Healing hard-to-heal diabetic foot ulcers: the role of dehydrated amniotic allograft with cross-linked bovine-tendon collagen and glycosaminoglycan matrix

The treatment of diabetic foot ulcers is complex and costly with an increased risk for infection, which may even lead to amputation. This prospective case series aims to assess the effectiveness of a dehydrated amniotic membrane allograft combined with a bilayer dermal matrix for healing complicated foot ulcers in patients with comorbidities. A total of six patients with complicated full-thickness ulcers and comorbidities, such as diabetes and peripheral vascular disease were treated with this technique. Each wound was measured intraoperatively just before graft application, at 14 days after application, and then at weeks 4, 8, and 12. Changes in wound volume and area were compared over time. One patient had complete wound closure by week eight, a second patient by week 12. The other four patients had wounds that decreased in size during the course of 12 weeks. The mean decrease in wound volume was 73.5% post-removal of the bilayer dermal matrix after two weeks of application. At week 12, the mean decrease in wound area and volume were 93.2% and 97.1%, respectively. This case series provides initial evidence that the combination of dehydrated amniotic membrane allograft with bilayer dermal matrix promotes complete wound closure in patients with comorbidities that may impede wound healing. Further clinical trials are needed to confirm these results.

Use of a dual-layer amniotic membrane in the treatment of diabetic foot ulcers: an observational study

BACKGROUND

Despite advances in the treatment, fewer than half of diabetic foot ulcers (DFUs) heal in 12 weeks and 85% of non-traumatic amputations follow the development of a DFU. The search for treatment options continues. Placental-derived products have shown promise in the treatment of DFUs. This study investigates Artacent (Tides Medical, US), a unique amniotic patch containing two layers of amnion and its potential to increase growth factor delivery.

METHOD

This observational analysis included patients with DFUs with documented failure to heal by >50% after the protocol-defined run-in period (either two or four weeks) of standard of care (SOC), and who had been randomised in a larger clinical trial that had been discontinued earlier for logistical reasons. Patients were randomised to either weekly or biweekly application of the dual-layer amniotic membrane (DLAM) plus SOC and were included in per-protocol effectiveness analyses. Descriptive statistics were chosen for this analysis. Primary endpoint was complete closure at 12 weeks.

RESULTS

A total of 26 patients were included in the analysis. Examination of baseline patient characteristics revealed that the ulcers were larger than in most DFU clinical trials (4.65±4.89cm²). For the primary endpoint, 17/26 (65%, 95% CI: 44-83%) of the combined treatment arms achieved complete closure. The small sample size precluded a meaningful comparison of healing between weekly and biweekly DLAM applications.

CONCLUSION

The observations taken from the discontinued clinical trial suggest that the DLAM promotes healing of DFUs. The healing rates are similar to those in other placental-based tissue studies. In addition, the relatively larger size of the ulcers suggests that the DLAM may be effective in ulcers that are more resistant to standard of care. In the future, a revised clinical trial with a greater sample size is planned.

Pterygium Surgery Utilizing Limbal Conjunctival Autograft and Subconjunctival Amniotic Membrane Graft in High-Risk Populations

Objective

To measure the outcomes of primary pterygium excision with a limbal conjunctival autograft when combined with the adjunctive use of a prophylactic subconjunctival graft of amniotic membrane to decrease the recurrence rate after surgery in an ethnically diverse population with a statistically higher risk for recurrence (African American, Asian, Caribbean, Asian, Latin).

Design

This is a retrospective, non-comparative study of post-operative outcomes.

Participants

A total of 355 patients, totaling 493 eyes, with clinically significant, primary pterygia.

Patients and Methods

Patients were enrolled into the study based on the need for pterygium surgery and if they underwent primary pterygium excision with conjunctival autograft with subconjunctival amniotic membrane placement. Patients with recurrent pterygium or those with pseudopterygium were excluded from this study. All surgeries took place at the Florida Eye Microsurgical Institute (Boynton Beach, FL) between June 2006 and October 2013 by a single surgeon (BAS). Patients were seen on post-operative day 1, 7, 30, 90, 180 and 365 to evaluate for pterygium recurrence. Pterygium recurrence is defined in this study as growth greater than 1 mm past the corneal limbus at or after 6 months.

Results

There were six cases of recurrent pterygium for a recurrence rate of 1.22% ± 0.97% (n=493, p=0.05). Follow-up ranged from 6 months to 6 years (mean 28 months).

Conclusion

Primary pterygium excision with a limbal conjunctival autograft and placement of a subconjunctival amniotic membrane graft has a low recurrence rate consistent with previously published data.

Palladium-103 plaque therapy for multifocal iris melanoma: Radiation of the entire anterior segment of the eye

PURPOSE

To investigate the safety and tolerability of total anterior segment palladium-103 (¹⁰³Pd) eye plaque brachytherapy for multifocal iris melanoma.

METHODS

Interventional case series of 11 patients with multifocal iris melanomas. Anterior segment ultrasound revealed tumor size, location, and intraocular margins. Epicorneal amniotic membrane grafts protected the cornea and decreased pain during total anterior segment 103-Pd ophthalmic plaque brachytherapy.

RESULTS

Eleven diffuse iris melanomas were American Joint Committee on Cancer 8th edition-classified as T1 (n = 5, 45.5%) and T2 (n = 6, 54.5%). Plaque radiation was completed to a minimum mean tumor dose of 85 Gy (mean dose rate, 58.1 cGy/h). Ultrasonographic tumor thickness regression was 41% (follow up mean 58.7, median 50, range: 8-139 months). Despite 100% local control and 100% eye retention, one patient (9.1%) developed metastatic disease. Four eyes required cataract surgery. There was no corneal stem-cell deficiency, corneal opacity, radiation maculopathy, or optic neuropathy. While visual acuity prior to treatment was 20/40 or better in 10 (91%), 9 were 20/40 or better (81.9%) at last follow-up. Four (36%) had glaucoma prior to treatment and three eyes developed glaucoma after treatment for a total of 63%.

CONCLUSION

Total anterior segment (¹⁰³Pd) plaque brachytherapy resulted in local control, good visual acuity, eye and life preservation in the treatment of multifocal iris melanoma.

Human tissue banking in Bangladesh: hope for the patients of massive burns, surgical wound and bone associated complications

Each year throughout Bangladesh, thousands of people suffering from massive burns and surgical wounds require amniotic grafts for transplantation. Additionally, the stricken persons of the country have to embrace bone associated disability for the whole life due to traumatic complications need bone graft to treat. As a result, these two problems are the largest financial burden as this situation not only affect the family of patients but also cripple down national economy. However, institute of tissue banking in Bangladesh has undertaken the service program on the processing, preservation and clinical applications of amnion membrane and bone graft for rehabilitative surgery. Importantly, in recent years, this institute has started cranial bone autograft processing and transplantation. In accidental cases such as head injury, it is difficult to provide suitable cranial bone allograft according to demand. In this situation, injured cranial bone of the patient is being transported to the lab of the institute, where the scientist, tissue banker and medic work together immediately to process the cranial bone and sterilize by gamma radiation; and after quality assurance, the processed cranial bone autograft is being supplied for replacement surgery. The use of irradiated amnion and bone allografts and cranial bone autograft in reconstructive surgery restore normalcy to lives of many patients from disabilities. This tissue bank is based on finding and obtaining qualified donors from the community and a demand for tissue grafts from the hospitals. Although growing needs for tissue transplantation but raw and processed tissue grafts preservation and banking braces enormous logistical limitations. The only human tissue bank in Bangladesh, however, ensures the availability of tissue allografts of high quality and acceptability to the recipients for rehabilitative surgery for a decade, regardless patients' socio-economic status.