Using Hyaluronic Acid Derivatives and Cultured Autologous Fibroblasts and Keratinocytes in a Lower Limb Wound in a Patient with
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C hronic lower extremity ulcers are a common and serious complication of diabetes mellitus. Moss1 estimates that patients with diabetes have a five to 15 times higher risk of requiring a lower extremity amputation than people who do not have diabetes. Foot ulcers are an important predictor of future lower extremity amputations in patients with diabetes and, despite efforts to prevent these ulcers from occurring, the incidence of lower extremity amputations continues to rise.2
Data are scant on the use of bioengineered tissue in the treatment of chronic wounds in patients with diabetes.3-5 This case study describes the use of an autologous tissue engineering approach to close a severe ulcer in the Achilles' tendon region of the lower limb of a patient with diabetes. The technique is based on the use of biodegradable scaffolds composed of an ester derivative of hyaluronic acid onto which autologous laboratory grown fibroblasts and keratinocytes (Hyalograft 3D® and Laserskin®, respectively, Fidia Advanced Biopolymers SrL, Abano Terme, Italy) are seeded.6 The ester derivatives of hyaluronic acid are used because they offer optimal biocompatibility and biodegradabilty in vitro and in vivo. Moreover, cultivated fibroblasts need a three-dimensional structure into which to grow; whereas, keratinocytes need a two-dimensional structure. The ester derivative has the necessary physical properties to be processed into different forms to obtain appropriate scaffolds for these different cell types. This two-stage approach has been used successfully to heal other chronic and acute wounds.7-8
The patient was a 65-year-old male, nonsmoker, with type 2 diabetes mellitus (treated with intensive insulin therapy), peripheral neuropathy, and infrapopliteal arteriopathy of the lower limbs. He also had a history of arterial hypertension and myocardial ischemic disease that was treated with warfarin, ACE-inhibitors, diltiazem, and nitrates. Diffuse infrapopliteal stenosis and the absence of a suitable vessel in the tibial and pedal region for distal arterial bypass run-off eliminated the possibility of revascularization. Due to the incorrigible critical ischemia and worsening of his infected lower leg wound, amputation was recommended.
The patient changed providers and visited the authors' clinic in October 1998. He presented with an extensive ulcer of the left lower limb (diagnosed 7 months earlier) caused by a minor trauma. The wound had remained unhealed despite ancillary treatments (see Figure 1). Up to this point, local treatment with saline solution-soaked gauze was performed daily. No surgical debridement had been performed. The patient received cyclic treatment with antibiotics. No orthesis or therapeutic shoes were used. Metabolic control measured at the first visit was discrete; his HbA1c was 6.9%.
The patient's ulcer measured 103.49 cm2 and was full thickness with exposure of a necrotic Achilles' tendon. Transcutaneous oxygen pressure (TcPO2) measured on the dorsal surface of the midfoot was 24 mm Hg and his ankle brachial index (ABI) was 0.3. Venous insufficiency was ruled out on the basis of the ultrasonography results. Distal neuropathy was also present.
The wound was clinically infected; Pseudomonas aeruginosa was isolated from microbiological specimens and intravenous antibiotic therapy (piperacillin plus tazobactam) was initiated. Treatment commenced on an outpatient basis. The wound was surgically debrided and the necrotic Achilles' tendon was removed. In this first phase, the lesion was treated with antiseptics (povidone-iodine and silver sulfadiazine) and subsequently with collagenase covered with a polyurethane foam dressing. During the week preceding the autologous graft, dressings with hyaluronic acid covered with a polyurethane foam were used.
1. Moss SE, et al. The prevalence and incidence of lower extremity amputation in a diabetic population. Arch Intern Med. 1992;152:610-616
2. American Diabetes Association's Consensus Report. Special Report. Wounds. 1999;11(5):93-104.
3. Gentzkow GD, Iwasaki SD, Hershon KS, et al. Use of Dermagraft, a cultured human dermis, to treat diabetic foot ulcers. Diabetes Care. 1996;19:350-354.
4. Pollak R, Edington H, Jensen J, Kroeker R, Gentzkow G. Dermagraft Diabetic Ulcer Study Group. A human dermal replacement for the treatment of diabetic foot ulcers. Wounds. 1997;9(1):175-183.
5. Pham HT, Rosenblum BI, Lyons TE, et al. Evaluation of Graftskin (Apligraft), a human skin equivalent, for the treatment of diabetic foot ulcers. Wounds. 1999;11(4):79-86.
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7. Brun P, Grosso F, Galassi G, et al. Use of dermal-like tissue in the management of chronic and acute full-thickness cutaneous wounds. Wounds. 2000;46(9):44-48.
8. Faglia E, Mantero M, Gino M, Quarantiello A, Signorini M. A combined conservative approach in the treatment of a severe Achilles' tendon region ulcer in a patient with diabetes: a case report. Wounds. 1999;11(5):105-109.
9. Zacchi V, Soranzo C, Cortivo R, Radice M, Brun P, Abatangelo G. In vitro engineering of human skin-like tissue. J Biomed Mater Res. 1988;40(2):187-194.