020: Chronic Nonhealing Combat Injury of the Foot Heals Using Novel Transforming Powder Wound Care Dressing 

Primary Author(s):

H. David Gottlieb, DPM, DABPM, FAPWCA; Kiana Trent DPM, FABPM, FASPS

Introduction

Several veterans deal with lasting effects of their military service long after discharge, and “their wounds from war are daily facts of life.”¹ That was the story of the veteran described here, who dealt with a foot wound from a combat injury for 53 years before enrolling in an ongoing randomized clinical trial funded by the Naval Medical Research Command (NMRC)-Naval Advanced Medical Development (NAMD) via the Medical Technology Enterprise Consortium (MTEC). 

Methods

A 75-year-old diabetic male sustained a high velocity injury to his heel (Vietnam War in 1968). Since the injury, he has had multiple infections, a plethora of standard of care (SOC) and advanced wound care treatments (including skin substitutes), and multiple surgical procedures (including grafts) in attempt to heal the wound.  Despite high quality SOC treatment, including a thorough investigation evaluating adequacy of vascular status and nutrition, and smoking cessation, the wound did not completely heal. The patient had been doing daily dressing changes himself and resigned himself to living with a wound the rest of his life. On 19SEP2022, his wound was treated with transforming powder dressing (TPD) for the first time. TPD is an extended wear powder dressing comprised primarily of polymers similar to those used in contact lenses, that when hydrated, aggregate to form a moist oxygen-permeable barrier that covers and protects the wound. 

Results

The patient had weekly TPD applications or “top offs” (additional powder sprinkled over existing TPD matrix) on the wound, covered by a nonadherent contact layer and secondary dressing over 7 weeks with only 2 debridements indicated. The wound healed in 52 days (09NOV2022). The wound has remained healed to date (1.5 years later). 

Discussion

Despite quality SOC for years, the wound didn’t heal. Once converted to TPD, the wound healed in less than 2 months, requiring only 2 debridements (less than typical), and has remained healed.  Use of novel technology innovations should always be considered, especially when SOC fails. The views and conclusions contained herein are those of the authors and should not be interpreted as necessarily representing the official policies or endorsements, either expressed or implied, of the U.S. Government.

References

1. Library of Congress. Digital Collections. Veterans History Project Collection. Serving: Our Voices. Impact of Service. CONGRESS.GOV. Accessed 28May2024.

021: Utilization of Piscine Acellular Dermal Matrix for Coverage Over Tendon and Bone in Diabetics: A Case Series

Submitter: Claire Shea, BS

Primary Author (s):

Introduction

Diabetic foot ulcers (DFU) are complex clinical situations and have proven difficult to successfully manage. They are typically associated with high failure rates, amputations, increased morbidity, ultimately creating a considerable burden on health-care resources. 

Management of lower extremity diabetic wounds include a spectrum of treatment modalities. While useful, they are often associated with complications.^1,2 

When treating chronic diabetic ulcerations, the wound care provider often turns to advanced allogenic or xenogenic skin graft substitutes for soft tissue coverage. The utilization of xenografts derived from piscine acellular dermal matrix (ADM) has emerged as a promising approach for coverage over tendon and bone defects. Piscine grafts have gained rapid recognition in wound care for their native dermal structural, porosity and biomechanical properties that favors rapid cell ingrowth and provides a natural bacterial barrier rich in Omega3 fatty acids. This case series aimed to evaluate the efficacy and clinical outcomes associated with the utilization of piscine ADM in a series of patients with tendon and bone defects.

Methods

A retrospective analysis was conducted on a series of 3 patients who underwent surgical grafting using piscine ADM for coverage over tendon and bone defects. Data regarding patient demographics, defect characteristics, surgical technique, postoperative outcomes, and complications were collected and analyzed. Each patient had a history of DM2. Each patient had exposed osseous and tendinous structures at the site of graft application. All patients underwent extensive surgical debridement, deep and irregular defects were filled to the level of epidermal tissue with fish skin particulate graft, and then secured with a more traditional sheet form of fish skin graft. Deep cultures were obtained, and antibiotics were initiated, as necessary. Patients received standard of care treatment at routine follow-up until complete healing was obtained.

Results

All wounds had irregular wound surfaces with exposed bone and tendon. Following the first week of initial fish skin graft application complete granulation tissue and coverage of depth, tendon and bone was noted in all. The piscine ADM was successfully integrated and provided adequate coverage in all cases, resulting in improved wound healing, reduced infection rates, and enhanced functional recovery. No cases of graft rejection or significant complications were reported during the follow-up period.

Discussion

Only about 30% of diabetic foot ulcers (DFU) are able to heal within 20 weeks. However, there is promising research indicating that fish skin grafts can play a significant role in improving wound healing outcomes. These grafts contain Omega-3 fatty acids, including EPA and DHA, which help reduce the inflammatory response, enabling the wound to transition from a chronic inflammatory state to an acute one. In a study conducted by Magnusson et al., fish skin grafts demonstrated superior support for the three-dimensional ingrowth of cells compared to dehydrated human amnion membrane. This suggests that fish skin grafts provide a favorable environment for cell growth and tissue repair. Furthermore, the particulate form of fish skin grafts has shown potential benefits, as it may facilitate more rapid incorporation into the wound site by optimizing the surface area to mass ratio while preserving the three-dimensionality, porosity, and natural complexity of intact fish skin. Our own research findings align with the results of a study by Lullove et al., showing that 67% of DFUs without exposed bone or tendon, treated with weekly fish skin graft sheets alongside standard care, achieved complete closure compared to only 32% in the group treated without fish skin grafts. These promising outcomes suggest that fish skin grafts hold significant promise as an adjunctive therapy for enhancing DFU healing.

References

1. CA 4th, Broach RB, et al. Indications and Limitations of Bilayer Wound Matrix-Based Lower Extremity Reconstruction: A Multidisciplinary Case-Control Study of 191 Wounds. Plast Reconstr Surg. 2020;145(3):813–822. doi:10.1097/PRS.0000000000006609

2. Wagstaff, Marcus JD., et al. “Biodegradable Temporising Matrix (BTM) for the Reconstruction of Defects Following Serial Debridement for Necrotising Fasciitis: A Case Series.” Burns Open. 2019;3(1):12–30. doi:10.1016/j.burnso.2018.10.002.

3. Magnusson S, Winters C, Baldursson BT, Kjartansson H, Rolfsson O, Sigurjonsson GF. Acceleration of wound healing through utilization of fish skin containing omega-3 fatty acids. Today’s Wound Clinic. 2016;10(5):26–29. 

4. Margolis DJ, Kantor J, Berlin JA: Healing of diabetic foot ulcers receiving standard treatment: a meta-analysis. Diabetes Care. 1999;22:692–695.

5. Magnusson S, Baldursson BT, Kjartansson H, Rolfsson Yang CK, Polanco TO, Lantis JC 2nd. A prospective, postmarket, compassionate clinical evaluation of a novel acellular fish-skin graft which contains omega-3 fatty acids for the closure of hard-to-heal lower extremity chronic ulcers. Wounds. 2016;28(4):112–118.

6. Sigurjonsson GF. Regenerative and Antibacterial Properties of Acellular Fish Skin Grafts and Human Amnion/Chorion Membrane: Implications for Tissue Preservation in Combat Casualty Care. Mil Med. 2017 Mar;182(S1):383-388. doi: 10.7205/MILMED-D-16-00142. PMID: 28291503.

7. Lullove EJ, Liden B, Winters C, McEneaney P, Raphael A, Lantis Ii JC. A Multicenter, Blinded, Randomized Controlled Clinical Trial Evaluating the Effect of Omega-3-Rich Fish Skin in the Treatment of Chronic, Nonresponsive Diabetic Foot Ulcers. Wounds. 2021 Jul;33(7):169-177. doi: 10.25270/wnds/2021.169177. Epub 2021 Apr 14. PMID: 33872197.