Oxygen Saturation or Tissue Oxygen Determinations on Skin Whose Viability is at Risk

The triad of ischaemia, neuropathy, and infection are among the principal causes of lower extremity wounds that are commonly prevalent in patients with diabetic foot (DF) a condition in which peripheral arterial disease commonly co-exists. The prevalence of this condition is increasing globally and with it, the mounting costs of its management. One aspect of management is saving limbs and or digits, a crucial part of this process is assessing tissue viability of skin which is a focus of this review: there are other aspects which are well described in the literature. Amputations are offered to limit the damage resulting from acute/chronic ischaemia. Holstein measured skin perfusion pressure using a radioisotope clearance technique to describe critically ischaemic skin; he found 30 mm Hg as the threshold above which healing may reliably be expected. Recent advances in vascular surgery and related technology have informed evidence-based advice to revascularize and save limbs; in practice, this may leave a wound in the distal skin unhealed; managing these raises questions of tissue viability. Much effort has been made to manage, prevent and to better understand these lower extremity wounds using measurements of tissue oxygen, oxygen saturation and skin imaging. The measurement techniques and their relevant merits are examined in this article. Advances in wound management systems and protocols can also facilitate the repair processes, and those which can have a particular impact on restoring or maintaining tissue perfusion are also discussed in the article.

Artificial intelligence for automated detection of diabetic foot ulcers: A real-world proof-of-concept clinical evaluation

OBJECTIVE

Conduct a multicenter proof-of-concept clinical evaluation to assess the accuracy of an artificial intelligence system on a smartphone for automated detection of diabetic foot ulcers.

METHODS

The evaluation was undertaken with patients with diabetes (n = 81) from September 2020 to January 2021. A total of 203 foot photographs were collected using a smartphone, analysed using the artificial intelligence system, and compared against expert clinician judgement, with 162 images showing at least one ulcer, and 41 showing no ulcer. Sensitivity and specificity of the system against clinician decisions was determined and inter- and intra-rater reliability analysed.

RESULTS

Predictions/decisions made by the system showed excellent sensitivity (0.9157) and high specificity (0.8857). Merging of intersecting predictions improved specificity to 0.9243. High levels of inter- and intra-rater reliability for clinician agreement on the ability of the artificial intelligence system to detect diabetic foot ulcers was also demonstrated (Kα > 0.8000 for all studies, between and within raters).

CONCLUSIONS

We demonstrate highly accurate automated diabetic foot ulcer detection using an artificial intelligence system with a low-end smartphone. This is the first key stage in the creation of a fully automated diabetic foot ulcer detection and monitoring system, with these findings underpinning medical device development.

The Effect of Standard Compression Adjuvant with a Tailored Exercise Training Program on Health-Related Quality of Life Outcomes in Treating Adults with Venous Leg Ulcer: A Randomized Controlled Trial

Exercise training adjuvant to standard compression is considered to improve calf muscle pump dysfunction in venous leg ulcer (VLU) and subsequent healing. The objectives of this trial were to assess the effectiveness of a tailored exercise training intervention in addition to standard compression therapy on health-related quality of life and anticipating wound healing. Twenty-four VLU participants were recruited and randomly divided into 2 groups. The control group was prescribed conventional compression, and the intervention group received compression plus progressive tailored exercise training. The 14-item chronic venous disease quality of life questionnaire (CIVIQ-14) was used to assess improvement after treatment over time (0, 6, and 12 weeks). Intervention and control groups achieved wound closure for 11 (92%) and 7 (58%) patients. After adjusting for age, sex, and wound size at baseline, the exercise intervention group had 2 times the probability of complete wound healing in 12 weeks than those in the control group (risk ratio = 1.98, 95% CI= 1.01-3.72, P = .047). The primary outcome was the difference in CIVIQ-14 score in 3 dimensions and global index score per visit. The outcomes were evaluated by independent assessors. Demographic, comorbidities, and wound assessments were collected on enrollment. The overall adherence to exercise protocol was 71%. After adjusting age, sex, size of VLU, and CIVIQ score at baseline, the participants in the intervention group had the average global index scores and psychological scores increase at week 12 than those in the control group (21.2; 95% CI= 7.1-35.2, P = .005, and 13.5; 95% CI = 2.9-24.2, P = .044, respectively). Both groups showed similar improvement in the mean change in physical and pain scores within-group over time. Patients with combined conventional compression therapy with exercise training appeared to have a higher quality of life score in psychological and global scores than those with compression therapy alone.

Effectiveness of combined conventional treatment with a tailored exercise training program on wound healing in patients with venous leg ulcer: A randomized controlled trial

INTRODUCTION

Venous leg ulcer (VLU) is a therapeutic challenge. The mainstay of care is compression therapy and wound care. Exercise is also recommended for facilitating wound healing. This study aimed to determine whether adding tailored exercise training to conventional treatment would be superior on wound healing, ankle mobility, calf muscle function, and functional ability compared to those with the conventional treatment alone.

METHODS

A randomized controlled trial, single-blinded was conducted. VLU patients were randomized to the conventional treatment plus tailored exercise training (intervention group) and the conventional treatment alone (control group) (12/group). The conventional treatment contained foam dressing and short-stretch bandage, while the tailored exercise training consisted of stretching, resistive, and aerobic exercise sessions (3-day/week, for 12-week). Primary outcomes included healing rate and wound size parameters. Secondary outcomes were ankle range of motion (ROM), calf circumference, calf muscle endurance and strength, and functional ability. All outcomes were assessed at baseline, 6-, and 12-week intervention.

RESULTS

The intervention group had a higher trend of healing rate after 12-week training than those in the control group, but this trend was not significantly different (92% versus 58%, p = 0.06). After training, the intervention group had significantly decreased wound size. The intervention group had significantly higher ankle ROM and dorsiflexor muscle strength after 6- and 12-week training than those in the control group.

CONCLUSION

Adding the tailored exercise training incorporated with the conventional treatment may provide a greater tendency on wound healing and have the potential to improve ankle mobility than the conventional treatment alone.

TRIAL REGISTRATION NUMBER

TCTR20170405002.

Blood Vessel Density Measured Using Dynamic Optical Coherence Tomography is a Tool for Wound Healers

Dynamic optical coherence tomography (D-OCT) is a relatively new technique that may be used to study the substructures in the retina, in the skin and its microcirculation. Furthermore, D-OCT is a validated method of imaging blood flow in skin microcirculation. The skin around venous and mixed arterio-venous ulcers was imaged and found to have tortuous vessels assumed to be angiogenic sprouts, and classified as dots, blobs, coils, clumps, lines, and curves. When these images were analyzed and measurements of vessel density were made, it was observed that the prevalence of coils and clumps in wound borders was significantly greater compared with those at wound centers. This reinforced the belief of inward growth of vessels from wound edge toward wound center which, in turn, reposed confidence in following the wound edge to study healing. D-OCT imaging permits the structure and the function of the microcirculation to be imaged, and vessel density measured. This offers a new vista of skin microcirculation and using it, to better understand angiogenesis in chronic wounds.

A Rule of Thumb for Evaluating Surface Areas of Chronic Wounds

BACKGROUND

Rapid estimation of the area of chronic wounds is clinically important. A simple method using the thumb was investigated for universal physical measurement, particularly of small and multiple wounds; the thumb surface area (TSA) was then compared with the total body surface area (TBSA).

METHODS

A cross-sectional observational study and random sampling were used to obtain the characteristics of 343 participants. Data related to handprint surface area of the thumb and palm were collected using a scanner and laptop and assessed using image software. The TSA as a percentage of TBSA was confirmed based on the traditional rule that regards palmar surface area as 1% of TBSA. Information on factors potentially influencing measurement was gathered with questionnaires to analyze correlations.

RESULTS

The left and right TSAs were on average 4.27% and 4.28%, respectively, of the palmar surface area for all participants. Multiple linear regression analysis found that male and older participants had higher TSA:TBSA proportions (sex, P = .0020; age, P < .0001). The TSA:TBSA proportion increased by age for both males (by age group, 0.0418%, 0.0426%, 0.0432%, and 0.0460%, respectively) and females (0.0400%, 0.0409%, 0.0427%, and 0.0430%, respectively).

CONCLUSIONS

Thumb size is relatively stable in relation to TBSA, lending itself to a universal method for estimating the size of chronic wounds as a percentage of TBSA. It therefore represents a convenient physical measurement for assessing the area of burns and other wounds.

The Application of Ultra-High-Frequency Ultrasound in Dermatology and Wound Management

The management of lower extremity wounds is frequently performed by means of clinical examination, representing a challenge for the clinician due to the various conditions that can potentially enter differential diagnosis. Several diagnostic techniques are available in the dermatologist’s arsenal as a support to diagnosis confirmation, including dermoscopy and ultrasonography. Recently, a novel ultrasonographic technique involving the use of ultra-high ultrasound frequencies has entered the scene, and appears a promising tool in the diagnostic workup of skin ulcerative lesions. The focus of this review is to discuss the potential role of ultra-high-frequency ultrasonography in the diagnostic workup of wounds in the light of the current applications of the technique.

Ultrasound Use in Diagnosis and Management of Venous Leg Ulcer

Leg ulcers caused by venous diseases are effectively assessed by Doppler ultrasonography. The examination provides clear anatomical and physiological information for the diagnosis, treatment planning, and real-time guiding during the surgical treatment. Diagnostic Doppler ultrasonography assesses deep, superficial, and perforator veins, starting from patency assessment by direct visualization and simply compression test. The internal flow can be assessed by pulse wave analysis, which is used for rule out downstream flow obstruction and valvular incompetence. The venous valve function of deep, superficial, and perforator systems can be evaluated by measuring the time of the retrograde flow after flow augmentation performing in the upright position. At the end of the study, the venous map will be obtained and this map will guide clinicians to target treatment where the culprit is. The ultrasound technology has made a big shift in the treatment in the venous disease. In recent years, after the evolution and wide availability of ultrasound, newer treatment modalities have emerged for venous treatment. These include endovenous thermal ablation, endovenous adhesive closure, and ultrasound-guided foam sclerotherapy. Patients no longer require general anesthesia or hospitalization. Therefore utilization of duplex ultrasound has also surged and played an essential role in both diagnosis and therapy in venous ulcer. This article has dedicated to reviewing basic anatomy, the technique in diagnosis, and treatment.

Perspectives on the Process of Negative Pressure Wound Therapy at Home in Patients With Chronic Wound: A Qualitative Descriptive Study

The purpose of this study was to explore the experience of negative pressure wound therapy (NPWT) at home among Chinese chronic wound patients. Qualitative descriptive study design was adopted, and qualitative data were collected through semistructured in-depth interviews. A purposive, sampling method was used. Informants were recruited from one single wound healing center of a teaching hospital and were interviewed following one course of NPWT at home. A thematic content analysis was undertaken in the framework of input-process-output theory to guide analysis. Of the 13 participants interviewed, 9 were female and 4 were male with an age ranging from 20 to 69 years. Two major categories with their corresponding codes were identified. The first, positive experience, had 6 codes: high-degree identity and feeling hope (input); easy operation and convenience (process); improvement of symptoms and effective treatment (output). The second category, negative experience, had 11 codes: high expenditure, defects of the NPWT device, health education deficiency, and lack of independence and rationales in making decision of NPWT (input); poor communication with wound professionals, unexpected circumstances, therapeutic side effects, and a change of self-image (process); impact on physical symptoms and daily life, impact on social activities, and impact on psychological well-being (output). Patients considered the NPWT at home as a promising regimen, but they also had a feeling of not being prepared and lack of health education to make medical decision independently. The participants' perceptions and experiences would provide valuable information to promote the intervention program of health education and advance service process optimization.

Treatment of hard-to-heal leg ulcers with hyaluronic acid, sodium alginate and negative pressure wound therapy

OBJECTIVE

Hard-to-heal lower extremity ulcer is a common healthcare problem and can lead to a poor quality of life (QoL). Despite the advances in wound care, conventional therapies, such as necrotic tissue debridement, cleansing, treatment of infection and local treatment with dressing application are still considered the standard of care in patients with hard-to-heal leg ulcers. However, managing hard-to-heal ulcers that do not respond well to these methods has led to new treatment strategies. In this study, the effects of hyaluronic acid (HA) and sodium alginate (SA), combined with negative pressure wound therapy (NPWT), in patients with hard-to-heal leg ulcers are evaluated.

METHOD

Patients with hard-to-heal lower extremity ulcers were treated with HA-SA combined with NPWT (HA-SA-NWPT, n=11), or conventional therapy (n=14), between June 2014 and September 2015. Demographics, comorbidities, time to complete healing and change in wound area were recorded and compared.

RESULTS

A total of 25 patients took part. Complete healing was achieved in 63.6% (n=7) of the patients in the HA-SA with NPWT group, compared with 14.3% (n=2) of the patients in the conventional therapy group (p=0.017). The mean decrease in wound size was significantly higher in the HA-SA-NPWT group than in the conventional therapy group (73.8% versus 34.8%, respectively, p=0.029). Despite a shorter healing period in the HA-SA-NPWT group than in the conventional group, no statistically significant difference was found between groups for time to complete healing (37 days versus 55 days, respectively).

CONCLUSION

These results demonstrate that the combination of HA-SA-NPWT is a promising treatment for decreasing the healing time and increasing the success rate by their synergistic effect on wound healing in hard-to-heal lower extremity ulcers. However, further studies with a larger number of patients are needed to confirm the results.

Regular Use of FlowAid FA100 SCCD Reduces Pain While Increasing Perfusion and Tissue Oxygenation in Contralateral Limbs of Amputees With Diabetic Neuropathy and Peripheral Arterial Disease: Results of an Open, Pre-Post Intervention, Single-Center Study

Patients with diabetic neuropathy and peripheral arterial disease often suffer pain, develop foot wounds, and go on to lose limbs leaving them with a painful limb. Electrical stimulation is one possibility open to physicians. In this study, the effects of the FlowAid FA100 SCCD, a sequential contraction compression device, were tested. The FA100 device is noninvasive; it uses 4 electrodes to sequentially stimulate the calf muscles in a modified intermittent pneumatic compression manner. A total of 14 patients with diabetic neuropathy, peripheral arterial disease, unilateral amputation, and a painful limb were treated with FlowAid FA100 (FlowAid Medical Technologies Corporation, New York, NY) with prior ethical approval. The study design was open, pre-post intervention comparison, and nonrandomized. Pain perceived was measured using Visual Analogue Scale (VAS) scores. Assessments of ankle brachial index (ABI), ultrasound color Duplex, and tissue oxygen using the transcutaneous oxygen technique were done at baseline and 2 successive follow-ups 4 weeks apart. Three out of 14 patients dropped out on account of distances involved in traveling to the clinic. Eleven out of 14 patients experienced statistically significant reduction in pain mean VAS scores (7.5 ± 0.93 to 5.8 ± 1.47, P = .002) associated with increase in ABI (0.64 ± 0.06 to 0.69 ± 0.04, P < .001) and transcutaneous oxygen tension measured on the dorsum (29.4 ± 4.03 to 33.2 ± 5.26 in mm Hg, P = .005). When pain scores were regressed against ABI and transcutaneous oxygen tension values, there was a significant association between these (r = 0.8, P = .002). The reduction in pain following regular use of FlowAid was accompanied by beneficial and statistically significant increases in perfusion and oxygenation.

Dynamic Optical Coherence Tomography Is a New Technique for Imaging Skin Around Lower Extremity Wounds

Chronic wounds such as venous leg ulcers invariably heal slowly and recur. In the case of venous leg ulcers, poor healing of chronic wounds is variously attributed to ambulatory hypertension, impaired perfusion and diffusion, presence of chronic inflammation at wound sites, lipodermatosclerosis, and senescence. The aim of this study was to investigate whether a new technique, optical coherence tomography (OCT), which permits imaging of blood capillaries in the peri-wound skin, can provide new insights into the pathology. OCT and its recent variant, dynamic OCT, permit rapid noninvasive depth-resolved imaging of the capillaries in the superficial dermis via a handheld probe, showing the morphology and density of vessels down to 20 µm in diameter. We used dynamic OCT to investigate 15 chronic wounds and assess characteristics of the vessels at the 4 poles around the wounds, the wound bed, adjacent dermatosclerosis, and unaffected skin. The results of the study show that both vessel morphology and density in the wound edges are dramatically different from that in healthy skin, showing clusters of glomuleri-like vessels (knot-like forms or clumps) and an absence of linear branching vessels, and also greater blood perfusion. Such vessel shapes are reported to be associated with tissue growth. The OCT imaging procedure was rapid and well tolerated by patients and provided new information not available from other devices. Thus, OCT appears to have great promise as a tool for the evaluation and study of chronic ulcers.

Maggot Therapy in Angiopathic Leg Ulcers: A Systematic Review and Meta-Analysis

Maggot therapy (MT) is a biological debridement tool using blowfly larvae to digest necrotic tissue as its food. In addition, maggot secretion contains several peptides that has antibacterial effect and healing stimulants that might enhance wound healing. Clinical outcomes from previous meta-analyses demonstrated benefit of MT, but results were highly heterogeneous. We have conducted an updated systematic review and meta-analysis with clearly defined clinical outcomes according to mechanism of MT including successful debridement, healing rate, and time to heal. Furthermore, our study was the first meta-analysis that reported wound-related pain between MT and conventional therapy. MEDLINE and Scopus were searched for comparative studies of MT and conventional therapy. Ten studies were eligible, of which 5 studies were angiopathic (venous or mixed arteriovenous ulcers) and the other 5 were diabetic foot ulcer. The MT had significant higher rate of successful debridement with risk ratio of 2.3 (95% confidence interval = 1.7-3.0) with low heterogeneity. Time to heal was about 3.1 weeks (95% confidence interval = 1.2-5.0), significantly shorter in MT but with high heterogeneity. Healing rate and pain were not significantly different between groups with high heterogeneity. In conclusion, MT was an effective debridement tool compared with conventional therapy. More studies should be done to confirm other findings because of high heterogeneity.

Role of Topical Biological Therapies and Dressings in Healing Ischemic Wounds

Ischemic wounds are the most severe expression of critical limb ischemia (CLI), and they have been defined clinically as an end stage of peripheral arterial disease. Urgent revascularization is a fundamental part for limb salvage in patients with CLI. However, the risk of revascularization should be weighed against the likelihood of success given a patient’s life-threatening comorbidities. Once the condition of arterial insufficiency is revascularized, wound care is an important aspect to promote the wound healing process and infection control. MOIST concept for wound care is a modern systematic treatment for enhanced wound healing process. Currently, advanced biological therapies are emerging in ischemic wound therapies to restore the wound healing process and involve active biological agents to support the wound healing process. We studied and summarized the different types of available topical biological therapies and their mechanisms on the healing process including platelet-derived growth factor, epidermal growth factor, fibroblast growth factor, and vascular endothelial growth factor, platelet-rich plasma, and honey for local wound care of patient with CLI. Our review suggests that topical platelet-derived growth factor, epidermal growth factor, platelet-rich plasma, and honey are available as well as considered in the ischemic wound healing process enhancement through the MOIST concept. In conclusion, biologic wound dressing or topical agent therapy may improve the wound healing process, increase limb salvage, is inexpensive, and provides potential safety with nontoxic low-risk therapy in patients with an ischemic wound. Thus, local wound care by biological dressing should be added in adjuvant treatment for ischemic wound patients. However, further randomized studies are needed to support efficacy and long-term outcomes of these biological dressing in patients with ischemic wound.

Current concepts for the evaluation and management of diabetic foot ulcers

The lifetime risk for diabetic patients to develop a diabetic foot ulcer (DFU) is 25%. In these patients, the risk of amputation is increased and the outcome deteriorates.More than 50% of non-traumatic lower-extremity amputations are related to DFU infections and 85% of all lower-extremity amputations in patients with diabetes are preceded by an ulcer; up to 70% of diabetic patients with a DFU-related amputation die within five years of their amputation.Optimal management of patients with DFUs must include clinical awareness, adequate blood glucose control, periodic foot inspection, custom therapeutic footwear, off-loading in high-risk patients, local wound care, diagnosis and control of osteomyelitis and ischaemia. Cite this article: EFORT Open Rev 2018;3:513-525. DOI: 10.1302/2058-5241.3.180010.

ImageJ: A Free, Easy, and Reliable Method to Measure Leg Ulcers Using Digital Pictures

Wound measurement to document the healing course of chronic leg ulcers has an important role in the management of these patients. Digital cameras in smartphones are readily available and easy to use, and taking pictures of wounds is becoming a routine in specialized departments. Analyzing digital pictures with appropriate software provides clinicians a quick, clean, and easy-to-use tool for measuring wound area. A set of 25 digital pictures of plain foot and leg ulcers was the basis of this study. Photographs were taken placing a ruler next to the wound in parallel with the healthy skin with the iPhone 6S (Apple Inc, Cupertino, CA), which has a camera of 12 megapixels using the flash. The digital photographs were visualized with ImageJ 1.45s freeware (National Institutes of Health, Rockville, MD; http://imagej.net/ImageJ ). Wound area measurement was carried out by 4 raters: head of the department, wound care nurse, physician, and medical student. We assessed intra- and interrater reliability using the interclass correlation coefficient. To determine intraobserver reliability, 2 of the raters repeated the measurement of the set 1 week after the first reading. The interrater model displayed an interclass correlation coefficient of 0.99 with 95% confidence interval of 0.999 to 1.000, showing excellent reliability. The intrarater model of both examiners showed excellent reliability. In conclusion, analyzing digital images of leg ulcers with ImageJ estimates wound area with excellent reliability. This method provides a free, rapid, and accurate way to measure wounds and could routinely be used to document wound healing in daily clinical practice.

High-Resolution Spectral Analysis Accurately Identifies the Bacterial Signature in Infected Chronic Foot Ulcers in People With Diabetes

Diabetic foot infections are a major cause of hospitalization, and delayed treatment can lead to numerous complications. The aim of this research was to investigate high-resolution spectroscopy of the wound center and periwound area for real-time estimation of multispectral signature of bacteria at the base of diabetic foot ulcers. We investigated the spectrum of the reflected visual light from diabetic foot ulcers and developed a method that identifies the presence of bacteria in the wound infections. We undertook a prospective pilot study on 18 patients with type 1 and type 2 diabetes and chronic diabetic foot ulcers. The spectral coefficients were directly compared with the results from the wound swab. The results of the multispectral analysis demonstrated 100% sensitivity, with 100% negative predictive values of identifying the presence of the bacteria, which was the cause of the infection in the wound. The results of our study suggest that the changes in the multispectral properties of the wound can be used to identify the presence of bacteria in the infected area using a noninvasive device without any contact with the wound. This technique holds great promise for real-time objective evaluation of the wound infection status beyond the standard visual assessment of diabetic foot ulcers.

The venous ulcer continues to be a clinical challenge: an update

Venous ulcers are a common chronic problem in many countries especially in Northern Europe and USA. The overall prevalence of this condition is 1% rising to 3% in the over 65 years of age. Over the last 25 years, there have been many developments applicable to its diagnosis and treatment. These advances, notwithstanding healing response and recurrence, are variable, and the venous ulcer continues to be a clinical challenge.

The pathogenesis of venous ulcers is unrelieved or ambulatory venous hypertension resulting mostly from deep venous thrombosis leading to venous incompetence, lipodermatosclerosis, leucocyte plugging of the capillaries, tissue hypoxia and microvascular dysfunction. It is not known what initiates venous ulcers. Triggers vary from trauma of the lower extremity to scratching to relieve itchy skin over the ankle region. Venous ulcers can be painful, and this condition presents an increasing burden of care. A systematic analysis of the role of technology used for diagnosis and management strongly supports the use of compression as a mainstay of standardised care. It further shows good evidence for the potential of some treatment procedures to accelerate healing. This article reviews the pathogenetic mechanisms, current diagnostic methods and standard care and its limitations.

Fifty-Patient Study Evaluating the Efficacy of Modified Collagen With Glycerin in Periwound Skin Management

The management of chronic nonhealing ulcers pose a great challenge because they are associated with morbidity and increased costs. This report presents the observations of standard management along with application of modified collagen with glycerin (MCG) in the periwound area for management of nonhealing wounds. This observational report included 50 patients (33 male, 17 female) aged 24 to 94 years having nonhealing wounds. All wounds were treated using standard treatment protocols (TIME concept), whereas the periwound severity was assessed using the Harikrishna Periwound Skin Classification (HPSC). All patients received once-daily application of MCG lotion directly in the periwound areas and compression bandaging until there was complete wound healing. Patient compliance was ensured by regular follow-up and counseling. All diabetic patients were counseled to ensure glycemic control during the entire follow-up period. The criteria used for wound healing were based on clinical observation, and proper epithelialization of the wound was the end point. The median age of the wounds was 12.0 weeks (95% CI = 8.00 – 58.08). Majority of the non-healing wounds were diabetic foot ulcers with age of wound between 4 weeks to 15 years. The median time to complete wound healing was 12.71 (95% CI = 10.00-16.67) weeks. Standard treatment protocol of TIME principle with periwound area assessment based on HPSC 2015 and treatment accordingly with topical application of MCG along with additional measures has shown complete healing of nonhealing wounds. However, further large-scale comparative studies are needed to substantiate these effects on a larger population.

Skin perfusion pressure as a predictor of ischemic wound healing potential

Skin perfusion pressure (SPP) is the blood pressure that is the requisite for the restoration of microcirculatory or capillary flow following controlled occlusion and subsequent flow return. The purpose of the current review was to evaluate the value of SPP for the prediction of wound healing in patients with limb ischemia. Articles published up to January 31, 2017 were searched in the PubMed database and Chinese database CNKI, using the keywords of 'skin perfusion pressure', 'limb ischemia' and 'wound healing'. Articles were obtained and reviewed to analyze the predictive value of SPP with regard to the healing potential of ischemia wounds on limbs. Three different types of techniques are currently used for the measurement of SPP, namely radioisotope clearance, photoplethysmography and laser Doppler, with laser Doppler as the most widely applied technique, due to its noninvasiveness and ease of operability. SPP may effectively assess wound healing potential in ischemic limbs with high sensitivity and specificity; however, its optimum cut-off point remains uncertain. Compared with other noninvasive microcirculatory assessment tools including ankle-brachial index, toe blood pressure and transcutaneous oxygen pressure, SPP has its advantages including that it is not affected by vascular calcification, anatomical structure or patient condition. In conclusion, SPP may be used as an index to accurately predict wound healing in patients with limb ischemia. However, it is difficult to determine the optimum cut-off of SPP due to the limitations of current data. Further study is necessary to confirm the optimum cut-off value of SPP in predicting wound healing potential.

Consensus guidelines for the identification and treatment of biofilms in chronic nonhealing wounds

BACKGROUND

Despite a growing consensus that biofilms contribute to a delay in the healing of chronic wounds, conflicting evidence pertaining to their identification and management can lead to uncertainty regarding treatment. This, in part, has been driven by reliance on in vitro data or animal models, which may not directly correlate to clinical evidence on the importance of biofilms. Limited data presented in human studies have further contributed to the uncertainty. Guidelines for care of chronic wounds with a focus on biofilms are needed to help aid the identification and management of biofilms, providing a clinical focus to support clinicians in improving patient care through evidence-based medicine.

METHODS

A Global Wound Biofilm Expert Panel, comprising 10 clinicians and researchers with expertise in laboratory and clinical aspects of biofilms, was identified and convened. A modified Delphi process, based on published scientific data and expert opinion, was used to develop consensus statements that could help identify and treat biofilms as part of the management of chronic nonhealing wounds. Using an electronic survey, panel members rated their agreement with statements about biofilm identification and treatment, and the management of chronic nonhealing wounds. Final consensus statements were agreed on in a face-to-face meeting.

RESULTS

Participants reached consensus on 61 statements in the following topic areas: understanding biofilms and the problems they cause clinicians; current diagnostic options; clinical indicators of biofilms; future options for diagnostic tests; treatment strategies; mechanical debridement; topical antiseptics; screening antibiofilm agents; and levels of evidence when choosing antibiofilm treatments.

CONCLUSION

This consensus document attempts to clarify misunderstandings about the role of biofilms in clinical practice, and provides a basis for clinicians to recognize biofilms in chronic nonhealing wounds and manage patients optimally. A new paradigm for wound care, based on a stepped-down treatment approach, was derived from the consensus statements.

Treatment of diabetic foot ulcers with Therapeutic Magnetic Resonance (TMR®) improves the quality of granulation tissue

Diabetic foot ulcers (DFUs) often result in severely adverse outcomes, such as serious infections, hospitalization, and lower extremity amputations. In last few years, to improve the outcome of DFUs, clinicians and researchers put their attention on the application of low intensity pulsating electro-magnetic fields through Therapeutic Magnetic Resonance (TMR®). In our study, patients with DFUs have been divided into two groups: The Sham Group treated with non-functioning TMR® device, and the Active Group treated with a functioning device. Biopsies were recovered from ulcers before and after a 15-day treatment with both kind of TMR® device. To recognize signs of inflammation or healing process, the harvested biopsies were subjected to histological and molecular analyses. The histological analysis showed a change in cell population after treatment with TMR®: an increase of fibroblasts and endothelial cells with a reduction of inflammatory cells. After TMR® application, the gene expression profile analysis revealed an improvement in extracellular matrix components such as matrix metalloproteinases, collagens and integrins, a reduction in pro-inflammatory interleukins, and an increase in growth factors expression. In conclusion, our research has identified histological and molecular features of reduced inflammation and increased cell proliferation during the wound healing process in response to TMR® application.

The Influence of AGEs Environment on Proliferation, Apoptosis, Homeostasis, and Endothelial Cell Differentiation of Human Adipose Stem Cells

The aim of this study was to evaluate the changes of proliferation, apoptosis, homeostasis, and differentiation of human adipose-derived stem cells (hASCs) in the simulated diabetic microenvironment and discuss the potential of the mesenchymal stem cell in the treatment of chronic diabetic wound. We simulated diabetic microenvironment with glycation end products (AGEs) in vitro and studied the changes of hASCs in proliferation and apoptosis. We found that AGEs inhibited the proliferation and lead to hASCs apoptosis, and the endothelial cell directed differentiation was also inhibited. AGEs upregulated growth-related oncogene and monocyte chemoattractant protein-1 and downregulated urokinase-type plasminogen activator receptor, which may inhibit the proliferation and transference of endothelial cells. The simulated diabetic microenvironment affects the proliferation, apoptosis, and homeostasis of hASCs, the endothelial cell migration, and the synthesis of collagen protein, leading to delayed wound healing.

A Clinicoepidemiological Profile of Chronic Wounds in Wound Healing Department in Shanghai

The aim of the study was to update the clinical database of chronic wounds in order to derive an evidence based understanding of the condition and hence to guide future clinical management in China. A total of 241 patients from January 1, 2011 to April 30, 2016 with chronic wounds of more than 2 weeks’ duration were studied in wound healing department in Shanghai. Results revealed that among all the patients the mean age was 52.5 ± 20.2 years (range 2-92 years). The mean initial area of wounds was 30.3 ± 63.0 cm2 (range 0.25-468 cm2). The mean duration of wounds was 68.5 ± 175.2 months (range 0.5-840 months). The previously reported causes of chronic wounds were traumatic or surgical wounds (n = 82, 34.0%), followed by pressure ulcers (n = 59, 24.5%). To study the effects of age, patients were divided into 2 groups: less than 60 years (<60), and 60 years or older (≥60). The proportion of wounds etiology between the 2 age groups was analyzed, and there was significant statistical difference ( P < .05, 95% confidence interval [CI] = 0.076-0.987). To study the associations between outcome and clinical characteristics in chronic wounds, chi-square test was used. There were significant differences in the factor of wound infection. ( P = .035, 95% CI = 0.031-0.038) Regarding therapies, 72.6% (n = 175) of the patients were treated with negative pressure wound therapy. Among all the patients, 29.9% (n = 72) of them were completely healed when discharged while 62.7% (n = 150) of them improved. The mean treatment cost was 12055.4 ± 9206.3 Chinese Yuan (range 891-63626 Chinese Yuan). In conclusion, traumatic or surgical wounds have recently become the leading cause of chronic wounds in Shanghai, China. Etiology of the 2 age groups was different. Infection could significantly influence the wound outcome.

A Double-Blind, Placebo-Controlled Randomized Evaluation of the Effect of Low-Level Laser Therapy on Venous Leg Ulcers

This study aimed to determine the effect of low-level laser therapy (LLLT) on chronic venous leg ulcers (VLUs). A double-blinded prospective randomized controlled trial was conducted to compare incidence of complete wound closure, ulcer size and pain reduction in patients randomized to 24 treatments of placebo or LLLT (635 nm) over 12 weeks. Patients presented with a 6-week history of VLUs ranging in size from 5 to 20 cm2. Venous origin was confirmed by Doppler ultrasound and an ankle brachial index of 0.8 or greater. Of 24 patients, 23% of the test group (n = 13) and 18% of placebo group (n = 11) achieved complete wound closure. At 12 weeks, patients in test and placebo groups had a mean surface area reduction of 6.26 cm2 ( P < .0001) and 6.72 cm2 ( P < .005), respectively, and a mean pain score decrease of 43.54 points ( P < .0001) and 25.73 points ( P = .002) respectively. Differences between groups was not statistically significant for wound closure ( P = 1.0) or ulcer size ( P = .80). Mean ulcer pain was significantly reduced from initiation of treatment compared with 4 weeks’ follow-up after 12 weeks with LLLT ( P < .01). Within the limitations of the study, LLLT may not have early effects as an adjunctive therapy to wound healing of VLUs, but LLLT may have delayed effects on VLU healing and associated pain, which requires further study.

Free-Flap Transfer for Coverage of Transmetatarsal Amputation Stump to Preserve Residual Foot Length

Surgical management of soft-tissue defects of the forefoot and midfoot caused by trauma or diabetic complications can be challenging because locoregional tissue is insufficient to provide adequate flap. This deficiency necessitates higher-level amputations, such as Chopart or even transtibial amputation, resulting in far more debilitating functional outcomes than are seen with partial foot amputation. The purpose of this study was to examine the surgical outcomes after transmetatarsal amputation and a free-flap transfer to preserve foot length. This prospective case series was conducted from January 2011 to December 2015 at the Department of Plastic and Reconstructive Surgery at our institute. A total of 16 patients (11 men and 5 women) were enrolled in this study, all of whom were candidates for higher-level amputation because of inadequate soft-tissue coverage after debridement. Each patient underwent transmetatarsal amputation and reconstruction of the amputation stump using free-flap transfers to preserve foot length. Preoperative and postoperative data were collected to evaluate the postoperative outcomes. All 16 free-flap transfers were successful, with no major complications. In 2 cases, partial flap necrosis required additional skin grafting. The mean follow-up period was 24.3 months (range = 7-55 months). Flap coverage was stable, and all the patients were comfortable with their prostheses at long-term follow-up. Use of a free flap to reconstruct a transmetatarsal amputation stump provided stable coverage, preserved maximal foot length, and resulted in good functional outcomes.

Wound Closure in Smoking Peripheral Arterial Disease Patients With Treatment-Refractory Ulcerations: A 12-Month Follow-up Case Series

Despite ongoing smoking cessation efforts and optimized perfusion, failed wound closure in the presence of peripheral arterial disease (PAD) and diabetes are common. A clinical effectiveness review was conducted in actively smoking diabetic patients diagnosed with PAD, treated with serial applications of a viable intact cryopreserved human placental membrane (vCPM) (Grafix, Osiris Therapeutics Inc, Columbia, MD) for recalcitrant lower extremity ulcerations (n = 6). More than half of the patients were not candidates for revascularization. Baseline vascular status in 5 of 6 lower-extremity wounds remained unchanged throughout the entire course of vCPM treatment. Daily cigarette consumption averaged 18 cigarettes per patient. Mean wound duration and mean surface area was 53 weeks and 4.6 cm2, respectively. Mean number of vCPM applications and time to closure was 7.0 grafts in 7.8 weeks. There were no wound-related infections or amputations and no vCPM-related adverse events. All 6 wounds remained closed at the 12-month follow-up visit. In conclusion, vCPM demonstrated clinically effective outcomes in 6 previously nonhealing ulcerations despite ongoing smoking habits in the presence of PAD and diabetes.

Silver Sulfadiazine–Impregnated Hydrocolloid Dressing Is Beneficial in Split-Thickness Skin-Graft Donor Wound Healing in a Small Randomized Controlled Study

Donor-site wound healing was tested with a silver sulfadiazine (SSD)-impregnated hydrocolloid dressing and hydrocolloid dressing applied manually by a physician on site. A total of 14 patients, 5 woman and 9 men (23-89 years old, average = 61.6 ± 18.70 years), were enrolled in this prospective controlled study. The degree of bleeding was significantly less with the SSD-impregnated than with the hydrocolloid dressing (P < .01). In the moisture meter analysis, the values of the effective contact coefficient and corneal thickness were significantly smaller with the SSD-impregnated dressing (P < .05). In the color analysis, the clarity was significantly lower with the hydrocolloid dressing after 3 months than that of intact neighboring skin (P < .01). Regarding red-green color, SSD-impregnated and hydrocolloid values were significantly greater than the intact skin value immediately after and at 3 months, and the hydrocolloid value was significantly greater than intact at 6 months (P < .01 immediately; P < .01 at 3 months and intact at 6 months) in redness. Regarding yellow-blue color, the hydrocolloid value was significantly lower than the intact skin value at 3 months (P < .05 and intact) in yellow. The extensibility was significantly lower with the hydrocolloid dressing than in intact skin immediately (P < .01), and viscoelasticity was significantly lower with the hydrocolloid dressing than in intact skin immediately and after 3 and 6 months (P < .01 immediately and at 6 months and P < .05 at 3 months). The SSD-impregnated hydrocolloid dressing led to superior wound healing, decreased the degree of bleeding, and demonstrated better corneal barrier function, clarity, color matching, and viscoelasticity in split-thickness donors.

A Mobile Application for Wound Assessment and Treatment: Findings of a User Trial

The D+Wound Solution is a mobile phone application (app) that assists users in the assessment and treatment of the wound. The app has 6 components for assessment: need for debridement, infection control, revascularization, and exudate control; whether it is chronic; and finally, the top surface of the skin. These components are named D.I.R.E.C.T. The app makes you review these components as an algorithm to provide a reasonable solution for dressing. It is designed to understand the status of the wound and provide a practical treatment idea for wound care providers. A total of 118 nurses were divided into 2 groups, designated as experienced and less-experienced groups, and surveyed. Both groups found the app to be helpful in making a treatment plan. However, the less-experienced group found it to be significantly more useful in assessing the wound ( P = .026) but difficult to understand the logic. The experienced group found the logic to be significantly easier to understand ( P = .018) and had significantly higher similarities ( P = .015) in treatment protocols compared with the less-experienced group. We may conclude that this app has a logical algorithm resembling experienced wound caregivers and is more useful in the less-experienced group.

Hyperbaric Oxygen Therapy in the Treatment of Fontaine Stage IV Thromboangiitis Obliterans

Ischemic wounds unresponsive to standard treatment in thromboangiitis obliterans are associated with amputation, morbidity, and mortality. In this study, hyperbaric oxygen therapy was added to standard treatment of 36 patients with thromboangiitis obliterans with ischemic ulcerated wounds in the extremities. Full recovery was observed in 52.7% of cases (25% at discharge, 27.7% during follow-up). Resting pain after treatment decreased significantly compared to pretreatment levels based on visual analog scale scores (7.1 ± 1.7 vs 2.2 ± 3.0, P = .0001). Mean wound area also decreased significantly after treatment (22.6 ± 17.5 vs 13.02 ± 16.5, P = .0001). The number of patients requiring no assistance during routine daily activities increased significantly (25% vs 55.5%, P = .001). All patients were at Fontaine stage IV before hyperbaric oxygen therapy. The number of patients at stage IIB increased significantly after treatment, while that of patients at stage IV decreased significantly (0% vs 47.2%, P = .0001, and 100% vs 47.2%, P = .0001, respectively). None of our patients was able to walk without pain before treatment; however, walking distance was significantly extended in 16 patients who were capable of walking (0 vs 190.6 ± 129.4 meters, P = .0001). In addition, 11.1% of patients underwent major amputation during follow-up.