Consensus recommendations for optimizing the use of intact fish skin graft in the management of acute and chronic lower extremity wounds

BACKGROUND

Since 2017, the clinical use of IFSG has increased substantially in the United States, with some use in Europe and Asia as well. However, scant consensus data have been published on such use.

OBJECTIVE

The authors sought to develop consensus recommendations for the clinical use of IFSG in the management of acute and chronic LEWs.

METHODS

A panel of 8 expert clinicians in the United States used a 2-cycle NFG process to develop consensus statements based on their own clinical practice and the literature. At their initial meeting in October 2021, panel members discussed the management of DFUs, VLUs, atypical LEWs, and traumatic LEWs in their practices. Consensus statements were drafted, voted on, and rated by relative importance. At the second meeting in October 2022, the panel discussed the initial survey results; a second survey was conducted, and panel members revised the recommendations and indicated the relative importance of each in the final report. A systematic literature review of English-language articles published from January 2016 through November 2022 was conducted as well, using the search terms: "fish skin," "piscine graft," "fish tissue," "intact fish skin graft," "Cod skin," "Omega 3 fatty acid graft."

RESULTS

Forty-three statements were generated and grouped into 5 sections comprising general recommendations for LEWs and recommendations specific to DFUs, VLUs, atypical LEWs, and traumatic LEWs. The primary general recommendation is the need to determine wound etiology based on clinical evaluation and reviewing related test results. For DFUs and VLUs, the main recommendations are to adhere to first-line therapy (ie, standard of care, follow conventional guidelines [multilayer compression therapy], offloading, and assessment of wound perfusion) before introducing IFSG.

CONCLUSIONS

Publications on and clinical experience in the use of IFSGs have increased substantially in the past several years. The 43 consensus recommendations are meant to guide physicians in the optimal use of IFSG in the management of acute and chronic LEWs.

Understanding the zebras of wound care: an overview of atypical wounds

Atypical wounds account for approximately 5% to 20% of chronic ulcerations. Typically, clinical suspicion of an uncommon etiology is warranted for wounds that do not show signs of healing with conventional care, that are associated with pain out of proportion to the clinical presentation, or that are atypical in appearance. This review provides a general overview of various atypical wound etiologies, clinical presentations and appearance, and current treatment protocols. The clinical presentation, pathophysiologic etiology, and current literature on each etiology are presented. The etiologies discussed are pyoderma gangrenosum, calciphylaxis, lichen planus, necrobiosis lipoidica, infectious ulcers, hidradenitis suppurativa, artefactual ulcers, hydroxyurea-induced ulcers, vasculopathies, and neoplastic ulcers. Patients with atypical wounds experience a poorer prognosis and slower healing rate compared with patients with typical wound etiologies (eg, vascular and diabetic wounds). Biopsy is often vital in wound care to identify and differentiate wound etiologies. It is important to note that multiple characteristics or histologic features can overlap in a biopsy with atypical wounds. Therefore, a biopsy will still require an understanding of the presentation of these different wounds and should only be used when appropriate. The proper diagnosis for an atypical wound can greatly hasten wound closure, decrease the cost for the patient and the health care system, and improve the patient's quality of life. Because of the limited availability of patient populations with atypical wound etiologies, literature concerning specific pathologies is limited. More research on each pathology is needed, as is a universally accepted treatment protocol for atypical wounds.

A dual pressure indicator, two-layer compression system for treatment of venous leg ulcers: a review

OBJECTIVE

Venous leg ulcers (VLUs) are considered the most frequent category of hard-to-heal limb ulcers. Although evidence-based care of VLUs suggests that compression therapy plays a pivotal role in the standard of care, patient adherence is considered low, with at least 33% non-compliance, either due to perceived problems from clinicians regarding their own competency in applying the bandages, or from the patient finding the wrapping bothersome. For many years, four-layer bandaging has been considered the 'gold standard', but application can be difficult and may also prove uncomfortable for patients. Accurate application may be facilitated by a stretch indicator which has been engineered to act as a surrogate for appropriate pressure application that can address the skill concern, while fewer layers can save clinicians' time and improve the quality of life of patients. Here, we review the literature supporting a two-layer system which combines elastic (long stretch) and inelastic (short stretch) components as well as both layers having graphic markers to define that the dressing has been applied at the proper tension.

METHOD

An initial search was conducted on PubMed and then followed up by a manual search of Google Scholar to retrieve evidence of different levels, in order to evaluate the outcomes of use of the specific two-layer compression system with pressure indicators in the management of patients presenting with VLUs.

RESULTS

A total of four papers discussing the specific compression system in question were identified from 32 publications retrieved from PubMed, while a further six were retrieved from Google Scholar. These 10 publications were considered relevant to the two-layer system and were analysed for the outcomes of care, including wound healing, appropriate application, time-saving and better patient acceptance and adherence.

CONCLUSION

Previous authors have demonstrated that two-layer systems are equivalent to four-layer systems. However, the ability to reproducibly apply appropriate compression has remained a question. The papers reviewed demonstrate that evidence suggests that the two-layer compression bandage system with indicators provides continuous, consistent and comfortable treatment that may be easier to apply with accurate pressure levels due to their indicator systems, and therefore, is a procedure that may increase patient adherence and acceptability to the wound therapy.

Practice Dilemmas: Conditions That Mimic Pressure Ulcers/Injuries— To Be or Not To Be?

BACKGROUND: Pressure ulcers/injuries (PU/Is) negatively affect patients by causing pain and increasing morbidity and mortality risks. Care teams have a heightened sense of awareness of the condition and may feel confident in their ability to appropriately identify and manage PU/Is, but the potential for, and consequences of, a misdiagnosis always should be considered. PURPOSE: The purpose of this compendium is to describe and illustrate conditions that may mimic PU/Is. METHODS: Advanced practice wound care nurses were asked to identify and describe conditions that may mimic PU/Is. Permission was obtained from all patients to use their cases and photos in this article. RESULTS: Sixteen (16) different skin and wound presentations resulting from vascular diseases, systemic infections, trauma, cancer, autoimmune disorders, coagulopathies, and multisystem organ dysfunction were identified and described. CONCLUSION: A complete patient history and assessment will help prevent misidentification of the etiology of a skin lesion or wound and misdiagnosis of these lesions as PU/Is.

Practice Dilemmas: Conditions That Mimic Pressure Ulcers/Injuries- To Be or Not To Be?

BACKGROUND

Pressure ulcers/injuries (PU/Is) negatively affect patients by causing pain and increasing morbidity and mortality risks. Care teams have a heightened sense of awareness of the condition and may feel confident in their ability to appropriately identify and manage PU/Is, but the potential for, and consequences of, a misdiagnosis always should be considered.

PURPOSE

The purpose of this compendium is to describe and illustrate conditions that may mimic PU/Is.

METHODS

Advanced practice wound care nurses were asked to identify and describe conditions that may mimic PU/Is. Permission was obtained from all patients to use their cases and photos in this article.

RESULTS

Sixteen (16) different skin and wound presentations resulting from vascular diseases, systemic infections, trauma, cancer, autoimmune disorders, coagulopathies, and multisystem organ dysfunction were identified and described.

CONCLUSION

A complete patient history and assessment will help prevent misidentification of the etiology of a skin lesion or wound and misdiagnosis of these lesions as PU/Is.

A dual compression system: preliminary clinical insights from the US

There is growing evidence on an interconnection between the venous and lymphatic systems in venous leg ulceration, and the possible effects of prolonged oedema and lymphatic impairment in delayed wound healing. Compression therapy is a widely accepted treatment for venous and lymphatic disorders, as it decreases recurrence rates and prolongs the interval between recurrences. Compression bandages improve venous return, increase the volume and rate of venous flow, reduce oedema and stimulate anti-inflammatory processes. The pressure at the interface (IP) of the bandage and the skin is related to the elastic recoil of the product used and its resistance to expansion. The pressure difference between the IP in the supine and standing positions is called the static stiffness index (SSI). Elastic materials provide little resistance to muscle expansion during physical activity, resulting in small pressure differences between resting and activity, with an SSI <10mmHg. Stiff, inelastic materials with a stretch of <100% resist the increase of muscle volume during physical activity, producing higher peak pressures, an SSI of >10mmHg and a greater haemodynamic benefit than elastic systems. UrgoK2 is a novel dual-layer high-compression system consisting of an inelastic (short stretch) and elastic (long stretch) bandage, resulting in sustained tolerable resting pressure and elevated working pressures over extended wear times. It is indicated for the treatment of active venous leg ulcers and the reduction of chronic venous oedema. Each bandage layer has a visual aid to enable application at the correct pressure level. Published European studies have assessed this compression system, exploring its consistency of application, tolerability and efficacy. This article presents the first reports of health professionals' clinical experience of using the compression system in the US, where it has been recently launched. Initial feedback is promising.

Management of Isolated Anterior Tibial Tendon Rupture: A Systematic Review and Meta-Analysis

Rupture of the tibialis anterior tendon is a rare condition reported to occur most often spontaneously in patients >45 years of age. Diagnosis is often delayed due to transient pain at the time of rupture and the ability of the long extensors to compensate for the lost action of the tibialis anterior. Treatment has been proposed to be based on the activity level of the individual; however, no consensus has been reached on the optimal treatment modality for this rare condition. A systematic review and meta-analysis were performed to determine outcomes obtained with conservative and surgical management. Twenty-four references (155 cases) were identified. Conservative management (21 cases, 13.55%) was associated with poorer outcomes (odds ratio [OR] 0.68; I² = 61%) because of pain and functional limitations related to ankle dorsiflexory weakness. Surgical intervention (134 cases, 86.45%) had a better chance for good outcome (OR 8.40; I² = 63%). Use of an ipsilateral split/turn-down ipsilateral tibialis anterior tendon graft (OR 32.15; I² = 0%) semitendinous autograft (OR 15.25; I² = 44%), or direct repair (OR 12.57; I² = 0%) provided the best postoperative outcomes, whereas extensor hallucis longus autograft was associated with the worst (OR 0.27, I² = 34%). The most common postoperative finding was objective mild dorsiflexory weakness (4/5 muscle strength), which did not translate to subjective functional limitation. Good functional results were found to occur regardless of patient age at the time of intervention. Results of this systematic review and meta-analysis suggests that surgical intervention provides better functional outcomes than conservative management. Use of an extensor hallucis longus autograft is not recommended if surgical intervention is performed.

Total Contact Cast Use in Patients With Peripheral Arterial Disease: A Case Series and Systematic Review

INTRODUCTION

As the majority of diabetic foot ulcerations (DFUs) occur on the plantar foot, excessive pressure is a major contributing factor to delayed healing. The gold standard for offloading is the total contact cast (TCC); yet, TCC use is contraindicated in patients with ischemia. Lower extremity ischemia typically presents in the more severe end stages of peripheral arterial disease (PAD). As PAD exists on a severity spectrum from mild to severe, designation of a clear cutoff where TCC use is an absolute contraindication would assist those who treat DFUs on a daily basis.

OBJECTIVE

The aim of this study is to determine if a potential cutoff value for PAD where TCC use would be an absolute contraindication could be ascertained from a retrospective case series and a systematic literature review of patients with PAD in which treatment included TCC use.

MATERIALS AND METHODS

A retrospective cases series and systematic review of patients with mild to moderate PAD treated with a TCC was performed. All reports of TCC use in patients with PAD and a neuropathic ulceration that included results of noninvasive vascular studies were included.

RESULTS

Results suggested that TCC use is a viable treatment modality for pressure-related DFUs in patients with an ankle pressure ≥ 80 mm Hg, a toe pressure ≥ 74 mm Hg, an ankle-brachial index ≥ 0.55, or a toe-brachial index ≥ 0.55.

CONCLUSIONS

Vascular evaluation, individual risk/benefit analysis, close follow-up, and patient education are essential components of TCC use in these patients. Repeat vascular evaluation is recommended if the wound fails to progress towards resolution with TCC use.