At the Orthopaedic Trauma Association Annual Meeting, Brett Crist, MD and Ravi Karia, MD presented this symposium, designed to increase knowledge of appropriate and safe use of ciNPT and improve outcomes in lower extremity surgery. They review clinical evidence, case studies and provide a practical demonstration of the latest evolution in incision and surrounding soft tissue management in lower extremity.
Understand the impact of surgical site infections
Tips and pearls for successful outcomes in lower extremity surgery
Review recent evidence examining the importance of using negative pressure therapy for incision and surrounding tissue management
Discuss case examples of outcomes associated with negative pressure therapy in complex lower extremity cases
Take part in a question-and-answer session
good afternoon. I'm Janine Hartfield, medical education manager with three m. I'd like to take this opportunity to welcome you to the symposium titled Next Generation Negative Pressure Therapy for Incision and Surrounding Soft Tissue Management. Improving Outcomes Following Lower Extremity Surgery This symposium is designed to increase knowledge of appropriate and safe use of close decision negative pressure therapy and improve outcomes. Are presenters will review clinical evidence case studies and provide a practical demonstration of the latest evolution incision and surrounding soft tissue management in lower extremity. Mm. I'd like to point out that if you have any questions about safety information or any indications for use for products discussed during the symposium, please refer to labelling provided with the product or visit the three m k CI website at www dot facility dot com for detailed instructions for use. Today, I am honoured to introduce Dr Breakfast and Dr Ravi Correa. Dr. Chris is vice chair of business development director of orthopedic trauma service and co director of the Orthopedic Trauma Fellowship in the Department of Orthopedic Surgery at the University of Missouri School of Medicine. Dr Correa is the associate professor and vice chair of Clinical affairs in the Department of Orthopedics at the University Texas Health Science Center in San Antonio. Those of our speakers have disclosed any commercial relationships that may be relevant to this talk. Most notably, they are both paid consultants and speakers for Casey, now part of three. Our objectives for this symposium are to help our viewers understand the impact of surgical citing section, provide you take some pearls for successful outcomes and lower extremity surgery. We will review with you a recent evidence examining the importance of using negative pressure therapy for incision and surrounding tissue management, and will provide a case. Examples from our speakers own personal experience. And finally, we strongly encourage you to use this time to ask questions of our experts so that you may get the most out of this educational activity. Now, without further ado, I will take. I will turn the light over to Dr Korea. Okay, thank you, Janine, for that introduction. Before we get started, I'll just review today we're going to discuss negative pressure therapy for incision management. In the discussion of that, we'll discuss why this came about will discuss research starting from the bench to animal studies including human trials, and we're going to introduce a new concept. As we've determined that negative pressure looks so well for incisions, we've now started to use it for surrounding soft tissue management, so to keep on our time frame will just get started. For those of you that are unfamiliar with Trevena, the dressing here is shown as a purple dressing. You can see it's very similar to the black sponge that everyone is familiar with. The big difference is not seen. Here is the layer of the dressing that contacts the skin. So this has been engineered to be appropriate to touch the incision and skin and, more importantly, the wick moisture away. Okay for today's talk and the audience today, we're going to focus on extremity injuries. Extremity fractures of the foot and ankle will focus both on high energy and low energies. When we're looking at high energy fractures. The big issue that we see issues there's problems with is the amount of soft tissue trauma that soft tissue trauma puts the incision at risk, uh, increasing rates of Burundi, Hisense and infection. When we talk about lower extreme low energy fractures, really, we're talking about the ones with patients that have co morbid conditions, whether it's diabetes, whether they have vascular issues, whether they have poor nutrition, for whatever reason or smokers. These patients also can have problems with wound healing wound infections. But more than that, they also have issues like in the high energy ones. With swelling, we expect swelling in our patients. We expect swelling in the in the injuries of the foot and ankle and swelling can cause problems with wound healing and increased complications like the Hisense and infection. But more than just at the incision, swelling causes problems for the entire extremity, from pain control to an inability to do range of motion to poor mobilization. And at least in theory, there's a concern that the more swelling there is, the more formation of scar and fibers tissue There will be at a later date. So moving back to just the incisions, we don't have to really talk too long about why we should be concerned about incisions. When you have surgical site infections that increases costs dramatically, that increases length of stay dramatically, and some payers, especially our government payers, are starting to not pay for these complications, and this is before we even really get into what happens to the actual patient. So when looking at this as a whole, this is a good slide to really put everything together. We want to try to determine which incisions which procedures were worried about which patients were worried about. There's nothing on this slide that isn't very obvious. There are certain incisions, whether it's trauma, traumatized tissue, high tension, incisions that we worry about. There's certain patient factors. We worry about the diabetics, the obese, the tobacco use. And there's certain surgeries that we have concerns about. So this is a good starting point to where we where we can lead into the research that's being done on negative pressure. Incision management, K CI now part of three m has done a really good job in separating this right so we can look at the research as what happens immediately from when you place the dressing right after surgery. What happens in the first few weeks and then what happens long term, even if some of that is theoretical so immediately? One of the things that I like a lot about the negative pressure dressings is that this is addressing that once applied in the O. R. Is going to stay in place for seven days. Some of the benefit that you'll see in this is just from having addressing in place for seven straight days. It's not being disturbed, and that's before you even get into the science behind all this dressing works. So this is a pig study where there's two incisions made and Trevena was applied for three days when this was removed. They looked at these incisions two days later. And yes, you can see the control incision looks fine. That wound is healed. There's no signs of infection. It does not appear to be draining. But when you look at the dress the wound that had the Praveen a therapy that incision is not only healed and looks good, it looks quite mature, too. It looks like an incision that you'd expect a few days a few weeks later, so that's some level of proof on how well this device works. The next slide is a little bit more theoretical. When we when I first looked at Trevena, you look at it and you think it's a compressive dressing and I like compression of my wounds. You think that you apply the dressing, you hook up section and it just squishes down and you get some localized compression on that wound. That is not what's happening. In fact, it's quite the opposite. It's not a compression dressing. It's a decompressing dressing, and so when you apply the dressing and you apply suction, that vacuum effect just does that. The top layer of skin and a few letters get sucked up to that addressing. By doing that, you're able to normalize the tensile forces across the wound. And so you can imagine if you have a highly, uh, tense wound in the middle, the dressing being much wider than the wound. The sides get pulled up, relieving some of that stress in the middle. Furthermore, further down in the wound by relieving and normalizing the tension forces, you have less dead space because those forces have been normalized. So again, that's pretty theoretical. But how do we actually test that with science? Right. So the first study here you look at the force that's required to stretch an incision open one centimeter, and with Trevena therapy, it's significantly stronger whether it's future or stapled next. I had brought up the decrease in dead space. But what happens in the dead space it's gonna fill up? It's gonna fill up with hematoma. Ciroma going to fill up with something you don't want there. So how can we prove that dead space is less and there's last hematoma? Ciroma formation. This is over the next few weeks, so the simple way is just to measure it. So, looking at an ultrasound model, you can the same pig model that was used previously. You can try to measure the size. The volume of hematoma, Ciroma that's underneath the surface. Well, again, here we see with Trevena therapy, it's less at a significant at four days after after treatment. But more than just stopping it, this is this is reality is why did that happen so we can understand it. This is probably the preeminent bench study with Trevena, and I really like it doesn't make a lot of sense, but, um and it doesn't make sense because I really don't know what Nana spheres are, but this really helps explain why this is happening. So Nana spheres are molecules that you can inject into this dead space you can inject into the syringe or hematoma, and what they did here is they were able to follow where those nameless fears go. So by decompressing the tissue that opens vascular structure, so it opens blood flow. But what? It also opens its lymphatic flow. So the lymphatic vessels have also been opened. And when you apply Praveen a therapy and then you go and biopsy the lymph nodes in the area, you notice that there's so many more nana spheres in those lymph nodes and without preventive therapy. And so the way this is working by decompressing those lymphatic vessels open up and can take all that hematoma Ciroma material, which is all the extra cellular fluid out of the way of your wound, relieving tension and improving the chances that this wound heals uneventfully. All right, now, as we go to the long term, we're gonna look at some clinical trials for this audience for these fractures, really. The gold standard trial here is done by Jim Standard about eight standard. About eight years ago here, he took 250 patients and they were randomized to getting negative pressure wound therapy, right? These were high risk fractures, tibia, plateaus, P lawns and cal Kenya's fractures. And when you see their end result that had significantly decrease infections and wounded, his is so this is a relatively old study. It's eight years old and the in fact used regular negative pressure wound therapy, just black sponge on skin and not really for that long of a period of time. And they still had these great results. We can do a cost analysis, and the cost of the Praveen addressing doesn't come close to two. How much savings you get by not having those infections and not having those take backs to surgery. Now there's a lot of other studies that we're going to go over fairly quickly because they're not directly related to orthopedic trauma. So revision, hip and knee surgery. This is a study that was done a few years ago and looking at it after applying for vino therapy, you can see significantly decreased risks for wound complications, surgical site infections, re operations and deep perry prosthetic joint infections or zero in this study. So this is really good data to show. How do we How do we make this applicable to Ortho trauma well revision hip surgery is not too dissimilar to high energy pelvic established surgery where you do not have an ideal a soft tissue envelope to work with. The next two are outside of the world of orthopedics, the first being poster. Not to me. Okay, so having to do an incision over a bone that subcutaneous I think we're familiar with that. And with a trauma as well as a study that involves groin wounds. Right. So having to do an incision on an area of the body that's not necessarily clean. Both of these with Praveen a treatment showed significantly less infections. Alright, so now we're gonna divert and start talking about How did the Praveen addressing come about? Where did we start from? And then we'll introduce another dressing that has recently hit the market and why we think that this is an improvement over what we've had before. So standard incision management, right, So we have some amount of gauze. Maybe some folks use, um, you know nonstick before that, and then we place tape over it. If you have an incision that's not gonna drain and you have surrounding tissue, that's healthy, and it's not traumatized. This likely works. Okay, you can probably places dressing on, and two weeks later it's going to be okay. An orthopedic trauma. Too often we don't have that. We have dressings that may leak a little bit. We have traumatized tissue. We have the ability to have dead space, which creates hematomas and aromas. So we're looking for something a little better in the high risk patients. Negative pressure wound therapy started about 15 years ago, and remember, this was just the regular black sponge with the tape over it. And that black sponge is not designed to wick away moisture, right? It's designed to take large quantities of moisture and take it through the tubing out to the pump, but it's not designed to stay dry on the surface. So the challenges were it was a little bit hard to put on. For those of you that remember and the Perry wound, management was challenging because when you place this on a traumatized wound, you take it off in a few days or a week, and you'd see that the wound edges were macerated because they were staying wet. These results led to the development of the venous system. So here, before we even talk about the slide, it's just that layer of dressing that touches the surface. It's anti wick material that will take moisture away. Get it up into the sponge so it can get it off of the wound quickly and so that first layer stays dry. You can deliver continuous negative pressure for seven days. Based on what we talked about being a D compressive dressing. You can decrease the tension at your wound surface. You can remove fluid and in a way and almost as important, you're allowed to keep this on for seven days without it being disturbed. So key differences. Some of this? Yes, his opinion right. But I think that that layer is definitely a game changer. Also, it's a lot easier to put on right. This is appeal and place dressing, Um, and so one of the thoughts that we've had over the years is if it's so good for a wound that's closed, what about using it on skin that doesn't have an incision at all? Can we use the same type of dressing on just native skin or skin that in our world has been traumatized, so getting to a quick case example here, you can see this is a proximal tibia injury, and some of those wounds are traumatic. Some of them are surgical. Uh, but this is a bad day for the patient. This does not look like a great day in the O. R either. And so you can see just supplying regular dressings here. Bring some concerns, right? You have areas of skin injury, they're not part of the actual of the lacerations or the wounds. You have a traumatic wound that there's a good chance may leak a little bit. And when we add something to this to help prevent complications. So this is a case from a number of years ago. Luckily, I have residents and I had a resident stick around and take the time to place a customizable Praveen addressing across this. And you can see how this takes a little bit of time to get into all the right places and to apply the therapy where we're worried about it. But it is very functional, and it works very well. Here's another example. From just a couple months ago, another bad day at the office and another bad day for a patient. Here's a distal tibia fracture, and you can see a combination of some traumatic lacerations as well as some surgical wounds. But you can also see that the surrounding tissue is also traumatized, right? It's not just where there's incisions. This entire circumferential lower extremity has it sustained trauma. So what can we do for this? And here we can introduce the latest in new shapes and the Praveen a product line. So this is Praveen to restore access to form. It's form fitting. It's designed to fit around the foot and ankle. But you know, we've noticed that you can use it in other areas as well. It increases surface area. Why is that important? Well, it's very important that you control all the incisions, but with the increased surface area, you can actually apply this therapy to more than just the incisions. You can apply to the traumatized tissue that surrounds the incisions and still get the benefit of decompressing those areas, improving lymphatic flow, improving blood flow that will hopefully help mitigate the swelling and the issues caused with the swelling. And you get to retain the ease of the ease of application right. We can do this with a customizable dressing, but this is another appeal in place dressing that is a lot easier to put on. So back to the case, the more later case here, the images again to remind you. And here is this dressing in place, right so you can see how it fits very nicely. There's not any areas of bunching. It fits this area of the body quite well. It sucks down nicely, and you can see how we've been able to get all the incisions and one peel in place dressing, as well as addressed some of the surrounding soft tissue damage. So some of the tips for applying this one clip the hair. We want to have clean, dry skin. When we say position the extremities really position the joint in a neutral position, so position the ankle. Position the foot in a neutral planet. Great position. I usually start on one edge. I start on the area I'm most concerned about, so I get maximum coverage there and then I work around. There are some patch plastic stick strips where you can use if there is some concern for bunching. If the patient's size or where the decisions are varying. So next I believe we're going to have a quick clip of one of them being applied. So we'll get to that next. Here we go. And so you can see here. What we've done is we've drawn a number of incisions along the foot and ankle, and some of these can be surgical. Some of these can be perky, Titanius. Some might be traumatic as well. Obviously the video is sped up, so we don't have to watch everything in real time. Um, and now you can see the ease of placing lights. You start to determine where you think you need to place it first, and then it's really just about taking all the tape off, and sealing it down later in this presentation will show an example of what you do. If there's some bunching and how you can use some of the patch strip tapes to mitigate those issues, um, it is helpful to have two people to apply this. As you can see, there's two sets of hands working there, Um, just so that you can work on both sides and try to make sure things are getting stuck down. As you can imagine, the areas of potentially tend to be right there. Um, and the door, some of the ankle and foot. And so just a little pressure There can help get that seal down there. You can see when it's fully done. All right? Is that is that video ends I'm going to hand off to my co presenter, Dr Chris, who's gonna go through some case examples. All right. Can everybody hear me? Okay, probably. Can you give me a thumbs up if you can hear me? All right. So we're going to go over a few foot ankle cases here, and there'll be some videos for the CT scan, so hopefully those will come across. So case one is 43 year old who fell 12 ft off of a ladder. Who's a smoker. And this patient was, um, x six, an outside facility and referred for definitive management. So here's, uh, see, if this CT scan will go, it doesn't look like at least I can tell that it's going through the CT scan. There we go. Okay, So these are the actual cuts, so you can see primarily interior and an trilateral involvement. And then he also has Cal Kenya's fracture that you can see there. And then these are some other reconstruction, uh, to the reconstructions, and we'll see those in videos here in a second. Here's the first one, I believe, the satchel reconstructions view that you can see and then this next one will be the criminal. And I know it may go kind of fast, but should be able to get the idea that there's definitely articular involvement of the Cal Kenya, um, and primarily and your involvement of the pylon. So just with that information from the CT scans either are the thoughts that I had for the pylon fractures. So intermodal approach with the medial plate and trilateral approach with an anterior lateral plates, uh, and remedial approach with two plates. An an trilateral approach with an trilateral plate and the rim plate. Because there is interior compaction and combination that you can see there and then basically three places the fifth option, including a rim plate and an intra lateral and medial plate. And then the last option that I thought of was the anti lateral plate template and then a screw going through the medium loyalists into the metaphysical region. And so that's what I had planned on doing so. These are the pictures on the day of surgery. He's been in its external 62 or three weeks, and I got transferred up day before surgery and he had a lot of you can see hemorrhagic fracture blisters that had re epithelial is, and so he spent a bit of time kind of cleaning it up before proceeding with surgery. And these are just some intra operative floral views showing the initial articular disc compaction interior early and maintaining the Mata Feel or Die official segment to the poster molecular component with K wires and then getting that interior impacted segment down and placing Allah graft bone there to help kind of filling that void and then provisional wire fixation, as you can see there and then placing like I mentioned a separate interior rim plates. And that's just because the primary implant, which is an anti lateral plate, really wasn't going to provide enough support for the articular surface, which is going to take a while to heal. You know, I was worried that it would kind of re displays back into that impacted area that was filled with bone with the L A graft. And so that's what it looked like at the end of the procedure with the screw for that medium molecular component that really wasn't displayed. So he didn't have very much media column involvement. And that's the lateral view there. And then did Al Gore Donati on a vertical mattress futures foreclosure and just measuring the length of the incision. As you can see there with a ruler and then use the actual form dressing that covered, I wanted to also kind of prepare his Cal Kennel area, where I was planning the incision or surgical management for that. And so I wanted a larger dressing that would help protect that rather than if you've used Trevena before or any kind of negative pressure device at the on the skin at the edge of the sponge, you're going to see a change in kind of a demon control, and so you're going to get increased the DM at the edge of the sponge, and so that's why I wanted to kind of protect that area. And so the indication for this patient was it's high energy injury you had to. High risk injury is not just yuan fracture, but also can, in particular Cal Kenya's fracture and, UH, three a three a. B uh Sanders. And then I was planning on stage management, and he was a smoker as well. So that's what it looked like after the dressing was compressed with negative pressure. So inter lateral and medial aspects of the patient's slim and then he actually stayed in the hospital for seven days because he's from about five or six hours away. But ankle looked like when the patina came down. Actually, form dressing came down on Day seven. You can see that anti lateral incision. There was actually areas that looked like that. It's already we have to feel. So I was pretty impressed with that. And then you can see that where the edge of the dressing was in the forefoot area, and you can see that on every time I've used the Praveen on a traumatic situation, you can see that edge area where there's a demon kind of D markets. And so I thought his Calacanis is ready for surgery, and so the video will play for the criminal reconstructions that show is Cal. Kenya's here in a second, but these are the different approaches that I've got to go about it. A lateral approach with a locking place, which now he's four weeks out from his injury. The alternative would be a sign of starts to approach with a locking plate, per cutaneous fixation with external fixer assisted reduction and screw fixation. Extents are lateral approach with bone graft. And then, uh, you know, try to elevate the articular surface and maintain it with obviously implants and then extends a lateral with acute sub Taylor fusion. Yeah, and so the video will play here in a second. So I will go through the reconstruction CT. You can see the involvement of the post here for set. And this was obviously pre fixation of the pylon. And so this is what I thought I wanted to do. I thought because he was now four weeks out, it would be pretty challenging to do. And I think it might just replay that video again. Sorry. Yeah, yeah. Give you another chance to see it. So, basically throughout the landmarks, including the central nerve, and that you can see an extra pinsight was right in the middle of this flap, which made me a little anxious as well. That's why. Also, why I wanted to use the actually form. And so these are inter operative photos. Shit, This is on the right, showing the articular depression and floral views there. You can see that as opposed to fit. That was pretty impacted. He's very short. So by the time I got his articular facet are opposed to your cassette back where it needed to be, he had a large defect. And usually I don't bone graft the defects because of the the idea about the triangle, uh, that perpetuated about not needing necessarily bone grafting. But this was too much of a void to me to leave alone. And so, basically, this is what the clinical photo looks like with the butcher first set reduced. And then I placed back the lateral wall to make sure I wasn't off as far as hell hype or lengthened. So that fit in nicely. And then these are actual views here on the left and the right of the lateral view of the plate in place. And then that's I think I used 60 ccs of Allah graph to settle in that defect. And then that's what it looked like at the end compared to his opposite foot. And this is what it looked like with again Al Gore tonight featuring. And that's how I looked at the end, and then I did another actually formed dressing. You can see here because again, he's a smoker. He had recent Fillon surgery, and so he had a high risk of potential wound breakdown and a delayed surgery. So this is when his futures are ready to get taken out two weeks later, after or after this call. Kenya, I thought you can tell the demarcation of where the swelling was as well, when the actual form was removed. So in summary. For that case, high energy injuries were actually for addressing smokers stage management. I felt like it helped me decrease the amount of time that I needed between surgeries. I felt like in this case it did help wound healing and definitely decreased swelling. As you can see in the photo. This was between the two surgeries, so we'll move on to case two, and then, uh, this is another P line fracture. 39 year old female with Renault syndrome and a recent urinary tract infection who fell off the ladder in our house while getting into her attic. And she presents about two weeks after her injury. Uh, this is the C T scan. No play here in a second, so there's a decent amount of articular combination, and this is the coronal reconstruction. Mhm. Yeah, yeah, yeah. And then the satchel reconstruction. Mm, yeah. So there's not a lot of impact in just a lot of different areas of articular involvement. And so the thoughts that were going through my mind would be and remedial approach at the medial plate and trilateral approach with an trilateral plate direct anterior approach with an trilateral plate and an anterior lateral approach with two plates. So I chose I felt like her media column involvement was also pretty straight forward and simple. There wasn't a lot of combination and her skin just with right now, and it looked like she may have been potentially amorous A, um uh huh. Basically carrier just what she had different skin lesion. So I wanted to minimize the number of incisions, if possible. So she underwent kind of kind of normal fashion, getting the reduction sequence, getting the poster meticulous to the metadata facil region and then reducing the medial and anterior lateral components back to that. And I promise you, the screw is not in the joint. I looked after the joint visually, and that's what she looked like at the end of surgery. The indication for actually form dressing was that she was a smoker, had renowned syndrome and then I just didn't like kind of how her overall skin appearance looked up. She wasn't obese or anything like that, or diabetic. I thought she was at a high risk for wound breakdown. And so this is the dressing going on and you can see here it covers the majority of her ankle. I thought it really protected the entire air pretty much the zone of injury for her, which appreciated. So these are her splinted X rays, post operatively. This is that two weeks and you can see the arrows emphasizing that area of demarcation where the edge of the sponges and so having a wider dressing like this move that demarcation out of the zone of injury, at least for the surgical incision. And so I think that that's definitely an improvement. There she she's at at three weeks, six weeks. She did have a little bit of breakdown. Dis leave, but it was superficial. And that's going on to heal as well. And she just actually saw her yesterday. And she's weight bearing is tolerated. Um, this is her at 10 weeks, and she's got even better ankle range of motion now. Um, and she's still using crutches. Um, two crutches. Mhm. So for that one again, the reason for using the actual form dressing was type of injury. That's the high risk injury right now has disease. Uh, and then smoker and it definitely I felt decreased swelling. As you can see, that clinical photo. And I thought in this high risk patient, um, improved her wound healing potential. So if that we'll switch back to other application techniques by rowdy. All right, thank you. So we'll just have a couple of slides here, another video, and then we'll lead into question and answer. So what about other places? Other techniques to the unique shape lends itself to other locations. Not just the foot and ankle encourage people to be creative. They promise more shapes and sizes to come. Um, you know, those that are familiar? This was the first in the new shapes for orthopedics. Restore art reform was designed for the knee. This is really designed for total knee replacement, and we've had some of my partners use it. Um, when I first saw it, we decided to use it for approximate tibial plateau in a duel incision, and so just turning it 90 degrees. And it fit both of those decisions and got good surface area as well. Um, here it is. Worked. This is the Arthur form worked around a a multi plant or external fixation device. And next we will show a video of it being applied on the posterior surface of the ankle. And so you can look at this as a potential Achilles, or, you know, maybe a poster approach to the Lafont. But again, here we are drawing a number of different incisions, Um, where they could potentially be and again, same peel in place where we start here. We start on the lateral aspects, and you can see here is an area where you could theoretically have some concern with bunching. But just taking your time with, you know, applying this, uh, making sure you get this down. Um, you know, the the areas that are supposed to stick and seal down to the skin surface. And if there's any issues, they actually have the extra take pieces to apply and to prevent any issues with that bunching. Now, here it is being sealed, and you can see how there's some extra stuff being added there very quickly, and now you can see how it is applied. And one thing to really notice is you can see how the model that's wearing this, how they're able to move around very well. They're able to move their foot and ankle fairly easily. Uh, they're able to kind of keep keep their range of motion up despite having this dressing. Alright. So conclusions. I'd say accident form is a significantly improved dressing shape, multiple uses around the foot and ankle as well as others. Um, it's nice to say that you can apply one peel in place dressing to multiple incisions instead of having to choose the one you're most worried about, but also an equally if not more importantly, you can get more soft tissue coverage uh, to, uh, cover traumatized tissue that you know is damaged. And, you know, this therapy can give some benefit to, um we have allowed. We've noticed that when you improve the swelling, you're gonna have improved wound healing, decreased pain, faster soft tissues, healing and less complications. Um, and my last statement, sometimes even away from Texas, bigger is better. And with that, I believe we're gonna go into question and answer. Mhm. Yep. So there are. There is one question and the question answer. We'll tackle this one. I'll let you answer. Um, So the question about the Trevena is that it's the one time use base. Um, do you change the dressing portion, the suction type between during that seven days or what the actual form would be for two weeks Because of the concern that you're not looking at the incision, could there be an infection developing underneath? Um, so how do you decide when to peek out the wound, or when do you usually change it? Sure. And so, uh, to be clear, you know, these are designed for seven day dressing applications, and, you know, I think that you know, the days of checking wounds routinely on post op Day two and then checking them every 1 to 2 days after that. I think we should, in my opinion, do away with that I think were causing more harm. When we're worried about an infection, there's a lot of other things that you can look at. How is the patient feeling? It's a pain increased. Are there any indices, whether it's vital signs or laboratory studies that are going up? And remember, it's not a circumferential dressing, so you still can look at the tissue around it where there isn't therapy and you can see Is there ara Thema? Is there increased swelling that's not being taken care of by the dressing? So I think there's other ways to really look at this dress. Look at the wound. If there's concerns and, yes, you can just take it off. But I believe that the importance of leaning on for seven days, the vast majority of the time is going to give you more benefit than concerns about not looking at it. So I'll take the next question, um, from Dr Jeff Smith, any pearls or cautions with use and trauma. I think some of that we discussed the other. You know, infections are real, Uh, when complications are real. And I think that when you apply this dressing when I apply it, I'm I'm getting ready to to not look at this for seven days. I'm getting ready to put this on and say I'm comfortable not taking this down in seven days if something changes it. Great. Um, if this is a wound that you really want to look at in that time frame, maybe wait until you're comfortable with that seven day period because, um, it really does help. The therapy is continuous over that seven days, and you're going to see the benefit if you leave it on for that time. Um, next is a question. Has this been used in conjunction with a dick loving injury? And I'd say absolutely it has. Um, you know, degloving injuries maybe aren't as common around the financial, but we've used them up in the thigh and around the pelvis. And I think where they help is something I talked about earlier in terms of the basic science in, you know, when you're trying to clear fluid in a dead space, having those channels open really does make a difference. And so allowing that vacuum effect to allow for some improved clearance of fluid from a dead space can be helpful where you're going to struggle. As if that if the skin above that dead space of that degloving injury is dead, of course, this is not a miracle worker. It's not going to revive that skin if it's already dead. And so I think that's something that needs to be looked at. Uh, when you're applying it, Okay, next question is privy to How helpful is it for wounded citizens or, if an implant is exposed, any effect on graduation? So I think remember that this is a different dressing than the black sponge Direct. The black sponge dressing is really designed for the wound, not epithelial tissue, right? And so the black sponge is what we really think is going to help with graduation tissue. Um, I would not recommend putting Trevena if there is exposed implant. I think in that regard likely we need to go back to surgery, make sure we have control of our wound. Make sure that there's adequate soft tissue there that can heal over whether it's a flap. Something of that degree, um, wounded in essence is a little bit of a mixed bag, right? There's wounded. His since that are just wounds that are draining a little bit with minimal opening. I think Trevena can help, and we've used that in that regard. But if you have a faulty Hisense and you're looking at the majority of that wound showing tissue below the feeling layer, I think in that regard, oftentimes you need to go back to the O. R. To get control of the wound again, maybe even some time. Traditional black sponge back prior to going to Praveen Praveen is really more beneficial for a fully closed wound. I definitely think I would avoid, uh, using this as a way to granulated tissue over implants. I think if you have implants exposed like Robbie was saying, you need to, uh, kind of come up with a different plan as far as addressing soft tissue coverage. That's where I'd get partners involved and do soft tissue transfer or if the implants can come out and that's another option. But I think this I don't believe this is meant to be a substitute for just standard. You have tissue coverage procedures, Robbie, do you just some kind of general questions? Do you think that you're privy to use has primarily switched to act your form? Are you still using the seven day pump consistently Like what helps you decide? So for me, if I can If I feel like I'm in an area where I don't feel like I'm wasting actually for me, if I just have one incision, I do have a hard time switching to actually form. But if I have multiple incisions or really traumatized soft tissue envelope or I think I can fit actually form or Arthur form there, I'm gonna use that, um, for a number of reasons, I think the more surface area which I've talked about a lot today, is a big deal. Second, having the 14 day pump does make it easier with in terms of follow up. Um, it's one thing if the patients are staying in house, it's not so hard. But if they're being discharged, having those extra days does make it easier with clinic follow up, especially given our current covid situation that has made it easier to diminish the times. We need to see our patients and follow up. And so, as often as I can, I'll use tax reform. Uh, one other question came in, um, so with Trevena use or actually form use, um, in other areas like the example that was brought up is that he's bringing up as a hip replacement. Are you able to avoid using external drains because you're using in visual negative pressure wound therapy? Sure. So I've never been a big user of external drains. I've never liked them. Um, but I think that what the question is, can we decrease wound drainage of used Trevena? And part of it sounds counterintuitive, right? If you're sucking on, if you're providing suction to the wound, are you going to create more drainage? Well, when you really talk to the engineers and they talk about this decompress effect, yes, the canister is there for excess fluid. But if everything is working well and we've done a good closure, we don't really want to see drainage in the canister, right? We want to be able to say we're bringing the tissue up to the dressing that creates a vacuum effect below that allows the fluid to flow via the lymphatic or the circulatory system out, and so that should help decrease any fluid that comes up to the surface. And so I would say to answer a question. I do believe when used Trevena, you end up getting less drainage outside out of the wound, you just get better flow. Uh, I don't like using drains. If I did, I think Trevena could help, uh, decrease the need for them in certain situations. Yeah, there's actually been a small case series published with Trevena use on total hip incisions, where the aroma was much smaller in patients that had negative pressure. One therapy. And because it's something related to the like, you said, as far as the opening, the flow for the lymphatic. But it's not just the width of the dressing is the height of the dressing, which is important, so thin dressing doesn't really cut it. It's part of it. Is that hike part, and so that kind of, um tags into one of the questions that I was going to ask you, because people not necessarily for traumatic foot and ankle ruins. But we'll use um, like Derma Bond or other commercial dressings like Borneo that incorporate Derma Bond. Do you feel like those types of closure devices with additional negative wound therapy is overkill, Or do you feel like that's additive? What's your thought about that? Um, so in full disclosure, I've never been a big user of it. But, you know, a lot of folks will say, If you seal the wound, what's the purpose of having this dressing? And I think it's not overkill because you're still getting the other effects, right? You're still getting the wound being brought up to the dressing. You're still normalizing tension forces. You're still, um, creating the decompression effect that we've talked a lot about. So I don't think it's overkill because you still get all the benefits of the ravine addressing from the engineering, even if you're unlikely to get as much leakage if you use, you know, a type of skin blue that you mentioned. Yeah, and so I actually do a lot of inter total hits, and I still use it even in patients that are high risk. Even if I use, we're feeling device like a like a term of entrepreneurial because of the effects that you mentioned one of the things that is going to ask you based on your volunteers, for your placement videos. What did they I don't remember if you said, but how did they say it felt when it was? Uh so you know, and I mentioned most of them like you can see how they can move everything. There's not as much of a feeling as you'd expect. You know, most people think, like, Do you feel like your skin is being sucked up? They don't really describe that. They don't really describe pinching. Um, it almost in a way, feels back to what I said before, Like a compress and dressing like a compressive sleeve or something is what they would describe. Um, is what it feels like, which we know isn't quite what it is, but it's none of them described it as being painful or itchy or anything like that. So I wouldn't say there were any negative any negative feedback for those folks that added on it seemed like they were really like you mentioned, really able to move around their ankle quite easily. Uh, what are your Sorry? Go ahead. No, I said yeah, that You know the range of motion with it is pretty impressive. They've actually spent a lot of time with the design of it to allow for joints, whether it's a knee and ankle so far to keep moving in their natural range of motion. Yeah, maybe there aren't any other questions in the Q and A, but I'll ask you kind of a final question. As far as like your thoughts about other negative pressure devices that are meant for decisions, Um, whether it's a thinner dressing or, you know, a different type of pump like what? What do you feel is the big difference for the Trevena kind of line versus those products in your mind? Sure, you know, there are a couple of other that are on the market, and when you first look at them, they actually look a little easier. Uh, they're smaller dressings. Brett. You mentioned the thickness of the dressing and how that's important. A lot of them are very thin. A lot of times the motor is very small, and I, in my true opinion, is if you're just looking for an isolation dressing like all you're looking to do is to put something on that's gonna last say seven days. Whatever. I think there's other ones are just fine. I think the difference with Trevena is given the thickness of the dressing. Given the power of the pump, you start getting the increased benefits. It's not just about isolation. It's not just about being able to control what flows out of the wound, and it ends up being more about decompressing effect that we spend a lot of time talking about it. I think the only dressing that involves negative pressure on the market that does that and has proven that is Praveen. Great. Thank you. Thank you both So much. On behalf of three m. I'd really like to thank Dr Chris and Dr Correa for sharing your expertise and your insights with us today. And I would also like to thank you to our center. Thank you. Our attendees for being part of this program. If you have further questions, please email them to medical education. Webinars at mm mm dot com And we will be sure to get your questions answered. So thank you again, doctors and thank you, everyone for your time today. And I hope you all have a great weekend. Thank you. Thank you.