Combination Therapies: Does ECM Replacement and NPWT Speed Up the Healing in Challenging Stage IV Pressure Ulcers? Editorial Summary Challenging non-healing wounds can prove a challenge to the wound care provider. As this article explores, consideration of combination therapies, which sequence different wound treatment modalities, can help flick the switch in the healing process.
Introduction
C
hronic non-healing wounds lead to enormous financial burden on the health care system, resulting in costs of more than $25 billion annually in the United States alone.1 These wounds are stuck in the inflammatory phase with increased levels of harmful metalloproteases.
Preoperative Factors All patients may not qualify or may decline flap reconstruction. Stage IV pressure ulcers are best covered with fascio or myocutaneous flaps. Addressing the etiology and associated risks of these wounds prior to surgery is key, since their complication and recurrence rates are very high.2 Other factors will of course influence the outcome such as compliance, nutrition status, offloading, ruling out osteomyelitis, clean wounds with no soft tissue infection, being on certain medications, and others. In patients who may not be a good candidate for flap closure but have met all the above-mentioned conditions, other therapeutic modalities and their combinations may lead to faster healing.
Cell and Tissue Products Dr Richard Simman Professor of Surgery, Division of Plastic and Reconstructive Surgery, University of Toledo College of Medicine and Life Sciences. Program Director of Wound Care at Jobst Vascular Institute, ProMedica Health Network Toledo OH, USA
120
Cell and Tissue-Based Products (CTPs) have increased in popularity in the last two decades with their proven favorable effects on chronic hard to heal wounds. They include extra cellular matrix (ECM) replacement (including bioengineered matrices, Allo and Xeno Grafts), cell signaling products and dehydrated, cryopreserved or fresh amniotic and umbilical cord products.3
Wound Masterclass - Vol 1 - September 2022
Extracellular matrix (ECM) derived from small intestinal submucosa (SIS) is widely used in clinical applications as a scaffold for tissue repair. The SIS-ECM is made from porcine small intestinal submucosa. This product has been previously reported to produce a dressing that inactivates the tissue metalloproteases, thereby preventing destruction of the provisional ECM. Its composition stimulates cell migration, reduces inflammation, and provides moisture to the wound bed; SIS-ECM also grants structural support and enhances cellular proliferation and attachments. The SIS-ECM has been employed for a variety of wounds including: • • • • • •
Chronic vascular Venous ulcers Diabetic ulcers Partial-thickness burns Donor sites and skin graft preparation Partial and full-thickness, surgical, and traumatic wounds4
In a recently published manuscript, we demonstrated with a prospective randomized controlled trial that combining ECM replacement with negative pressure wound therapy (NPWT) will hasten the healing rate in this patient population.5 In this study 16 patients were randomized to receive either the SIS-ECM plus NPWT (8 study) or NPWT alone (8 control) for stage 4 pressure ulcers treatment. Wounds were photographed and measured weekly. The experimental group had their ECM dressings changed every other week and their NPWT changed twice weekly. After the 12-week study period, the average control