The Use of Vacuum-Assisted Closure and GranuFoam Silver® Dressing in the Management of Diabetic Foot Ulcer

The Use of Silver Oxynitrate Wound Dressings in the Treatment of Chronic Wounds: A Feasibility Pilot Study

OBJECTIVE

To evaluate the feasibility and effectiveness of a silver oxynitrate (Ag 7 NO 11 ) dressing on wound healing in patients with stalled chronic wounds.

METHODS

A prospective pilot study was conducted to determine the feasibility and effect of using silver oxynitrate dressings within an outpatient setting in Alberta, Canada. A total of 23 patients (12 women and 11 men; mean age, 66.1 ± 13.8 years) with a chronic wound that failed to heal with conventional treatment were included in the study. Wound assessments including the Bates-Jensen Wound Assessment Tool, wound-related pain, wound size, and patient quality of life (QoL) were conducted at baseline, after dressing application for 1 and 2 weeks, and during 4- and 12-week follow-ups.

RESULTS

Dressing application at 1 and 2 weeks improved patients' wound healing progression as measured through significantly decreased Bates-Jensen Wound Assessment Tool scores with a more than 10% decrease at 4- and 12-week follow-up ( P < .001). Pain ( P = .004), and QoL psyche subscore ( P = .008) significantly improved at 4-week follow-ups, although wound area, perimeter, and QoL body and everyday subscores were not significantly affected. Wound size was not significantly affected.

CONCLUSIONS

The silver oxynitrate dressing may improve healing progression in patients with chronic wounds, enhance patient experience by reducing wound-related pain, and improve patients' mental well-being. Further studies are warranted to elucidate the effect of silver oxynitrate dressings on wound area, perimeter, and volume measurements.

Prospective randomised placebo-controlled trial assessing the efficacy of silver dressings to enhance healing of acute diabetes-related foot ulcers

AIMS/HYPOTHESIS

Silver dressings are used for their antimicrobial properties but there is limited evidence of clinical benefit when managing diabetes-related foot ulcers (DFUs). We aimed to assess whether silver dressings in acute DFUs increased the proportion of ulcers healed compared with non-silver dressings.

METHODS

In this open-labelled, randomised controlled trial, consecutive individuals who presented to a tertiary multidisciplinary diabetic foot service with a DFU without osteomyelitis or tendon on view of <6 weeks' duration were randomised 1:1 via a computer-generated randomisation process to receive Acticoat (Smith & Nephew, England) dressing (silver group) or dressing without silver (control group) in addition to standard care. Stratified randomisation was performed to ensure that the presence of peripheral arterial disease and infection were equally managed within the two groups. The primary outcome was the proportion of ulcers healed at 12 weeks. Secondary outcomes included time to heal and to 50% ulcer reduction, rates of osteomyelitis and amputation, and need for and duration of antibiotics.

RESULTS

Seventy-six ulcers (55 participants) in the control group and 91 ulcers (63 participants) in the silver group were included. There was no difference in the proportion of ulcers healed by 12 weeks in the control vs silver group (75% vs 69%, p=0.49). After adjustment for presence of peripheral arterial disease, infection and initial ulcer size, silver dressing was not associated with odds of healing (OR 0.92; CI 0.26, 3.22; p=0.53). There was no difference in time to healing, progression to osteomyelitis, need for amputation, or duration of or need for antibiotic treatment.

CONCLUSIONS/INTERPRETATION

In individuals with acute DFUs without osteomyelitis or tendon on view, Acticoat silver dressings did not improve wound healing or reduce need for antibiotics compared with non-silver dressings.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12614001234606 FUNDING: Australian Diabetes Society-unrestricted research award.

Comparative study of various dressing techniques in diabetic foot ulcers in the Indian population: a single-center experience

Introduction

A prospective randomized study was conducted to evaluate and compare the efficacy of conventional dressing, foam dressing, and vacuum-assisted closure (VAC) in the management of diabetic foot ulcers (DFUs).

Material and methods

Ninety patients with DFU were included in the study conducted between 2018 and 2021 at a tertiary care center. Group 1 patients (n = 30) were treated with conventional dressing, group 2 patients (n = 30) with foam dressing, and group 3 patients (n = 30) with VAC dressing. The duration of treatment, number of debridement, need for the secondary procedure, cost of treatment, and duration of hospital stay were compared between the three groups.

Results

There was a significant difference in the duration of treatment among the three groups with VAC being the least (group 1, 31.17 days; group 2, 24.13 days; group 3, 15.17 days). The mean number of debridement was also significantly less in the VAC group (2.37, 2.43, and 1.60, respectively). The need for the secondary procedure, like flap or skin graft, was also the least in the VAC group, although insignificant. The mean hospital stay of the study subjects was 31.17 days, 24.13 days, and 15.17 days in the 3 groups, respectively. The mean cost of the treatment was 3076.67 INR, 3717.33 INR, and 10,680 INR, respectively.

Conclusion

VAC dressing is the best option amongst the available dressing modalities in terms of faster healing and a short hospital stay. Foam dressing does provide an economically viable option with better results than conventional dressing.

Polymer-Based Wound Dressing Materials Loaded with Bioactive Agents: Potential Materials for the Treatment of Diabetic Wounds

Diabetic wounds are severe injuries that are common in patients that suffer from diabetes. Most of the presently employed wound dressing scaffolds are inappropriate for treating diabetic wounds. Improper treatment of diabetic wounds usually results in amputations. The shortcomings that are related to the currently used wound dressings include poor antimicrobial properties, inability to provide moisture, weak mechanical features, poor biodegradability, and biocompatibility, etc. To overcome the poor mechanical properties, polymer-based wound dressings have been designed from the combination of biopolymers (natural polymers) (e.g., chitosan, alginate, cellulose, chitin, gelatin, etc.) and synthetic polymers (e.g., poly (vinyl alcohol), poly (lactic-co-glycolic acid), polylactide, poly-glycolic acid, polyurethanes, etc.) to produce effective hybrid scaffolds for wound management. The loading of bioactive agents or drugs into polymer-based wound dressings can result in improved therapeutic outcomes such as good antibacterial or antioxidant activity when used in the treatment of diabetic wounds. Based on the outstanding performance of polymer-based wound dressings on diabetic wounds in the pre-clinical experiments, the in vivo and in vitro therapeutic results of the wound dressing materials on the diabetic wound are hereby reviewed.

Application of Electrospun Nanofiber Membrane in the Treatment of Diabetic Wounds

Diabetic wounds are complications of diabetes which are caused by skin dystrophy because of local ischemia and hypoxia. Diabetes causes wounds in a pathological state of inflammation, resulting in delayed wound healing. The structure of electrospun nanofibers is similar to that of the extracellular matrix (ECM), which is conducive to the attachment, growth, and migration of fibroblasts, thus favoring the formation of new skin tissue at the wound. The composition and size of electrospun nanofiber membranes can be easily adjusted, and the controlled release of loaded drugs can be realized by regulating the fiber structure. The porous structure of the fiber membrane is beneficial to gas exchange and exudate absorption at the wound, and the fiber surface can be easily modified to give it function. Electrospun fibers can be used as wound dressing and have great application potential in the treatment of diabetic wounds. In this study, the applications of polymer electrospun fibers, nanoparticle-loaded electrospun fibers, drug-loaded electrospun fibers, and cell-loaded electrospun fibers, in the treatment of diabetic wounds were reviewed, and provide new ideas for the effective treatment of diabetic wounds.

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.

Poly(lactic-co-glycolic acid)-Chitosan-Gelatin Composite Nanomaterials for the Treatment of Diabetic Foot Ulcer Wound Infection

In this experiment, a solid carrier was prepared with PLGA, gelatin, and chitosan as the main raw materials, so that BMSCs could exert their repairing effect directly in the ulcer area under the stimulation of Klotho protein. We chose to use electrospun PLGA as the main technical means to provide suitable adhesion growth environment for BMSCs by preparing PLGA nanofibers. At the same time, PLGA nanofibers are also a controlled release material, so that Klotho protein can remain active, thereby achieving the purpose of stimulating BMSCs for a long time. Through the nano-scale porous structure provided on the surface of the PLGA film, BMSCs can adhere well to the surface of the material and continuously receive stimulation from the inner Klotho protein. We applied this composite to mice with diabetic ulcers, and verified the effects of Klotho protein and BMSCs on DFU healing in five groups of mice. From the results, the Klotho+BMSCs group achieved the best healing effect, followed by the Klotho group alone, while the other three groups had no significant difference in healing effects. It is proved that both Klotho and BMSCs can help the healing of diabetic ulcers, but BMSCs alone cannot survive in harsh environments, and it is difficult to play a normal repair role. The purpose of this study was to investigate the effect of Klotho protein on BMSCs and ECs under high glucose conditions, and to find a suitable carrier for planting BMSCs on it. At the same time, the material also has a certain sustained release function. We have concluded that Klotho protein can promote the proliferation and migration of BMSCs and ECs under high glucose conditions. When combined with electrospinning technology to prepare a protein that can release Klotho, it also provides a microstructure suitable for BMSCs adhesion, thereby ensuring that BMSCs can successfully survive. In the end, we artificial Klotho protein can promote angiogenesis in diabetic ulcer areas by protecting BMSCs and ECs, thereby promoting healing of ulcer areas.

Global recurrence rates in diabetic foot ulcers: A systematic review and meta-analysis

Recurrence rates of diabetic foot ulcers vary widely in the published literature. The aim of this systematic review is to estimate recurrence rates of diabetic foot ulcers. We did a PubMed search and performed a review of reference lists for studies reporting recurrence of diabetic foot ulcers. The weighted relative risk (RR) and corresponding 95% confidence interval (CI) for recurrence was estimated. Forty-nine studies reporting recurrence of diabetic foot ulcers were included. A pooled estimate for recurrence rate was 22.1% per person-year (py) (95% CI, 19.0-25.2%). Recurrence rate was 24.9% per py in Europe (95% CI, 20.0%-29.7%), 17.8% per py in North America (95% CI, 12.7%-22.9%), 16.9% per py in Africa (95% CI, 4.7%-29.0%), and 17.0% per py in Asia (95% CI, 11.1%-23.0%). Turkey had the highest recurrence rate of 44.4% per py (95% CI, 24.9%-63.9%), and Bangladesh had the lowest of 4.3% per py (95% CI, 2.3%-6.3%). Recurrence rates of diabetic foot ulcers before 2002, between 2002 and 2008, and after 2008 were 22.2% per py (95% CI, 17.6%-26.8%), 21.9% per py (95% CI, 17.0%-26.8%), and 21.8% per py (95% CI, 16.3%-27.2%), respectively. Recurrence rates of diabetic foot ulcers are high. Recurrence rates vary widely in different regions and have decreased recently. More attention towards recurrence of diabetic foot ulcers is urgently required.

Silver in Wound Care-Friend or Foe?: A Comprehensive Review

Due to its strong antimicrobial activity, silver is a commonly used adjunct in wound care. However, it also has the potential to impair healing by exerting toxic effects on keratinocytes and fibroblasts. The published literature on the use of silver in wound care is very heterogeneous, making it difficult to generate useful treatment guidelines.

Silver-Impregnated Negative-Pressure Wound Therapy for the Treatment of Lower-Extremity Open Wounds: A Prospective Randomized Clinical Study

OBJECTIVE

To investigate the antibacterial efficacy of silver-impregnated negative-pressure wound therapy (NPWT) in lower-extremity acute traumatic wounds.

METHODS

Open contaminated wounds caused by high-velocity trauma in the lower extremities were randomly allocated into two groups. The wounds in the control and experimental groups were treated with conventional NPWT (n = 31) and silver-impregnated NPWT (n = 35), respectively.

MAIN OUTCOME MEASURES

Serial bacterial cultures were obtained from the participants' wounds, polyurethane foam, and suction tubes weekly during the 4-week follow-up to identify bacteria and follow their conversions.

MAIN RESULTS

Bacterial colonization rates in the silver NPWT group were generally lower than those in the conventional NPWT group, and the difference increased with time. For methicillin-resistant Staphylococcus aureus colonization, wounds treated with silver-impregnated NPWT showed a significant reduction in bacterial load compared with those treated with conventional NPWT.

CONCLUSIONS

Silver-impregnated NPWT effectively decreases bacterial load in open contaminated wounds of the lower extremities. It can be used as a temporizing measure to manage bacterial colonization while patients and wounds are being prepared for final wound reconstruction.

Efficacy of negative pressure wound therapy using vacuum-assisted closure combined with photon therapy for management of diabetic foot ulcers

BACKGROUND

Diabetes mellitus, one of the most prevalent chronic metabolic diseases, causes many complications. Among the complications, one of the most common chronic complications is diabetic foot ulcers (DFUs).

OBJECTIVE

This study was conducted to investigate the efficacy of negative pressure wound therapy using vacuum-assisted closure (VAC) combined with photon therapy for the management of DFUs.

PATIENTS AND METHODS

The study included a total of 69 patients with DFUs during the period from January 2014 to December 2015. All patients were diagnosed with DFUs with Wagner's stage 2 or 3 and were divided into two groups - the VAC group in which patients received only VAC and the combined group in which patients received both VAC and photon therapy. Data on duration of the treatment, pre- and postoperative wound surface areas, dressing changing times, pain conditions assessed using visual analog scale scores, recurrence rate and amputation rate were collected.

RESULTS

Among all patients, 35 patients were divided into the VAC group and 34 patients into the combined group. Areas of foot ulcers for all patients ranged from 5 to 100 cm2. The treatment duration, dressing changing times and the peak value of visual analog scale scores were all significantly lower in the combined group compared with the VAC group (P < 0.05). However, the reduced area for wound surface showed no significant difference between the two groups. Both recurrence and amputation rates showed no significant difference between the two groups of patients.

CONCLUSION

Both VAC and VAC combined with photon therapy were effective and safe in the treatment of DFUs, while the combined therapy might have accelerated wound healing, but did not influence the long-term efficacy.

The Management of Critically Colonized and Locally Infected Leg Ulcers with an Acid-Oxidizing Solution: A Pilot Study

OBJECTIVE:

Critical colonization or local infection is very common in chronic wounds, but clinically problematic. Because therapeutic options for these conditions are limited in number and efficacy, the study authors tested a new acid-oxidizing solution (AOS [Nexodyn]; APR Applied Pharma Research S.A., Balerna, Switzerland) to determine its ancillary antimicrobial properties and potential support for wound healing.

DESIGN AND SETTING:

This open-label clinical case series was conducted with a prospective, single-arm design at the Federal County Hospital in Bregenz, Austria.

PATIENTS:

In the study, 30 patients with critically colonized or locally infected chronic leg ulcers of any origin were included.

INTERVENTIONS:

The AOS was applied on each leg ulcer at every dressing change for 35 days.

MAIN OUTCOME MEASURES:

The tolerability and performance of the AOS were assessed by evaluating the ulcer characteristics and comparing them with those at baseline. The clinical course of wounds was analyzed using standard measures for bioburden, local infection, pain, pH, and wound healing.

MAIN RESULTS:

Application of the solution was well tolerated, and no adverse events were recorded. In all patients, local infection was overcome, and wound bed pH and wound area decreased significantly. In addition, patient pain levels decreased to a level where interventions were not required after study day 7. In 37% of all patients, a complete resolution of chronic ulcers was achieved by the end of the study period.

CONCLUSION:

According to these results, the AOS seems to be a valid and highly tolerable treatment to support wound healing in locally infected ulcers. Nevertheless, larger controlled cohort studies are needed to substantiate these findings.

Effect of oil gauze silver dressings on diabetic foot ulcers in the elderly

OBJECTIVE

To compare the clinical efficacy and safety of oil gauze silver dressing and silver ions dressing on diabetic ulcers in elderly outpatients.

METHODS

Twenty-two patients with Type-2 diabetic foot ulcers were included in the study conducted at Yantai Yuhuangding Hospital between April 2013 and April 2014. At the time of enrolment they were divided into the silver ions and oil gauze silver groups based on the order of admission. Dressings were changed twice weekly until the ulcer had healed. Clinical efficacy measures were healing outcomes and speed of healing. Adverse events were recorded.

RESULTS

The silver ions and oil gauze silver groups were comparable at baseline (P>0.05). Before treatment, the fasting blood glucose (FBG) and two hour postprandial blood glucose (2h PBG) levels were 6.88±0.50 mmol /L and 15.55±2.47 mmol/L in the oil gauze silver group, and 6.93±0.41 mmol/L and 15.23±2.58 mmol/L in the silver ions group, respectively. After treatment, the FBG and 2h PBG levels were 6.82±0.32 mmol/L and 8.67±0.86 mmol/L in the oil gauze silver group, and 6.85±0.27 mmol/L and 8.83 ± 0.61 mmol/L in the silver ions group, respectively. The healing time of foot ulcers was 23.8±2.7 days in the silver ions group and 15.8±2.5 days in the oil gauze silver group (P<0.05).

CONCLUSION

Oil gauze silver dressings for diabetic foot ulcers were associated with favorable clinical outcomes compared with silver ion dressings, especially with respect to ulcer healing speed.