Poster session 17: Wound healing

Poster session 17: Wound healing
P17.01
Use of argon beam coagulator for the surgical debridement of lower leg wounds in the
anticoagulated patient
Tiffany Hoh, MedStar Washington Hospital Center, Arlington, VA, United States
Caitlin Garwood, MedStar Georgetown University Hospital, Washington, DC, United States
Christopher Attinger, MedStar Georgetown University Hospital, Washington, DC, United
States
John Steinberg, MedStar Georgetown University Hospital, Washington, DC, United States
Aim: The etiology of lower leg wounds can be due to venous insufficiency, lymphedema,
malignancies, infections, or of other mixed etiologies. When conservative wound care
therapies are not adequate in the treatment of these wounds, surgical debridement is
considered to decrease the bioburden and fibrous or hypergranular tissue accumulated. The
argon beam coagulator allows a steady flow of ionized argon gas to generate a thermal
coagulation on target tissues. We describe the technique of utilizing an argon beam
coagulator for the surgical debridement of lower leg wounds in the anticoagulated patient.
Methods: Patients with shallow lower leg wounds must often be taken for surgical
debridement without stopping anticoagulation therapy. An argon beam coagulator is set with
the lowest settings, an output power at 40 W and automatic gas flow. The probe is held 1 cm
from the wound surface and moved quickly back and forth across the entire wound bed. The
resultant wound bed appears as a charred, dry eschar within a few seconds of applying the
argon beam coagulator. The wounds are covered with a nonadherant dressing with or
without application of a xenograft and the lower legs are wrapped with a multilayer
compression dressing.
Results: Upon removal of surgical dressings, the debrided lower leg wounds have a
granular wound base with minimal drainage through dressings. Use of this tool coagulates
the superficial wound bed producing an eschar to eliminate the fibrous tissue and promote
wound healing.
Conclusions: The argon beam coagulator should be considered in the surgical debridement
of lower extremity wounds in the anticoagulated patient. This technique can decrease blood
loss and the risk of postoperative bleeding while reducing the risk of deeper tissue damage
from traditional bovie coagulation techniques., It is a valuable tool that can be used for
surgical debridement of lower leg wounds that are not responding to conservative wound
care therapy alone.
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Page 1 of 11
P17.02
Preliminary case series results evaluating Ultrasonic Assisted Wound debridement
for treatment of complicated diabetic foot ulcers (DFU)
José Luis Lázaro-Martínez, Complutense University of Madrid, Madrid, Spain
Yolanda García-Álvarez, Complutense University of Madrid, Madrid, Spain
Javier Aragón-Sánchez, La Paloma Hospital, Las Palmas de Gran Canaria, Spain
Esther García-Morales, Complutense University of Madrid, Madrid, Spain
Raúl Molinés-Barroso, Complutense University of Madrid, Madrid, Spain
Francisco Javier Álvaro-Afonso, Complutense University of Madrid, Madrid, Spain
Background: Diabetic foot infections are common complications in patients with DFU. Even
in absence of clinical signs of infection bacterial load have a deleterious influence in wound
healing.
Regular wound debridement has been proposed as part of a multifaceted treatment strategy
in biofilm-based wound care (BBWC). Clinical experiences with a low frequency ultrasonic
wound debridement device (UAW) have proven to provide effective and safe wound
debridement without damaging the surrounding healthy tissue.
Aim: To evaluate the outcomes of wound debridement with UAW used in combination with
a, super-oxidized antiseptic solution in a clinical case series with, complicated DFU.
Methods: Five patients diagnosed infected DFU were recruited at Diabetic Foot Unit of
Complutense University of Madrid between October and November 2014. Debridement of
DFU with UAW used in combination with a super-oxidized antiseptic solution was performed
at least once a week in the operating room. Wound area, wound bed characteristics and
microbiological data from wound cultures were analysed before treatment and at weekly
basis during a 5 weeks.
Results:, Four males and one female with average age of 63.2+12.6 years were included in
the case series. All patients were diabetes type 2 with an average of 16.2+10.4 years since
diabetes was first diagnosed. Three DFU were TEXAS 2B and two were TEXAS 2C. Before
treatment average wound size was 4.96+5.66 cm2 with only two DFU showing a low
percentage of granulation tissue. Microbiological cultures were positive with polymicrobial
flora in all ulcers. After 5 weeks with at least once a week UAW debridement ulcer wound
size reduced to an average of 3.6+5.09 cm2 (p=0.042). All ulcers showed granulation tissue
and microbiological cultures resulted positive for monomicrobial presence in only two of five
DFU, No adverse events and complications were recorded during the follow up.
Conclusions: UAW used in combination with an antiseptic super-oxidized antiseptic solution
showed to be effective in wound debridement whilst kick starting wound healing of
complicated DFU., More and broad research is required to deeply understand the
advantages and utility of this technology in treatment of infected DFU.
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Page 2 of 11
P17.03
Ultrasonic assisted wound debridement (UAWD) system in diabetic foot ulcers - is it
of real value or just another gimmick ?
Rumneek Sodhi, Medanta-The medicity, Gurgaon Haryana, India
We studied the rates of wound healing in diabetic foot ulcers of 72 patients that underwent
surgical debridement (using curettage debridement) and those that underwent ultrasonic
wound debridement (UAWD) alternatively.
Method: UAWD applies a low frequency power ultrasound (22 kHz to 35 kHz) in conjunction
with an irrigation solution via a moving receptacle applied directly to the wound tissue. The
duration of each UAWD treatment session was around 20 minutes each and the total
number of sessions received per patient was variable, depending on the extent of infection.
Vascularity of all the wounds was satisfactory and all patients received standard wound care
with normal saline and a non-adhesive foam dressing. The total duration of the study was 12
weeks.
Results: On an average, we found that wounds that underwent UAWD healed at a faster
rate. The ulcer healing time decreased from 6 weeks to 3.5 weeks in patients who recieved
UAWD as compared to those who underwent surgical debridement
We also found that the effects of UAWD lasted significantly longer. In a 12-week period, we
recorded performing an average of 4 debridements per patient with the ultrasonic debrider in
comparison to an average of 7 sharp debridements per patient.
In comparison with sharp debridement, bleeding and pain were both found to be negligible
with the UAWD system. In most cases, one could easily achieve haemostasis with elevation
and compression without the need of cautery and control pain with topical anesthesia.
Conclusion: UAWD system has found a home in wound care. This technology has a
number of benefits and appears very promising. It certainly has the real value to be present
in our diabetic foot care centre and we have found it to be useful in a variety of wounds.
The study has not been sponsored by anyone.
Ultrasound assisted wound debridement system
www.diabeticfoot.nl
Page 3 of 11
P17.04
Surgical debridement, grafting, and negative pressure wound therapy treatment for
gas gangrene of the lower extremity with retained hardware
Brett Chatman, Washington Hospital Center, Washington, United States
John Steinberg, Washington Hospital Center, Washington, United States
Katherine Raspovic, Washington Hospital Center, Washington, United States
Tiffany Hoh, Washington Hospital Center, Washignton, United States
David Vieweger, Washington Hospital Center, Washington, United States
Aim:, Gas gangrene of the lower extremity is a surgical emergency, which requires
emergent debridement and frequently results in lower extremity amputation. We present a
case of gas gangrene of the lower extremity with retained hardware treated with serial
surgical debridement and negative pressure wound therapy with ultimate application of a
split thickness skin graft.
Methods:, A 71-year-old female with a history of diabetes, hypertension, and previous right
ankle fracture with retained hardware presented to the ER with gas gangrene of the right
lower extremity seen on radiographs. Upon examination, she was febrile at 38.3°C and labs
revealed leukocytosis of 16 900. She had severe pain on palpation accompanied by large
blister formation with extensive erythema of the right lateral ankle and right hallux that had
been worsening over the past five days., She was first treated with emergent incision and
drainage of the right lateral leg and hallux with removal of ankle hardware., The patient
underwent serial surgical debridement, negative pressure wound therapy, and ultimately split
thickness skin grafting of the entire lateral wound. A amputation of the right hallux was also
performed.
Results:, At five weeks after her last surgery, the right lateral ankle wound and hallux
amputation sites were completely healed. This case illustrates the beneficial effects that
repeat surgical debridement with subsequent split thickness skin grafting can have on limb
salvage. At the start of care, several consulting physicians had identified this patient as
requiring a proximal amputation., Through serial debridement, graft placement, and negative
pressure wound therapy, the patient’s limb was ultimately salvaged.
Conclusion:, It is important for the clinician to explore all possibilities when it comes to limb
salvage. Limbs once considered non-salvageable may now be spared from amputation and
can return to function., We present a case example of surgical debridement and negative
pressure wound therapy with split thickness skin graft application for limb salvage.
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Page 4 of 11
P17.05
Soft tissue repair changes in patients with diabetic foot ulcers after NPWT and
standard management.
Ekaterina Zaitseva, Endocrinology Research Centre, Moscow, Russia
Ludmila Doronina, Endocrinology Research Centre, Moscow, Russia
Roman Molchkov, Endocrinology Research Centre, Moscow, Russia
Iya Voronkova, Endocrinology Research Centre, Moscow, Russia
Alla Tokmakova, Endocrinology Research Centre, Moscow, Russia
Aim: To evaluate clinical histological immunohistochemical effects of negative pressure
wound therapy(NPWT)compared to standard care in diabetic ulcers.
Methods: Clinical examination transcutaneous oxygen monitoring(TcpO2) ulcer
biopsies(stained with haemotoxylin-eosin immunohistochemistry for MMP-9 TIMP1(proteolytic activity), CD68(macrophages) before and after treatment.
Results: We observed 31patients with diabetic ulcers after surgical debridement and before
plastic surgery divided them into 2groups.The wound bed filled with granulation tissue>75%
was the clinical criteria of wound preparation to plastic surgery.In group1(n=13)we used
NPWT(-90-120mmHg) in group2 (n=18)we used standard atraumatic dressings for 8 ± 4
days. Both groups were represented mainly by patients with T2DM and reliably matched by
age glycaemic control severity of microvascular complications form of DFU( neuropathic–12,
neuroischemic-19 wound size (group1 35 8 ± 26cm2, group2 37 ± 25cm2) wound
depth(group1 4 05 ± 2 79 cm group2 3 57 ± 1 8 cm) tcpO2 group1 43 7 ± 17, group2 32 1 ±
17 8 mmHg. Histologically both groups had edema, poorly organized extracellular matrix
(ECM) low amount of fibroblast-like cells and severe inflammatory
infiltrate.Immunohistochemically: increased staining ofCD68 and MMP-9; TIMP level
reduction were found.At the end of the treatment tcpO2 in group1 increased to 53 ±
13mm.Hg(38 0±14 7 mm Hg in group2 (p <0.04) wound size decreased in 26.6±17.6% in
group2 in23.3±19 %(p <0.05), wound depth in group1 decreased in 40.5±25 % in group2 in
1.8 ± 21.1%(p <0.03).Levels of CD68 decreased(p < 0.05) slightly increased the level of
TIMP(p <0.03)mostly in group1. Histologically in group1 was the reduction of edema
formation of, ECM high quality of granulation tissue reduction of inflammation(p <0.05)were
shown.All wounds in group1 after treatment were prepared to plastic closure.After treatment
95% of, patients in group2 had, low quality of granulation, tissue and excessive exudation
which required repeated surgical debridement.
Conclusion: NPWT is more effective in tissue repair processes compared to standard
therapy quickly reduces wound size and depth, increases local perfusion reduces
inflammation which was confirmed by histological and immunohistochemical tests.
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Page 5 of 11
P17.06
The role of Renasys-GOTM in the treatment of diabetic lower limb ulcers: a case
series
Keng Lin Francis Wong, National University Health System, Singapore, Singapore,
Singapore
A Aziz, National University Health System, Singapore, Singapore, Singapore
Introduction: This case series aims to study the effectiveness of Renasys-GOTM negative
pressure wound therapy system in the healing of diabetic lower limb ulcers.
Materials and methods: An electronic vacuum pump (Renasys-GOTM, Smith & Nephew
GmbH) was used to apply negative pressure wound therapy on wounds, with pressure
settings determined according to clinical indication. Changes in wound dimension, infection
status and duration of treatment were recorded over the course of Renasys-GOTM therapy
in 10 patients with diabetic lower limb ulcers.
Results: Healing was achieved in all wounds, three by secondary closure and seven by
split-thickness skin grafting. Eight wounds showed a reduction in wound size. The average
duration of treatment with Renasys- GOTM therapy was 15.9 days, and all wounds showed
sufficient granulation and were cleared of bacterial infection at the end of therapy.
Conclusions: Renasys-GOTM therapy may be beneficial in the treatment of diabetic lower
limb ulcers and wounds. In this study, which included wounds presenting as post-surgery ray
amputation, metatarsal excision wounds, post-debridement abscesses and ulcers, the
Renasys-GOTM therapy prepared all wounds for closure via split-thickness skin grafting or
secondary healing by promoting granulation tissue and reducing bacterial infection in
approximately 2 weeks.
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Page 6 of 11
P17.07
The efficacy safety and cost effectiveness of Russian Natural Honey in the
management of chronic diabetic foot ulcers
Hashim Mohamed, Weill Cornell Medical College-Qatar, Doha, Qatar
Aim: To demonstrate the efficacy, safety and cost effectiveness of Russian Natural Honey in
the management of chronic diabetic foot ulcers
Methods: This study is an open label non randomized prospective study . 183 patients with
type 2 diabetes suffering from chronic diabetic foot ulcers who presented consecutively were
followed up by an interdisciplinary team at primary care level. The ulcers were assessed on
admission, on a weekly basis according to the PEDIS, system, digital planimetry and the
visual analogue score . Data monitoring, patient comments, HbA1c fasting blood glucose
and observation were used to add greater reliability and validity to the findings. Wounds
were cleaned with normal saline and a layer of of Russian Natural Honey was applied and
covered with a paraffin impregnated gauze and held in place by a lightly applied cottage
bandage. Wounds were dressed on a daily basis, and an independent observer un aware of
the nature of the trial assessed the wounds on a weekly basis along with pain scale
recording.
Results: Overall wound size decreased significantly during the study period and many
wounds healed after relatively short periods .Similarly perceived pain level decreased
significantly and the wounds showed noticeably less slough / necrosis .
Conclusions: The use of Russian, Natural Honey, was associated with a statistically
significant decrease in wound size, pain threshold and cost of dressing .However, further
double blind randomized controlled studies are needed to confirm these findings.
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Page 7 of 11
P17.08
Risk factors of delay of wound healing in diabetic foot patients
Tatiana Zelenina, Northwestern Medical University n.a. I.I. Mechnikov, St. Petersburg,
Russia
Natalia Belevantseva, Northwestern Medical University n.a. I.I. Mechnikov, St. Petersburg,
Russia
Natalia Vorokhobina, Northwestern Medical University n.a. I.I. Mechnikov, St. Petersburg,
Russia
Alexandr Zemlyanoy, Northwestern Medical University n.a. I.I. Mechnikov, St. Petersburg,
Russia
Aim: To estimate risk factors of healing delay and role of diabetic neuropathy.
Methods: We examined 108 diabetic outpatients after foot surgery and partial foot
amputations. The mean age was 60.0±1.3 yrs, mean duration of diabetes was 12.9±1.5 yrs.
HbA1c level was 9.10±0.47%. All of them had open wound and were treated at the Center
and received standardized therapy. We excluded patients with critical limb ischemia. The
participants underwent a neurological examination and set off cardiovascular autonomic
functional tests. We assessed the time for wound closure., Some factors like age, gender,
diabetes duration, glucose control, presence of chronic diabetic complications were
expected to influence the process of healing. We also believed that local factors (size, depth
of lesion, infection, localization of the wound) would be greatly involved in process of
healing.
Results: The mean time of wound healing was 12.7±1.55 weeks. The presence of infection
and osteomylitis were detected in 45 cases (44.1%) and 19 (18.1%) cases respectively. The
mean size of wound was 17.0±2.82 cm², and mean time of wounds presence before appeal
to the Center was about 130±2.8 weeks. We found autonomic and sensory-motor
neuropathy in all, patients. Analyzing variants we found that local parameters were major
factors for delay of neuropathic wound healing. Than we managed to distinguish such
factors applying classification trees method. The osteomielitis was the most impotence
parameter. The second one was diabetic foot infection. Size (more than 10 sm²), location of
the wound (forefoot or plantar face) and time before referral to the Center (more than 9
weeks) were also great determinants.There weren’t associations of age, gender, duration of
diabetes, HbA1c% with time of completed healing.
Notably severe sensory-motor neuropathy and damage of cardiac autonomic were also
significant predictors of delay healing.
Conclusions: Prognosis of wound healing in diabetic patients first of all depended on local
wound parameters. Peripheral sensory-motor and autonomic neuropathy were involved in
the process of wound healing along with local factors. The early diagnosis and treatment of
these diabetic complications will prevent diabetic foot damage and delay of wound healing.
www.diabeticfoot.nl
Page 8 of 11
P17.09
Non-suture technique utilizing negative pressure wound therapy for ischemic foot
Shinobu Ayabe, Yao Tokushukai General Hospital, Osaka, Japan
Aim: In minor amputation surgery, stumps are usually closed with sutures such as vertical
mattress. In the ischemic foot, however, wound dehiscence and necrosis of wound edges
are sometimes observed. This can be caused by poor blood flow due to tension of suturing.
Therefore, a bony stump has to be sufficiently shortened for tension free suturing. It results
in a decreased weight-bearing area and leads to gait instability. To avoid this undesirable
result, we performed non-suture technique utilizing negative pressure wound therapy
(NPWT) for the ischemic foot.
Methods: The incision planning for debridement was designed based on the assumption
that the defect would be closed by fillet flaps. The bony stump was resected to allow
adequate soft tissue closure. The wounds were left open and alginate dressings were
applied for hemostasis. On post-operative day one, the wounds were treated with NPWT.
Fillet flaps were gradually advanced by NPWT, and complete wound closure was achieved.
Results: 15 patients underwent this non-suture technique for wound closure. All wounds
healed successfully without utilizing skin grafts and there were no complications.
Conclusions: Minor amputation wound closure is generally achieved using sutures. In order
to avoid wound dehiscence or necrosis of wound edges in the ischemic foot, bony stumps
must be sufficiently shortened for tension free suturing. To completely reapproximate
wounds with suture technique the residual foot length may be compromised. This may lead
to gait instability. On the other hand, skin grafting is usually performed after NPWT, but skin
grafts tend to be weaker in resisting friction and load in comparison to skin flaps. Non-suture
technique utilizing NPWT is considered a practical and appropriate measure. In comparison
to direct closure, the non-suture technique maximizes the weight-bearing area and maintains
the foot length more. This technique also creates a more resistant amputation site than the
skin graft technique making it more advantageous in gait stability. This technique was found
to be convenient and safe, but a prospective comparative study is needed to confirm the
usefulness in ischemic foot.
www.diabeticfoot.nl
Page 9 of 11
P17.10
A treatment of diabetic gangrene using negative pressure wound therapy and
regenerative acellular dermal matrix in a compromised patient
Eunsoo Park, Soonchunhyang University Bucheon Hospital, Bucheon, Korea, South
YongBae Kim, Soonchunhyang University Bucheon Hospital, Bucheon, Korea, South
SeungMin Nam, Soonchunhyang University Bucheon Hospital, Bucheon, Korea, South
Despite numerous advances, non-healing wounds continue to be a treatment challenge. The
negative pressure wound therapy and regenerative acellular dermal matrix have been
reported to minimize operative morbidity and speed up the healing time of various chronic
wound. So we applied the negative pressure wound therapy (VACⓇ) and regenerative
acellular dermal matrix (PelnacⓇ) for treatment of the intractable diabetic gangrene with
infection non-healthy granulation tissue, or systemic factor that could impair wound healing.
The negative pressure wound therapy facilitated granulation tissue proliferation and
eradication of any pre-existing infection. For adequate proliferation of granulation tissue,
regenerative acellular dermal matrix is good material, especially preparing skin graft or flap
coverage. It provides a favorable microenvironment for bioingrowth by promoting nutritional
diffusion and cellular
proliferation at the graft site. Diabetic Gangrene were healed by successively with this
methods.
www.diabeticfoot.nl
Page 10 of 11
P17.11
A leukocytes and platelet rich fibrin patch as a novel treatment of malleoli ulcers in
patients with diabetes
Katarina Fagher, Skane University Hospital, Lund, Sweden
Per Katzman, Skane University Hospital, Lund, Sweden
Åsa Asmundsson, Skane University Hospital, Lund, Sweden
Gunilla Larsson, Skane University Hospital, Lund, Sweden
Mirja Rouonakoski Ley, Skane University Hospital, Lund, Sweden
Magnus Londahl, Skane University Hospital, Lund, Sweden
Aim: Autologous platelet-rich fibrin, a treatment containing fibrin and high concentrations of
growth factors, has been used for treatment of diabetic foot ulcers. Recently, a novel
treatment Leucopatch™, using viable leucocytes in an autologous platelet-rich fibrin patch
has been introduced. The patch is produced from patient's own venous blood, without
anticoagulant or any other additives. To produce one patch (5cm2 area), 18 mL of the
patient´s own blood is drawn into a Leucopatch™ device, and spinned for 20 minutes. Initial
studies indicate that this treatment might enhance healing of Wagner grade 1-2 foot ulcers in
diabetic patients. Non-venous ulcers at the malleoli are usually painful and hard-to-heal.
The aim of the present cases series was to elucidate the feasibility of Leucopatch™
treatment in superficial malleoli ulcers in people with diabetes.
Method: Patients with non-ischemic (TcPO2≥ 30 mm Hg) diabetic malleoli foot ulcers with a
duration of at least 10 weeks, were consecutively offered this treatment, which was then
applied once every second week for up to 20 weeks.
Results:, This small case series includes 6 ulcers in 6 patients. The ulcer duration ranged
from 18 to 120 weeks as shown in table 1. 4 out of 6 ulcers healed., In healers, an enhanced
ulcer area reduction was seen already after the first or second patch.
Conclusions: Leucopatch™ seems to be feasible to use and might, enhance healing of
hard-to-heal ulcers on the malleoli in patients with diabetes. The efficacy needs to be proven
before routine clinical use can be recommended.
Sex /DM type/ age
Ulcer
Duration
(weeks)
36
# treatments
M; II; 74 y
Ulcer
size
(mm)
o 12
F; II, 85 y
M; II; 83 y
7x12
21x14
28
26
6
5
F; I; 63 y
M; I; 63 y
M; II; 78 y
o 14
o 25
o 22
120
14
45
2
5
4
3
Time to
healing
(weeks)
unhealed at
20 weeks
11
unhealed at
20 weeks
4
10
10
www.diabeticfoot.nl
Comments
on warfarin –
problems with
coagulation
venous foot ulcer
Page 11 of 11