APMA News - March/April 2020 - 24

SPECIAL WOUND CARE SECTION

Collaborative Care at the Heart of Baylor's Limb Preservation Powerhouse
Jeffrey Ross, DPM, MD, is Associate Professor of Surgery, Division of Vascular Surgery and
Endovascular Therapy, at Baylor College of
Medicine. Over the course of his nearly 40-yearlong career, he has worked with some of the
healthiest patients in the world (professional,
college, high school, and marathon athletes at
the peak of their careers) and some of the highest-risk patients (those with diabetes and multiple comorbidities).
Along with Joseph Mills, MD, chief of Vascular Surgery at Baylor,
Dr. Ross helped to launch an innovative, multidisciplinary limb preservation center, the Save the Extremity Program (STEP) at Baylor
that has become a model for multidisciplinary collaboration in
wound care.
APMA News talked to Dr. Ross to learn more about his approach to wound care and the value of the "toe-and-flow" model.
APMA News: Tell us about how you became involved in wound care.
Dr. Ross: I started in private podiatry practice in 1981, and my focus was always surgery and sports medicine. I was the president of
the American Academy of Podiatric Sports Medicine, and I worked
with my local sports teams and marathon runners in Houston.
But I was treating diabetics in addition to athletes and thought,
we really need to take better care of these people. This was around
the time that Dr. [Larry] Harkless [DPM] and his disciples were
proselytizing converts to the idea of limb salvage. People like
David Armstrong [DPM, MD, PhD], John Steinberg [DPM], Peter
Blume [DPM], Lawrence Lavery [DPM], Javier LaFontaine
[DPM], and others around the country were starting limb preservation programs.
I had been working with KCI using GRAFTJACKET [a regenerative tissue matrix] for ankle and tendon repairs in sports medicine, and when that product went to the wound care world, it kindled an interest for me, as well. I approached the administration at
Baylor College of Medicine to advocate for a limb preservation program. It didn't happen overnight. It took years, but eventually
Joseph Mills, MD, became chief of Vascular Surgery at Baylor. He
had worked with Dr. Armstrong in the past, and he and I started
working closely together and getting to know each other. Before I
knew it, I had left private practice and joined the Baylor faculty fulltime, and Dr. Mills and I started STEP. I should acknowledge Dr.
Armstrong, because I don't think I'd be doing this today if he and
Dr. Mills and I hadn't connected.
The vascular team-Joseph Mills, MD; Jayer Chung, MD; Miguel Montero, MD; Zachary Pallister, MD-and podiatry team-
including Brian Lepow, DPM, and me-are working in concert to
save limbs. It's an incredible, multidisciplinary team effort. We call
each other Flow [vascular] and Toe [podiatry], and we are proud of
the work we do and the accomplishments we achieve. As Dr. Montero says, we work hard and laugh hard.
APMA News: What do you perceive as the most exciting developments in the field of wound care? Technologies? Products? Techniques?
Dr. Ross: We have indocyanine green angiography (SPY) and
handheld Kent Snapshot imaging to assess perfusion, tissue oxygenation, and hemoglobin to wounds and surrounding tissues.
24 APMA News March/April 2020

We're able to measure perfusion to the foot and oxygenation and
hemoglobin in areas of a wound to determine whether a wound will
heal or whether we'll need our vascular surgery team to intervene.
We have a head-to-head study1 on acellular dermal matrices comparing DermaCELL to Integra®. Then we can place a skin substitute or a split thickness skin graft on the wound when it has reached
a specific stage of healing. Of course, there are also biologicals such
as amniotic stem cells, hydrolyzed collagen, and platelet-rich plasma. There are so many new toys.
In addition, we have new methods of standardized communication. The Society for Vascular Surgery released the WIfI classification system (Wounds, Ischemia, and foot Infection), which
has since been endorsed by the APMA Board of Trustees. It's a
system for analyzing lower-extremity wound care outcomes that
allows every member of the wound care team to speak the same
language-whether podiatrists, vascular specialists, orthopedic
surgeons, or plastic surgeons. WIfI is a repeatable and standardized stratification system, allowing any physician, whether in the
same hospital or on the other side of the world, to use the same
terminology to understand and document a patient's wound,
level of perfusion, and level of infection. It improves continuity
of care and, ultimately, patient outcomes.
APMA News: What is on the horizon? What makes you excited
about the future of wound care?
Dr. Ross: We're doing research on biofilm and how to degrade it
so we have healthier wounds. There are new amniotic stem cell
products that come in patch, injection, or gel to speed up healing.
Now the vascular surgeons are performing interventions, retrograde through the trifurcation of vessels in the foot, that they
didn't do even 10 or 15 years ago. They're opening vessels when
20 years ago it was bypass surgery and antigrade angioplasty, and
if those were unsuccessful, patients faced below-knee or aboveknee amputations.
I'm looking at the future, and one question I ask medical students is, where do you see yourself 50 years from now? Forty years
ago, we didn't have wound vacs or skin substitutes; we had topical antibiotics. Think about how far we've come in 40 years!
APMA News: Has anything changed about the patients in the years
you have been practicing wound care?
Dr. Ross: We have so many patients now who suffer from obesity
and because of lack of exercise and diet control, they develop diabetes at a much earlier age. They have multiple comorbidities, which
put them more at risk and can also lead to chronic limb-threatening
ischemia, so this is a challenge for us.
In addition to the work in limb preservation, we as physicians
have a role in trying to teach and educate the kids about what
they're facing-how many are going to be diabetic or on dialysis,
how many will no longer be able to work? It's why I co-chaired the
Texas Governor's Council on Physical Fitness.
That's one of the challenges we face, as a profession. We can do
something about that. Students today need a strong background
in medicine, because we're going to have an increased number of
patients with diabetes mellitus, PAD, end-stage renal disease, and
heart disease. You really need to know your medicine.
continued on page 26

1 https://clinicaltrials.gov/ct2/show/NCT03476876

https://www.clinicaltrials.gov/ct2/show/NCT03476876

APMA News - March/April 2020

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