Amniotic Membrane: Can It Have An Impact For DFUs?

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

   On June 20, the patient had application of lyophilized particulate placental tissue followed by weekly evaluation. Prior to application, the wound had sharp debridement to good, healthy granulation tissue. We placed the lyophilized placental tissue within the wound bed and applied a dressing consisting of Adaptic 4x4, Kling and a layered compressive dressing. We applied new dressings weekly. No further debridements were necessary. The patient’s wound went on to heal completely in four weeks with no further application of additional amnion or debridement.

   Case study 4. A 58-year-old male presented with a history of post-traumatic arthritis to the right ankle. He had a significant history of gout and arthritis. The patient’s past surgical history is significant for six ankle surgeries, including a most recent total right ankle replacement on May 1, 2013. The patient developed a wound on the medial aspect of the right ankle and got a referral to the senior author on May 21. His attempted treatments were Silvercel, Prisma and compression dressings.

   On June 20, the patient received an application of lyophilized particulate placental tissue with weekly evaluation. Prior to applying this modality, we performed sharp debridement to good, healthy granulation tissue. We placed the lyophilized placental tissue within the wound bed and applied a dressing consisting of Adaptic 4x4, Kling and a layered compressive dressing. We applied new dressings weekly. No further debridement was necessary. His wound went on to heal completely in 16 days with no further application of amnion graft or debridement to this site.

   In regard to the application of amnion graft, we noted that minimal disturbance of the wound provided a more optimal outcome. In addition, it was imperative to control the amount of edema with each of these patients for the wounds to heal.

   Dr. Swan is in private practice at the Orthopedic Foot and Ankle Center in Westerville, Ohio.

   Dr. Hyer is a Fellow of the American College of Foot and Ankle Surgeons, and serves on its Board of Directors. He is the Fellowship Director and an attending physician at the Orthopedic Foot and Ankle Center in Westerville, Ohio.

References

1. Sheehan P, Jones P. A percent change in wound area of diabetic foot ulcers over a 4-week period is a robust predictor of complete wound healing in a 120-week prospective trial. Diabetes Care. 2003;26(6):1879-1882.
2. Toda A, Okabe M, Yoshida T, Nikaido T. The potential of amniotic membrane/amnion-derived cells for regeneration of various tissues. J Pharmacol Sci. 2007;(105): 215-228.
3. Tseng CG, Espana EM, Kawakita T, et al. How does amniotic membrane work? Ocul Surf. 2004;2(3):177-187.
4. Tan EK, Cooke M, et al. Wet vs. dry amniotic membrane tissue grafts: a comparison of cryopreserved and dehydrated tissue processing methods in preserving bioactivity. Tissue Tech Inc. Miami, Fla.
5. Liu J, Sheha H, Fu Y, et al. Update on amniotic membrane transplantation. Expert Rev Ophthalmol. 2010; 5(5):645-661.

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Comments

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 ?

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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