[Cost-effectiveness in wound care]

Combining Biocompatible and Biodegradable Scaffolds and Cold Atmospheric Plasma for Chronic Wound Regeneration

Skin regeneration is a quite complex process. Epidermal differentiation alone takes about 30 days and is highly regulated. Wounds, especially chronic wounds, affect 2% to 3% of the elderly population and comprise a heterogeneous group of diseases. The prevailing reasons to develop skin wounds include venous and/or arterial circulatory disorders, diabetes, or constant pressure to the skin (decubitus). The hallmarks of modern wound treatment include debridement of dead tissue, disinfection, wound dressings that keep the wound moist but still allow air exchange, and compression bandages. Despite all these efforts there is still a huge treatment resistance and wounds will not heal. This calls for new and more efficient treatment options in combination with novel biocompatible skin scaffolds. Cold atmospheric pressure plasma (CAP) is such an innovative addition to the treatment armamentarium. In one CAP application, antimicrobial effects, wound acidification, enhanced microcirculations and cell stimulation can be achieved. It is evident that CAP treatment, in combination with novel bioengineered, biocompatible and biodegradable electrospun scaffolds, has the potential of fostering wound healing by promoting remodeling and epithelialization along such temporarily applied skin replacement scaffolds.

Consensus on the application of negative pressure wound therapy of diabetic foot wounds

Because China is becoming an aging society, the incidence of diabetes and diabetic foot have been increasing. Diabetic foot has become one of the main health-related killers due to its high disability and mortality rates. Negative pressure wound therapy (NPWT) is one of the most effective techniques for the treatment of diabetic foot wounds and great progress, both in terms of research and its clinical application, has been made in the last 20 years of its development. However, due to the complex pathogenesis and management of diabetic foot, irregular application of NPWT often leads to complications, such as infection, bleeding and necrosis, that seriously affect its treatment outcomes. In 2020, under the leadership of Burns, Trauma and Tissue Repair Committee of the Cross-Straits Medicine Exchange Association, the writing group for ‘Consensus on the application of negative pressure wound therapy of diabetic foot wounds’ was established with the participation of scholars from the specialized areas of burns, endocrinology, vascular surgery, orthopedics and wound repair. Drawing on evidence-based practice suggested by the latest clinical research, this consensus proposes the best clinical practice guidelines for the application and prognostic evaluation of NPWT for diabetic foot. The consensus aims to support the formation of standardized treatment schemes that clinicians can refer to when treating cases of diabetic foot.

Banana leaves as an alternative wound dressing

BACKGROUND

There is a need for cheap and efficacious wound dressings in developing countries. Banana leaves have been described as an excellent, inexpensive, easily available dressing material in tropical countries. As a natural product, banana leaves are heavily contaminated with various pathogens that must be removed before they can be used as wound dressings, but effective sterilization methods that do not affect the beneficial wound-dressing properties of banana leaves have not been described.

OBJECTIVES

To study different sterilization methods and determine which can be used on banana leaves without affecting their beneficial wound-dressing properties.

MATERIALS AND METHODS

We first compared the use of different decontamination techniques to reduce the natural microflora of the leaves and then tested the wound-dressing properties of the leaves in a mouse model of skin transplantation and in postsurgical patients in Uganda, Africa.

RESULTS

Steam sterilization proved to be the optimal sterilization technique. Banana leaves displayed wound-dressing properties that equaled those of petroleum jelly gauze dressings and were tested successfully in a clinical setting in postsurgical patients in Uganda, Africa.

CONCLUSION

We found banana leaves to be an excellent alternative wound dressing, combining the desirable properties of modern wound-dressing material with low cost.

Four-stage regimen for operative treatment of diabetic foot ulcer with deformity - a results of 300 patients

BACKGROUND

An operative four-stage regimen (stage 1, debridement; stage 2, closure; stage 3, unloading; stage 4, correction) for operative treatment of diabetic foot ulcer with deformity, and first clinical results are introduced.

METHODS AND RESULTS

335 patients entered stage 1 between 01/09/2006 and 31/08/2010. Stage 1: In 189 cases (56%), one debridement resulted in sterile postoperative specimens. Stage 2: 210 cases (63%) sustained secondary closure, 97 (29%) local shifted skin graft, and 20 (6%) functional amputation. Stage 3: 304 (90%) finished stage 3, 14 (4%) presented with recurrent ulcer. Stage 4: In 185 cases (55%), correction arthrodeses were performed successfully.

FOLLOW-UP

300 (90%) completed follow-up at 26months on average (12-48months). Recurrent ulcer was registered in 46 (15%). Overall amputation rate was 14%, the majority at digital or midfoot level. Four cases (1%) required a below-knee amputation.

CONCLUSIONS

The management of diabetic foot ulcer combined with deformity with the introduced regimen showed low major amputation rate and low recurrent ulcer rate compared with the literature.

[Surgical management of Pyoderma gangrenosum]

Pyoderma gangrenosum is a rare affection of unknown etiology, which is often associated with systemic diseases such as chronic inflammatory bowel disease, hematologic disorders, carcinomas and arthritis. Treatment may include topical corticosteroids or calcineurin inhibitors in combination with systemic corticosteroids, cyclosporine A, azathioprine, cyclophosphamide, mycophenolate mofetil, intravenous immunoglobulins or monoclonal antibodies against TNFα but all these approaches are off-label. Surgical therapy is difficult because of pathergy. Nevertheless, after having stopped the inflammation, the ulcers can be treated by split thickness skin grafts and simultaneous immunosuppression. We present three cases with successful surgical treatment.

Infected internal fixation after ankle fractures--a treatment path

In the emergency treatment of infected internal fixation after ankle fractures, the infection needs to be resolved quickly to protect the implants, bone, and tendons. Vacuum wound therapy (topical negative pressure therapy) has been used for more than 15 years to assist in closure and to accelerate healing of a wide range of wounds. In the present report, we describe the results of treatment of 7 angiopathic (dysvascular) patients who developed a deep wound infection after ankle osteosynthesis. Each patient was treated with initial surgical debridement, followed by vacuum wound therapy and meshed split-thickness skin graft transplantation. The mean inpatient length of vacuum wound therapy was 14.0 ± 4.31 days, and the mean total duration of vacuum treatment was 54.43 ± 7.74 days.

Mesh graft infection following abdominal hernia repair: risk factor evaluation and strategies of mesh graft preservation. A retrospective analysis of 476 operations

BACKGROUND

Mesh graft infection after prosthetic hernia repair is a challenging complication usually treated by mesh removal. The aim of this study was to identify risk factors associated with mesh infection and to assess the efficacy of conservative wound therapy in preserving an infected mesh.

METHODS

We performed a retrospective analysis of 476 consecutive patients with incisional hernia who received mesh graft repair between February 1, 2000 and February 28, 2005 at our institution using chart review and clinical investigation.

RESULTS

Thirty-one of 476 (6.5%) patients developed a deep surgical site infection involving the implanted mesh graft. Upon multivariate analysis, operation time was the only significant risk factor associated with mesh infection (p = 0.0038). Seventeen (55%) of 31 infected mesh grafts were preserved by conservative means. There was a significant association between the type of mesh graft used and the probability of mesh preservation in case of infection: While conservative therapy led to preservation of 100% of infected polyglactin/polypropylene meshes, only 20% of infected polypropylene and 23% of infected PTFE/polypropylene meshes could be salvaged using conservative means (p < 0.0001). In none of the patients with preserved mesh graft was hernia recurrence at the former site of infection observed.

CONCLUSIONS

Operation time is the only significant risk factor associated with mesh graft infection following incisional hernia repair. Conservative treatment should be applied in case of infection of absorbable mesh grafts such as polypropylene/polyglactin, while nonabsorbable meshes such as PTFE/polypropylene or pure polypropylene are much less amenable to conservative treatment, usually requiring early surgical removal.

[Ankle osteosynthesis infection: vacuum therapy as the treatment of choice]

BACKGROUND

Should osteosynthesis infection occur after ankle fractures in patients with microangiopathy, the infection needs to be cured quickly and safely to protect implants, bone, and tendons. Vacuum therapy (TNP) provides a perfect treatment plan that keeps the inpatient time low whilst ensuring high patient comfort.

METHODS AND PATIENTS

Four angiopathic patients with deep wound infection after ankle osteosynthesis were treated. At admission, loss of stability and spread of the infection were the immediate risks. To prevent this, we treated the patients with vacuum therapy after initial debridement until skin cover was achieved.

RESULTS

In all cases stability was secured and after 2 dressing changes, the swabs were sterile. The inpatient time was 13 days; overall vacuum therapy time was 59 days. Patient satisfaction was high.

DISCUSSION

Vacuum therapy is a perfect strategy after surgical debridement and before secondary mesh grafting. It protects the stability of the bone and open-lying delicate structures in patients with infected osteosynthesis of the ankle and angiopathy and offers an easy, safe, and successful treatment path with a short inpatient time.

Assessment of incidence, cause, and consequences of pressure ulcers to evaluate quality of provided care

BACKGROUND

Pressure ulcers are one of the most frequently registered complications in general surgery.

OBJECTIVE

To obtain insight into the incidence, cause, and consequences of pressure ulcers and to evaluate the value of pressure ulcer registration to assess quality of care.

RESULTS

During the 9-year study period, 275 pressure ulcers were registered (5.8% of total registered complications). Age and female sex were independent risk factors for pressure ulcer development. Pressure ulcer classification was as follows: mild (53.3%), moderate (35.6%), severe (9.5%), and irreversible damage (1.5%). Patients undergoing hip surgery and major limb amputation were at risk for pressure ulcer development (10.4% and 8.8%, respectively). In most patients (89.5%), pressure ulcers had no consequences other than local wound therapy; in 12 patients (4.4%), pressure ulceration led to alteration in medication; in 15 patients (5.5%), length of hospital stay was prolonged; and four patients (0.4%) suffered from irreversible damage.

CONCLUSION

The incidence of pressure ulcers is strongly correlated to sex, age, and indication of admittance. Most ulcers were classified as mild and had no consequences. The insight obtained into incidence, cause, and consequences of pressure ulcers can be used as an indicator of quality of provided care if adjusted for case mix and indication of operation.

Definition of efficiency in vacuum therapy--a randomised controlled trial comparing with V.A.C. Therapy

Redon drains are still used to suction wounds for vacuum sealing. Vacuum-assisted closure (V.A.C.((R)); Kinetic Concepts Inc, San Antonio, TX) is a computer-controlled therapy system for delivering topical negative pressure therapy. The efficiency of V.A.C. in the treatment of pressure ulcers was prospectively studied in a randomised controlled trial in which patients with pressure ulcers were randomly assigned to negative pressure wound therapy (NPWT) using either V.A.C. or Redon bottles. The target parameters were absolute and relative proportion of wound area consists of granulation tissue, fibrin and necrosis. Other outcome measures were the number of dressing changes and time invested using each system. The study was terminated after a post hoc analysis after inclusion of ten patients because of the significantly better results when using V.A.C., and the substantially larger care effort needed in the Redon group compared with the V.A.C. group. An increase in surface granulation tissue of 54% was observed in the V.A.C. group, and a reduction in the Redon group (P = 0.001). The Redon group showed an increase in fibrin tissue at the wound base of 21.8%, whereas in the V.A.C group, a 27% reduction was observed (P = 0.035). Necrosis was reduced in the V.A.C. group, but this difference did not reach significance. Redon bottles are not a good alternative for V.A.C. therapy for delivering NPWT.

[Economic aspects of surgical wound therapies]

INTRODUCTION

Health care insurers in Germany pay 5 billion Euros annually in materials alone for pressure ulcers, diabetic foot ulcers, and ulcus cruris. With such figures it is necessary to consider, economic aspects of treatment.

METHODS

Due to the lack of evidence-based data on wound treatment costs, we investigated available studies for an effect on treatment costs when standard moist wound therapy was compared with alternative methods. Suited medical parameters are calculated and compared. Daily costs and length of treatment are correlated and compared.

RESULTS

Published data show that alternative wound therapies may lead to an earlier wound closure, fewer complications, and reduction in hospital admissions and length of stay. Despite higher daily costs, some alternative wound therapies turn out to be more cost effective, when all economical factors are considered. In this respect a move towards alternative wound therapies could possibly lead to major savings.

DISCUSSION

At present there is insufficient evidence to prove the efficacy of various treatment modalities for chronic wounds. This is due to numerous factors such as comorbidities and frequent multimorbidity. Nevertheless critical evaluation of one innovative treatment alone already uncovered an enormous potential for savings in a wider economic context, despite the comparatively higher cost of a single treatment. It is of utmost importance that conservative wound care become firmly embedded in surgical concepts.

MOC-PSSM CME article: Pressure sores

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Understand and describe the physiology of pressure sore development. 2. Understand and describe population risk factors. 3. Understand and describe examination and classification. 4. Understand and describe common surgical treatment algorithms. 5. Understand and describe strategies for prevention and postoperative recurrence.

SUMMARY

Pressure sores are ischemic damage to soft tissues resulting from unrelieved pressure, usually over a bony prominence. In both acute and chronic circumstances, a careful, structured multidisciplinary strategy is required from initial diagnosis to resolution. Mechanical issues, such as the relief of pressure, adequate surgical debridement, and flap coverage, are of little value if educational, nutritional, social, and resource-based issues are not in place. The authors discuss a range of topics, including etiology, physiology, classification, operative options, and strategies to prevent recurrence.

How precise is the evaluation of chronic wounds by health care professionals?

Chronic wounds are a growing challenge for physicians and health insurance agencies. The burden of affected patients is enormous, because of pain but also because of long-lasting therapies and dependence on nursing services. In other areas of medicine, computer-based diagnostics is established, yet, accurate wound documentation is rarely conducted and is often limited to size measurement with a ruler and a rough photo documentation. Objective assessment of lesions by evaluation of granulation tissue, fibrin coverage and necrosis is not performed. The aim of this study was to investigate the spread and variety in judgement of a chronic wound. A diabetic ulcer was described by 16 wound therapists (eight physicians and eight nurses). Granulation tissue, fibrin coverage, necrosis, size and depth of the lesion, wound exudate and wound edges were judged, and the therapeutical consequences were determined. Study data show an extensive inhomogeneity and a wide spread of the results, like in no other field of medical diagnostics. This could be shown in the group of physicians, as well as in the group of nursing personnel. As the choice of treatment by a specialist is based upon the assessment of the wound, it is possible that in practice it can lead to suboptimal therapy. This is a consequence of varying treating physicians and subsequent changes in treatment regimens. This results in a prolongation of treatment and burden for the patient. Circumstances like this contribute to rising of costs in this area of the health care system. The goal is to apply objective wound diagnostic technologies in the field of chronic wounds to catch up with other diagnostic procedures.