What's New on the Wound Care Horizon?

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What’s New on the

Wound Care Horizon?

Georgeanne Botek, DPM FACFAS Orthopaedic and Rheumatologic Institute

WHAT’S NEW on the WOUND CARE HORIZON

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•  Cost •  Products •  Modalities

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Wound Healing

Moisture Balance

Perfusion

Offloading Infec8on Control

Edema Control

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1980s 1990s 2000s 2010s

WOUND CARE TIMELINE

Wet-‐to-‐Dry Dressings Silver Dressings

Advanced Biologics Arterial Perfusion

Bioengineered Skin products

Total Contact Cast

Hydrocolloids Subatmospheric Pressure (VAC)

Regranex Hyperbaric Oxygen

Accuzyme, Panafil

PRFE Ultrasound

HYPERBARIC OXYGEN •  Increases Oxygen •  Enhances Perfusion •  Reduces Edema •  Controls Inflamma8on •  Promotes:

–  Fibroblast Prolifera8on –  Collagen Deposi8on –  Angiogenesis

•  An8microbial Ac8vity •  Mobilizes stem cells

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PITFALLS of HYPERBARIC OXYGEN

•  Availability •  Cost

–  $50,000 to $200,000 •  Time Consuming

–  60 hours •  Pa8ent Percep8on •  Adverse effects •  Is it worth it?

HYPERBARIC OXYGEN: EVIDENCE

Significantly healed ulcers in the short term,

but long term benefit unproven.

Major amputaLon may be reduced, but lacked staLsLcal significance

Cochrane Library April 2012

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HYPERBARIC OXYGEN EVIDENCE

•  94 pa8ents randomized •  Pa8ent baseline similar

–  Average age: 68 –  DM dura8on: 21 years –  Ulcer:

•  Most Wagner 3-‐4 •  10 month dura8on

•  55% had previous Vascular IntervenLon performed on affected limb

Löndhal M et al. Diabetes Care 2010


•  At end of treatment: –  Complete ulcer healing: 61% HBOT vs. 27% Placebo

•  At 1 year: –  Complete ulcer healing: 52% of HBOT vs. 27% Placebo

•  Number Needed to Treat: 4.2 •  Conclusion:

–  Adjunc8ve treatment that facilitates wound healing

Löndhal M et al. Diabetes Care 2010

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•  Treatment (n=8) –  Age: 72 –  DM dura8on 12 years –  Ulcer: Wagner 1 or 2

•  Result: –  6 weeks: 5/8 –  1 year: 0/8

•  Placebo (n=8) –  Age: 70 –  DM dura8on: 10 years –  Ulcer: Wagner 1 or 2

•  Result: –  6 weeks 1/8 –  1 year: 0/8

Abidia A et al. Eur J Vasc Endovasc Surg 2003

1980s 1990s 2000s 2010s

WOUND CARE TIMELINE


Advanced Biologics


Total Contact Cast



Accuzyme, Panafil

PRFE Ultrasound

Arterial Perfusion

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ADVANCED CELL-‐BASED TECHNOLOGIES

•  Fibroblasts

–  Grown on an absorbable mesh

–  With kera8nocytes grown on bovine collagen

•  STSG harvested from human cadavers

•  Growth factors •  Decellularized collagen

materials –  Ac8ng as scaffolds – fetal bovine 8ssues

Bioengineered Skin Subs8tutes:

MESENCHYMAL STEM CELLS

•  Mul8potent cells •  Self-‐renewal capacity •  Sources

–  Bone marrow –  Human placenta

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MESENCHYMAL STEM CELLS

Inflamma8on

•  Regulate •  AnLmicrobial AcLvity

Prolifera8on •  Cell MigraLon •  Angiogenesis

Remodeling •  Collagen DeposiLon

MESENCHYMAL STEM CELLS: AMNIOTIC MEMBRANE

•  Minimal Criteria –  Adherence to plas8c –  Fibroblast colony forma8on –  Differen8a8on poten8al –  Human fetal origin

•  1-‐4x104 cells/cm2

•  Skin subs8tutes –  Fibroblasts and epithelial cells

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MESENCHYMAL STEM CELLS: AMNIOTIC MEMBRANE

•  Advantages: –  Availability –  Easy procurement –  Ease of isola8on and expansion in culture prior to transplanta8on

•  Limita8ons: –  Cost to pa8ent –  Steriliza8on techniques –  Collec8on –  LITERATURE

1980s 1990s 2000s 2010s

WOUND CARE TIMELINE


Advanced Biologics


Total Contact Cast



Accuzyme, Panafil

PRFE Ultrasound

Arterial Perfusion

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INTERMITTENT PNEUMATIC COMPRESSION: ARTERIAL COMPRESSION PUMPS

How Does It Work?

•  Enhances lympha8c return •  Disengorges the 8ssue •  Allows arterioles to open •  Improves arterial perfusion •  Triggers release of Nitric Oxide •  Reduces edema •  Oxygenates wound •  Delivers inflammatory cells

INTERMITTENT PNEUMATIC COMPRESSION: CIRCULATOR BOOT

•  Synchronized with the heartbeat •  Uses a leg bag rather than cuff

–  Allows any por8on of leg to be treated •  Limits compression pressure to diastole

–  Providing pressure to disseminate the arterial inflow •  Can immerse the limb in bags containing an8bio8c solu8on

– May help remove bioburden in the ulcers

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INTERMITTENT PNEUMATIC COMPRESSION: EVIDENCE-‐BASED MEDICINE

1.  Abu-‐Own A, Cheatle T, Scurr JH, and Smith PDC: Eur J Vasc Surg 1993 2.  Agerskov K, Ton HP, Jensen FB, Engell, Dan Med Bull: 1990 3.  Alpagut U, Dayioglu E: Angiology. 56:19-‐23, 2005 4.  Amsterdam EA, Lee G, Tonkon MJ, DeMaria AN and Mason DT: 1977 5.  Bergan JJ, Sparks S, Angle N: Vascular and Endovascular Surgery 32:455-‐462, 1998 6.  Blackshear WM, Pescoo C, LePain F, Benoit S, Dickstein R, Seifert KB: J Vasc Surg 5:432-‐6, 1987

7.  Bolli R, Marbán E: Physiol Rev 79:609-‐34, 1999 8.  Chleboun GS, Howell JN, Baker HL, Ballard TN, Graham JL, Hallman HL, Perkins LE, Schauss JH and Conatser RR: Arch Phys Med Rehabil 76:744-‐749, 1995

9.  Delis KT, Nicolaides AN, Wolfe JH, Stansby G: J Vasc Surg 31:650-‐61, 2000 10.  Delis KT, Nicolaides AN, Labropoulos N, Stansby G:. J Vasc Surg 32:284-‐92, 2000 11.  Delis KT, Knaggs AL: J Vasc Surg 42(4): 717-‐25, 2005 12.  Delis KT, Nicolaides AN: Ann Surg 241: 431-‐441, 2005


13.  Dillon RS: J Clin Engineering 3:63, 1980 14.  Dillon RS: Angiology 31:614-‐638, 1980 15.  Dillon RS: Angiology 37: 47-‐56, 1986 16.  Dillon RS: Ann Surg 204: 643-‐649, 1986 17.  Dillon RS: Vasc Surg (Westerminister Press) 24: 682-‐695, 1990 18.  Dillon RS: 48, Number 5, Part 2: S17-‐S34, 1997 19.  Dillon RS:. Angiology 48, Number 5, part 2: S35-‐S58, 1997 20.  Dillon RS: Chapter 13 in "The Wound Management Manual" pages 141-‐211. Bok Y. Lee editor. McGraw-‐Hill 2005

21.  Eze AR, Comerota AJ, Cisek PL, Holland BS, Kerr RP, Veeramasuneni R and Comerota Jr. A|J: IntermiEent calf and foot compression increases lower extremity blood flow. Am J Surg 172:130-‐135, 1996

22.  Filip JR, Dillon RS: Treatment of end-‐stage "trash feet" with the end-‐diastolic pneumaMc boot. Angiology 59(2):214-‐9, 2008

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23.  Ginsberg JS, Brill-‐Edwards P, Kowalchuk G, Hirsh J: Arch Intern Med 149: 1651-‐2, 1989

24.  Kakkos SK, Griffin M, Geroulakos G, Nicolaides AN:. J Vasc Surg 42:296-‐303, 2005 25.  Kakkos SK, Geroulakos G, Nicolaides AN: Eur J Vasc Endovasc Surg 30:164-‐75, 2005 26.  Kavros SJ, Delis KT, Turner NS, Voll AE, Liedl DA, Gloviczki P, Rooke TW.: J Vasc Surg 47(3):543-‐9,2008

27.  Labropoulos N, Watson WC, Mansour MA, Kang SS, Lioooy FN, Baker WH: Arch Surg 133:1072-‐5, 1998

28.  Labropoulos N, Leon LR, Bhas A et al:. J Vas Surg 42:710-‐6, 2005 29.  Liu K, Chen LE, Seaber AV, Urbaniak JR: J Orthop Res 17(3):415-‐20, 1999


30.  McCulloch JM, Marler KC, Neal MB and Phifer TJ: Advances in Wound Care 7:22-‐26, 1994

31.  Montori VM, Kavros SJ, Walsh EE, Rooke TW: Int Angiol 21(4):360-‐6. 2002 32.  Morgan RH, Carolan G, Psaila JV, Gardner AMN, Fox RH and Woodcock JP: Vasc Surg 25: 8-‐15, 1991

33.  Ramaswami G, D'Ayala M, Hollier LH et al: J Vasc Surg 41:794-‐801, 2005 34.  Smith PC, Sarin S, Hasty J and Scurr JH: Surgery 108: 871-‐875, 1990 35.  Sultan S, Esan O, Fahy A: Vascular 16: 130-‐9, 2008 36.  van Bemmelen PS, Maoos MA, Faught WE, Mansour MA, Barkmeier LD, Hodgson KJ, Ramsey DE, Sumner DS: AugmentaMon of blood flow in limbs with occlusive arterial disease by intermiEent calf compression. J Vasc Surg 19:1052-‐8, 1994

37.  van Bemmelen PS, Gitlitz DB et al: Arch Surg 136:1280-‐5, 2001 38.  Vella A, Carlson LA, Blier B, Felty C, Kuiper JD and Rooke TW: Vascular Medicine 5:21-‐25, 2000

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INTERMITTENT PNEUMATIC COMPRESSION

•  Group 1 (IPC group): –  24 pa8ents, average age 70 –  Post pedal amp –  85-‐95 mmHg; 3, 2-‐hour

sessions

•  42% BKA –  Failed wound healing

•  Group 2 (control): –  24 pa8ents, average age 69 –  Post pedal amp

•  83% resulted in BKA

Kavros SJ, Delis KT et al. Society for Vasc Surg 2008

Wound healing and limb salvage were significantly beZer in the

IntermiZent PneumaLc Compression Group

Within 18 months, 3 Lmes as many people with IPC

healed their wounds and avoided BKA Kavros SJ, Delis KT et al. Society for Vasc Surg 2008

INTERMITTENT PNEUMATIC COMPRESSION

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ARTERIAL COMPRESSION PUMPS: EVIDENCE

•  Retrospec8ve review –  101 cases from Gonda Vascular

Center at Mayo Clinic –  2 of 3 used Air Cast Arterial Flow for

6 hours at home –  1 of 3 used Circulator Boot in

Wound Center for 2, 45-‐minute sessions

•  47% complete wound healing

Montori VM, Kavros SJ et al Int Angiology 2002

•  74 year-‐old male –  Second opinion regarding right foot rest pain and wounds

•  10/2008: right foot purple discolora8on

•  12/2008: seen by Vascular Surgery –  Angiogram:

•  Occlusion of the AT and PT with patent peroneal artery to the level of the foot

•  Recommended right BKA

INTERMITTENT PNEUMATIC COMPRESSION: CASE

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PAST MEDICAL HISTORY

•  CAD s/p CABG LIMA-‐LAD and SVG-‐RCA

•  s/p PTCA 1997 prox RCA

•  HTN

•  Hyperlipidemia

•  DM2

•  Afib s/p DCCx2, s/p PPM

•  Hyperthyroidism – amiodarone induced

•  CKD

•  Right LE –  ABI: 1.33 –  TBI: 0.23

Recommended:

•  Arterial flow device to use

for 6 hours a day

•  Aquacell AG between toes

WORKUP and PLAN

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MONOPHASIC RIGHT DP, PT by DOPPLER DEPENDENT RUBOR

INTERMITTENT PNEUMATIC COMPRESSION: CASE a\er 6 MONTHS

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7 MONTHS a\er INITIATION of ARTERIAL COMPRESSION PUMP in the HOME

INTERMITTENT PNEUMATIC COMPRESSION: CASE a\er 8 MONTHS

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•  Does it provide beoer outcomes, Watson?

•  Is the therapy cost effec8ve?

•  Is it efficient?

•  Technically simple?

WHAT’S NEW

on the WOUND CARE HORIZON

•  Hyperbaric Oxygen Therapy •  Mesenchymal Stem Cell Therapy •  Arterial Perfusion

In Conclusion…

Education

What's New on the Wound Care Horizon?