Amniotic Membrane: Can It Have An Impact For DFUs?

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Author(s): 
Jennifer Swan, DPM, and Christopher Hyer, DPM, FACFAS

Does amniotic membrane represent a promising technology that can speed the healing of complicated wounds such as diabetic foot ulcers? These authors take a closer look at how amniotic membranes work and offer several case study examples.

Diabetic foot ulcers continue to be a challenge for podiatrists and other healthcare providers. With the diagnosis of diabetes increasing in prevalence year after year, we continue to find ways to heal these wounds as quickly, efficiently and economically as possible.

   Recently, there has been an increase in interest in the use of amniotic membranes for wound healing. Even though this technology has been around for years, it has had a recent surge of popularity. Ophthalmologists have used amniotic membranes dating back to 50 years ago. The use of amniotic membrane for other applications started in the 20th century but dropped out of favor with the discovery and rise of human immunodeficiency virus (HIV).

   Clinicians should reserve amniotic membrane and any advanced biological dressing for wounds that are considered “chronic.” Sheehan and Jones defined a chronic wound as a wound that is still present after 30 days and has less than 50 percent reduction in size during this timeframe.1 It is important to get these wounds healed as quickly as possible in order to reduce the risks of infection and limb loss, and return patients to activity and work. Unfortunately, it does not appear that this definition of chronic wound will change nor will the criteria for use of these products become any easier.

   There are many products on the market that physicians have utilized in healing wounds but not all products are created equally. Of these products, only a few are FDA approved. Hopefully with continued prospective studies, more products will gain approval not only for diabetic wounds but for those challenging postoperative wounds as well.
However, advanced biologics should not replace the basic tenets of wound care management. If one does not address these basics, even the best biologic dressing will fail. When treating a wound, appropriate wound debridement is essential but we must not forget to treat the entire patient and not just the wound.

   Of course, one must first start with a thorough history and physical. As simple as this sounds, if one forgets these basics, the standard of care will often go overlooked. There are many things that impact healing: age, medical history (especially diabetes, rheumatoid arthritis, etc.), and social history (smoking, alcohol use and poor nutrition). While we cannot change some of these factors, one must address the variable items in the equation. All too often we downplay the amount of influence nutrition can play in healing.

   In addition, our physical exam will also help guide us to define what type of wound we are treating so we can implement the best options to obtain rapid healing. Clinicians should also perform a vascular exam, a neurologic exam and ascertain the patient’s overall health by obtaining lab work. It is also important to control the amount of edema as it has a huge impact on wound healing.

   There is a wealth of literature that has demonstrated the financial burden that managing diabetic wounds has on our economy. Even with this understanding and evidence-based medicine to support advanced biologics, insurance companies still make it difficult for physicians to implement and utilize these products. Therefore, we want to make sure that we utilize the appropriate dressings and advanced biologics for each scenario to heal our patients as quickly as possible.

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Dr Leslie aufseesersays: March 4, 2014 at 7:57 pm

I have an end-stage renal patient with poor blood flow, calcified vessels etc. Her wound is over the bunion joint 3 cm x 2.5 cm and channels 2 inches under the first met head. Can I pack the graft into the dead space and use a second graft over the ulcer ?

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H. David Gottlieb, DPMsays: March 31, 2014 at 1:05 pm

Dr. Aufseeser:

I think in your patient's case, you would get better results by using an injectable amniotic implant. This is infiltrated around and under the ulcer, usually in a series of 2 or 3 every other week. In my experience, this promotes vascular neogenesis and then wound healing. It doens't happen overnight but I usually see a dramatic change at week 3 or 4.

The injectables seem to all be similar in action despite what their manufacturers say. My personal favorite seems to be Flograft but I'll use whatever my institution has on hand.

Dave Gottlieb, DPM
Baltimore

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