Amniotic Membrane: Can It Have An Impact For DFUs?

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

   Liu and coworkers demonstrated that hyaluronan in amniotic tissue is present in the form of a heavy chain of inter-alpha-inhibitor-hyaluronan (HC-HA) complex. The authors believe this complex plays a role in anti-angiogenic activity as well as stabilizing the extracellular matrix.4,5 Results of the study via western blot analysis demonstrated high levels of HC-HA using the CryoTek process. The dehydrated process had the presence of HC-HA but it was minimal or with an altered band appearance. Accordingly, it certainly appears that the way the tissue is processed also makes a difference in maintaining the integrity of the amniotic membrane.

Case Studies On The Use Of Amniotic Membrane For Healing Wounds

We have started using amniotic membrane for wounds that have been a particular challenge. We have seen great results with just one application. Below are some case studies to demonstrate the process of application, the different forms of the product we have used and the patient outcomes.

   Case study 1. A 70-year-old female presented 12 weeks after ankle fusion with an anterior ankle wound dehiscence and exposure of the tendon. The patient had a history of diabetes, chronic kidney disease, obesity, gastrointestinal esophageal reflux disease, depression and hypertension. Some additional challenges with this case were the development of deep vein thrombosis and infection after surgery, which led to two incision and drainage (I&D) procedures.

   The patient went back to the OR for I&D and application of an amnion graft. We placed the graft within the wound and wrapped it around the tendon. The dressing we applied consisted of Adaptic (Systagenix) 4x4 and a four-layered compression dressing.
We saw the patient weekly but did not perform debridement. We continued to apply a four-layered compression dressing to control edema and occasionally used a collagen (Prisma, Systagenix) dressing.

   The patient went on to heal completely and is now back to pre-surgical activity.

   Case study 2. A 72-year-old patient presented with a long history of rheumatoid arthritis and alcoholism. Even though this patient does not have diabetes, his pertinent medical history presents similar barriers to healing that are just as challenging. He had previous amputations and similar difficultly healing wounds. The patient had amputation of the left second and third digits secondary to infection on April 23, 2013. He went on to wound dehiscence and had various treatment modalities prior to amnion grafting.

   In this case, we used one application of lyophilized particulate placental tissue with weekly evaluation. Prior to application, we performed sharp wound debridement to good, healthy granulation tissue. We placed the lyophilized placental tissue within the wound bed and used a dressing consisting of Adaptic 2x2, Kling and Ace wrap. The dressings remained in place until weekly follow-up appointments in which we applied a new Adaptic 2x2 and Kling. No further debridement occurred. The patient’s wound went on to heal completely in seven weeks with no further application of additional amnion or debridement.

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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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