Bacterial load in relation to vacuum-assisted closure wound therapy: a prospective randomized trial.

Vacuum-assisted closure has become a new technique in the challenging management of contaminated, acute, and chronic wounds. Although promising clinical results have been described, scientific proof to substantiate the mechanism of action of this therapy is scarce. In the present study, we examined whether the positive effect on wound healing found in vacuum-assisted closure-treated wounds could be explained by an effect on the bacterial load. Fifty-four patients who needed open wound management before surgical closure were included in this study. Wounds were randomized to either vacuum-assisted closure therapy (n= 29) or treatment by conventional moist gauze therapy (n= 25). Healing was characterized by development of a clean granulating wound bed ("ready for surgical therapy") and reduction of wound surface area. To quantify bacterial load, biopsies were collected. No significant difference was found in time needed to reach "ready for surgical therapy" comparing both therapies. Wound surface area reduction was significantly larger in vacuum-assisted closure-treated wounds: 3.8 +/- 0.5 percent/day (mean +/- SEM) compared to conventional-treated wounds (1.7 +/- 0.6 percent/day; p < 0.05). The total quantitative bacterial load was generally stable in both therapies. However, nonfermentative gram negative bacilli showed a significant decrease in vacuum-assisted closure-treated wounds (p < 0.05), whereas Staphylococcus aureus showed a significant increase in vacuum-assisted closure-treated wounds (p < 0.05). In conclusion, this study shows a positive effect of vacuum-assisted closure therapy on wound healing, expressed as a significant reduction of wound surface area. However, this could not be explained by a significant quantitative reduction of the bacterial load.     

Efficacy of treatment with Repithel and Jelonet in comparison to treatment with Jelonet alone - a randomized clinical trial in patients receiving meshed skin grafts

Moist wound treatment is a well recognized method for the treatment of aseptic acute and chronic wounds. While the moist environment is beneficial to the woundhealing process, it also increases the risk of bacterial superinfection. We here report on the results of a clinical phase-III-study in which we tested the effect of a new PVP-iodine liposomal hydrogel (Repithel) on split-thickness skin grafts. This formulation optimizes moist wound treatment by improving the cell proliferation rate while preventing wound infection. AIM: The aim of this phase-III-study was to analyse the efficacy and tolerance of Repithel in patients receiving meshed skin grafts. METHODS: 167 patients with transplantation wounds were either treated with lipid gauze alone (control group) or with lipid gauze and Repithel. In both groups the extent of neoepithelization, the frequency and severity of graft losses and the time until complete wound closure was achieved were determined. Analysis of the re-epithelization was achieved by photoplanimetry. Impedance measurements gave additional information on the regeneration of the epidermal barrier. RESULTS: Wounds receiving Repithel showed a significantly faster neoepithelisation than wounds which were treated with lipid gauze alone. Treatment with Repithel significantly reduced both the number of graft losses and the size of area lost. The time until wounds were closed completely was significantly shorter in patients receiving Repithel than in controls. The positive effects of Repithel on wound healing were especially observed in smokers, patients with chronic wounds, burns or infected wounds. CONCLUSIONS: Repithel supports healing of meshgraft transplants and reduces the risk of graft loss. Patients who heal poorly benefit particularly from the Repithel treatment.     

Effective Management of Difficult Surgical Defects Using Tissue-Engineered Skin

BACKGROUND: Graftskin, a bilayered living skin construct, is an effective therapeutic option in the management of chronic venous ulcerations and simple acute surgical excisions. However, it is not routinely used in the management of complicated surgical wound defects. OBJECTIVE: To determine the effectiveness of graftskin as a therapeutic modality in difficult surgical defects. METHODS: Two patients with complex surgical wound defects after Mohs micrographic surgery underwent a single application of graftskin. The engineered skin was fenestrated and sutured in place. The wounds were examined on a weekly basis. One hundred percent healing was defined as complete reepithelialization (wound coverage). RESULTS: Graftskin was well tolerated by these patients and resulted in complete wound healing within 9 weeks of application. CONCLUSION: Graftskin is an excellent alternative for difficult surgical wounds not amenable to other therapies. Graftskin results in a shortened healing time and decreased morbidity. It should be considered for wounds in which healing by secondary intention is preferably avoided.     

重组人表皮细胞生长因子在慢性溃疡创面中的应用

目的　观察重组人表皮细胞生长因子 (rh EGF)对慢性溃疡创面愈合的影响。方法　 1999年 10月～ 2 0 0 1年 1月在局部清创后随机对 2 6例患者的慢性溃疡创面 (3cm× 3cm～ 5 cm× 8cm )作为治疗组 ,用rh EGF喷雾剂以 40 0 U / 10 cm2 进行局部喷涂 ,无菌敷料覆盖 ;同期随机对另 2 6例慢性溃疡创面 (2 .5 cm×3.0 cm～ 4.0 cm× 6 .5 cm )用 0 .9%生理盐水进行局部湿敷作为对照组 ,观察创面愈合时间、创面局部及全身反应情况。结果　治疗组中创面不适感消失早 ,脓性分泌物少 ,肉芽组织生长快 ,无过度增生现象。溃疡创面愈合时间治疗组较对照组缩短 7～ 10天 ,经统计学处理 ,有显著性差异 (P<0 .0 1)。结论　 rh EGF有明显促进慢性溃疡创面愈合的作用 ,且愈合时间短、质量好     

Negative pressure wound therapy via vacuum assisted closure following partial foot amputation: what is the role of wound chronicity?

Randomised clinical trials (RCTs) to evaluate diabetic foot wound therapies have systematically eliminated large acute wounds from evaluation, focusing only on smaller chronic wounds. The purpose of this study was to evaluate the proportion and rate of wound healing in acute and chronic wounds after partial foot amputation in individuals with diabetes treated with negative pressure wound therapy (NPWT) delivered by the vacuum-assisted closure (VAC) device or with standard wound therapy (SWT). This study constitutes a secondary analysis of patients enrolled in a 16-week RCT of NPWT: 162 open foot amputation wounds (mean wound size = 20.7 cm(2)) were included. Acute wounds were defined as the wounds less than 30 days after amputation, whereas chronic wounds as the wounds greater than 30 days. Inclusion criteria consisted of individuals older than 18 years, presence of a diabetic foot amputation wound up to the transmetatarsal level and adequate perfusion. Wound size and healing were confirmed by independent, blinded wound evaluators. Analyses were done on an intent-to-treat basis. There was a significantly higher proportion of acute wounds (SWT = 59; NPWT = 63) than chronic wounds (SWT = 26; NPWT = 14), evaluated in this clinical trial (P = 0.001). There was no significant difference in the proportion of acute and chronic wounds achieving complete wound closure in either treatment group. Despite this finding, the Kaplan-Meier curves demonstrated statistically significantly faster healing in the NPWT group in both acute (P = 0.030) and chronic wounds (P = 0.033). Among the patients treated with NPWT via the VAC, there was not a significant difference in healing as a function of chronicity. In both the acute and the chronic wound groups, results for patients treated with NPWT were superior to those for the patients treated with SWT. These results appear to indicate that wound duration should not deter the clinician from using this modality to treat complex wounds.     

生长因子应用于临床创伤修复--十年的主要进展与展望

目的回顾研究和评价10年来有关生长因子在临床创面治疗中的作用,特别是在中国的应用实践. 方法从文献和互联网检索近10年来发表的有关生长因子在临床治疗急慢性创面的报告,分析其疗效和不良反应. 结果临床应用生长因子显著加速了急慢性创面愈合速度,缩短了愈合时间,提高了愈合质量,尚未见不良反应发生. 结论应用生长因子促进创面愈合已显示出有效性和安全性.为了将来更好地临床应用,尚有一些潜在的问题需要探讨.     

Epidemiological characteristics and clinical analyses of chronic cutaneous wounds of inpatients in China: Prevention and control

The increased incidence of chronic cutaneous wounds is likely to lead to increased mortality, and therefore, deserves greater attention. More insight is needed into the magnitude of the problem of chronic cutaneous wounds and methods for their prevention and treatment in China. A retrospective analysis of data retrieved from an electronic health‐records database on 3300 patients with chronic skin wounds was conducted from 1 January 2018 to 31 December 2018. The patients had been admitted to the medical and surgical wards of 17 third‐grade class‐A hospitals in China. The study's aim was to compare the characteristics (eg, demographic and clinical) associated with different causes and distributions of patients' chronic wounds. Among the 3300 patients, 66.03% were males and 33.97% were females. The mean age was 57 years and the increasing prevalence of chronic skin wounds with aging was quite high. The primary causes of chronic wounds were diabetes or infection, followed by pressure ulcers, trauma, and iatrogenic wounds. The distribution of skin wounds was mainly in the lower extremities (56.1%), followed by the trunk (18.6%). The mean duration of hospital stay was 29 days and the mean recurrence was 3 months. Chronic skin wounds were related to occupation, educational level, lifestyle habits, and income. The main cause of chronic skin wounds has shifted from trauma to chronic disease. Normalization checks, bacterial cultures, and antibiotic use in China need to be standardized and the training of wound specialists should be further strengthened. The association of aging and wound infection was significant. Preventive management and efficient treatment should correspond to the needs of the different regions of China. These results may serve as a reference for other developing countries in their transitional development.     

封闭负压技术治疗各种术后伤口裂开

目的：观察封闭负压技术治疗外科手术后伤口裂开的临床效果及总结应用经验。方法：从2007年5月至2009年12月,采用封闭负压技术治疗各类外科术后伤口裂开患者17例,其中男10例,女7例,平均年龄41岁。创面面积为0.5cm×3.2cm～5.5cm×18.6cm,创面形成时间为8～94天,期间采用常规湿敷或中药换药治疗伤口未愈。给予-120mmHg～-150mmHg负压持续吸引,治疗时间为6～37天。结果：10例经封闭负压治疗后创面直接愈合,其余7例创面清洁,肉芽组织新鲜,伤口缩小,4例清创缝合,2例行局部皮瓣转移,1例行皮片移植修复,伤口均一期愈合。术后随访2～12个月,所有伤口愈合良好,无再次裂开。结论：封闭负压技术简便、无创,能有效促进伤口清洁,加快肉芽组织生长,缩短创面愈合时间,适合治疗各种外科术后伤口裂开,有较高的临床推广应用价值。     

Initial experience using a hyaluronate-iodine complex for wound healing

Hyaluronate-iodine complex is a wound healing adjuvant approved for use in the European Union. The objective of this study is to validate hyaluronate-iodine as a potential wound healing agent. Patients were recruited from the hospital, the outpatient clinic, and the wound healing center. Hyaluronate-iodine soaked gauze was applied to wounds either daily or every other day depending on the amount of wound exudate. Wounds were measured weekly, and progression was documented with digital photography. All wounds were debrided as needed using standard surgical techniques. Fourteen patients (19 wounds) were entered into this prospective study, and 10 patients completed treatment. Fourteen wounds progressed to complete healing with a mean healing time of 18.1 ± 15.1 weeks. Treatment was interrupted in four patients. One patient discontinued treatment due to pain related to application of hyaluronate-iodine, another patient for transportation issues, and the other two patients were lost to follow-up due to relocation out of state and noncompliance with scheduled appointments. Hyaluronate-iodine was helpful in the healing of all types of wounds treated in this pilot study. The antiadhesive and antimicrobial properties of hyaluronate-iodine create a desirable environment conducive to wound healing without apparent detrimental effects.     

101VAC Therapy Versus Conventional Therapy in Acute and Chronic Wounds

Introduction : Vacuum therapy is a new concept in wound treatment. Animal studies have shown good results in chronic and acute wounds. In clinical practice we have used the system for many wounds with very promising results. However there are few randomized clinical trials that prove the efficacy of the system. Patients and methods : In 2002 we have started a randomized prospective clinical trial to compare the results of Vacuum Assisted Closure versus our wound management protocol with mainly foam dressings and alginates. In this study we have included acute and chronic wounds. The wounds were assessed 3 times a week by 3 researchers (a medical doctor and 2 nurses). We looked at the wound healing, described in terms of color, smell, temperature and aspect of the wound. The size and depth of the wound was recorded and photographs were taken. Once a week we did a swab of the wound. Besides the effect on wound healing we also looked at the time that was needed for dressing changes, the benefits for the patient and the nurses and the costs of the therapy. Results : At this moment we have treated 35 patients. The preliminary results will be presented at the meeting. With this study as an example we will also illustrate some of the problems that can be encountered when designing a clinical trial in wound healing.     

An innovative enterostomal therapy nurse model of community wound care delivery: a retrospective cost-effectiveness analysis.

PURPOSE: A Canadian specialty nursing association identified the necessity to examine the role and impact of enterostomal (ET) nursing in Canada. We completed a retrospective analysis of the cost-effectiveness and benefits of ET nurse-driven resources for the treatment of acute and chronic wounds in the community. DESIGN: This was a multicenter retrospective pragmatic chart audit of 3 models of nursing care utilizing 4 community nursing agencies and 1 specialty company owned and operated by ET nurses. An analysis was completed using quantitative methods to evaluate healing outcomes, nursing costs, and cost-effectiveness. MAIN OUTCOME MEASURES: Kaplan-Meier estimates were calculated to determine the average time to 100% healing of acute and chronic wounds and total nursing visit costs for treatment in a community setting. Average direct nursing costs related to management of each wound were determined by number of nursing visits and related reimbursement for each visit. A Monte Carlo simulation method was used to help account for costs and benefits in determination of cost-effectiveness between caring groups and the uncertainty from variation between patients and wounds. RESULTS: Three hundred sixty chronic wounds and 54 acute surgical wound charts were audited. Involvement of a registered nurse (RN) with ET or advanced wound ostomy skills (AWOS) in community-level chronic and acute wound care was associated with lower overall costs mainly due to reduced time to 100% closure of the wound and reduced number of nursing visits. The differences in health benefits and total costs of nursing care between the ET/AWOS and a hybrid group that includes interventions developed by an ET nurse and followed by general visiting nurses that could include both RNs and registered practical nurses is an expected reduction in healing times of 45 days and an expected cost difference of $5927.00 per chronic wound treated. When outcomes were broken into ET/AWOS involvement categories for treatment of chronic wounds, there was a significantly faster time to 100% closure at a lower mean cost as the ET/AWOS involvement increased in the case. For acute wound treatment, the differences in health benefits and total costs between the ET/AWOS and a hybrid nursing care model were an expected reduction in healing times of 95 days and an expected cost difference of $9578.00 per acute wound treated. Again, there was a significant difference in healing times and reduced mean cost as the ET/AWOS became more involved in the treatment. The financial benefit to the Ontario Ministry of Health and Long-Term Care is estimated to increase as the involvement of nurses with ET/AWOS specialty training increases. CONCLUSIONS: The greater the involvement both directly and indirectly of an ET/AWOS nurse in the management of wounds, the greater the savings and the shorter the healing times.     

Long‐term follow‐up of negative pressure wound therapy with instillation: a limb salvage procedure?

Negative pressure wound therapy (NPWT) is a treatment to reduce oedema, stimulate granulation tissue formation, remove wound exudate and diminish wound area, thus preparing it for secondary healing, skin grafting or coverage with flaps. The association of instillation to NPWT (NPWTi) is a new method for treating severe wounds, in particular, limb lesions at high risk for amputation. This therapy helps to deliver instillation fluid automatically into the contaminated wound, before application of negative pressure. These steps, repeated cyclically, help to remove infectious material, leading to a better moist environment, a necessary condition for wound healing. We report our experience of treating three patients with complex wounds and associated noble structure exposition conservatively with NPWTi and flap coverage. In a long‐term follow‐up (5 years), we were able to achieve a stable surgery reconstruction on preserved limbs, without evidence of chronic infection and other sequelae or complications. Despite the fact that our experience is limited , as it is based on only a few cases, it suggests how NPWTi could be considered useful in a conservative approach to the treatment of acute complex wounds of the lower extremities. In these patients with high risk of amputation, a long‐term follow‐up becomes fundamental in order to evaluate wound bed status after NPTWi.     

Extracorporeal shock wave therapy for chronic wounds: A systematic review and meta‐analysis of randomized controlled trials

A growing number of clinical studies demonstrate that extracorporeal shock wave therapy (ESWT) is a feasible noninvasive method for improving chronic wound healing. This systematic review and meta‐analysis aimed to assess the effectiveness of ESWT compared with that of the standard care treatment for the healing of chronic wounds, irrespective of etiology, in clinical practice. Randomized controlled trials that investigated the effect of ESWT on chronic wounds with different etiologies from 2000 to 2017 were included in this review. The methodological quality of each selected article was rated using the Jadad scale. A fixed or random effects model was used to calculate the pooled effect sizes according to the heterogeneity of the studies. The cumulative effect of ESWT on each outcome was illustrated using forest plots. Seven randomized controlled trials involving 301 subjects were included in this review. Meta‐analyses revealed that the use of ESWT as an adjunct to wound treatment could significantly accelerate the impaired healing process of chronic wounds. Compared with the control treatment, ESWT markedly increased the wound healing rate by 1.86‐fold (OR = 2.86, 95% CI: 1.63–5.03, p = 0.0003) and the percentage of the wound healing area by 30.46% (SMD = 30.46; 95% CI: 23.80–37.12; p < 0.00001). In addition, the wound healing time was reduced by 19 days (SMD = ?19.11, 95% CI: ?23.74–(–14.47), p < 0.00001) in chronic wound patients. No serious complications or adverse effects were observed secondary to the application of ESWT. The above data suggested that ESWT as an adjunct to wound treatment, could more significantly improve the healing process of chronic wounds than the standard care treatment alone. More high‐quality, well‐controlled randomized trials are needed to evaluate the efficacy of ESWT in clinical practice.     

Aging influences wound healing in patients with chronic lower extremity wounds treated in a specialized wound care center

With the dramatic increase in the aging population, the study and care of wounds in the elderly have become priority topics for both researchers and clinicians. The effects of aging on wound healing in humans have remained controversial. The study was a 5-year epidemiological evaluation of standardized data collected regularly during patients' visits at a specialized Wound Care Center with the aim to determine the key factors influencing the healing of chronic lower extremity wounds. In this analysis of 1,158 chronic wounds, the frequency of wound closure was statistically significantly lower in older patients compared with younger patients. The share of closed wounds decreased by nearly 25% in the elderly patients (≥70 years). The relationship between the patient's age and the proportion of wound closure was nonlinear. The effect of aging on the frequency of wound closure of chronic wounds became clinically apparent after age 60. The chronicity of the wounds was illustrated by their recurrent nature, their long duration, the presence of multiple wounds, and the frequency of concurrent infection. Comorbidity was documented by the coprevalence of up to three underlying diseases related to impaired wound healing. The present study clearly showed that aging affects chronic wound healing negatively.     

Wound sterilization: CO2 laser versus iodine

Control of infection in a surgical wound remains a challenge, especially if further surgery in the area is needed. This study was designed to compare the effectiveness of sterilization of a standard experimental infected wound by surgical skin preparation (Betadine) as compared to treatment with the CO2 laser. Standard wounds (5 x 6 cm) were created superficial to the panniculus carnosus on each flank of 37 adult male New Zealand rabbits. Each wound was infected with a standard dose of Pseudomonas aeruginosa. All wounds became grossly infected. On the third day one flank wound was treated with the CO2 laser, the other with the Betadine solution, and a punch biopsy (4 mm) was taken from each wound for quantitative bacterial counts. Less than 10% of the laser-treated wounds grew Pseudomonas, whereas nearly 40% of the iodine-treated wounds remained infected (P less than 0.005). Our early clinical experience using the CO2 laser for the sterilization of infected wounds is also reported.     

Recombinant adenoviral mediated gene transfer in ischemic impaired wound healing

Chronic nonhealing wounds represent a large clinical problem resulting in severe disabilities and large healthcare expenditures. Despite the scope of this problem, effective new therapies are lacking. The deficiency of growth factors in chronic wounds has brought attention to the topical application of growth factors, but initial clinical trials have resulted in only modest improvements in healing despite large, repetitive doses. The modest improvement in healing observed in these trials show that growth factors can improve chronic wound healing, but a better means of growth factor delivery is needed. We hypothesized that gene therapy using a recombinant adenoviral vector could be used to induce transgene production directly by cells in the wound. An adenovirus containing the beta-galactosidase reporter transgene (Ad-LacZ) was used in the ischemic rabbit ear model to test this hypothesis. Ad-LacZ resulted in efficient transgene delivery to cells participating in the wound healing response, with expression up to 2 weeks. However, wound reepithelialization was impaired in Ad-LacZ treated wounds compared to vehicle control wounds. Adenoviral mediated gene transfer is a promising efficient means of growth factor delivery to chronic wounds. However, selection of the proper transgene with appropriate biologic activity in wound healing may be essential to overcome the potential adverse effects of adenoviral infection.     

The use of hyperbaric oxygen therapy to treat chronic wounds: A review

Chronic wounds, defined as those wounds which fail to proceed through an orderly process to produce anatomic and functional integrity, are a significant socioeconomic problem. A wound may fail to heal for a variety of reasons including the use of corticosteroids, formation of squamous cell carcinoma, persistent infection, unrelieved pressure, and underlying hypoxia within the wound bed. Hypoxia appears to inhibit the wound healing process by blocking fibroblast proliferation, collagen production, and capillary angiogenesis and to increase the risk of infection. Hyperbaric oxygen therapy (HBOT) has been shown to aid the healing of ulcerated wounds and demonstrated to reduce the risk of amputation in diabetic patients. However, the causal reasons for the response of the underlying biological processes of wound repair to HBOT, such as the up‐regulation of angiogenesis and collagen synthesis are unclear and, consequently, current protocols remain empirical. Here we review chronic wound healing and the use of hyperbaric oxygen as an adjunctive treatment for nonhealing wounds. Databases including PubMed, ScienceDirect, Blackwell Synergy, and The Cochrane Library were searched for relevant phrases including HBOT, HBO/HBOT, wound healing, and chronic/nonhealing wounds/ulcers.     

人工皮覆盖技术加外固定器在小腿重度开放骨折中的应用

目的:研究治疗小腿严重开放性骨折的有效治疗方法。方法:自2009年1月至2011年2月治疗56例严重小腿开放骨折患者,其中男42例,女14例;年龄18～68岁,平均43.6岁。清创后骨折用外固定支架固定加人工皮覆盖,接负压封闭吸引,5～7d后Ⅱ期缝合、植皮或皮瓣转移。观察创面修复情况、创面细菌培养情况、骨折愈合时间及患肢功能恢复情况并分析治疗疗效。结果:56例创面均愈合,平均愈合时间5.8个月。骨折愈合53例,延迟愈合3例。浅表感染1例,针道感染3例,无其他并发症。参照Ovadia等关节功能评定标准,优45例,良9例,可2例。结论:人工皮覆盖技术联合外固定支架治疗小腿GustiloⅢ型开放骨折,能促进创面修复及骨折愈合,缩短病程,值得推广。     

自体富血小板血浆治疗供皮区创面延迟不愈的疗效观察

目的 探讨自体富血小板血浆(platelet-rich plasma,PRP)治疗供皮区延迟不愈创面的疗效.方法 回顾性分析自2016年10月至2019年10月三峡大学人民医院烧伤整形外科收治的7例取皮后延迟不愈创面患者的临床资料.应用PRP凝胶进行治疗后随访6～24个月,观察创面愈合时间及愈后瘢痕增生情况.结果 本组...     

Factors associated with positive outcomes in 131 patients treated with gauze-based negative pressure wound therapy

Negative Pressure Wound Therapy (NPWT) is commonly used in many surgical specialties to improve wound management and healing outcomes. This study reports the ability of gauze-based NPWT to address several treatment goals commonly defined at the onset of therapy. A prospective, multi-center, non-comparative clinical investigation was carried out using gauze-based NPWT in chronic and acute wounds. 131 patients including traumatic, post-surgical and chronic wounds were assessed. Weekly percentage reductions in wound area, depth and volume were 8.3%, 15.8% and 20.5% respectively (p < 0.001). A reduction in exudate level was observed from baseline to treatment discontinuation (p < 0.001). An increase (p = 0.007) in red granulation tissue and a decrease (p < 0.001) in non-viable tissue was observed. Baseline wound characteristics associated with slower rates of progress included chronic wound aetiologies, longer wound duration prior to NPWT and presence of diabetes as a co-morbidity. Important indicators of wounds which had improved sufficiently and no longer required NPWT included reduction in volume and exudate levels. Gauze-based NPWT can be used to address many of the treatment goals commonly defined at the onset of therapy including reduction in wound volume, management of exudate and infection status, and improvement in wound bed quality.