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Wound Bed Preparation: Is It Time to Up Your Game?
Two years ago, I embarked on a journey to bring 21st century wound healing strategies to a rural veteran’s hospital. This journey led to the development of a wound healing center as a pilot program. An important step in this process was the development of an evidence-based, dual-protocol algorithm. The first part (Decision Protocol) honored the fundamentals of wound healing and included optimized perfusion, proper offloading, infection control, diet, and debridement1-3; the second part (Treatment Protocol) guided the clinician with the option of continuing conventional therapy or switching to an advanced graft.4
Despite this algorithm, during the first quarter of the 12-month pilot program, 144 advanced grafts (or skin substitutes) were used but only 24 wounds progressed to closure.4 Based on 1) the needs of our chronic wound population, 2) growing evidence on the effect of matrix metalloproteinase (MMP) imbalances on wound healing5,6; and 3) a published study7 linking dermal graft cellular tissue-based product (CTP) failure to elevated MMP levels in diabetic foot ulcers, I was compelled to refocus efforts on the fundamentals of wound bed preparation. As a result, we altered our algorithm at the start of the second quarter of the pilot program by switching to an alternative collagen dressing, Endoform Dermal Template (Hollister Inc, Libertyville, IL), to be used as a first-line conventional treatment strategy.4
Endoform is a collagen dressing; more specifically it is an intact extracellular matrix (ECM) dressing that retains the structure and function of the ECM seen in healing tissues.8-10 It can assist the body through all phases of wound healing; for example, when placed in an acute wound where the patient’s ECM is damaged or missing, the dressing is designed to provide a temporary ECM the patient’s body can use to help grow new tissue. In addition, the literature6 shows Endoform provides broad-spectrum MMP reduction. This is useful for chronic wounds in which elevated protease levels are hindering wound advancement.5
With the addition of Endoform dermal template to our algorithm, we discovered an interesting trend. From quarter 1 to quarter 2, our advanced graft usage decreased from 144 to 84 and wound resolution increased from 24 to 55. These dramatic trends continued in quarter 3, with 58 grafts used and 80 wounds resolved. Thus, from the first quarter through the end of the third quarter, graft usage decreased by 59.7% while wound resolution increased by 95.5% (see Figure 1).4
One case treated under this new algorithm involved a 60-year-old man who presented with diabetic foot ulcers on the hallux and second digit of his left foot (see Figure 2A) and a complex medical history. The wounds were debrided and attention was paid to diet. Noninvasive vascular diagnostic testing was done, wounds were offloaded, vascular intervention was provided, and mental/spiritual counseling was offered. After wound bed preparation, Endoform was applied with a gentian violet and methylene blue foam as a cover dressing. At week 9, a bilayered skin substitute was applied to the wound to speed resolution (see Figure 2B). After the patient sustained an injury to the foot, setting wound healing back several weeks, Endoform was continued and a fetal bovine dermal repair scaffold was placed on week 12 to help speed restoration of the collagen-rich wound bed. Endoform then was continued (see Figure 2C) until both ulcers fully healed at 6.5 months (see Figure 2D).4
In summary, we all need a game plan to reach our healing goals. Equally important are the players in that game and how they can work together. This modification to our protocol to incorporate Endoform was a game changer and greatly impacted wound healing trend in my center.
To learn more about Dr. Ferreras’ protocol and data, view his webcast at www.holllister.com/ferrerasbookending.com.
Affiliation
Dr. Ferreras is Lead/Chief Podiatrist, Surgical Services, Carl Vinson VA Medical Center Dublin, GA.
Disclosure
Ostomy Wound Management welcomes Wound Care in the First Person to its stable of columns sponsored by leading manufacturers of wound, ostomy, and continence care products. This new column from Hollister Inc. (Libertville, IL) will take a first-person approach to the challenges providers overcome in the care of their patients.
References
1. Sibbald RG, Goodman L, Woo KY, et al. Special considerations in wound bed preparation 2011: an update. Adv Skin Wound Care. 2011;24(9):415–436. doi: 10.1097/01.ASW.0000405216.27050.97.
2. Snyder RJ, Kirsner RS, Warriner RA 3rd, Lavery LA, Hanft JR, Sheehan P. Consensus recommendations on advancing the standard of care for treating neuropathic foot ulcers in patients with diabetes. Ostomy Wound Manage.2010;56(4 suppl):S1–S24.
3. Lavery LA, Armstrong DG, Wunderlich RP, Mohler MJ, Wendel CS, Lipsky BA. Risk factors of foot infections in individuals with diabetes. Diabetes Care. 2006;29(6):1288–1293.
4. Ferreras DT, Craig S, Malcomb R. Use of an ovine collagen dressing with intact extracellular matrix to improve wound closure times and reduce expenditures in a US military veteran hospital outpatient wound center. Surg Technol Int. 2017;30:61–69.
5. Gibson DJ, Schultz GS. Molecular wound assessments: matrix metalloproteinases. Adv Wound Care (New Rochelle). 2013;2(1):18-23. doi:10.1089/wound.2011.0359.
6. Negron L, Lun S, May BC. Ovine forestomach matrix biomaterial is a broad spectrum inhibitor of matrix metalloproteinases and neutrophil elastase. Int Wound J. 2014;11(4):392–397. doi: 10.1111/j.1742-481X.2012.01106.x.
7. Uccioli L, Izzo V, Meloni M, Vainieri E, Ruotolo V, Giurato L. High matrix metalloproteinase levels are associated with dermal graft failure in diabetic foot ulcers. Int J Low Extrem Wounds. 2014;13(3):191–196. doi: 10.1177/1534734614544959. Epub 2014 Aug 8.
8. Endoform Dermal Template Instruction for Use. Libertyville, IL: Hollister Inc.
9. Lun S, Irvine SM, Johnson KD, et al. A functional extracellular matrix biomaterial derived from ovine forestomach. Biomaterials. 2010;31(16):4517–4529. doi: 10.1016/j.biomaterials.2010.02.025.
10. Irvine SM, Cayzer J, Todd EM, et al. Quantification of in vitro and in vivo angiogenesis stimulated by ovine forestomach matrix biomaterial. Biomaterials. 2011;32(27):6351–6361. doi: 10.1016/j.biomaterials.2011.05.040.
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