Practical Things You Should Know about Wound Healing and Vacuum-Assisted Closure Management

Physical therapy in diabetic foot ulcer: Research progress and clinical application

Diabetes foot ulcer (DFU) is one of the most intractable complications of diabetes and is related to a number of risk factors. DFU therapy is difficult and involves long-term interdisciplinary collaboration, causing patients physical and emotional pain and increasing medical costs. With a rising number of diabetes patients, it is vital to figure out the causes and treatment techniques of DFU in a precise and complete manner, which will assist alleviate patients' suffering and decrease excessive medical expenditure. Here, we summarised the characteristics and progress of the physical therapy methods for the DFU, emphasised the important role of appropriate exercise and nutritional supplementation in the treatment of DFU, and discussed the application prospects of non-traditional physical therapy such as electrical stimulation (ES), and photobiomodulation therapy (PBMT) in the treatment of DFU based on clinical experimental records in ClinicalTrials.gov.

Portable Negative Pressure Wound Dressing in Oncoplastic Conservative Surgery for Breast Cancer: A Valid Ally

Background and Objectives: The use of oncoplastic techniques has spread widely in the last decade, with an expansion of the indications and demonstration of excellent oncological safety profiles. A potential downside may be the increased complication rates, which could influence the timing of adjuvant therapy. To date, there is increasing evidence that negative pressure therapy on closed wounds can reduce complication rates after surgery. From this perspective, we tested the use of portable negative pressure wound dressings (NPWDs) in oncoplastic surgery to minimize early post-operative admissions to the outpatient clinic and prevent surgical complications. Materials and Methods: An observational prospective cohort study was conducted on a population of patients who underwent quadrantectomy and wise-pattern reduction mammoplasty for breast cancer. The primary objective of the study is represented by the evaluation of the impact of NPWD on post-operative outcomes in an oncoplastic surgery setting. Patients enrolled between January 2021 and January 2023 were divided into two groups, the conventional dressing (CD) group and the NPWD group, by a simple randomization list. Results: A total of 100 patients were enrolled, with 52 in the CD group and 48 in the NPWD group. The use of NPWD significantly reduced the wound dehiscence rate (2.0% vs. 7.7% p = 0.002) and the number of one-month postoperative admissions to our clinic (3.8 ± 1.1 vs. 5.7 ± 1.3 p = 0.0009). Although not significant, it is possible to note a trend of reduction of clinically relevant postoperative total complications in patients treated with NPWDs. Conclusions: NPWDs may represent a useful tool in the post-surgical management of complex oncoplastic procedures, ensuring less wound dehiscence. Furthermore, the use of these dressings led to a significant reduction in admissions to the clinic, promoting a lower use of resources by hospitals and effective prevention of possible complications.

Negative pressure wound therapy: Where are we in 2022?

The use of negative pressure wound therapy (NPWT) continues to be an important tool for surgeons. As the use and general acceptance of NPWT have grown, so have the indications for its use. These indications have expanded to include soft tissue defects in trauma, infection, surgical wound management, and soft tissue grafting procedures. Many adjuvants have been engineered into newer generations of NPWT devices such as wound instillation of fluid or antibiotics allowing surgeons to further optimize the wound healing environment or aid in the eradication of infection. This review discusses the recent relevant literature on the proposed mechanisms of action, available adjuvants, and the required components needed to safely apply NPWT. The supporting evidence for the use of NPWT in traumatic extremity injuries, infection control, and wound care is also reviewed. Although NPWT has a low rate of complication, the surgeon should be aware of the potential risks associated with its use. Furthermore, the expanding indications for the use of NPWT are explored, and areas for future innovation and research are discussed.

The Role of Myofibroblasts in Physiological and Pathological Tissue Repair

Myofibroblasts are the construction workers of wound healing and repair damaged tissues by producing and organizing collagen/extracellular matrix (ECM) into scar tissue. Scar tissue effectively and quickly restores the mechanical integrity of lost tissue architecture but comes at the price of lost tissue functionality. Fibrotic diseases caused by excessive or persistent myofibroblast activity can lead to organ failure. This review defines myofibroblast terminology, phenotypic characteristics, and functions. We will focus on the central role of the cell, ECM, and tissue mechanics in regulating tissue repair by controlling myofibroblast action. Additionally, we will discuss how therapies based on mechanical intervention potentially ameliorate wound healing outcomes. Although myofibroblast physiology and pathology affect all organs, we will emphasize cutaneous wound healing and hypertrophic scarring as paradigms for normal tissue repair versus fibrosis. A central message of this review is that myofibroblasts can be activated from multiple cell sources, varying with local environment and type of injury, to either restore tissue integrity and organ function or create an inappropriate mechanical environment.

Surgical outcome after using negative pressure therapy in infected leg wounds in coronary bypass grafting surgery

Background

Infection of leg wounds is a common complication following great saphenous vein harvesting (GSV) for coronary bypass grafting (CABG). This complication can result in increased risk of patient morbidity and mortality by causing septicemia, and gangrene, subjecting the patients to amputation. This study aimed to assess the efficacy of negative pressure wound therapy (NPWT) compared to conventional wound care in infected leg wounds following GSV harvesting for myocardial revascularization.

Results

The NPWT group had a significantly lower rate of deep vein thrombosis (p = 0.013), osteomyelitis (p < 0.001), bed sores (p < 0.001), shorter duration of tissue edema (p < 0.001), and lesser discharge (p < 0.001). Also, the length of hospital stay was significantly shorter in the NPWT group (p < 0.001). Multivariable analysis revealed that traditional wound care (without NPWT, p < 0.001) and wound stage IV (p = 0.001) significantly and independently prolonged the length of hospital stay.

Conclusions

The use of NPWT in advanced complicated infected leg wounds could improve patients’ outcomes and satisfaction by decreasing the rate of complications and the length of hospital stay.

"Closed Incision Negative Pressure Therapy (ciNPT) reduces abdominal donor site surgical wound dehiscence in Deep Internal Epigastric Perforator (DIEP) flap breast reconstructions: DEhiscence PREvention Study II (DEPRES II) - a Randomized Clinical Trial"

BACKGROUND

In breast reconstruction surgeries, surgical wound dehiscence is a serious complication which generates a significant burden on patients and healthcare systems. There are indications that postoperative treatment with closed incision negative pressure therapy (ciNPT) has been associated with reduced wound dehiscence rates. This randomized clinical trial examines the effect of ciNPT application on abdominal donor site surgical wound dehiscence in low- and high-risk patients undergoing a breast reconstruction with a deep internal epigastric perforator (DIEP) flap.

METHODS

Eighty eligible women, stratified as low- or high-risk patients, were included and were randomized for treatment with either ciNPT or adhesive strips (AS) by drawing sealed, opaque envelopes. All surgeons were kept blind for allocation. Primary outcomes were surgical wound dehiscence and surgical site infection at the abdominal donor site upon follow-up after 12 weeks. Secondary outcomes were seroma and hematoma formation. Five patients were excluded from the study due to non-sufficient exposure to the study treatment (n=4) or major protocol deviation (n=1).

RESULTS

A total of 75 women, low-risk (n=38) and high-risk (n=37), received either ciNPT (n=36) or AS (n=39). Patients' demographics did not differ significantly. Donor-site surgical wound dehiscence occurred in 23 patients; the Absolute Risk Reduction was statistically significant (21.6%, 95% Confidence Interval [1.5-41.7]). No statistically significant differences were found in surgical site infection or secondary outcomes.

CONCLUSIONS

In this randomized clinical trial, postoperative treatment with ciNPT decreased the incidence of surgical wound dehiscence at the abdominal donor site in low- and high-risk DIEP flap breast reconstruction patients.

Urinary Bladder Matrix Improves Irradiated Wound Healing in a Murine Model

ABSTRACT

Radiation skin damage is associated with chronic wounds and poor healing. Existing localized treatment modalities have limited benefit. Therefore, there has been increased interest in biologically based solutions. In this study, we aimed to determine the effect of topical urinary bladder matrix (UBM) on chronic irradiated skin wounds using an established murine model. Our findings demonstrated that topical urinary bladder matrix significantly accelerated the healing of irradiated wounds on day 7 (P = 0.0216), day 14 (P = 0.0140), and day 21 (P = 0.0393). Histologically, urinary bladder matrix treatment was associated with higher-quality reorganization and reepithelialization of wounds, an increased density of myofibroblasts (P = 0.0004), and increased collagen deposition (P < 0.0001). In addition, quantitative real-time polymerase chain reaction data demonstrated decreased expression of profibrotic mediators (P = 0.0049). We conclude that urinary bladder matrix may be a useful, noninvasive, adjunctive therapy for the treatment of chronic irradiated skin wounds.

Recent Advances in Nanozymes for Bacteria-Infected Wound Therapy

Bacterial-infected wounds are a serious threat to public health. Bacterial invasion can easily delay the wound healing process and even cause more serious damage. Therefore, effective new methods or drugs are needed to treat wounds. Nanozyme is an artificial enzyme that mimics the activity of a natural enzyme, and a substitute for natural enzymes by mimicking the coordination environment of the catalytic site. Due to the numerous excellent properties of nanozymes, the generation of drug-resistant bacteria can be avoided while treating bacterial infection wounds by catalyzing the sterilization mechanism of generating reactive oxygen species (ROS). Notably, there are still some defects in the nanozyme antibacterial agents, and the design direction is to realize the multifunctionalization and intelligence of a single system. In this review, we first discuss the pathophysiology of bacteria infected wound healing, the formation of bacterial infection wounds, and the strategies for treating bacterially infected wounds. In addition, the antibacterial advantages and mechanism of nanozymes for bacteria-infected wounds are also described. Importantly, a series of nanomaterials based on nanozyme synthesis for the treatment of infected wounds are emphasized. Finally, the challenges and prospects of nanozymes for treating bacterial infection wounds are proposed for future research in this field.

Wound healing: what is the NICE guidance from the UK?

Alteration of wound healing increases the risk of a patient's morbidity and mortality. This can lead to scarring, infection, malignant transformation and a reduction in quality of life. Management of wounds costs the UK an estimated £5.3 billion annually which is paid for by the state, with further financial burden due to health related productivity loss. Wound care is managed by a broad spectrum of different health professionals leading to different standards of care. For example, only 16% of lower leg wounds have either an ankle-brachial pressure index measurement or Doppler scan. Due to this variation in wound care, we have summarised all available NICE guidelines and guidance up to February 2021 on the topic of wound healing listed in the National Institute for Health and Care Excellence (NICE) archives. The goal is to provide an easy to access summary of wound care interventions. Our search provided us with 18 technology appraisals related to wound healing which have been summarised.

Negative pressure wound therapy for surgical site infections: A systematic review and meta-analysis

OBJECTIVE

Negative pressure wound therapy is one of the most common treatments for infected wounds. The aim of this meta-analysis was to compare the efficacy of negative pressure wound therapy with conventional treatment methods in the treatment of surgical site infection.

DESIGN

This study is registered with International Prospective Register of Systematic Reviews.

DATA SOURCES

The Pubmed, Embase and the Cochrane Central Register of Controlled Trials databases were searched.

METHODS

The systematic review was searched by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses method. All trials reporting the use of negative pressure wound therapy for surgical site infection treatment were included regardless of surgery type. The primary outcome measure was wound healing. Secondary outcomes were length of hospital stay, medical costs, adverse events, and reoperation rates. Results are presented with 95% confidence intervals and report estimates as odds ratios. Heterogeneity was determined through the I² test, with I²  > 50% indicating substantial heterogeneity and p < .10 significance. The search was performed on 10 March 2020.

RESULTS

We identified 13 eligible trial comparisons, of which 2 were randomized controlled trials and 11 cohort study. Negative pressure wound therapy in surgical site infection (SSI) patients significantly increased wound healing rate, accelerated wound healing time, increased daily wound healing area, reduced hospital stay, and reduced adverse events. However, negative pressure wound therapy was associated with increased medical costs.

CONCLUSION

Negative pressure wound therapy may be more effective for the treatment of surgical site infection relative to conventional debridement, dressings and other treatments. However, further high-quality randomized controlled trials are needed to determine the most optimal application of negative pressure wound therapy.

IMPACT

Negative pressure wound therapy is the best treatment strategy for surgical site infection. This study can improve medical practitioners' awareness of negative pressure wound therapy for surgical site infection, promoting the development of relevant randomized controlled trials.

Fundamentals of Wound Healing

At the moment of soft tissue injury, an immediate wound healing ballet commences. This coordinated cascade of events works over minutes, hours, weeks, and months to restore tissue integrity and viability in an attempt to rebuild the site to its preinjured state. A thorough understanding of these processes, and options to navigate forks in the road, can help guide patient selection, surgical planning and execution, management of complications, and ultimately the restoration of tissue form and function for optimal outcomes. An exhaustive account of tissue healing mechanics is beyond the scope of this writing. However, a summation of much that is known of these processes and the directions research and therapeutic developments are currently aimed will help the facial plastic surgeon prevent or minimize debilitating functional and cosmetic consequences in the head and neck.

Negative pressure wound therapy: device design, indications, and the evidence supporting its use

Introduction: Negative pressure wound therapy (NPWT) has become a mainstay in the armamentarium for wound care. Since the initial commercial vacuum-assisted closure device became available in 1995, subsequent research has confirmed the positive physiological effects of negative pressure on wound healing. Traditionally, NPWT has been used to improve healing of open nonsurgical wounds by secondary intention. However, the clinical applications of NPWT have significantly broadened, and now also include use in open surgical wounds, closed surgical incisions, and skin graft surgery. In addition, devices have evolved and now include functionality and features such as instillation, antimicrobial sponges, and portability.Areas covered: This article reviews the history, background, and physiology underlying NPWT, as well as the most commonly used devices. In addition, an evidence-based discussion of the current clinical applications of NPWT is presented, with a focus on those with high levels of evidence.Expert opinion: Future directions for device development include modifications to increase ease of use by patients and to allow its use in a broader array of anatomic areas. Lastly, more research with high levels of evidence is needed to better define the outcomes associated with NPWT, including in relation to specific clinical applications and cost.

Does negative pressure wound therapy with saline instillation improve wound healing compared to conventional negative pressure wound therapy? - A randomized controlled trial in patients with extremity ulcers

BACKGROUND

Wounds are important health problems that cause significant financial burden and loss of time to work, more so in low and lower middle income countries. Negative pressure wound therapy (NPWT) is widely established in managing acute and chronic extremity wounds. We studied the effects of addition of normal saline instillation to NPWT in terms of changes in granulation tissue, bacterial-burden and overall wound healing using readily available means and materials including wall suction for negative pressure, sponge and adhesive transparent sheet for dressing and normal saline for irrigation.

METHODS

All patients with extremity ulcers initially underwent surgical debridement. They were then allotted into two groups, group 1 (NPWT with normal saline instillation- NPWTi) including 25 patients and group 2 (NPWT) including 23 patients. Tissue-bit samples taken on day1 and day 10 were used for bacteriology and for assessing histology. The wound surface-area was measured using the software ImageJ on day 1 and day 10.

RESULTS

Median log difference in colony-count between day1 and day10 was 0.6 (0.2-1.4) in group1 and 0.13 (0.04-0.6) in group 2 (p < 0.05). Mean percentage reduction in wound size was 28.82 and 19.80 in group 1 and group 2 respectively (p < 0.05). Histological parameters of wound healing assessed as surface epithelium, granulation, inflammatory cells, proliferative blood-vessels and fibroblasts were significantly better in group1. A drawback observed with NPWTi was skin maceration around the ulcer which was successfully managed.

CONCLUSION

Our findings suggest that wound healing is significantly better when saline instillation is combined with NPWT. It can aid in complex extremity ulcers management by reducing the size of the wound with healthier looking granulation tissue.