Advances in the topical treatment of diabetic foot ulcers

Use of injectable acellular dermal matrix combined with negative pressure wound therapy in open diabetic foot amputation

Objective:

Skin grafts after negative pressure wound therapy (NPWT) and acellular dermal matrix (ADM) usage have both been useful for treating diabetic foot amputation. We hypothesised that injectable ADM combined with NPWT would be more useful than NPWT only for healing after amputation in patients with diabetic foot ulcers (DFUs). The aim of this study was to investigate the clinical outcomes of injectable ADM combined with NPWT in patients with DFU who have undergone amputation.

Method:

This retrospective study reviewed patients with infected DFUs who were administered NPWT. Patients were divided into two groups: Group 1 included patients who were treated with NPWT only, while Group 2 included patients who were treated with injectable ADM combined with NPWT. Clinical results including the number of NPWT dressing changes, wound healing duration, and full-thickness skin graft (FTSG) incident rate between the two groups were compared.

Results:

A total of 41 patients took part in the study (Group 1=20, Group 2=21). The mean number of NPWT dressing changes was significantly lower in Group 2 (8.71±3.77) than in Group 1 (13.90±5.62) (p=0.001). Mean wound healing period was shorter in Group 2 (3.17±1.36 weeks) than in Group 1 (5.47±1.68 weeks) (p=0.001). Finally, the rate of patients who underwent FTSG for complete wound closure was 85% in Group 1, whereas it was only 14.3% in Group 2.

Conclusion:

In this study, the use of injectable ADM combined with NPWT in patients with DFU who underwent amputation favoured complete wound healing, without the need to resort to the use of skin grafts.

Topical gel-based biomaterials for the treatment of diabetic foot ulcers

Diabetic foot ulcers (DFUs) are a devastating ailment for many diabetic patients with increasing prevalence and morbidity. The complex pathophysiology of DFU wound environments has made finding effective treatments difficult. Standard wound care treatments have limited efficacy in healing these types of chronic wounds. Topical biomaterial gels have been developed to implement novel treatment approaches to improve therapeutic effects and are advantageous due to their ease of application, tunability, and ability to improve therapeutic release characteristics. Here, we provide an updated, comprehensive review of novel topical biomaterial gels developed for treating chronic DFUs. This review will examine preclinical data for topical gel treatments in diabetic animal models and clinical applications, focusing on gels with protein/peptides, drug, cellular, herbal/antioxidant, and nano/microparticle approaches. STATEMENT OF SIGNIFICANCE: By 2050, 1 in 3 Americans will develop diabetes, and up to 34% of diabetic patients will develop a diabetic foot ulcer (DFU) in their lifetime. Current treatments for DFUs include debridement, infection control, maintaining a moist wound environment, and pressure offloading. Despite these interventions, a large number of DFUs fail to heal and are associated with a cost that exceeds $31 billion annually. Topical biomaterials have been developed to help target specific impairments associated with DFU with the goal to improve healing. A summary of these approaches is needed to help better understand the current state of the research. This review summarizes recent research and advances in topical biomaterials treatments for DFUs.

Human umbilical cord mesenchymal stem cells in type 2 diabetes mellitus: the emerging therapeutic approach

The umbilical cord has been proved to be an easy-access, reliable, and useful source of mesenchymal stem cells (MSC) for clinical applications due to its primitive, immunomodulatory, non-immunogenic, secretory and paracrine, migratory, proliferative, and multipotent properties. This set of characteristics has recently attracted great research interest in the fields of nanotechnology and regenerative medicine and cellular therapy. Accumulating evidence supports a pronounced therapeutic potential of MSC in many different pathologies, from hematology to immunology, wound-healing, tissue regeneration, and oncology. Diabetes mellitus, branded the epidemic of the century, is considered a chronic metabolic disorder, representing a major burden for health system sustainability and an important public health challenge to modern societies. The available treatments for type 2 diabetes mellitus (T2DM) still rely mainly on combinations of oral antidiabetic agents with lifestyle and nutritional adjustments. Despite the continuous development of novel and better hypoglycemic drugs, their efficacy is limited in the installment and progression of silent T2DM complications. T2DM comorbidities and mortality rates still make it a serious, common, costly, and long-term manageable disease. Recently, experimental models, preclinical observations, and clinical studies have provided some insights and preliminary promising results using umbilical cord MSCs to treat and manage diabetes. This review focuses on the latest research and applications of human-derived umbilical cord MSC in the treatment and management of T2DM, exploring and systematizing the key effects of both umbilical cord MSC and its factor-rich secretome accordingly with the major complications associated to T2DM.

Nonpharmacological Management of Diabetic Foot Ulcers: An Update

Diabetic foot ulcers (DFUs) are a common and serious complication of diabetes mellitus that is associated with increased morbidity and mortality, as well as substantial economic burden for the health care system. The standard of care for DFUs includes pressure off-loading, sharp debridement, and wound moisture balance, along with infection control and management of peripheral arterial disease. A variety of advanced modalities that target distinct pathophysiological aspects of impaired wound healing in diabetes are being studied as possible adjunct therapies for difficult to heal ulcers. These modalities include growth factors, stem cells, cultured fibroblasts and keratinocytes, bioengineered skin substitutes, acellular bioproducts, human amniotic membranes, oxygen therapy, negative pressure wound therapy, and energy therapies. Additionally, the use of advanced biomaterials and gene delivery systems is being investigated as a method of effective delivery of substances to the wound bed. In the present narrative review, we outline the latest advances in the nonpharmacological management of DFUs and summarize the efficacy of various standard and advanced treatment modalities.

Involvement of miRNA203 in the proliferation of epidermal stem cells during the process of DM chronic wound healing through Wnt signal pathways

Background

The biological role of miR-203 and the underlying mechanisms on the proliferation of epidermal stem cells (ESCs) have not yet been reported during the progression of chronic wound healing in diabetes mellitus. Our previous studies have observed that the expression of miR-203 showed a marked upregulation and ESC proliferation capacity was impaired in diabetes mellitus skin wounds in rats.

Methods

Wound models were established in normal rats and rats with type 2 diabetes. Expression level of miR-203 and the alteration of ESCs’ number and function were detected. ESCs were isolated from the back skin of fetal rats to assess the effects of glucose in vitro. An antagomir to miR-203 was used to assess its effect on ESCs. Using microarray analysis, we further identified potential target genes and signaling pathways of miR-203.

Results

We found that high glucose significantly upregulated the expression of miR-203 and subsequently reduced the number of ESCs and impaired their proliferation capacity. Meanwhile, over-expression of miR-203 reduced the ESCs’ numbers and impaired the proliferation capacity via downregulation of the Notch and Wnt signaling pathways. Conversely, inhibition of miR-203 enhanced the proliferation capacity. Additionally, silencing miR-203 in skin of rats with type 2 diabetes accelerated wound healing and improved healing quality via the upregulation of the Notch and Wnt signaling pathways. Finally, over-expression of miR-203 downregulated genes ROCK2, MAPK8, MAPK9, and PRKCA.

Conclusion

Our findings demonstrated that induced expression of miR-203 by high glucose in type 2 diabetic rats decreased the number of ESCs and impaired ESC proliferation capacity via downregulating genes related to Notch and Wnt signaling pathways, resulting in a delayed wound healing.

Advancing pharmacotherapy for diabetic foot ulcers

INTRODUCTION

Standard treatment for diabetic foot ulcers (DFUs) includes off-loading, debridement, moisture balance, management of infection and peripheral arterial disease (PAD) as well as adequate glycemic control. The outcomes so far are unsatisfactory.

AREAS COVERED

Herein, the authors provide an outline of newer pharmacological agents for the management of DFUs and give their expert perspectives on future treatment strategies.

EXPERT OPINION

Evidence-based healthcare calls for high quality evidence from large RCTs before the implementation of new guidelines for the management of DFUs. Empagliflozin and liraglutide can be recommended for glucose control in patients with DFUs and PAD, while intensive lipid lowering therapy with evolocumab when primary cholesterol goals are not met could be offered to patients with DFUs. Further clinical studies are warranted to develop a structured algorithm for the treatment of DFUs that fail to heal after four weeks of current standard of care. Sucrose octasulfate dressings, becaplermin gel, and platelet-rich plasma (PRP) could also be considered as advanced treatment options for the management of hard to heal DFUs.

Hyperbaric Oxygen Therapy in Ischaemic Foot Ulcers in Type 2 Diabetes: A Clinical Trial

Background and Aims:

Several treatment modalities and protocols for ischaemic foot ulcers are available. However, little consensus exists on optimal treatment. The aim of this study was to compare Standard Wound Care (SWC) alone vs. SWC with adjunct hyperbaric oxygen therapy (HBOT) in the treatment of ischaemic Diabetic Foot Ulcers (DFUs).

Patients and Methods:

Twenty-six patients with Type 2 Diabetes Mellitus (T2DM) presenting with a newly diagnosed ischaemic foot ulcer were included. These were divided into group A (SWC with adjunct HBOT) and group B (SWC only). Participants were followed every week for 4 weeks and their ulcers were measured for their surface area and depth to assess any change in wound size.

Results:

Both treatment arms succeeded in reducing ulcer area and depth (p<0.001). However, ulcer area (p<0.001) and depth (p<0.001) exhibited superior improvement in group A.

Conclusion :

Adjunctive HBOT appears to improve wound healing in ischaemic DFUs and merits further study.

Comparison of human umbilical cord blood-derived mesenchymal stem cells with healthy fibroblasts on wound-healing activity of diabetic fibroblasts

Various types of skin substitutes composed of fibroblasts and/or keratinocytes have been used for the treatment of diabetic ulcers. However, the effects have generally not been very dramatic. Recently, human umbilical cord blood-derived mesenchymal stromal cells (hUCB-MSCs) have been commercialised for cartilage repair as a first cell therapy product using allogeneic stem cells. In a previous pilot study, we reported that hUCB-MSCs have a superior wound-healing capability compared with fibroblasts. The present study was designed to compare the treatment effect of hUCB-MSCs with that of fibroblasts on the diabetic wound healing in vitro. Diabetic fibroblasts were cocultured with healthy fibroblasts or hUCB-MSCs. Five groups were evaluated: group I, diabetic fibroblasts without coculture; groups II and III, diabetic fibroblasts cocultured with healthy fibroblasts or hUCB-MSCs; and groups IV and V, no cell cocultured with healthy fibroblasts or hUCB-MSCs. After a 3-day incubation, cell proliferation, collagen synthesis levels and glycosaminoglycan levels, which are the major contributing factors in wound healing, were measured. As a result, a hUCB-MSC-treated group showed higher cell proliferation, collagen synthesis and glycosaminoglycan level than a fibroblast-treated group. In particular, there were significant statistical differences in collagen synthesis and glycosaminoglycan levels (P = 0·029 and P = 0·019, respectively). In conclusion, these results demonstrate that hUCB-MSCs may have a superior effect to fibroblasts in stimulating diabetic wound healing.

Oxidized Regenerated Cellulose/Collagen Dressings: Review of Evidence and Recommendations

OBJECTIVE

Healthcare systems are being challenged to manage increasing numbers of nonhealing wounds. Wound dressings are one of the first lines of defense in wound management, and numerous options exist. The oxidized regenerated cellulose (ORC)/collagen dressing may offer healthcare providers a robust and cost-effective tool for use in a variety of wounds.

DESIGN

A multidisciplinary panel meeting was convened to discuss the use of ORC/collagen dressings in wound care and provide practice recommendations. A literature search was conducted to provide a brief review of the peer-reviewed studies published between January 2000 and March 2016 to inform the meeting.

SETTING

A 2-day panel meeting convened in February 2017.

PARTICIPANTS

Healthcare providers with experience using ORC/collagen dressings. This multidisciplinary panel of 15 experts in wound healing included podiatrists, wound care specialists (doctors, certified wound care nurses, and research scientists), and an orthopedist.

RESULTS

The literature search identified 58 articles, a majority of which were low levels of evidence (69.3% were level 3 or lower). Panel members identified wound types, such as abrasions, burns, stalled wounds, diabetic foot ulcers, and pressure injuries, where ORC/collagen dressing use could be beneficial. Panel members then provided recommendations and technical pearls for the use of ORC/collagen dressings in practice. Barriers to ORC/collagen dressing use were discussed, and potential resolutions were offered.

CONCLUSIONS

An ORC/collagen dressing can be a critical tool for clinicians to help manage a variety of wounds. Clinical and economic studies comparing standard-of-care dressings and plain collagen dressings to ORC/collagen dressings are needed.

Effects of human umbilical cord blood-derived mesenchymal stromal cells and dermal fibroblasts on diabetic wound healing

BACKGROUND AIMS

A previous study demonstrated that human umbilical cord blood-derived mesenchymal stromal cells (hUCB-MSCs) have superior wound-healing activity compared with fibroblasts in vitro. However, wound healing in vivo is a complex process that involves multiple factors. The purpose of this study was to compare the effects of hUCB-MSCs and fibroblasts on diabetic wound healing in vivo. This study especially focused on collagen synthesis and angiogenesis, which are considered to be the important factors affecting diabetic wound healing.

METHODS

Porous polyethylene discs were loaded with either fibroblasts or hUCB-MSCs, and a third group, which served as a control, was not loaded with cells. The discs were then implanted in the back of diabetic mice. During the first and the second week after implantation, the discs were harvested, and collagen level and microvascular density were compared.

RESULTS

In terms of collagen synthesis, the hUCB-MSC group showed the highest collagen level (117.7 ± 8.9 ng/mL), followed by the fibroblast group (83.2 ± 5.2 ng/mL) and the no-cell group (60.0 ± 4.7 ng/mL) in the second week after implantation. In terms of angiogenesis, the microvascular density in the hUCB-MSC group was 56.8 ± 16.4, which was much higher than that in the fibroblast group (14.3 ± 4.0) and the no-cell group (5.7 ± 2.1) in the second week after implantation.

CONCLUSIONS

These results demonstrate that hUCB-MSCs are superior to fibroblasts in terms of their effect on diabetic wound healing in vivo.

Understanding Diabetic Foot Infection and its Management

Diabetic Foot Ulcers (DFUs), a dreadful micro-vascular complication is liable for substantial increase in morbidity and mortality. DFU is a complicated amalgam of neuropathy, peripheral arterial diseases, foot deformities and infection. Spanning the spectrum from superficial cellulitis, microbial flora leads to chronic ostemyelitis and gangrenous extremity lower limb amputations. Wounds without affirmation of soft tissue or bone infection do not require antibiotic therapy. Treatment of mild and moderate infection requires empiric therapy covering gram-positive cocci, whereas severe or infection caused by drug resistant organisms needs broad spectrum anti-microbial targeting aggressive gram-negative aerobes and obligate anaerobes. Definitive therapy employed should be based on culture reports and clinical response. Evaluation of bone infection requires imaging by plain radiographs or MRI to increase sensitivity and specificity. Surgical interventions are must and may range from minor debridement to resections or revascularization and major amputations depending upon wound severity. On time and forceful management of diabetic foot ulcers by employing multidisciplinary management approaches focusing on prevention, learning, regular foot assessment, aggressive intervention, and optimal use of therapeutic footwear can often prevent exacerbation of the difficulty and eliminate the potential for amputation. Here, we review recent studies addressing diabetic foot infections with emphasis on pathophysiology, exclusive risk factors; evaluation including physical inspection, laboratory investigations, relevant treatment strategies and assessment of infection severity.

Efficacy of a New Heparan Sulfate Mimetic Dressing in the Healing of Foot and Lower Extremity Ulcerations in Type 2 Diabetes: A Case Series

A novel heparan sulfate glycosaminoglycan mimetic product for local application to promote wound healing (CACIPLIQ) has recently become available. It is a biophysical therapeutic product comprising a polysaccharide as an innovative biomaterial to accomplish mechanical tissue engineering and skin regeneration in the site of ulceration. We present a series of 12 patients with type 2 diabetes (4 men and 8 women; age 53-87 years; diabetes duration 8-25 years) having chronic resistance to therapy for foot and lower extremity ulcerations. CACIPLIQ was locally applied twice per week after careful debridement. Complete ulcer healing was accomplished in all patients after a mean treatment duration of 4.92 months (range = 2-12 months). The product was very well tolerated. In conclusion, these results, although preliminary, are encouraging and suggest adequate efficacy and safety of the new product in difficult-to-heal foot and lower extremity ulcerations in type 2 diabetes.

A Comparison of Conventional Collagen Sponge and Collagen-Gelatin Sponge in Wound Healing

The objective of this study was to compare the effectiveness of the collagen-gelatin sponge (CGS) with that of the collagen sponge (CS) in dermis-like tissue regeneration. CGS, which achieves the sustained release of basic fibroblast growth factor (bFGF), is a promising material in wound healing. In the present study, we evaluated and compared CGSs and conventional CSs. We prepared 8 mm full-thickness skin defects on the backs of rats. Either CGSs or CSs were impregnated with normal saline solution (NSS) or 7 μg/cm(2) of bFGF solution and implanted into the defects. At 1 and 2 weeks after implantation, tissue specimens were obtained from the rats of each group (n = 3, total n = 24). The wound area, neoepithelial length, dermis-like tissue area, and the number and area of capillaries were evaluated at 1 and 2 weeks after implantation. There were no significant differences in the CGS without bFGF and CS groups. Significant improvements were observed in the neoepithelial length, the dermis-like tissue area, and the number of newly formed capillaries in the group of rats that received CGSs impregnated with bFGF. The effects on epithelialization, granulation, and vascularization of wound healing demonstrated that, as a scaffold, CGSs are equal or superior to conventional CSs.

Wound-healing potential of human umbilical cord blood-derived mesenchymal stromal cells in vitro--a pilot study

BACKGROUND AIMS

Our previous studies demonstrated that human bone marrow-derived mesenchymal stromal cells have great potential for wound healing. However, it is difficult to clinically utilize cultured stem cells. Recently, human umbilical cord blood-derived mesenchymal stromal cells (hUCB-MSCs) have been commercialized for cartilage repair as a first cell therapy product that uses allogeneic stem cells. Should hUCB-MSCs have a superior effect on wound healing as compared with fibroblasts, which are the main cell source in current cell therapy products for wound healing, they may possibly replace fibroblasts. The purpose of this in vitro study was to compare the wound-healing activity of hUCB-MSCs with that of fibroblasts.

METHODS

This study was particularly designed to compare the effect of hUCB-MSCs on diabetic wound healing with those of allogeneic and autologous fibroblasts. Healthy (n = 5) and diabetic (n = 5) fibroblasts were used as the representatives of allogeneic and autologous fibroblasts for diabetic patients in the control group. Human UCB-MSCs (n = 5) were used in the experimental group. Cell proliferation, collagen synthesis and growth factor (basic fibroblast growth factor, vascular endothelial growth factor and transforming growth factor-β) production were compared among the three cell groups.

RESULTS

Human UCB-MSCs produced significantly higher amounts of vascular endothelial growth factor and basic fibroblast growth factor when compared with both fibroblast groups. Human UCB-MSCs were superior to diabetic fibroblasts but not to healthy fibroblasts in collagen synthesis. There were no significant differences in cell proliferation and transforming growth factor-β production.

CONCLUSIONS

Human UCB-MSCs may have greater capacity for diabetic wound healing than allogeneic or autologous fibroblasts, especially in angiogenesis.

Human acellular dermal wound matrix for treatment of DFU: literature review and analysis

Diabetic foot ulcers (DFUs) affect a significant number of people and the treatment is challenging and costly. Since only a small portion of patients respond to standard care, the majority require more advanced wound healing interventions. Human acellular dermal matrices-regenerative tissue matrices derived from human tissue and processed from screened donated skin-can aid wound closure by restoring the missing physiological factors to the microenvironment. A literature review of the clinical literature was performed to estimate the comparative effectiveness of one specific human acellular dermal wound matrix (HADWM; Graftjacket regenerative tissue matrix) versus standard care in healing DFUs. Outcomes from three prospective, controlled clinical trials, which included 154 patients with DFUs, were pooled. A comparative analysis revealed a statistically significant reduction in mean wound healing time, 1.7 weeks, as well as a nearly four-fold improvement in the chance of healing ulcers treated with HADWM versus moist wound-care. These pooled results suggest that HADWM may improve healing outcomes for these difficult-to-heal lower extremity wounds.

DECLARATION OF INTEREST

Alexander Reyzelman is a consultant for KCI, an Acelity company.

Randomised controlled clinical trial for autologous fibroblast-hyaluronic acid complex in treating diabetic foot ulcers

OBJECTIVE

Diabetic foot ulcers (DFUs) often pose a treatment problem. Bioengineered skin substitutes have been reported to result in accelerated diabetic wound healing. The purpose of this clinical trial was to evaluate the efficacy and safety of the autologous fibroblast-hyaluronic acid complex for treating DFUs.

METHOD

A stratified, randomised, controlled, multicentre study was carried out. Patients with DFUs were allocated to either a treatment group with grafting of an autologous fibroblast-hyaluronic acid complex or a control group with non-adherent foam dressing. Except for application of the fibroblast complex, treatment of the study ulcers was identical for patients in both groups. The maximum follow-up period for each patient was 12 weeks.

RESULTS

Complete ulcer healing was achieved in 84% (26/31 patients) of the treatment group and 34% (11/32 patients) of the control group (p<0.05). The times required for complete healing were 36.4 ± 17.6 and 48.4 ± 13.1 days in the treatment and control groups, respectively (p<0.05). No adverse events related to treatment occurred.

CONCLUSION

These results indicate that autologous fibroblast-hyaluronic acid complex may offer a safe and effective treatment for DFUs.

Wound Healing: Biologics, Skin Substitutes, Biomembranes and Scaffolds

This review will explore the latest advancements spanning several facets of wound healing, including biologics, skin substitutes, biomembranes and scaffolds.

Expression of a novel recombinant fusion protein BVN-Tβ4 and its effects on diabetic wound healing

A recombinant fusion protein BVN-Tβ4 is successfully expressed in Escherichia coli, purified in the laboratory and applied onto the wounds of diabetic mice to investigate its effects on diabetic wound healing. Our results show that the recombinant protein BVN-Tβ4 can promote diabetic wound healing in the murine model.

Effect of platelet lysate on human cells involved in different phases of wound healing

Background

Platelets are rich in mediators able to positively affect cell activity in wound healing. Aim of this study was to characterize the effect of different concentrations of human pooled allogeneic platelet lysate on human cells involved in the different phases of wound healing (inflammatory phase, angiogenesis, extracellular matrix secretion and epithelialization).

Methodology/Principal Findings

Platelet lysate effect was studied on endothelial cells, monocytes, fibroblasts and keratinocytes, in terms of viability and proliferation, migration, angiogenesis, tissue repair pathway activation (ERK1/2) and inflammatory response evaluation (NFκB). Results were compared both with basal medium and with a positive control containing serum and growth factors. Platelet lysate induced viability and proliferation at the highest concentrations tested (10% and 20% v/v). Whereas both platelet lysate concentrations increased cell migration, only 20% platelet lysate was able to significantly promote angiogenic activity (p<0.05 vs. control), comparably to the positive control. Both platelet lysate concentrations activated important inflammatory pathways such as ERK1/2 and NFκB with the same early kinetics, whereas the effect was different for later time-points.

Conclusion/Significance

These data suggest the possibility of using allogeneic platelet lysate as both an alternative to growth factors commonly used for cell culture and as a tool for clinical regenerative application for wound healing.

Vascular Nursing in Greece

Although peripheral arterial disease is prevalent in the primary care setting, insufficient vascular education among nurses and physicians coupled with certain economic constraints undermines treatment efficacy. Moreover, the burden of advanced venous pathology such as posthrombotic syndrome, venous ulcers, and lymphedema remains suboptimally treated. This article advocates the development of a vascular nursing specialty as a means to improving vascular care especially nowadays, when health care providers dictate comprehensive and cost-effective nursing practice and patient management. It also presents the first attempt to organize a Vascular Nursing Educational Session in Greece.

Porcine xenografts vs. (cryopreserved) allografts in the management of partial thickness burns: is there a clinical difference?

Porcine xenografts and cryopreserved allografts are used for the management of partial thickness burns and both biological materials have strong advocates with regard to clinical performance, the possibility of disease transfer from donor to recipient and other clinical aspects. A literature analysis was performed in an attempt to investigate whether true (statistically significant) differences exist on clinical performance and on other determinants for use. Comparing the results of this study with a similar, previously published study performed on possible differences amongst different types of allograft in the management of partial thickness burns, both allografts and porcine xenograft seem to perform equally well clinically with regard to healing related outcomes. In addition, the risk of disease transfer, in real life, was shown to be minimal. Consequently, clinical aspects being equal, other aspects such as price and availability should be used to decide which material to use for the management of partial thickness burns.

Current achievements with topical negative pressure to improve wound healing in dehiscent ischemic stumps of diabetic patients: a case series

Negative pressure wound therapy has been increasingly used either as a primary or as an adjunctive therapeutic measure to treat a variety of recalcitrant wounds during the past years. It is thought to act by creating a local environment that promotes cell proliferation, angiogenesis, and granulation tissue formation, leading to accelerated wound healing to the point of spontaneous closure or reducing the wound size to facilitate significantly further surgical reconstruction. This case series presents our preliminary experience with the use of a Topical Negative Pressure system in the treatment of challenging ischemic wounds of diabetic patients. It aims to underscore its beneficial effects and explore its potential role in the management of ischemic amputated stumps to avoid ipsilateral re-amputation at a higher level.