Hard-to-heal wound treated with Integra Flowable Wound Matrix: analysis and clinical observations

Skin healing defects severely impair the quality of life of millions of people and burden healthcare systems globally. The therapeutic approach to these pathologies still represents a challenge. Novel scaffolds, used as dermal substitutes, possibly represent a promising strategy in complex wound management. Integra Flowable Wound Matrix (IFWM) is composed of a lyophilised, micronised form of collagen/chondroitin sulphate matrix, already used in regenerative medicine and endorsed in the therapy of diabetic foot lesions. In this paper, IFWM was applied to a tunnelling hard-to-heal skin lesion in order to restore tissue integrity. Although the different phases of skin wound healing are well established, the molecular mechanism underpinning IFWM-induced tissue repair are almost unknown. Here, we report, for the first time, the comparative analysis of molecular, histological and clinical observations of the healing process of a hard-to-heal tunnelling skin wound. The therapeutic success of this clinical case allowed us to recommend the use of IFWM as a tissue substitute in this rare type of hard-to-heal wound in which the high inflammatory status hampered the natural healing process.

Expanded negative pressure wound therapy in healing diabetic foot ulcers: a prospective randomised study

OBJECTIVE

This study aims to evaluate the benefits of treating diabetic foot ulcers (DFU) through a revised procedure using the mechanisms underlying negative pressure wound therapy (NPWT) in such a way as to achieve reduced and more evenly distributed lateral tension lines across the wound.

METHOD

Patients with type 2 diabetes were assessed for elegibility. Included patients were divided randomly into two groups: the NPWT control group and the NPWT+ group. Patients in the NPWT control group were treated in the traditional manner: wounds were covered with foams shaped to fit the wound precisely. In the NPWT+ group, foams were shaped to fit the wound precisely, and an additional foam was then wrapped around the foot.

RESULTS

Some 85 patients were assessed for eligibility; 59 were randomised into two groups: 29 patients in the NPWT+ group and 30 patients in the NPWT group. The primary objective was median healing time (NPWT+ 19 days, interquartile ratio (IQR) 7.5; NPWT 33 days, IQR 16; p<0.00001), and complete wound healing at three weeks (NPWT+ 55.20% NPWT 26.70% p=0.02). Secondary endpoints included number of major amputations (none in either group) and number of infections (NPWT+ 3.44% of patients, NPWT 6.66% of patients; p=0.57).

CONCLUSION

Our initial findings show that this treatment significantly reduced wound closure times and accelerated healing in DFUs. It also demonstrated promising improvements in healing rates, with no significant increase in wound complications.

Acellular Dermal Matrix Used in Diabetic Foot Ulcers: Clinical Outcomes Supported by Biochemical and Histological Analyses

Diabetic foot ulcer (DFU) is a diabetes complication which greatly impacts the patient's quality of life, often leading to amputation of the affected limb unless there is a timely and adequate management of the patient. DFUs have a high economic impact for the national health system. Data have indeed shown that DFUs are a major cause of hospitalization for patients with diabetes. Based on that, DFUs represent a very important challenge for the national health system. Especially in developed countries diabetic patients are increasing at a very high rate and as expected, also the incidence of DFUs is increasing due to longevity of diabetic patients in the western population. Herein, the surgical approach focused on the targeted use of the acellular dermal matrix has been integrated with biochemical and morphological/histological analyses to obtain evidence-based information on the mechanisms underlying tissue regeneration. In this research report, the clinical results indicated decreased postoperative wound infection levels and a short healing time, with a sound regeneration of tissues. Here we demonstrate that the key biomarkers of wound healing process are activated at gene expression level and also synthesis of collagen I, collagen III and elastin is prompted and modulated within the 28-day period of observation. These analyses were run on five patients treated with Integra® sheet and five treated with the injectable matrix Integra® Flowable, for cavitary lesions. In fact, clinical evaluation of improved healing was, for the first time, supported by biochemical and histological analyses. For these reasons, the present work opens a new scenario in DFUs treatment and follow-up, laying the foundation for a tailored protocol towards complete healing in severe pathological conditions.

Efficacy of a New Flowable Wound Matrix in Tunneled and Cavity Ulcers: A Preliminary Report

INTRODUCTION

In chronic wounds the healing is stagnant, and regenerative surgery is often needed. Many engineered tissues with a conventional bidimensional sheet are ineffective for tunneling wounds, because adherence to the wound bed is not complete. An advanced wound matrix for treating wounds with irregular geometries has been developed (Integra Flowable Wound Matrix, Integra LifeScience Corp, Plainsboro, NJ).

METHODS AND MATERIALS

Between March 2013 and December 2013 the authors treated 18 patients (11 female) with tunneled or cavity ulcers with the advanced wound matrix at the Unit of General and Geriatric Surgery of the Second University of Naples, Naples, Italy. Two patients (11.1%) had postsurgical wounds, two (11.1%) had post-traumatic wounds, and 14 (77.8%) had neuropathic ulcers. After debridement and antibiotic therapy, the lesions were filled with the wound matrix product. Surgical wound edges were either approximated with stitches or left to heal by secondary intention and covered with wet gauze. During the first week, follow-up visits were carried out every 3 days, then once a week until complete healing was achieved. All patients underwent preoperative and postoperative ultrasonography scans and plain radiograph controls.

RESULTS

Twenty-one applications were performed. Engraftment was complete in all but 1 patient who had diabetes and graft failure. Three patients needed repeated applications to complete the filling of the lesions. Median (range) pain Visual Analog Scores-on a scale of 0 to 10, where 0 = no pain, and 10 = intolerable pain-were 6.3 (range 3-8) preoperatively and 0.5 (range 0-2) at first follow-up (P ≤ 0.001). All but 2 patients showed a progressive remodeling of the tissue gap at scheduled radiographic controls.

CONCLUSIONS

To the author's knowledge, the advanced wound matrix used in this study is the only available biomaterial for the treatment of tunneled lesions. It stimulates tissue regeneration by filling surfaces which cannot be repaired spontaneously or by using conventional biomaterials in the form of sheets. Its application is atraumatic, painless, and safe.

New advances in negative pressure wound therapy (NPWT) for surgical wounds of patients affected with Crohn's disease

Surgical site complications (SSC) negatively affect costs of care and prolong length of stay. Crohn's disease (CD) is a risk factor for SSC. CD patients often need surgery, sometimes requiring stoma. Our primary aim was to compare the effects on SSC of a portable device for NPWT (PICO, Smith & Nephew, London, UK) with gauze dressings after elective surgery for CD. Secondary aims were manageability and safety of PICO and its feasibility as home therapy. Between 2010 and 2012, 50 patients were assigned to treatment with either PICO (n = 25) or conventional dressings (n = 25). Each patient completed 12-month follow-up. Parameters of interests for primary aim were SSC, surgical complications, and readmission rates. Data on difficulties in managing PICO and device-related complications were also collected. Patients receiving PICO had less SSC, resulting in shorter hospital stay. At last follow-up, readmission rates were lower with PICO. No differences were observed in surgical complications between groups. No patients reported difficulties in managing the device. Among patients discharged with PICO, none needed to come back to the hospital for device malfunctioning or inability to manage it. PICO reduces SSC and length of stay in selected CD patients compared with conventional dressings. The device is safe and user friendly.

[Excisional biopsy with wire localisation of non-palpable breast lesions: indications and limitations]

Preoperative localisation of non-palpable breast lesions is necessary for excisional biopsies. This can be achieved with methods such as anchor wire, charcoal marking, or radio-guided localisation. The aim of the present study was to evaluate retrospectively our experience with the wire localisation technique. One hundred and eighty-two patients with non-palpable breast lesions (diameter: 0.4-1.5 cm) were operated on under local anaesthesia. Intraoperative X-rays were performed in all cases. No serious perioperative complications occurred. Three patients (2 with postoperative haematomas and 1 with wound infection) underwent conservative therapy. The lesions were benign in 67/182 patients (37%), ductal and/or lobular invasive cancer in 42 (23%), carcinoma in situ in 23 patients (12.5%) and ADH-ALH in 50 patients (27.5%). Our experience confirms that wire localisation biopsies constitute an excellent method for the excision of non-palpable breast lesions. This technique is characterised by high reliability (100% total excisions) and assures a prognostic evaluation of high-risk lesions such as ductal an/or lobular atypical hyperplasia.