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.