The International Journal of Lower Extremity Wounds recent issues

Does Translational Apply to Research in Wound Care?

Mari, R. — Tue, 24 Nov 2009 03:34:27 PST

Admission Trends Over 8 Years for Diabetic Foot Ulceration in a Specialized Diabetes Unit in Cameroon

Tue, 24 Nov 2009 03:34:27 PST

High rates of foot complications have been reported in people with diabetes in sub-Saharan Africa (SSA). However, there is a paucity of data in support of the changing pattern with time. We report here data on trends in hospitalization for foot ulceration over an 8-year consecutive period in a specialized diabetes unit in SSA. Admission and discharge registers of the diabetes and endocrine unit of the Yaounde Central hospital, Cameroon, were reviewed for the period 2000 through 2007. Data were collected on the status for diabetes, presence of foot ulcer, age, sex, duration of hospitalization, amputation, and deaths.We found that 1841 patients with diabetes were admitted during the study period. The prevalence of foot ulceration was 13% (95% confidence interval [CI] = 11%-15%) and varied significantly by year of study (P = .001). The mean duration of hospitalization significantly decreased with time. Foot ulcer was associated with 115% (95% CI = 87%-148%) more bed use than other conditions in diabetes. Foot ulcer was associated with a nonsignificantly lower risk of death or dropout, with evidence of some attenuation with time. With one exception, the amputation rate of 16% (95% CI = 11%-20%) was similar across years. Foot ulcer is a major cause of hospital admission and bed use for diabetes in Cameroon.

Increased Transcutaneous Oxygen Tension in the Skin Dorsum Over the Foot in Patients With Diabetic Foot Disease in Response to the Topical Use of an Emulsion of Hyperoxygenated Fatty Acids

Tue, 24 Nov 2009 03:34:27 PST

The aim of this study was to examine changes in the skin over the feet of patients with diabetic foot syndrome after local application of a product containing hyperoxygenated fatty acids (HOFAs) by measuring transcutaneous oxygen. In 64 patients, transcutaneous oxygen pressure (TcPo₂) was measured on days 0, 7, 30, 60, and 90 of the study. Foot skin dryness, shedding, and skin color were also assessed using a clinical score. The patients were grouped on the basis of initial levels of transcutaneous oxygen; group 1 comprised patients with TcPo₂ >30 mm Hg and group 2 comprised patients with TcPo₂ <30 mm Hg on the skin over the dorsum of the feet. Increases in local oxygenation values were observed at a local level in group 2 patients after 30 days of treatment. Skin trophism showed clinical improvement in all patients and these observations may be attributed to improved local microcirculation.

Venous Leg Ulcers and Emotional Consequences

Tue, 24 Nov 2009 03:34:27 PST

Venous leg ulcers are a chronic disease that affects populations around the world. For sufferers, it leads to physical, social, economic, and emotional consequences. The aim of this study was to assess the presence of anxiety and depression, as well as to investigate possible associations with sociodemographic variables. A total of 30 patients, both men and women, with venous ulcers receiving care under outpatient treatment in a teaching hospital of a provincial city of São Paulo State, were included in this study. The evaluation tools used were the following: the Hospital Anxiety and Depression Scale (HADS) and a sociodemographic questionnaire that included job status, religion, marital status, gender, duration of disease, and age. A descriptive analysis of the data was performed. Statistical analysis used means, the Student t test, and the ² test. Anxiety was identified in 30% of the patients and depression in 40%. No statistically significant correlation was found between anxiety or depression and the sociodemographic variables. Patients with chronic venous ulcers may present with anxiety and depression independent of socioeconomic variables such as religion, occupation, marital status, and duration of lesion.

A Comparison of Superficial and Deep Bacterial Presence in Open Fractures of the Lower Extremities

Ako-Nai, A.K., Ikem, I.C., Daniel, F.V., Ojo, D.O., Oginni, L.M. — Tue, 24 Nov 2009 03:34:27 PST

This open prospective study compared the bacterial flora of superficial and deep-wound biopsies and swabs over a 2-year period in 4 different samples cultured from open fracture wounds at the Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Nigeria. Samples were taken from 47 patients with factures graded according to Gustilo and Anderson’s classification as grade 1 (2.1%), grade II (29.8%), grade IIIA (36.2%), and grade IIIB (31%). A total of 248 samples were cultured using standard techniques. The incidence of open fracture wounds was 78.7% in male patients and 21.3% in female patients. Tibia fractures constituted 66.1%. A total of 203 bacterial isolates were cultured from 248 samples. Gram-negative bacteria constituted 53.2% of isolates, with Escherichia coli being predominant (12.8%). Staphylococcus aureus were the predominant Gram-positive cocci (15.3%), and Staphylococcus epidermidis (13.3%) may be considered to be the major source of open fracture wound contamination. The bacterial species cultured from superficial and deep-wound swabs and biopsies were similar. Resistance to antimicrobials was high for penicillins (amoxicillin and cloxacillin), with values of 68.6% and 58.3%, respectively, for superficial bacterial species and 58.2% and 31.9%, respectively, for deep-wound biopsies.

Detecting Aerobic Bacterial Diversity in Patients With Diabetic Foot Wounds Using ERIC-PCR: A Preliminary Communication

Tue, 24 Nov 2009 03:34:27 PST

The polymicrobial nature of diabetic foot infection is a reflection of the immune compromised state of the host.The methods of microbial identification based on colony morphology and biochemical characteristics have limitations as they may not differentiate the diverse microorganisms that infect foot wounds. The aim of the present study was to find out the bacterial diversity in diabetic foot infections at genetic level by finger printing, that is, ERIC-PCR (enterobacterial repetitive intergenic consensus -polymerase chain reaction). Nine patients with infected diabetic foot ulcers were recruited to the study. Pus and tissue samples were collected from the wound site. Aerobic bacteria were isolated employing standard microbiological culture methods and their genetic variability was analyzed using the ERIC-PCR. Sensitivity test for these isolates against commonly used antibiotics were performed using disc diffusion method. The standard microbiological culture technique yielded 38 morphotypes of bacteria and their genetic diversity was confirmed by ERIC-PCR assay. Analysis of the similarity index using NTSYSpc 2.1 software revealed 34 types of banding pattern among these isolates. Based on the similarity index these isolates were divided into 7 groups. As many as 8 types of aerobic bacterial isolates were detected from a single patient using the above technique compared with 2 on routine culture analysis. Genetically diverse isolates showed differential sensitivity pattern against commonly used antibiotics in the assay. The observed diversity at genetic level is attributed to variable sensitivity pattern of these isolates against the class of antibiotics. A molecular technique such as ERIC-PCR is a more sensitive detection method than conventional techniques, the potential of which needs to be fully understood.

The Use of a Dermal Substitute (Integra) to Preserve Maximal Foot Length in a Diabetic Foot Wound With Bone and Tendon Exposure Following Urgent Surgical Debridement for an Acute Infection

Clerici, G., Caminiti, M., Curci, V., Quarantiello, A., Faglia, E. — Tue, 24 Nov 2009 03:34:27 PST

In this report, the authors present the case of a 62-year-old female patient who was admitted to our hospital with an acute deep foot infection. The patient was taken immediately to the operating room where she underwent surgical debridement to completely remove all infected tissues; at the end of this first surgical step, all 5 metatarsal bones remained exposed dorsally. Once eradication of infection was completed, we had to decide whether to perform a transmetatarsal amputation at proximal levels, which would have allowed healing by first intention but would have left the patient with a smaller foot stump, or amputation at more distal levels followed by coverage of healthy tendon and bone tissues with a dermal regeneration template (Integra, Integra Life Sciences Corporation, Plainsboro, NJ), which would have preserved the foot stump length and allowed better walking. We opted for the second choice, and the use of a dermal template actually enabled our patient to maintain a considerable foot stump length, much longer than would have resulted from an amputation with immediate primary closure.

Successful Pharmacological Treatment and Treatment of Large Soft-Tissue Ulceration With Split-Thickness Skin Graft in a Chronically Critical Ischemic Leg

Firat, C., Kenan Coban, Y. — Tue, 24 Nov 2009 03:34:27 PST

The authors present the results of preoperative and postoperative prostacyclin analog treatment with skin grafting in a large ulceration of a chronic critical ischemic leg in a man who had lost his contralateral extremity 5 years ago. Healing was uneventful at the 6-month follow-up.

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Tue, 24 Nov 2009 03:34:27 PST

Thank you List of Referees for 2009

Tue, 24 Nov 2009 03:34:27 PST

Training in Wound Healing and Tissue Repair

Mani, R. — Mon, 24 Aug 2009 08:38:48 PDT

Effectiveness and Safety of a Novel Gel Dressing in the Management of Neuropathic Leg Ulcers in Diabetic Patients: A Prospective Double-Blind Randomized Trial

Mon, 24 Aug 2009 08:38:48 PDT

Neuropathic leg ulcers (NLUs) affect more than 10% of diabetic patients with peripheral neuropathy and represent the most common cause of ulceration of the leg in these patients. Though their pathogenesis is well known, related to the chronic neuropathic edema, the management of NLUs, mainly based on elastocompression, is still controversial, with lower healing rates than nondiabetic venous leg ulcers. The authors tested if a novel gel formulation, containing amino acids and hyaluronic acid (Vulnamin^® gel; Errekappa, Milan, Italy), will improve the outcomes of NLUs when used together with elastocompression. Thirty patients affected by NLU were randomized into 2 groups, both treated with 4-layer elastocompressive bandaging: patients in group A were topically treated with the application of Vulnamin^® gel, whereas patients in group B received only the inert gel vehicle. The healing rate at 3 months was evaluated as the primary endpoint, whereas the secondary endpoints were healing time, reduction in ulcer area and ulceration score in 4 weeks, number of infective complications, and overall satisfaction of patients. Healing rate was significantly (P < .05) higher in patients in group A when compared with those in group B; healing time, patients’ satisfaction, and reduction in ulcer area and ulceration score in 4 weeks were also higher in patients in group A. However, no significant differences were found in the prevalence of infections and other adverse events. The use of Vulnamin^® gel with elastocompression is safe and effective in the management of NLUs of diabetic patients.

Necrotizing Soft-Tissue Infections in the Feet of Patients With Diabetes: Outcome of Surgical Treatment and Factors Associated With Limb Loss and Mortality

Mon, 24 Aug 2009 08:38:48 PDT

The aim of this study was to analyze the outcomes of treatment of necrotizing soft-tissue infections (NSTIs) in the feet of diabetic patients and to determine factors associated with limb salvage and mortality. A retrospective study of a consecutive series of 145 diabetic patients suffering from NSTIs treated in the Diabetic Foot Unit, La Paloma Hospital was done. NSTIs were classified as necrotizing cellulitis if it involved the subcutaneous tissue and the skin, as necrotizing fasciitis if it involved the deep fascia, and as myonecrosis in those cases where muscular necrosis was present. In the necrotizing cellulitis group (n = 109), 8 (7.3%) major amputations were performed. In the necrotizing fasciitis group (n = 25), 13 (52%) major amputations were undertaken. In the myonecrosis group (n = 11), 6 (54.5%) major amputations were performed. Predictive variables related to limb loss were fasciitis (OR = 20, 95% CI = 3.2-122.1) and myonecrosis (OR = 53.2, 95% CI = 5.1-552.4). Predictive variables of mortality were age >75 years (OR = 10.3, 95% CI = 1.9-53.6) and creatinine values >132.6 µmol/L (OR = 5.8, 95% CI = 1.1-30.2). NSTIs of the foot are an important cause of morbidity and mortality in diabetic patients.When fascia and/or muscle are involved, there are significant risks of major amputation.

Evaluation of the Healing Potential of Schrebera swietenioides in the Dexamethasone-Suppressed Wound Healing in Rodents

Rasal, A. S., Nayak, P. G., Baburao, K., Shenoy, R. R., Mallikarjuna Rao, C. — Mon, 24 Aug 2009 08:38:48 PDT

The wound healing potential of the aqueous, alcoholic extracts, and the butanolic fraction of the alcoholic extract obtained from the bark of Schrebera swietenioides were evaluated in the dexamethasone suppressed wound healing model. The work was conducted on rodents using incision, excision, and dead space wound models. The extracts of S swietenioides enhanced the breaking strength of incision wounds significantly (P < .05). Faster epithelization and contraction of excision wounds were observed in the treated groups (P < .05). Dead space wound model demonstrated an increase in breaking strength of granulation tissue and weight of dried granulation tissue after treatment with the extracts.The extracts attenuated the effect of dexamethasone on healing.The total RNA isolated from the granulation tissues of the extract-treated animals was significantly higher than in both dexamethasone and normal groups, (P < 0.05). It was observed that the DNA was intact in all the groups. These findings suggest that dexamethasone suppresses wound healing, possibly through an inappropriate transcription rather than causing DNA damage.The S swietenioides extracts have the capacity to reverse this effect.

A Multidisciplinary Diabetic Foot Protocol at Chiang Mai University Hospital: Cost and Quality of Life

Rerkasem, K., Kosachunhanun, N., Tongprasert, S., Guntawongwan, K. — Mon, 24 Aug 2009 08:38:48 PDT

The consensus is that a multidisciplinary approach for patients with diabetic foot ulcer is effective in reducing the number of leg amputations. Concern remains, however, about cost and health-related quality of life issues. From August 2005 to March 2007, a multidisciplinary diabetic foot protocol (DFP) was used at the authors’ teaching hospital.There were devices to reduce pressure on the foot.After healing, there were custom-fabricated orthoses and footwear, and monitoring of progress in ambulation. All subjects were educated about diabetic foot disease and its complications and prevention.They were also instructed to call and visit the hospital if there were any signs of new lesions.This study compared responses to the short form 36 questionnaires (SF-36) about health-related quality of life and the cost of medical care for patients receiving DFP care from August 2005 to March 2007 and those who had standard care from August 2003 to July 2005.There were 56 and 40 diabetic foot ulcer patients on DFP and standard care packages, respectively. Their gender distribution and mean age were similar. The average total cost of DFP patients was significantly lower than that for standard care patients ($1127.02 and $1824.58, respectively, P = .02). DFP patients had significantly higher scores on the SF-36 for both the physical and mental health dimensions than standard care patients. It was concluded that DFP was less expensive and gave patients a better quality of life, compared to standard care. On the basis of this finding, DFP should be used by every hospital to improve outcomes for patients with diabetic foot ulcer.

Case Presentation: Xenograft Resistance to Protease Degradation in a Vasculitic Ulcer

Mulder, G., Lee, D. K. — Mon, 24 Aug 2009 08:38:48 PDT

Vasculitic ulcers are related to numerous underlying etiologies including autoimmune disease, rheumatoid arthritis and other inflammatory conditions.The resulting ulcerations are associated with high levels of pain, inflammation and tissue necrosis. Current therapies, including surgical intervention, are limited by the underlying inflammatory process and complications secondary to the wound etiology. conservative care has been relatively unsuccessful in promoting wound closure.This case presentations reviews the successful results of using a xenograft in the treatment of an inflammatory ulcer associated with cryoglobulinemia and vasculitis. Product integrity was maintained postoperatively, compared to an allograft, thereby allowing the wound treatment site to progress to closure.The type of cross linkage of acellular grafts may have a direct effect on product stability and treatment outcomes.

Hemipelvectomy and Reconstruction in a Patient With Advanced Marjolin's Ulcer: A Case Report

Carlesimo, B., Monarca, C., Rizzo, M. I., Tariciotti, F., Staccioli, S. — Mon, 24 Aug 2009 08:38:48 PDT

Patients with squamous cell carcinoma of the lower limb may exhibit locally advanced or metastatic disease. Surgical resection to control the primary tumor is often extensive.The case of a 51-year-old man with squamous cell carcinoma on Marjolin’s ulcer affected, rapidly growing, and involving soft and bone tissues is described. Treatment required performing a hemipelvectomy. Immediate reconstruction was chosen as surgical procedure planning the harvest of 4 superficial muscles and 1 deep muscle of the abdomen to protect the pelvic content and to eliminate the dead spaces.The chosen technique minimized postoperative complications, and at 7 years follow-up, the patient is disease free.

Panniculitis Ossificans of the Lower Leg

Wollina, U., Koch, A., Schonlebe, J., Witzigmann, H., Kittner, T. — Mon, 24 Aug 2009 08:38:48 PDT

The authors present a rare case of panniculitis ossificans (PO) in a 30-year-old woman. Differential diagnoses and treatment are discussed. PO is an important differential diagnosis to sarcomas.

The Potential Role of Magnetic Resonance Imaging in Patients With Hansen's Neuropathy of the Feet: A Preliminary Communication

Mon, 24 Aug 2009 08:38:48 PDT

A magnetic resonance imaging (MRI) protocol was performed in leprosy patients with a neuropathic foot and superficial ulcers and/or localized cellulitis but no clinical suspicion of osteomyelitis. The aim of the study was to determine if unsuspected osteomyelitis was present in this defined group of leprosy patients. A total of 15 neuropathic feet from 9 patients were included. Clinically and on MRI, the forefoot was predominantly affected. MRI findings of osteomyelitis were found in 4 feet. In feet with osteomyelitis, 3 had a superficial ulcer and 3 had clinical signs of localized cellulitis. A clinical diagnosis of cellulitis was confirmed on MRI in 2 feet.A striking discrepancy between clinical and MRI findings was found.This study shows that, compared with clinical evaluation, MRI is a sensitive method for the detection of unsuspected osteomyelitis in neuropathic feet with superficial ulcers and/or cellulitis. MRI findings in this group of patients may influence clinical decision making and may prevent further complications, because osteomyelitis requires more aggressive medical treatment. This preliminary communication should pave the wave for designed controlled studies so that patients with Hansen’s neuropathy may get the best medical care.

Diary Page

Mon, 24 Aug 2009 08:38:48 PDT

Instructions to Authors

Mon, 24 Aug 2009 08:38:48 PDT

Living in a world of change

Mani, R. — Thu, 14 May 2009 16:11:42 PDT

Double Trouble: Infection and Ischemia in the Diabetic Foot

Edmonds, M. — Thu, 14 May 2009 16:11:43 PDT

The Impact of Interventional Management on Healing of Ischemic Foot Lesions

Lazarides, M. K. — Thu, 14 May 2009 16:11:43 PDT

Woundcare R&D in the Credit Crunch

Richardson, M. — Thu, 14 May 2009 16:11:43 PDT

Risk Factors for Ipsilateral Reamputation in Patients with Diabetic Foot Lesions

Thu, 14 May 2009 16:11:43 PDT

This study aimed to examine the rates and risk factors for ipsilateral re-amputation in 121 patients with diabetic foot and prior amputation. Twenty-six (21.5%) patients required re-amputation during a mean follow-up of 18 months. Most re-amputations were performed within the first 6 months of the initial amputation. Re-amputation was more common among patients in whom the initial amputation had only affected one or two toes. Age (hazard ratio: 1.06) and heel lesions (hazard ratio: 2.69) were significantly associated with re-amputation. There is a high risk of re-amputation in the diabetic foot, especially within the first 6 months of the initial amputation, mainly due to poor selection of the original amputation level in an effort to save a greater part of the lower extremity. Patients 70 years and those with heel lesions are at greatest risk of re-amputation.

Review: Peripheral Arterial Disease and Diabetes: A Clinical Update

Dinh, T., Scovell, S., Veves, A. — Thu, 14 May 2009 16:11:43 PDT

Peripheral arterial disease is characterized by a gradual reduction in blood to the extremities secondary to atherosclerosis. In diabetes, the pattern of atherosclerotic occlusion typically shows a propensity toward the infrapopliteal vessels. Additionally, impairment of the microcirculation manifests in diminished vasoreactivity and a functional ischemia that is not always correctable with surgery. However, when a nonhealing wound is complicated by peripheral arterial disease, revascularization is paramount to wound healing. Revascularization can be accomplished through traditional bypass surgery or newer endovascular interventions, such as angioplasty and stenting. These less invasive techniques of revascularization offer the advantages of quicker recovery and lower morbidity but durability may be compromised. Ultimately, the choice of revascularization procedure should be based on the clinical characteristics of the atherosclerotic lesion along with the individual patient history.

Emerging Evidence for Neuroischemic Diabetic Foot Ulcers: Model of Care and How to Adapt Practice

Ndip, A., Jude, E. B. — Thu, 14 May 2009 16:11:43 PDT

Although neuropathic ulceration remains the commonest type of foot ulcers among patients with diabetes, recent data suggest that ischemic (and therefore, neuroischemic) ulcers are on the rise. The high prevalence and incidence of diabetes and its attendant foot complications, coupled with the current trend where increasingly diabetes care is being provided by general practitioners (primary care physicians) would mean that primary care practices are expected to see greater numbers of diabetic foot ulcer patients. Unfortunately, these settings are frequently ill-equipped to appropriately manage diabetic foot ulcers either due to lack of adequately trained personnel and access to multidisciplinary foot care teams. Whereas neuropathic foot ulceration may appear to be less challenging, neuroischemic or ischemic ulcers portend a higher risk of adverse outcomes, including non-healing, infection, amputation, and death. The last 2 decades have witnessed a paradigm shift from neuropathy as the main etiological factor in diabetic foot disease to an ever-increasing preponderance of ischemic and/or neuroischemic ulceration. Available literature does not always consider the limited access primary care practices have to specialized multidisciplinary foot care teams. Additionally, in the case of neuroischemic and/or ischemic ulcers, existing guidelines on their diagnosis and management are varied and unclear. This review aimed at providing a simple understanding to the complex evidence base for diagnosing and treating neuroischemic and/or ischemic ulcers in a primary care setting. It emphasizes the need for urgent vascular review in all patients with ischemic/ neuroischemic ulcers and advocates effective participation of vascular specialists in diabetic foot clinics and combined ward rounds.

Altered Molecular Mechanisms of Diabetic Foot Ulcers

Blakytny, R., Jude, E. B. — Thu, 14 May 2009 16:11:43 PDT

The continuously increasing worldwide prevalence of diabetes will be accompanied by a greater incidence of diabetic foot ulcer, a complication in which many of the morphological processes involved in normal wound healing are disrupted. The highly complex and integrated process of wound healing is regulated by a large array of molecular factors. These often have overlapping functions, ensuring a certain degree of tolerance through redundancy. In diabetes, changes to the expression of a large number of molecular factors have been observed, overwhelming this inbuilt redundancy. This results in delayed healing or incomplete healing as in ulceration. Understanding the relationship between altered levels of molecular factors and the inhibited healing process in such ulcers will permit the development of targeted treatments aimed to greatly improve the quality of life of patients, at the same time helping to reduce the huge costs associated with treating this diabetic condition and its long-term consequences. This short review examines how changes in the expression of molecular factors are related to altered morphology in diabetic foot ulceration and very briefly considers treatment strategies at molecular level.

Evidence-Based Recommendations for the Use of Topical Oxygen Therapy in the Treatment of Lower Extremity Wounds

Gordillo, G. M., Sen, C. K. — Thu, 14 May 2009 16:11:43 PDT

Topical oxygen therapy provides another tool in the armamentarium of clinicians treating refractory lower extremity wounds. Devices suitable for providing topical oxygen therapy in a clinical setting have recently become available. This article reviews the evidence to justify the use of this treatment modality, including in vitro, preclinical data, and clinical data. It also provides a protocol for how to administer topical oxygen therapy as well as guidance on patient selection and management to optimize outcomes. Randomized controlled trials are not yet reported and clearly necessary. The current body of evidence suggests that topical oxygen therapy may be considered as a second line of therapy for refractory wounds.

A Case Series Describing 118 Patients With Lower Limb Necrotizing Fasciitis

Khanna, A.K., Tiwary, S. K., Kumar, P., Khanna, R., Khanna, A. — Thu, 14 May 2009 16:11:43 PDT

Necrotizing fasciitis of the lower limb is not uncommon, with poor outcome. This study reviewed 118 cases (78 males and 40 females) with mean age of 45 + 16.5 years (range 12-95 years) of lower limb necrotizing fasciitis admitted to the Department of Surgery, BHU in India between 1995 and 2007. Most patients (n = 97) presented with fever. Other presenting symptoms included painful swelling, bullae, erythema, ulcer, and necrosis. Comorbid conditions such as diabetes, tuberculosis, malignancy, and immunosuppressive therapy were associated in 72 (61%) cases. Amputations were done in 24 patients. Thirty one patients developed septic shock. Renal dialysis was done in 16 patients and ventilatory support was needed in 12 patients. The most common organism identified was β-hemolytic streptococci (n = 42). Eighteen patients died, a mortality of 15%. The authors consider early diagnosis and aggressive surgical intervention to be crucial for the successful treatment of disease.

A Case Report of the Eradication of Pseudomonas aeruginosa from Leg Ulcer in a Patient with Essential Thrombocythemia

Savini, V., Catavitello, C., Bianco, A., Balbinot, A., D'Antonio, D. — Thu, 14 May 2009 16:11:43 PDT

A patient treated with hydroxyurea had a lower extremity ulcer that was found infected with Pseudomonas aeruginosa. Drug discontinuation and ceftazidime treatment did not initially lead to resolution due to misidentification of inducible betalactamases expressed by the organism and subsequent clinical failure of the cephalosporin in eradicating infection. These class C enzymes may be strongly induced after betalactam exposure and confer resistance to penicillins, cephalosporins, betalactamase inhibitors but not to carbapenems. Though hydroxyurea represents a major cause of essential thrombocythemia-related ulcers, lesion infections by difficult-to-treat organisms should be eradicated to promote wound healing.

Kaposi's Sarcoma Misdiagnosed as a Diabetic Plantar Foot Ulcer

Caminiti, M., Clerici, G., Quarantiello, A., Curci, V., Faglia, E. — Thu, 14 May 2009 16:11:43 PDT

In this report, the authors describe the case of a patient with Kaposi's sarcoma that was initially misdiagnosed as a plantar ulcer. The ulcer typically appeared as a neuropathic foot ulceration located on the plantar aspect of the first metatarsal head. There was hyperkeratosis on the plantar surfaces of the other metatarsal heads. However, the lesion had mushrooming granulation tissue, without undermined perilesional edges. A wound biopsy revealed the presence of Kaposi's sarcoma. The presence of cancerous lesions on the plantar aspect of the foot is an infrequent event in diabetic patients. However, given the malignant nature of some skin cancers careful clinical examination and biopsy of the wound are advisable.

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Thu, 14 May 2009 16:11:43 PDT

Change and Wound Healing

Mani, R. — Tue, 17 Feb 2009 05:30:22 PST

Prolonged Mechanical Noise Restores Tactile Sense in Diabetic Neuropathic Patients

Tue, 17 Feb 2009 05:30:22 PST

Acute application of stochastic resonance (SR), defined as a subsensory level of mechanical noise presented directly to sensory neurons, improves the vibration and tactile perception in diabetic patients with mild to moderate neuropathy. This study examined the effect of 1 hour of continuous SR stimulation on sensory nerve function. Twenty diabetic patients were studied. The effect of stimulation was measured at 2 time points, at the beginning and after 60 minutes of continual SR stimulation. This effect was measured using the vibration perception threshold (VPT) at the big toe under 2 conditions: a null (no SR) condition and active SR, defined as mechanical noise below the subject's own threshold of perception. The measurements under null and active conditions were done randomly and the examiner was blinded regarding the type of condition. Immediately after SR application, the VPT with SR in null condition was similar to baseline (32.2 ± 13.1, P = nonsignificant) but was significantly lower during active SR (27.4 ± 11.9) compared with both baseline (P = .018) and off position (P = .045). The 60 minutes VPT with active SR (28.7 ± 11.1) reached significance comparing the baseline when one outlier was removed from the analysis (P = .031). It may be concluded that SR for a continuous 60-minute period can sustain the VPT improvement in diabetic patients with moderate to severe neuropathy. These results permit the conclusion that there is no short-term adaptation to the stimulation signal. Long-term application of this technique, perhaps in the form of a continually vibrating shoe insert, or insole, may result in sustained improvement of nerve function.

Apligraf in the Treatment of Neuropathic Diabetic Foot Ulcers

Edmonds, M., European and Australian Apligraf Diabetic Foot Ulcer Study Group — Tue, 17 Feb 2009 05:30:22 PST

This study compared the efficacy and safety of Apligraf (Organogenesis, Inc., Canton, MA) in combination with standard therapy versus standard therapy alone in the treatment of neuropathic diabetic foot ulcers. Efficacy was assessed by time to complete wound healing (by 12 weeks) and incidence of complete wound closure (at 12 weeks). This was an international multi-center, randomized, controlled study. Patients were eligible for entry into the study if the following criteria were met: type 1 or type 2 diabetes mellitus, age 18 to 80 years, adequate glycemic control, and the presence of a full-thickness neuropathic ulcer for at least 2 weeks prior to the initial screening visit. Following the 2-week screening period, the 2 treatment groups received standard ulcer care consistent with international treatment guidelines that comprised sharp debridement, saline-moistened dressings, and a non—weight bearing regimen. There were 106 subjects screened for enrollment, 82 randomized to the treatment groups, and 72 treated (33 Apligraf subjects and 39 standard therapy subjects) before the study was terminated. Kaplan—Meier curves indicated a trend for shorter time to complete wound healing in the Apligraf group compared with the standard therapy group (p = .059; log-rank test). The median time to healing was 84 days in the Apligraf group, whereas no median time to healing could be determined for the standard therapy group because <50% of the standard therapy subjects healed. By 12 weeks, 51.5% (17/33) Apligraf subjects had achieved complete wound closure compared with 26.3% (10/38) of standard therapy subjects (p = .049; Fisher's exact test). Even though the study was halted prematurely, this study suggested that the use of Apligraf resulted in a higher incidence of wound closure by 12 weeks.

Review: Finding the Culprit: A Review of the Influences of Proteases on the Chronic Wound Environment

Rayment, E. A., Upton, Z. — Tue, 17 Feb 2009 05:30:22 PST

Chronic leg ulcers are a complex medical condition with varied underlying causes and requiring diverse treatment strategies. It is generally accepted that chronic ulcers occur when the normal wound healing process is interrupted. These wounds are characterized by excessive protease activity, abundant granulation tissue, and decreased levels of growth factors, resulting in an overall poor prognosis for the patient. Many studies have focused on identifying the key proteases, specifically matrix metalloproteinases (MMPs), responsible for an ulcer's chronicity. Of note, the results of these studies are often conflicting. This report therefore focuses on a review of this literature to identify which MMPs are important in terms of ulcer prognosis and healing outcome. This has revealed that MMPs are clearly important in many biological processes in wound healing, hence are critical to consider when developing improved therapies to enhance both ulcer healing times and ulcer healing outcomes.

Giant VAC in a Patient With Extensive Necrotizing Fasciitis

Steinstraesser, L., Sand, M., Steinau, H.-U. — Tue, 17 Feb 2009 05:30:22 PST

The authors present a case of an extensive fulminant necrotizing fasciitis of the left flank, thigh, and lower parts of the leg treated with debridement, split-thickness skin grafting, and a giant negative pressure wound dressing covering 0.53 m² or 18% of the body surface. To the authors' knowledge, this is the largest split-thickness grafted body surface successfully treated with negative pressure wound dressing documented in the literature.

A Case Report of a Double Advancement Flap Closure Combined With an Ilizarov Technique for the Chronic Plantar Forefoot Ulceration

Belczyk, R., Stapleton, J. J., Zgonis, T. — Tue, 17 Feb 2009 05:30:22 PST

Soft tissue closure of defects on the plantar surface of the foot continues to be a challenge for the reconstructive surgeon secondarily to the limited number of surgical options and often difficulty of replacing durable and similar soft tissue coverage. Primary closure and skin grafting may not be suitable for the weight-bearing surfaces of the plantar forefoot area, and closure may then be obtained by other means of plastic surgery techniques.

Treatment in an Outpatient Setting for a Patient With an Infected, Surgical Wound With Hypergranulation Tissue

Stevens, N. M., Shultz, T., Mizner, R. L., Gersh, M. — Tue, 17 Feb 2009 05:30:22 PST

The purpose of this article is to describe a multifaceted approach to wound care in an outpatient setting for a patient with an infected, nonhealing surgical wound with hypergranulation tissue following fasciotomy for acute compartment syndrome. A 44-year-old male underwent an anterior and lateral lower extremity compartment fasciotomy and developed a persistent right anterolateral lower leg wound. Thirty-six days after fasciotomy he came to the authors' clinic after 2 failed skin grafts with an infected wound covered in hypergranulation tissue. Treatment included sharp debridement, saline irrigation, patient education, and dressing changes during 9 treatment sessions. The patient's total wound surface area decreased from 5.2 cm x 17.3 cm to 4 cm x 15 cm with increased epithelialization from approximately 40% to 85% after 29 days of treatment. This article demonstrates the positive effect of a multifaceted approach for facilitation of wound healing in a lower extremity wound following fasciotomy.

Cell Proliferation Induction: Healing Chronic Wounds Through Low-Energy Pulsed Radiofrequency

Frykberg, R., Tierney, E., Tallis, A., Klotzbach, T. — Tue, 17 Feb 2009 05:30:22 PST

Chronic lower extremity wounds are a major source of morbidity and health care expenditure across the world. In the last decade, numerous advanced modalities have become available that can help expedite wound healing when standard wound care modalities are unsuccessful. In this case report, the authors present their early experience with one such modality that uses pulsed radiofrequency energy to initiate cell proliferation induction in chronic lower extremity wounds of different etiologies that had failed to respond to standard therapy.

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Tue, 17 Feb 2009 05:30:22 PST