound closure without revascularization: Inadequate perfusion prevents healing regardless of other interventions 1
• Using expensive antimicrobial or specialty dressings routinely: These do not improve outcomes over basic wound contact dressings 1, 4
• Prescribing removable offloading devices: Non-removable devices (total contact cast) heal faster and more reliably 1
• Delaying referral for "unstable" wounds: Progressive wounds require specialist evaluation within 48-72 hours to prevent amputation 1

Documentation and Follow-Up

Wound centers should perform weekly reassessment to evaluate healing progress, identify biofilm or persistent infection, and adjust treatment. 1, 5 Regular documentation allows:

• Tracking healing trajectory (wounds should show 50% size reduction by 4 weeks) 1
• Early identification of treatment failure requiring escalation 1, 5
• Coordination between specialties (vascular, infectious disease, orthopedics) 1, 5