A comparison of diabetic foot ulcer outcomes using negative pressure wound therapy versus historical standard of care

Analysis of Diabetic Foot Deformation and Plantar Pressure Distribution of Women at Different Walking Speeds

Official guidelines state that suitable physical activity is recommended for patients with diabetes mellitus. However, since walking at a rapid pace could be associated with increased plantar pressure and potential foot pain, the footwear condition is particularly important for optimal foot protection in order to reduce the risk of tissue injury and ulceration of diabetic patients. This study aims to analyze foot deformation and plantar pressure distribution at three different walking speeds (slow, normal, and fast walking) in dynamic situations. The dynamic foot shape of 19 female diabetic patients at three walking speeds is obtained by using a novel 4D foot scanning system. Their plantar pressure distributions at the three walking speeds are also measured by using the Pedar in-shoe system. The pressure changes in the toes, metatarsal heads, medial and lateral midfoot, and heel areas are systematically investigated. Although a faster walking speed shows slightly larger foot measurements than the two other walking speeds, the difference is insignificant. The foot measurement changes at the forefoot and heel areas, such as the toe angles and heel width, are found to increase more readily than the measurements at the midfoot. The mean peak plantar pressure shows a significant increase at a faster walking speed with the exception of the midfoot, especially at the forefoot and heel areas. However, the pressure time integral decreases for all of the foot regions with an increase in walking speed. Suitable offloading devices are essential for diabetic patients, particularly during brisk walking. Design features such as medial arch support, wide toe box, and suitable insole material for specific area of the foot (such as polyurethane for forefoot area and ethylene-vinyl acetate for heel area) are essential for diabetic insole/footwear to provide optimal fit and offloading. The findings contribute to enhancing the understanding of foot shape deformation and plantar pressure changes during dynamic situations, thus facilitating the design of footwear/insoles with optimal fit, wear comfort, and foot protection for diabetic patients.

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.

NPWT in diabetic foot wounds-a systematic review and meta-analysis of observational studies

PURPOSE

Negative-pressure wound therapy (NPWT) is an adjunct modality in diabetic foot ulcerations (DFUs). Randomized controlled trials (RCTs) have shown its advantage over standard approaches; however, data from observational studies remain scarce.We performed a systematic review of observational non-RCTs evaluating NPWT efficacy and safety in patients with DFU.

METHODS

Electronic databases were searched for observational studies involving NPWT. The results of single-arm studies were presented as percentages of patients with the outcome of interest. A meta-analysis of comparative studies provided point estimates of outcomes. Continuous outcomes were reported as either weighted or standardized mean differences and dichotomous data as relative risks (RR).

RESULTS

The search identified 16 relevant observational studies, 12 single-arm, and 4 comparative, reporting on a total of 18,449 patients with DFU, of whom 1882 were managed with NPWT. In the NPWT-treated patients, ulcers were larger (average size range 6.6-27.9 cm²), as compared with controls (≤3 cm²). The pooled results showed healing and major amputation in 51% and 5% of NPWT patients, respectively. The meta-analysis of comparative studies revealed lower risk of major amputation [RR = 0.23 (0.07; 0.80)] in NPWT-treated patients. The pooled results for healing rate and risk of any amputation were inconclusive due to large between-study heterogeneity. Overall, 6 deaths out of 158 patients were reported, none of them related to NPWT. Serious adverse events occurred in 6% of patients on NPWT.

CONCLUSIONS

This systematic review of observational studies provided supportive evidence that NWPT is an efficient and safe adjunct treatment in the management of DFUs.

Negative-Pressure Wound Therapy in Foot and Ankle Surgery

Negative Pressure Wound Therapy (NPWT) is frequently utilized to manage complex wounds, however its mechanisms of healing remain poorly understood. Changes in growth factor expression, micro- and macro-deformation, blood flow, exudate removal, and bacterial concentration within the wound bed are thought to play a role. NPWT is gaining widespread usage in foot and ankle surgery, including the management of traumatic wounds; diabetic and neuropathic ulcers; wounds left open after debridement for infection or dehiscence; high-risk, closed incisions; tissue grafts and free flaps. This article reviews the rationale for NPWT, its proposed mechanisms of action, and the evidence regarding its clinical applications within the field of foot and ankle surgery. Level of Evidence: Level V, expert opinion.

DNA methylation analysis of negative pressure therapy effect in diabetic foot ulcers

OBJECTIVE

Negative pressure wound therapy (NPWT) has been used to treat diabetic foot ulcerations (DFUs). Its action on the molecular level, however, is only partially understood. Some earlier data suggested NPWT may be mediated through modification of local gene expression. As methylation is a key epigenetic regulatory mechanism of gene expression, we assessed the effect of NPWT on its profile in patients with type 2 diabetes (T2DM) and neuropathic non-infected DFUs.

METHODS

Of 36 included patients, 23 were assigned to NPWT and 13 to standard therapy. Due to ethical concerns, the assignment was non-randomized and based on wound characteristics. Tissue samples were obtained before and 8 ± 1 days after therapy initiation. DNA methylation patterns were checked by Illumina Methylation EPIC kit.

RESULTS

In terms of clinical characteristics, the groups presented typical features of T2DM; however, the NPWT group had significantly greater wound area: 16.8 cm2 vs 1.4 cm2 (P = 0.0003). Initially only one region at chromosome 5 was differentially methylated. After treatment, 57 differentially methylated genes were found, mainly located on chromosomes 6 (chr6p21) and 20 (chr20p13); they were associated with DNA repair and autocrine signaling via retinoic acid receptor. We performed differential analyses pre treatment and post treatment. The analysis revealed 426 differentially methylated regions in the NPWT group, but none in the control group. The enrichment analysis showed 11 processes significantly associated with NPWT, of which 4 were linked with complement system activation. All but one were hypermethylated after NPWT.

CONCLUSION

The NPWT effect on DFUs may be mediated through epigenetic changes resulting in the inhibition of complement system activation.

EWMA Document: Negative Pressure Wound Therapy

1. Introduction Since its introduction in clinical practice in the early 1990's negative pressure wounds therapy (NPWT) has become widely used in the management of complex wounds in both inpatient and outpatient care.¹ NPWT has been described as a effective treatment for wounds of many different aetiologies^2,3 and suggested as a gold standard for treatment of wounds such as open abdominal wounds,^4-6 dehisced sternal wounds following cardiac surgery^7,8 and as a valuable agent in complex non-healing wounds.^9,10 Increasingly, NPWT is being applied in the primary and home-care setting, where it is described as having the potential to improve the efficacy of wound management and help reduce the reliance on hospital-based care.¹¹ While the potential of NPWT is promising and the clinical use of the treatment is widespread, highlevel evidence of its effectiveness and economic benefits remain sparse.^12-14 The ongoing controversy regarding high-level evidence in wound care in general is well known. There is a consensus that clinical practice should be evidence-based, which can be difficult to achieve due to confusion about the value of the various approaches to wound management; however, we have to rely on the best available evidence. The need to review wound strategies and treatments in order to reduce the burden of care in an efficient way is urgent. If patients at risk of delayed wound healing are identified earlier and aggressive interventions are taken before the wound deteriorates and complications occur, both patient morbidity and health-care costs can be significantly reduced. There is further a fundamental confusion over the best way to evaluate the effectiveness of interventions in this complex patient population. This is illustrated by reviews of the value of various treatment strategies for non-healing wounds, which have highlighted methodological inconsistencies in primary research. This situation is confounded by differences in the advice given by regulatory and reimbursement bodies in various countries regarding both study design and the ways in which results are interpreted. In response to this confusion, the European Wound Management Association (EWMA) has been publishing a number of interdisciplinary documents^15-19 with the intention of highlighting: The nature and extent of the problem for wound management: from the clinical perspective as well as that of care givers and the patients Evidence-based practice as an integration of clinical expertise with the best available clinical evidence from systematic research The nature and extent of the problem for wound management: from the policy maker and healthcare system perspectives The controversy regarding the value of various approaches to wound management and care is illustrated by the case of NPWT, synonymous with topical negative pressure or vacuum therapy and cited as branded VAC (vacuum-assisted closure) therapy. This is a mode of therapy used to encourage wound healing. It is used as a primary treatment of chronic wounds, in complex acute wounds and as an adjunct for temporary closure and wound bed preparation preceding surgical procedures such as skin grafts and flap surgery. Aim An increasing number of papers on the effect of NPWT are being published. However, due to the low evidence level the treatment remains controversial from the policy maker and health-care system's points of view-particularly with regard to evidence-based medicine. In response EWMA has established an interdisciplinary working group to describe the present knowledge with regard to NPWT and provide overview of its implications for organisation of care, documentation, communication, patient safety, and health economic aspects. These goals will be achieved by the following: Present the rational and scientific support for each delivered statement Uncover controversies and issues related to the use of NPWT in wound management Implications of implementing NPWT as a treatment strategy in the health-care system Provide information and offer perspectives of NPWT from the viewpoints of health-care staff, policy makers, politicians, industry, patients and hospital administrators who are indirectly or directly involved in wound management.

Negative pressure wound therapy use in diabetic foot syndrome-from mechanisms of action to clinical practice

BACKGROUND

Diabetes and its complications constitute a rising medical challenge. Special attention should be given to diabetic foot syndrome (DFS) due to its high rate of associated amputation and mortality. Negative pressure wound therapy (NPWT) is a frequently used supportive modality in a diabetic foot with ulcerations (DFUs).

DESIGN

Here, we reviewed the current knowledge concerning the tissue and molecular mechanisms of NPWT action with an emphasis on diabetes research followed by a summary of clinical DFU studies and practice guidelines.

RESULTS

Negative pressure wound therapy action results in two types of tissue deformations-macrodeformation, such as wound contraction, and microdeformation occurring at microscopic level. Both of them stimulate a wound healing cascade including tissue granulation promotion, vessel proliferation, neoangiogenesis, epithelialization and excess extracellular fluid removal. On the molecular level, NPWT results in an alteration towards more pro-angiogenic and anti-inflammatory conditions. It increases expression of several key growth factors, including vascular endothelial growth factor and fibroblast growth factor 2, while expression of inflammatory cytokinesis reduced. The NPWT application also alters the presence and function of matrix metalloproteinases. Clinical studies in DFU patients showed a superiority of NPWT over standard therapy in terms of efficacy outcomes, primarily wound healing and amputation rate, without a rise in adverse events. International guidelines point to NPWT as an important adjuvant therapy in DFU whose use is expected to increase.

CONCLUSIONS

This current knowledge improves our understanding of NPWT action and its tailoring for application in diabetic patients. It may inform the development of new treatments for DFU.

Postsurgical Treatment of Split Skin Graft Donor Sites in Dermatological Departments

The surgical removal of split skin grafts (SSGs) leads to superficial wounds that can be covered with different wound dressings. Currently, international guidelines that recommend a standard treatment of the donor sites are not yet established. We developed a questionnaire to evaluate the treatment of SSG donor sites and sent it to all dermatological departments in Germany. Altogether 78 of the 115 contacted departments in Germany participated in our cross-sectional trial. Our analysis reveals that multiple wound dressings with different frequencies of replacement are used. On an average, complete reepithelialization of the donor site takes 14-21 days. Foams and coated gauzes are used in 73% of all surgical procedures for postsurgical treatment of SSG donor sites. Still, neither a significant faster reepithelialization nor a lower rate of wound healing disorders can be assigned to any of the wound dressings. The results of our study indicate that a large number of wound care products and treatment strategies are currently applied on SSG donor sites in dermatological departments in Germany. The selection of the wound dressing is not based on scientific data but rather on the experience of individual experts.

Cost-effective Alternative for Negative-pressure Wound Therapy

Background:

Current predominantly used equipments for negative-pressure wound therapy (NPWT) are expensive. In current healthcare climate continually emphasizing cost containment, importance in developing more cost-effective alternatives cannot be understated. Previously, therapeutically equivalent methods of providing NPWT was demonstrated using just low-cost, universally available supplies, coined Gauze-SUCtion (GSUC). Here, we examine long-term potential financial savings of utilizing GSUC over commercialized products.

Methods:

A retrospective cost analysis was performed at the University of Chicago Medical Center between 1999 and 2014. All NPWT was provided via either GSUC or commercialized vacuum-assisted closure (VAC, KCI) device. Sum of all material component costs were reviewed to determine theoretical average daily cost. For the VAC group, recorded institutional spend to KCI was also reviewed to determine actual daily cost. In the GSUC group, this figure was extrapolated using similar ratios. Labor costs for each method were determined using analysis from prior study. Patient demographics, etiology, wound location, and treatment length were also reviewed.

Results:

Total of 35,871 days of NPWT was provided during the 15-year span. Theoretical average cost of VAC was $94.01/d versus $3.61/d for GSUC, whereas actual average was $111.18/d versus $4.26/d. Average labor cost was $20.11/dressing change versus $12.32. Combined, total cost of VAC therapy was estimated at $119,224 per every 1,000 days of therapy versus $9,188 for the GSUC.

Conclusions:

There is clear and significant cost savings from utilization of GSUC method of NPWT. Furthermore, the added advantage of being able to provide NPWT from universally accessible materials cannot be overstated.

Negative pressure wound therapy as an adjunct in healing of chronic wounds

Negative pressure wound therapy (NPWT) has emerged as a cutting-edge technology and provides an alternative solution to the problem of wounds. This study was undertaken to assess the efficacy of this technique in the treatment of chronic wounds. A prospective clinical study was used to evaluate our experience in use of NPWT in the healing of pressure ulcers and chronic wounds over 2 years. The primary end point of the study group was the time taken for appearance of healthy granulation tissue and full reepithelialisation without drainage. All patients with sepsis were excluded from the study. The statistical analysis of the data was carried out. Of the 60 patients studied, 41 had associated comorbidities including diabetes mellitus. The commonest site of occurrence was the lower limb. Coverage in the form of a flap was required at presentation in 63·33% of patients. However, after initiation of NPWT, none of them required the procedure and they healed spontaneously either by secondary intention or by skin grafting. The time taken for appearance of healthy granulation tissue was 14·36 ± 4·24 days. Complete healing of wounds occurred by 33·1 ± 10·22 days. There was a statistically significant difference in the volume of the wounds before and after the intervention (P = 0·000). Complications resulting from NPWT were minimal. This technique is an excellent adjunct to surgical debridement.

Negative pressure wound therapy technologies for chronic wound care in the home setting: A systematic review

The use of negative pressure wound therapy (NPWT) is increasing in both the inpatient and outpatient settings. We conducted a systematic review on the efficacy and safety of NPWT for the treatment of chronic wounds in the home setting. We searched MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, and the Cumulative Index to Nursing and Allied Health Literature, up to June 2014. Two independent reviewers screened search results. Seven studies met our criteria for inclusion. Six of the studies compared NPWT devices to other wound care methods and one study compared two different NPWT technologies. Data were limited by variability in the types of comparator groups, methodological limitations, and poor reporting of outcomes. We were unable to draw conclusions about the efficacy or safety of NPWT for the treatment of chronic wounds in the home setting due to the insufficient evidence. Consensus is needed on the methods of conducting and reporting wound care research so that future studies are able inform decisions about the use of NPWT in the home environment for chronic wounds.

Negative-pressure wound therapy for management of diabetic foot wounds: a review of the mechanism of action, clinical applications, and recent developments

Negative-pressure wound therapy (NPWT) plays an important role in the treatment of complex wounds. Its effect on limb salvage in the management of the diabetic foot is well described in the literature. However, a successful outcome in this subgroup of diabetic patients requires a multidisciplinary approach with careful patient selection, appropriate surgical debridement, targeted antibiotic therapy, and optimization of healing markers. Evolving NPWT technology including instillation therapy, nanocrystalline adjuncts, and portable systems can further improve results if used with correct indications. This review article summarizes current knowledge about the role of NPWT in the management of the diabetic foot and its mode of action, clinical applications, and recent developments.

The fluid dynamics of simultaneous irrigation with negative pressure wound therapy

Saline irrigation has been shown to be both experimentally and clinically efficacious in decreasing bacterial contamination as well as decreasing infection rates. The dynamics of irrigation delivery fall into two primary categories: simultaneous and intermittent irrigation. An important component to irrigation therapy is distribution of irrigation solution to hard-to-reach areas of a wound bed, including undermining and fissure-like structures. Here we test the effectiveness of simultaneous irrigation to fill the irregular structures of a wound bed. In order to visualise the dynamic movement of irrigation solution, three-dimensional wound models were constructed using clear synthetic ballistic gel. Wounds with the aforementioned characteristics were carved into the ballistic gel with varying area, depth and volume. All three wounds were dressed as per manufacturer's instructions. Data demonstrate that simultaneous irrigation is effective in reaching all parts of a wound bed in wound models that have both undermining and tunnelling, and irrigation effectively saturates bridged wounds. Finally, this study shows that there is constant turnover of irrigation solution in the wound that is driven more by administration volume and less by flow rate. These data show that simultaneous irrigation is an effective technique for delivering irrigation solution to both simple and complex wounds.

Vacuum Assisted Closure- utilization as home based therapy in the management of complex diabetic extremity wounds

Objective:

Vacuum assisted closure is a reported technique to manage complex wounds. We have utilized this technique by using simple locally available material in the management of our patients on outpatient basis. The objective of this study is to present our experience.

Methods:

This study was conducted from June 2011 to June 2013 at Dow University Hospital and Aga Khan University Hospital, Karachi. There were 38 patients managed with vacuum assisted closure. Mean age was 56±7.8 years. Twenty three patients presented with necrotizing fasciitis and 15 patients with gangrene. Lower limbs were involved in majority of the patients. Debridement or amputations were done. Vacuum dressing was changed twice weekly in outpatient department. Wounds were closed secondarily if possible or covered with split thickness skin graft in another admission.

Results:

All the wounds were successfully granulated at the end of vacuum therapy. Mean hospital stay was 7.5 days. Vacuum dressing was applied for a mean of 20 days. There was reduction in the size of the wound. Thirteen patients underwent secondary closure of the wound under local anesthesia, 18 patients required coverage with split thickness skin graft and 7 patients healed with secondary intention.

Conclusion:

Vacuum assisted closure appeared to be an effective method to manage complex diabetic wounds requiring sterile wound environment.

Single-stage application of a novel decellularized dermis for treatment-resistant lower limb ulcers: positive outcomes assessed by SIAscopy, laser perfusion, and 3D imaging, with sequential timed histological analysis

We present results of an original clinical study investigating efficacy of a decellularized dermal skin substitute (DCD) as part of a one-stage therapeutic strategy for recalcitrant leg ulcers. Twenty patients with treatment-resistant ulcers underwent hydrosurgical debridement, after which DCD was applied and covered with negative pressure dressings for 1 week. Participants were reviewed on seven occasions over 6 months. 3D photography, full-field laser perfusion imaging, spectrophotometric intracutaneous analysis, and sequential biopsies were used to monitor healing. Mean ulcer duration and surface area prior to DCD placement were 4.76 years (range 0.25-40 years) and 13.11 cm(2) (range 1.06-40.75 cm(2)), respectively. Seventy percent of ulcers were venous. Surface area decreased in all patients after treatment (range 23-100%). Mean reduction was 87% after 6 months, and 60% of patients healed completely. Wound bed hemoglobin flux increased significantly 6 weeks after treatment (p = 0.005). Histological and immunohistochemical analysis confirmed progressive DCD integration with colonization by host fibroblasts, lymphocytes, and neutrophils, resulting in fibroplasia, reepithelialisation, and angiogenesis, with correlating raised CD31, collagen I, and collagen III levels. Subgroup analysis showed differing cellular behavior depending on wound duration, with delayed angiogenesis, reduced collagen deposition, and smaller reductions in surface area in ulcers present for over 1 year. The stain intensities of immunohistochemical markers including fibronectin, collagen, and CD31 differed depending on depth from the wound surface and presence of intact epithelium. DCD safely produced significant improvement in treatment-resistant leg ulcers. With no requirement for hospital admission, anesthetic, or autogenic skin grafting, this treatment could be administered in hospital and community settings.

Monitoring of systemic inflammatory response in diabetic patients with deep foot infection treated with negative pressure wound therapy

BACKGROUND

The purpose of this study was to establish the safety of negative pressure wound therapy (NPWT) in the treatment of acutely debrided, deep diabetic foot infections (DDFI) and to determine the value of inflammatory markers in monitoring of treatment of these infections with negative pressure wound therapy.

METHODS

A group of ten patients with DDFI treated by radical surgical debridement and simultaneous NPWT was prospectively studied. During the debridement, a deep tissue sample was obtained and sent for microbiological testing. The patients were followed clinically for 10 days and NPWT dressings were changed every 2 to 3 days or sooner when indicated. The peripheral blood samples were obtained before the radical debridement and 3 and 10 days afterwards and concentrations of white blood cell, neutrophils, lymphocytes and C-reactive protein (CRP) were measured. The changes in concentration of inflammatory markers were analyzed with a Friedman test.

RESULTS

In all but one patient the presence of DDFI was confirmed by the culture results. At baseline, the elevated WBC and neutrophil concentrations were observed only in half of the patients while the CRP concentration was elevated in nine patients. During followup, all patients showed a favorable clinical evolution and statistically significant decrease of WBC, neutrophils and CRP (p<0.001). There were not statistically significant changes in lymphocyte count.

CONCLUSION

NPWT can be safely applied in acutely debrided DDFI. CRP seems to be the most adequate parameter for both diagnosis and monitoring of treatment of DDFI.

Laparostomy management using the ABThera™ open abdomen negative pressure therapy system in a grade IV open abdomen secondary to acute pancreatitis

Wound control in laparostomy for the treatment of intra-abdominal hypertension remains challenging and numerous techniques have been described. We report the first UK experience with a new commercially available device specifically designed to facilitate management of the open abdomen. A 44-year-old gentleman presented with a 3-day history of constant severe epigastric pain and associated vomiting. Amylase was markedly elevated and he was admitted for supportive management of pancreatitis, with subsequent transfer to intensive care due to severe systemic inflammatory syndrome. The patient decompensated, developing intra-abdominal hypertension with renal and respiratory failure. This was successfully managed by performing a laparostomy and using an ABThera™ Open Abdomen Negative Pressure Therapy System (KCI, San Antonio, TX). We describe its use to facilitate wound control, including enteroatmospheric fistula, allowing granulation and eventual restoration of gastrointestinal continuity 383-days after admission. We found the ABThera™ System proved to be a useful treatment adjunct, protecting intra-abdominal contents while removing large volumes of exudate and infected material from within the abdominal cavity. Complex cases such as this remain infrequent and this article provides a summary of our experience, including a review of indications for laparostomy and the underlying basic science in this difficult area.

Comparative effectiveness of the SNaP™ Wound Care System

Diabetic lower extremity wounds cause substantial burden to healthcare systems, costing tens of thousands of dollars per episode. Negative pressure wound therapy (NPWT) devices have been shown to be cost-effective at treating these wounds, but the traditional devices use bulky electrical pumps that require a durable medical equipment rental-based procurement process. The Spiracur SNaP™ Wound Care System is an ultraportable NPWT system that does not use an electric pump and is fully disposable. It has superior healing compared to standard of care with modern dressings and comparable healing to traditional NPWT devices while giving patients greater mobility and giving clinicians a simpler procurement process. We used a mathematical model to analyse the costs of the SNaP™ system and compare them to standard of care and electrically powered NPWT devices. When compared to standard of care, the SNaP™ system saves over $9000 per wound treated and more than doubles the number of patients healed. The SNaP system has similar healing time to powered NPWT devices, but saves $2300 in Medicare payments or $2800 for private payers per wound treated. Our analysis shows that the SNaP™ system could save substantial treatment costs in addition to allowing patients greater freedom and mobility.

An alternative coverage for split thickness skin graft donor site wounds

Diabetic foot and ankle soft tissue reconstruction poses a difficult challenge to the treating surgeon, especially in cases associated with previous infection or amputation. Maintenance of a functional, plantigrade limb is important with regard to prevention of persistent or recurrent cutaneous compromise following diabetic limb salvage. Wound coverage by means of application of a split thickness skin graft (STSG) is a useful technique; however, donor site wounds require care during the early postoperative period, and can pose a challenge to wound healing in and of themselves. In this article, we describe a technique of management of STSG donor site wounds that we have found to be useful and well tolerated by our patients.

A prospective study of negative pressure wound therapy with integrated irrigation for the treatment of diabetic foot ulcers

OBJECTIVE

Patients with diabetes often present with pedal wounds resistant to standard wound healing modalities and become chronic in nature. These chronic wounds in diabetic patients have a high incidence of complications including infection and amputation. Negative pressure wound therapy has been found to facilitate healing of the stagnant pedal wound. This protocol was designed to determine wound closure rates using a unique negative pressure wound therapy system that delivers vacuum-assisted wound closure with a simultaneous irrigation feature (Svedman Wound Treatment System).

METHODS

A prospective single center study was conducted in adults with diabetic foot ulcers ≥cm(2) or more in size showing no signs of clinical infection, and having adequate blood flow. Patients received dressing changes and irrigation on a standard regimen with weekly wound assessments for a minimum of 6 weeks.

RESULTS

11 women and 8 men with a mean wound size of 2.4 cm × 2.2 cm were treated with the device. A total of 14 of /19 (74%) patients healed completely, with a median healing time of 34 days (range, 9-114). Eleven of 19 patients (58%) healed within the 6-week evaluation period. For the 5 patients who did not heal completely with the device, other treatments were utilized, including further wound debridement, muscle flaps, and skin grafting procedures.

CONCLUSIONS

Negative pressure wound therapy with integrated irrigation was well tolerated by the patients without complications related to the device application or irrigation feature. The data clearly suggests that this technology may be a promising alternative for the chronic nonhealing diabetic wound.

Economic evaluation of Vacuum Assisted Closure® Therapy for the treatment of diabetic foot ulcers in France

The objective of the study was to assess the cost-effectiveness of Vacuum Assisted Closure® (V.A.C.®) Therapy compared with advanced wound care (AWC) for the treatment of diabetic foot ulcers (DFUs) in France. A cost-effectiveness model intended to reflect the management of DFUs was updated for the French setting. The Markov model follows the progression of 1000 hypothetical patients over a 1-year period. The model was populated with French-specific data, obtained from published sources and clinical experts. The analysis evaluated costs and health outcomes, in terms of quality-adjusted life-years (QALYs), wounds healed and amputations, from the perspective of the payer. The patients treated with V.A.C.® Therapy experienced more QALYs (0.787 versus 0.784) and improved healing rates (50.2% versus 48.5%) at a lower total cost of care (€24,881 versus €28,855 per patient per year) when compared with AWC. Sensitivity analyses conducted around key model parameters indicated that the results were affected by hospital resource use and costs. DFU treatment using V.A.C.® Therapy in France was associated with lower costs, additional QALYs, more healed ulcers and fewer amputations than treatment with AWC. V.A.C.® Therapy was therefore found to be the dominant treatment option.

Effectiveness of Vacuum-assisted Closure (VAC) Therapy in the Healing of Chronic Diabetic Foot Ulcers

Introduction: This is the first prospective study done locally to determine the effectiveness of vacuum-assisted closure (VAC) therapy in the healing of chronic diabetic foot ulcers. Materials and Methods: An electronic vacuum pump was used to apply controlled negative pressure evenly across the wound surface. Changes in wound dimension, presence of wound granulation and infection status of diabetic foot ulcers in 11 consecutive patients with diabetes were followed over the course of VAC therapy. Results: Healing was achieved in all wounds. Nine wounds were closed by split-skin grafting and 2 by secondary closure. The average length of treatment with VAC therapy was 23.3 days. Ten wounds showed reduction in wound size. All wounds were satisfactorily granulated and cleared of bacterial infection at the end of VAC therapy. Conclusions: VAC therapy was useful in the treatment of diabetic foot infection and ulcers, which after debridement, may present with exposed tendon, fascia and/or bone. These included ray amputation wounds, wounds post-debridement for necrotising fasciitis, wounds post-drainage for abscess, a heel ulcer and a sole ulcer. It was able to prepare ulcers well for closure via split-skin grafting or secondary closure in good time. This reduced cost of VAC therapy, as therapy was not prolonged to attain greater reduction in wound area. VAC therapy also provides a sterile, more controlled resting environment to large, exudating wound surfaces. Large diabetic foot ulcers were thus made more manageable. Key words: Diabetic foot wound, Negative pressure dressing, Wound healing

An overview of negative pressure wound therapy for the lower extremity

Since its introduction into the market, negative pressure wound therapy (NPWT), also known as topical negative pressure, has become an important adjuvant therapy for the treatment of many types of wounds. Surgeons and physicians of all subspecialties have adopted NPWT into their practices. NPWT has become a mainstay in the management of lower extremity soft tissue pathology, especially in patients with traumatic, diabetic, postsurgical, and peripheral vascular disease-associated wounds. This article reviews the background, currently understood mechanisms of action, applications, contraindications, reported complications, advantages, criticisms, and techniques in the lower extremity.

A systematic review of the effectiveness of negative pressure wound therapy in the management of diabetes foot ulcers

Foot ulcers are a common complication in patients with diabetes. Negative pressure wound therapy (NPWT) is a wound care therapy that is being increasingly used in the management of foot ulcers. This article presents a systematic review examining the effectiveness of this therapy. The review question is how effective is NPWT in achieving wound healing in diabetes foot ulcers? The primary outcome for this study was the number of patients achieving complete wound healing (secondary outcomes, other markers of wound healing, adverse events and patient satisfaction). A systematic literature review and tabulative synthesis of randomised controlled trials (RCTs). The review identified four RCTs of weak to moderate quality. Only one study examining NPWT in postamputation wound healing reported data on the primary outcome. These data show a 20% improvement in wound healing [odds ratios = 2.0%, confidence interval (CI) -1.0 to 4.0] and number needed to treat = 6 (CI 4-64). No serious treatment-related complications were reported by any of the studies. One study suggested a reduction in the risk of secondary amputation (absolute risk reduction = 7.9%, CI 0.5-15.43). Studies also reported an increase in granulation and wound-healing rates in patients treated with NPWT therapy. No data on patient satisfaction or experience were reported. While all the studies included in the review indicated that the NPWT therapy is more effective than conventional dressings, the quality of the studies were weak and the nature of the inquiries in terms of outcome and patient selection divergent. There is a strong need for larger trials to assess NPWT therapy in diabetes care with different groups of patients and in relation to different clinical objectives and parameters.