04/21/2025    Perry K. Geistle,r DPM

Acellular Grafts

I have been in practice for 33 years. I do work in
my private office as well as call at our hospital
and see patients in our hospital wound care
center. I went over my statistics for last year
and I averaged seeing 32 ulcers a week for 48
weeks, not individual patients but ulcers. I have
found it the gross exception to have to use a
graft to heal anything. I certainly use grafts but
when I went over my numbers, I used a graft on
4.8% of my patients last year.

Most people who have ulcers are going to heal with
using the basic paradigms. Such as, offloading,
establishing circulation, taking care of systemic
illnesses or contributing morbidities, surgically
removing exostosis etc....

From what I have seen the reliance on graft
materials has made providers very lazy in basic
care at the very least. To say that greed is
present would be an understatement. Not caring
about what is actually good medical care for the
patient, and being more concerned about drumming
up charges looks to be a prime motivator.

As a small example, I see someone who has had an
ulcer underneath their 4th metatarsal head. They
are diabetic and have had this area for a year.
They have been to multiple practitioners. They
have had the full array of graft material and
wound care supplies. However, they are stunned
when we discussed pressure, non-weight bearing,
and re positioning or removal of bone to heal
them. This man simply needed a metatarsal
osteotomy as he had ample blood supply. He was
healed in 3 weeks.

I see people with end stage kidney disease in the
last year of their life. They have no circulation,
they are in obvious decline, they have buttocks
ulcers. However, they see providers on a weekly
basis to get their grafts and in my opinion, have
been given very false hope for healing that will
never occur because of their circumstances. Again,
they have had the full gamut of grafts and
hyperbaric. What they really need, and are
relieved to hear, is that we are going to start
palliative care, and they do not have to proceed
with efforts that will not add one iota to the
quality of their life.

These are small examples of several hundred I
could share throughout the years.

I think grafts have been one of the worst things
thrown into our profession to treat people yet one
of the best when used appropriately.
As a podiatrist and a taxpayer, the non-ethical
use of these products has led to millions of
dollars wasted. I would support a large crackdown
on these practices.

I am anxious to hear opinions.

Perry K. Geistler, DPM, St. Louis MO

Other messages in this thread:

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04/23/2025    llen M. Jacobs, DPM

Acellular Grafts (Perry K. Geistler, DPM)

The increasing cost of wound care, including the
employment of skin graft substitutes, is not a
podiatry centric problem. Many factors, such as an
ageing population, the rise in disorders with
which wounds are associated (eg: diabetes, PAD,
venous disease) have continued to drive the need
for wound care. The failure of insurers to provide
reasonable or in fact any payment for preventive
care is a factor. Socioeconomic issues such as
patient access, patient education, patient
financial concerns are factors.

The expense associated with dressings, skin graft
substitutes, de-facto referral of patient
referrals to wound care centers, contribute to the
problem. With specific reference to skin graft
substitutes, Dr. Geistler notes in PM News that in
his experience, skin graft substitutes are not
required for the management of most wounds. There
are over 350 "skin graft substitutes" available
world-wide. Many are extraordinarily expensive,
with little if any good literature support for
use. When we speak of abuse, we must recall that
such abuse may not be intentional and ill-
motivated, but may be the result of a clinician
truly believing that these products would be of
benefit to the patient with a recalcitrant or
difficult to heal wound.

The potential to abuse such products is no
different than the potential to abuse any
diagnostic or therapeutic modality such as
hyperbaric oxygen, bunionectomy, orthotics, or
corticosteroid injections. Ultimately, individual
clinician ethics and prioritizing what is
appropriate and needed for patient care is the
priority in all circumstances.

Wound care is big business. Like most aspects of
medicine, corporate influence in wound care has
infiltrated our profession. The strength of
evidence supporting many of these products is weak
at best. It is the responsibility of those who
choose such products to be familiar with the
studies and the legitimacy of such studies
justifying the use of such products, not just the
"reimbursement per unit" of such products. If we
fail to do so, external regulatory forces will
determine when and how you may manage each patient
with a wound under your care. AI cannot provide
the art of medicine. However, if profit trumps
patient needs in the selection of wound care
therapy, AI will determine the manner n which you
treat wounds.

Personally, I believe Dr. Geistler is correct in
his conclusions. The basics of wound care remain
stable to this day: debridement when indicated,
off-loading and pressure reduction which may be
non-surgical or surgical, control of infection
and/or bioburden, assurance of arterial perfusion,
control of edema, control of venous and lymphatic
disease if possible, management of comorbid
disorders such as diabetes, thyroid disease,
nutrition deficits, moisture balance, patient
education. As Dr. Geistler noted, there is a
subset of wounds which may never heal. There is a
subset which may require advanced wound care
products. There is a major subset that will
improve or heal with basic wound care and patient
compliance. The potential for the abuse of
advanced wound care products for profit is no
different than the potential for abuse for profit
for anything we do.

With reference to diabetic foot wounds, I would
suggest the readers examine the most recent
evaluation of advanced wound care products,
available on line at no charge, published by the
International Working Group on the Diabetic Foot.

Allen M. Jacobs, DPM, St. Louis, MO

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04/22/2025    James Koon, DPM

Acellular Grafts (Perry K. Geistler, DPM)

I too am a seasoned provider and all too often
encounter some of the issues Dr. Geistler
mentions. I attribute failed care for foot ulcers
primarily to non-compliance from the patient,
improper/insufficient offloading, vascular and
then metabolic problems. I’m not aware of many in
my area that use these grafts much but we all have
patients that might benefit from them. The current
LCD should clean up some of the problems. It is
quite clear on the matter and defines the
indication and use rules distinctly. It is
evident that CMS felt it necessary to implement.

Every practitioner practices differently.Not
everyone was trained the same way. For instance,
the quality of a residency can be a significant
influence. If you are in a surgically focused
program, you learn to solve problems with an
arsenal of procedures you have seen work and why.
But if you’ve never seen or done them, then you
are at an unbeknownst disadvantage because you may
not know a surgical procedure could be curative.

Perhaps a practitioner who has a heavy reliance on
these grafts thinks that’s the most important
thing they can do because they aren’t experienced
with osteotomies, GS recessions, tenosuspensions,
fusions, etc.

If your training lacked exposure to a multi-
disciplinary environment you may not know how, who
or where to direct patients appropriately or
timely enough. If you don’t know what these
specialists do then you don’t know what they can
do to help you and your patient.

Most doctors I know are trying to do what they
think is best for their patients. Assuredly there
are some who find financial gain as a motivator.
I can’t do anything about that but my experience
has shown they are the ones who somehow always
seem to have problems. I’ll let the Lord judge
them. That is, after Medicare does.

James Koon, DPM, Winter Haven, FL