Use of an Autologous Heterogenous Skin Construct in the Treatment of Intractable Late-Effect Radiation Wounds: Case Series

Background

Late-effect radiation-induced wounds represent a particularly difficult category of wounds to manage and treat. Fibrosis, impaired cellular activity, ischemia, and wound chronicity all work to impair healing, and this becomes more pronounced when defects are large or when avascular structures such as bone are exposed. Effective treatment options for this type of wound are limited. Thorough excision of irradiated tissue followed by distal pedicled or free flap closure is the most successful; however, this often requires multiple-stage surgeries and prolonged hospitalization and is associated with significant donor site morbidity. This is complicated further when wounds are large or in difficult locations, when surgery is not appropriate, or when there is limited access to surgeons with the appropriate experience/skill to perform such procedures.

Methods

This case series describes the use of an autologous heterogenous skin construct (AHSC) made from a small full-thickness sample of the patient's healthy skin. Three patients with intractable late-effect radiation wounds were treated with AHSC. Case 1 describes an abdominal wound with tunneling of 7.5 cm to the pubic symphysis, which had been treated for known osteomyelitis, and a shallower full-thickness groin wound. Case 2 describes a right scapular wound with exposed bone, which had failed flap closure. Case 3 describes a right thigh wound in a patient who had been treated for sarcoma with extensive radiation therapy. This eventually resulted in an above-the-knee amputation, which failed to heal, and full exposure of the distal end of the resected femur. All wounds had been present for greater than 10 months.

Results

Mean percent volume reduction was 83% (±2.7) at 3 weeks and 92.9% (±4.7) at 4 weeks. The tunneled abdominal wound decreased in depth from 7.5 cm to 1.2 cm in 3 weeks. Complete closure was achieved at 11 weeks for the abdominal and groin wounds (patient 1) and at 16 weeks for the thigh wound (patient 3). The scapular wound volume of patient 2 had decreased by 91.8% at week 4 but was not fully restored until week 21. Mean time to closure was 16.1 (±4.7) weeks.

Conclusions

AHSC was effective in covering exposed bone, improving wound bed vascularity, filling in significant wound depth, and achieving complete wound closure with one application in patients with intractable late-effect radiation wounds.

Treatment of Stage 4 Pressure Injuries With Autologous Heterogenous Skin Construct: A Single-Center Retrospective Study

Background

Pressure injuries (PIs) are a challenging problem in health care affecting 2.5 million people per year in the US, with 60,000 deaths directly attributed to PIs annually. Surgical closure is the treatment of choice for stage 3 and 4 PIs, but with complication rates of 59% to 73%, less invasive and more effective treatments are needed. Autologous heterogeneous skin construct (AHSC) is a novel autograft made from a small full-thickness harvest of healthy skin. This single-center retrospective cohort study sought to determine the effectiveness of AHSC in the treatment of recalcitrant stage 4 pressure injuries.

Methods

All data were collected retrospectively. The primary efficacy outcome was complete wound closure. Secondary efficacy outcomes included percent area reduction, percent volume reduction, and coverage of exposed structures.

Results

Seventeen patients with 22 wounds were treated with AHSC. Complete closure was achieved in 50% of patients in a mean time of 146 (SD ± 93) days, and the percent area and volume reductions were 69% and 81%, respectively. A 95% volume reduction was achieved in 68.2% of patients at a mean time of 106 (SD ± 83) days, and critical structures were fully covered in 95% of patients in a mean time of 33 (SD ± 19) days. After AHSC treatment, there was a mean decrease of 1.65 hospital admissions (P = .001), 20.92 hospital days (P < .001), and 2.36 operative procedures per year (P < 0.001).

Conclusions

AHSC demonstrated the ability to cover exposed structures, restore wound volume, and achieve durable wound closure in chronic refractory stage 4 PIs with better closure and recurrence rates than current surgical and nonsurgical treatments. AHSC represents a minimally invasive alternative to reconstructive flap surgery that preserves future reconstructive options while minimizing donor-site morbidity and promoting improved patient health.

Case Report of a Chronic Wound Due to Venous Insufficiency Following a Traumatic Arteriovenous Fistula

Chronic lower limb wounds are common. They can be of arterial or venous origin. In this article, we will present a clinical case of a 30-year-old patient with a chronic injury to the right medial malleolus. In his history, we can note a gunshot wound to the right leg. Ultrasonography and CT angiography helped in the diagnosis of traumatic arteriovenous fistula. The patient underwent a fistula embolization which allowed the wound to heal. The clinical presentation, additional examinations and the latest treatment recommendations will be discussed in this article.

Evaluation of a Clinical Decision Support System in the Domain of Chronic Wound Management

The PosiThera project focuses on the management of chronic wounds, which is multi-professional and multi-disciplinary. For this context, a software prototype was developed in the project, which is intended to support medical and nursing staff with the assistance of artificial intelligence. In accordance with the user-centred design, national workshops were held at the beginning of the project with the involvement of domain experts in wound care in order to identify requirements and use cases of IT systems in wound care, with a focus on AI. In this study, the focus was on involving nursing and nursing science staff in testing the software prototype to gain insights into its functionality and usability. The overarching goal of the iterative testing and adaptation process is to further develop the prototype in a way that is close to care.

Implementation and Analysis of Two Knowledge Base Approaches for the Treatment of Chronic Wounds

The access to data in healthcare is an enabler for the implementation of clinical decision support systems (CDSS) in practice. The usage of CDSS aims to be of efficient assistance to healthcare providers. The aim of the BMBF project "PosiThera", is to support the involved professions in the treatment process of chronic wounds. In this study we implemented the formalized knowledge of chronic wound diagnosis into two different knowledge base approaches, the HL7 Arden Syntax and a Petri net approach. The motivating factor behind our study was to use both approaches for the implementation of the projects knowledge base and to compare the results. We implemented the formalized knowledge successfully in both approaches. The results of our comparison showed similarities and differences of the Arden Syntax and the Petri net approach, which might support the evolution of both approaches in the future.

Vasculitic Diseases and Prothrombotic States Contributing to Delayed Healing In Chronic Wounds

PURPOSE

Autoimmune diseases are a common cause of delayed wound healing and should be considered in patients with chronic wounds who do not respond to local wound care or who fail skin grafting in the absence of infection.

RECENT FINDINGS

Epidemiologic studies have shown that, of patients with chronic wounds evaluated in specialized wound healing clinics, 20-23% have autoimmune etiologies for their wounds including vasculitis, rheumatoid arthritis, systemic lupus erythematosus, scleroderma, pyoderma gangrenosum and other autoimmune diseases.

SUMMARY

In this article autoimmune diseases known to be associated with chronic wounds and delayed wound healing are reviewed and the importance of a multidisciplinary approach for patients with chronic wounds, with involvement of rheumatology and dermatology is highlighted. This approach allows for investigation of underlying systemic disease and improves clinical outcomes for many of these challenging patients.