Wound Dimensions Research Articles

A Novel Topical Oxygen Treatment for Chronic and Difficult-to-Heal Wounds: Case Studies

Background: Pressure ulcers are one of the most prevalent causes of morbidity in patients with spinal cord injury (SCI). For those requiring hospital-based management, conventional wound management may necessitate a prolonged institutional stay. This may subsequently increase the likelihood of comorbidities and increase the social, psychological, and financial burdens associated with wound management. Therefore, novel adjunct treatments that potentiate improved healing rates should be seriously considered.Study Design: Case reports.Objective: To observe the efficacy of the EpiFLO device as an adjunct treatment modality in chronic wound management.Setting: An SCI unit at a Veterans Affairs Medical Center.Methods: Three men with SCI, who each presented with a stage IV pressure ulcer in the pelvic region, were treated with the EpiFLO device as an adjunct therapy. In Case 1, the patient was monitored for 9 weeks, whereas in Cases 2 and 3, the patients were monitored for 5 weeks. Healing was determined on a weekly basis by wound dimensions and volume, which were compared before and after the intervention.Results: Comparison of pre- and posttreatment outcome measurements showed significant improvement with EpiFLO in each case.Conclusion: EpiFLO seems to have had a positive effect on the healing rate of chronic pressure ulcers in individuals with SCI.

A pilot study on the effect of topical negative pressure on quality of life

To discover the impact of topical negative pressure (TNP) on quality of life. An exploratory prospective cohort study was conducted on 26 patients undergoing TNP. The Cardiff Wound Impact Schedule (CWIS), a wound-specific tool, was used to investigate quality-of-life scores before therapy and four weeks after therapy or at wound closure. Wound dimensions were measured at both assessments, and the values for the CWIS domains (physical symptoms, social functioning, well-being and overall quality of life) were investigated using parametric and non-parametric tests. The mean duration of TNP therapy was 3.3 +/- 1.7 weeks. Topical negative pressure therapy helped to achieve complete wound closure in 14 patients (54%), and there was a mean reduction in wound surface area from 52.2 cm2 (range 4-150) to 26.8 cm2 (0-120). While there was no significant change in quality of life in patients whose wounds healed (1 +/- 11.9), the physical-functioning domain improved in obese patients (20 +/- 21, p < 0.05) and worsened in ambulatory patients (-3 +/- 13, p < 0.05). The portableTNP system had no significant impact on quality of life (-3 +/- 16), while the global quality-of-life score worsened with surgical intervention (-0.5 +/- 2, p < 0.05). Although TNP aids wound closure in patients with complex wounds, in selected cases their quality of life can worsen. This is the first exploratory cohort study of its kind, and has identified an urgent need to validate the use of patient-based outcome measures in TNP therapy. Such data can be useful in allocating resources and justifying funding in wound care.

Platelet-Rich Plasma Combined With Skin Substitute for Chronic Wound Healing: A Case Report

Contemporary management of chronic wounds focuses on improving natural healing and individualization of treatment. Incorporating multiple therapies has become increasingly common. Of interest are autologous growth factors, which are especially important in chronic wound healing and may contribute to tissue formation and epithelialization. Autologous platelet concentrate or platelet-rich plasma (PRP) is a concentration of at least five autologous growth factors and has been shown to accelerate wound healing and may have infection-fighting properties. Chronic wound healing is complicated by both decreased growth factor availability and infection, making PRP use valuable in these types of wounds. In this report, the use of PRP therapy alone and in combination with a bioengineered skin substitute as a platelet-rich tissue graft in a chronic, non-healing wound is detailed. Over 27 weeks, the patient received multiple therapies in attempts to heal a severe decubitus ulcer of the sacrum. The introduction of PRP therapy at Week 14 led to a 26% reduction in wound depth over 4 weeks. At Week 19, PRP therapy was combined with a powdered skin substitute to create a platelet-rich tissue graft. The combination brought dramatic results, eliminating wound tunneling and reducing the wound dimensions from 6.2 cm long × 6.7 cm wide × 2.7 cm deep to 5.0 cm long × 6.0 cm wide × 1.4 cm deep. The promising observations from this case report indicate that further study on the combining of PRP therapy and skin substitutes is necessary.

Synthetic TGF-ß antagonist promotes healing of injured epithelial surfaces

18586 Background: Cancer treatment often results in injury to epithelial surfaces. These injuries are often symptomatic and can delay or prevent further treatment. Since transforming growth factor-1 (TGF-ß) mediates inflammation, fibrosis, and epithelial mitogenesis, agents modulating TGF-ß may be useful in treating such wounds. We synthesized a dodecapeptide containing the active site of human TGF-ß. It is a TGF-ß antagonist in vitro. We investigated whether application to cutaneous wounds might promote epithelialization and decrease scarring by directly blocking local TGF-ß activity. Methods: We applied synthetic TGF-ß antagonist (1.5 mM in gel carrier, topically), with gel-only and no-treatment controls, to 6 standardized thermal burn wounds in each of 4 pigs. Wounds were measured and photographed for 41 d., then excised. Wound dimensions and percent epithelialization were calculated from photographs. Scar volume was estimated as surface area (photographs) x depth (microscopy). Statistical analysis employed student’s t-test. Additional experiments utilized skin excision wounds in rabbits and pigs. Recombinant TGF-ß and platelet-derived growth factor (PDGF) were applied to identical wounds in other pigs and rabbits in parallel experiments as additional controls. Results: In TGF-ß antagonist-treated pig burn wounds, epithelialization was complete on d. 26 ± 2 (mean ± SD); control wounds were 70 ± 10% re-epithelialized by d. 26 (p &lt; 0.001). Contraction rate, collagen and fibronectin content, and scar volume were all significantly less in treated wounds. TGF- ß and PDGF each retarded wound epithelialization. Conclusions: Treatment of standard skin wounds with a synthetic TGF-ß antagonist promotes epithelialization in a whole-animal model. This agent may be useful in human epithelial injuries due to chemotherapy or radiation. No significant financial relationships to disclose.

Prediction and monitoring the therapeutic response of chronic dermal wounds

A significant proportion of chronic wounds fail to heal in response to treatment of underlying pathologies combined with good wound care practice. Current prognostic tests to identify these wounds rely on the use of algorithms based on clinically measurable parameters such as wound dimensions and wound duration. Venous leg ulcers may be stratified into healing/non healing at 24 weeks of compression therapy and diabetic foot ulcer treatment outcome assessed using a 3-parameter algorithm. Accurate and reproducible measurement of wound area is required for these algorithms to have clinical utility. Whilst a number of attempts have been made to develop computerised wound-assessment techniques, wound tracing by clinicians combined with planimetry remains the standard methodology. Once treatment has been initiated, it is important to continuously monitor the wound to assess efficacy of treatment. This can be achieved by measuring wound area change over the first weeks of treatment to identify whether re-assessment of treatment strategy is required. A number of algorithms for assessing rate of wound area change have been evaluated to determine a surrogate endpoint for healing. Retrospective analysis of large patient groups indicates that approximately 75% correct prediction of healing outcome can be achieved.

Measurement of optical properties to quantify healing of chronic diabetic wounds

Measurement of scattering and absorption characteristics of tissue by near infrared spectroscopy may provide a clinically applicable, quantitative method of assessing healing of diabetic wounds. Twenty SICH-1 hairless rats were divided into a control group and a streptozotocin-induced diabetic group. Full-thickness wounds were made on the dorsal surface of each animal. Wounds were examined using a near infrared device with three wavelengths of incident light. Amplitude and phase of scattered light were obtained at four different source detector distances at each wavelength. The probe was positioned at six different locations. Tissue absorption and scattering coefficients were calculated from amplitude and phase data. Wound dimensions were calculated by cross and parallel polarization. Thirty-eight wounds were evaluated during the experiment. Wound size decreased at twice the rate in the control animals, whereas the average absorption coefficient was higher by a factor of two while the average value of the reduced scattering coefficient was 30% higher in the diabetic wounds. During healing, both scattering and absorption coefficients increased faster in the diabetics. Higher absorption in diabetic rats suggests impaired blood flow. Scattering may reflect tissue disorganization observed in delayed wound healing. We conclude that near infrared spectroscopy may differentiate between healing diabetic and nondiabetic wounds.

Traumatic total iridectomy after clear corneal cataract extraction

The increasing use of topical clear cornea techniques has led to an intense debate regarding wound stability. We present a case of traumatic aniridia post cataract extraction which illustrates the importance of wound dimensions and construction.

118 Dermagraft as an Adjunct in the Treatment of Venous Leg Ulcers

Aim: To document successful healing of a recalcitrant venous ulcer with adjunctive use of Dermagraft Materials and Methods: A 74‐year‐old Hispanic male presented with a chronic venous ulcer at the medial aspect of his right ankle. Biopsy failed to reveal malignancy and confirmed stasis changes. Treatment was ongoing including compression therapy, local debridements, and moist wound healing, off‐loading, and nutritional support. The wound remained free of infection. Due to the continued recalcitrant nature of the lesion multiple applications of Dermagraft were utilized to augment healing. Results: The researcher observed dramatic improvement in wound dimensions, wound contracture, and granulation tissue. Conclusions: Dermagraft appears to augment healing in patients with venous ulcers and may be useful as adjunctive therapy. Acknowledgements: Smith &amp; Nephew Wound Management, Largo, Fl.

Wound-healing outcomes using standardized assessment and care in clinical practice.

Wound-healing outcomes applying standardized protocols have typically been measured within controlled clinical trials, not natural settings. Standardized protocols of wound care have been validated for clinical use, creating an opportunity to measure the resulting outcomes. Wound-healing outcomes were explored during clinical use of standardized validated protocols of care based on patient and wound assessments. This was a prospective multicenter study of wound-healing outcomes management in real-world clinical practice. Healing outcomes from March 26 to October 31, 2001, were recorded on patients in 3 long-term care facilities, 1 long-term acute care hospital, and 12 home care agencies for wounds selected by staff to receive care based on computer-generated validated wound care algorithms. After diagnosis, wound dimensions and status were assessed using a tool adapted from the Pressure Sore Status Toolfor use on all wounds. Wound, ostomy, and continence nursing professionals accessed consistent protocols of care, via telemedicine in home care or paper forms in long-term care. A physician entered assessments into a desktop computer in the wound clinic. Based on evidence that healing proceeds faster with fewer infections in environments without gauze, the protocols generally avoided gauze dressings. Most of the 767 wounds selected to receive the standardized-protocols of care were stage III-IV pressure ulcers (n = 373; mean healing time 62 days) or full-thickness venous ulcers (n = 124; mean healing time 57 days). Partial-thickness wounds healed faster than same-etiology full-thickness wounds. These results provide benchmarks for natural-setting healing outcomes and help to define and address wound care challenges. Outcomes primarily using nongauze protocols of care matched or surpassed best previously published results on similar wounds using gauze-based protocols of care, including protocols applying gauze impregnated with growth factors or other agents.

A Prospective Randomized Evaluation of Negative-pressure Wound Dressings for Diabetic Foot Wounds

Optimal treatment for large diabetic foot wounds is ill defined. The purpose of this study was to compare the rate of wound healing with the Vacuum Assisted Closure device trade mark (VAC) to conventional moist dressings in the treatment of large diabetic foot wounds. Diabetics with significant soft tissue defects of the foot were considered for enrollment. Patients were randomized to receive either moist gauze dressings or VAC treatments for 2 weeks, after which they were treated with the alternative dressing for an additional 2 weeks. Wounds were photographed weekly and wound dimensions calculated in a blinded fashion with spatial analysis software. Percent change in wound dimensions were calculated and compared for each weekly assessment and over 2 weeks of therapy with each dressing type. Ten patients were enrolled in the trial, but two were lost to follow-up and two were withdrawn. Complete data were available for analysis on seven wounds in six patients. Average length, width, and depth of the wounds at initiation of the trial was 7.7, 3.5, and 3.1 cm, respectively. Only the wound depth was significantly decreased over the weeks of the trial to 1.2 cm ( p < 0.05). VAC dressings decreased the wound volume and depth significantly more than moist gauze dressings (59% vs. 0% and 49% vs. 8%, respectively). VAC dressings were associated with a decrease in all wound dimensions while wound length and width increased with moist dressings. In summary, over the first several weeks of therapy, VAC dressings decreased wound depth and volume more effectively than moist gauze dressings. Negative-pressure wound treatment may accelerate closure of large foot wounds in the diabetic patient.

When less is more: revascularization and sural artery fasciocutaneous flaps in ischemic limb salvage.

Nine patients underwent ischemic limb salvage via a combination of revascularization and wound reconstruction with a reverse sural artery fasciocutaneous flap. All flaps healed primarily. There were no untoward donor-site complications. At 6 months postoperative, limb preservation and function were maintained in this cohort. Revascularization and reverse sural artery flap reconstruction of limb-threatening ischemic wounds is a safe and reliable approach to limb salvage. Factors important in decision-making include the wound dimensions and the presence of peroneal blood flow. Serious consideration of this reconstructive plan should be given, when appropriate, over revascularization and microsurgical transplantation.

Patterns of wounding and decay in stems of Quercus robur due to bark peeling

A total of 118 Quercus robur L. trees 22–47 yrs of age, 6–24 cm diameter at breast height (DBH) was selected in a forest stand situated in central Lithuania. Among them 77 showed open and 41 healed bark peeling wounds caused by moose 8–25 yrs previously. Selected trees were cut, dissected and examined. Oaks were damaged at the age of 9–31 yrs, while being 3–13 cm DBH. Over 80% of wounds were situated 100–190 cm high. Mean initial wound length was 114.8 ± 52.0 cm and mean initial wound width—11.6 ± 6.3 cm. Average length of decay in stems was 127.1 ± 90.5 cm and average lateral decay spread over stem cross‐section was 19.4 ± 19.0 cm2. Differences in decay extension beyond open and closed wounds were statistically significant (p<0.1%). Age of injury had no significant influence on spread of decay. Extent of decay was mainly determined by initial wound dimensions. The most prominent positive relationships occurred between length of wound and length of decay column (r = 0.73), and between width of wound and lateral spread of decay in stem cross‐section (r = 0.81). Average wound healing rate was 1.0 cm yr−1 and was positively correlated with tree radial growth (r = 0.42). Most common basidiomycetes growing on Q. robur wounds were Stereum hirsutum (Willd.: Fr.) S. F. Gray and Coniophora puteana (Schum.: Fr.) Karst.

A practical framework for wound assessment. 2: Methods.

Accurate measurement and documentation of wound healing are essential if practitioners are to effectively evaluate the benefits of various treatment approaches. Increasingly, sophisticated wound measurement techniques are evolving, but many are impractical and costly. The physiology of healing and the relationship of each stage of this delicate process to the complex task of wound assessment were reviewed in part one of this article (Vol 5 (22): 1391-7) to help improve practitioners' clinical assessment skills. Part two will discuss ways in which the accuracy of simple, non-invasive measurement approaches may be improved so that overall alterations in wound dimension can be effectively monitored.

Evaluation of a porous bovine collagen membrane bandage for management of wounds in horses

Abstract Objective To evaluate the effect of a porous bovine-derived collagen membrane (pbcm) on the rates of wound healing, cellular events, presence of granulation tissue, and appearance at termination of the study in surgically created full-thickness cutaneous wounds of the distal portion of the extremities of horses. Design Treated wounds (n = 12) received a pbcm dressing and control wounds were covered with a nonadherent dressing. Forelimbs and hind limbs were cross paired; the right forelimb and left hind limb always received the same dressing application, as did the left forelimb and right hind limb. Limbs pairs were then randomly assigned to 1 of the 2 dressings. Animals Six healthy male horses (3 sexually intact, 3 geldings) ranging from 2 to 10 (mean, 6.5) years and weighing between 278 and 568 (mean, 408.5) kg were studied. Procedure Full-thickness skin wounds (6.25 cm2) were created on the dorsal metatarsi and metacarpi of the experimental animals. A preformed pbcm dressing was evaluated in half the wounds (n = 12). Control wounds (n = 12) were dressed with a nonadherent gauze dressing. At each bandage change, wounds were subjectively assessed and were photographed, and measurements of horizontal and vertical wound dimensions were documented. Wound biopsy specimens obtained on days 2, 5, 7, 10, 21, and 31 were evaluated for presence of collagen, fibrin, inflammation, epithelium, and cellular elements of healing. Planar morphometry was used to determine total wound area and granulation area from the wound photographs. Percentage of contraction and epithelialization were calculated from these values. Linear regression analysis of the square root of the total wound area and the granulation area was performed. Wound area measurements were analyzed, using anova for repeated measures. Regressions were compared, using covariance analysis and anova. Significance was considered at P &lt; 0.05. Results Fibrin score, neutrophil score, and degree of inflammation were significantly greater in the pbcm-treated wounds. No significant differences in the total wound, epithelialized, or contraction areas were detected between the pbcm-treated and control (nonadherent-treated) wounds. Rates of wound healing were not statistically different between the 2 treatment groups, though they were significantly slower in the hind limbs, compared with the forelimbs. Scabs were formed more frequently in the pbcm-treated wounds. Conclusions Application of a porous collagen bandage was not detrimental to full-thickness cutaneous wound healing in horses.

A Structured Light System For Measuring Wounds

The lack of an accepted method of accurate and objective measurement of wound dimensions is a major obstacle to the assessment of effective wound management regimes. This paper addresses the problems associated with wound measurements and introduces a new instrument based on the principle of coded structured light. The instrument projects a sequence of parallel stripes of light onto the surface of the lesion. These patterns are observed by a video camera which is linked to a computer system where the images can be stored and processed. Using the positions of the focal points of the camera and the stripe projector, the computer calculates a three dimensional map of the observed scene by triangulation. This map is then used to reconstruct the original, healthy skin surface by cubic spline interpolation. The area of the reconstructed surface is the area of the wound. Its volume is sandwiched between the measured and the reconstructed surface. The system also calculates the depth and the circumference of the wound. The instrument measures the volume of the wound with a precision of about 5 per cent provided that the ratio of volume to area is greater than 4 mm.

An instrument to measure the dimensions of skin wounds

A new instrument based on the principle of color-coded structured light has been developed to measure the area, volume, and color of skin ulcers and pressure sores. A set of parallel stripes of alternating colors is projected onto the ulcerated skin and recorded by a CCD camera. The color, width, distance, and coding of the stripes have been adjusted to maximize the precision of the instrument. Algorithms have been developed to extract the stripes and determine their centers to better than 0.1 mm, even under circumstances where the skin reflectivity varies widely over short distances. A depth map for the ulcerated skin is calculated by triangulation. The volume of the ulcer is that sandwiched between the base of the lesion and the original healthy skin, which is simulated by a cubic spline interpolation between the surrounding areas of healthy skin. The instrument measures the ulcer's volume with a precision of about 5% provided the ratio of the ulcer's volume to area is greater than 0.4 cm. The technique has been used in hospital clinics for a wide variety of wounds. >

Evaluation of the heat pulse velocity technique for measurement of sap flow in rainforest and eucalypt forest species of south‐eastern Australia

ABSTRACTSap flow in the stems of two cut saplings each of Eucalyptus maculata (a canopy eucalypt forest tree), Doryphora sassafras and Ceratopetalum apetalum (both canopy rainforest trees of south‐eastern coastal Australia) was measured by the heat pulse velocity technique and compared with water uptake from a potometer. Scanning electron micrographs of wounding caused by implantation of temperature sensor and heater probes into the sapwood showed that wounding was similar in rainforest and eucalypt species and was elliptical in shape. A circular wound has been implicitly assumed in previous studies. Accurate measurements of sapling water use were obtained using the smaller transverse wound dimension rather than the larger longitudinal dimension because maximum disruption of sap flow through the xylem vessels occurred in the transverse plane. Accurate measurements of sap flux were obtained above a minimum threshold sap velocity. These velocities were 15·7,10·9 and 9·4 cm h−1 for E. maculata, C. apetalum and D. sassafras, respectively. Below the threshold sap velocity, however, sap flow could not be accurately calculated from measurements of heat pulse velocity. The minimum threshold sap velocity appeared to be determined by probe construction and xylem anatomy. Despite the elliptical wounding and inaccurate measurement of sap flow below the threshold sap velocity, total sap flow over the experimental period for two saplings of each species was within 7% of water use measured by the potometer.

Relative strength of scleral tunnel incisions with internal corneal lips constructed in cadaver eyes

We constructed scleral tunnel wounds with internal corneal lips and sutureless closures in ten cadaver eyes without previous intraocular surgery. Each wound differed in width, total incision length, and internal corneal lip size. At a low and high range of initial intraocular pressure (IOP, 10 to 15 mm Hg or 20 to 25 mm Hg), we compared the wounds' resistance to leakage during application of external pressure. A square wound with a 4.0 mm width and 4.0 mm overall length, including a 1.5 mm corneal lip, had the optimum wound dimensions. These produced a stable incision that resisted leakage at external pressures up to 525 pounds per square inch equally well at both IOP ranges. Leakage occurred at lower external pressures for wounds with greater width, smaller corneal lips, or wound widths that were greater than wound lengths; such wounds were also more prone to leakage at the low IOP range. When constructed properly and adequately, the 4.0 mm wide scleral tunnel incision with 1.5 mm internal corneal lip is a strong and safe wound for sutureless cataract surgery.

Stimulation of Fruit Ethylene Production by Wounding and by Botrytis cinerea and Geotrichum candidum Infection in Normal and Non‐Ripening Tomatoes

AbstractInoculations with both Botrytis cinerea and Geotrichum candidum stimulated ethylene evolution in the pre‐climacteric normal tomato fruit and the non‐ripening nor mutant which did not show any rise in ethylene when uninfected. In the post‐climacteric normal fruits, new peaks in ethylene production were formed. The rise in ethylene evolution in all types of infected fruits has already been detected during the incubation period of the disease. Ethylene peaks were detected earlier and were higher in fruits infected with B. cinerea than with G. candidum, coinciding with the faster rate of growth of the former. Mechanical wounding also stimulated ethylene synthesis by the non‐ripening fruits, production being directly proportional to wound dimension. Considerably higher rates of ethylene were recorded for infected fruits than for mechanically‐injured fruits in which wound dimensions were similar to those of lesion development.Applying aminoxyacetic acid at the site of inoculation inhibited ethylene production by 55–60 % in the normal fruits and by about 80 % in the nor mutant fruits. A similar pathway of ethylene synthesis was suggested for normally ripening tomato fruit and non‐ripening infected tissues.

Effect of high-velocity missile injury on plasma cortisol concentration in dogs.

Plasma cortisol concentrations were measured in nine dogs after high-velocity missile injury induced by spherical steel bullets. All nine dogs sustained soft-tissue wounds in the thighs without damage to large vessels, femur, or nerves. When the dogs were considered as one group the mean plasma cortisol concentration increased promptly 10 min after injury (p less than 0.05) and reached its peak at 1 hour and then decreased. The mean concentration at 6 hours after injury was still higher than that before injury (p less than 0.05). Even though the severities of the injuries varied rather much there was a significant difference (p less than 0.01) between the plasma cortisol concentrations at 1 hour of the two groups into which the dogs were divided according to the severity of their injuries. The changes of the plasma cortisol concentrations may be parallel with the extent of the injuries and there was a positive correlation with the dimensions of the entrance wounds.