Wound care: The role of advanced wound healing

technologies
Stephanie C. Wu, DPM, MD, PhD,a William Marston, MD,b and David G. Armstrong, DPM, MSc,c
North Chicago, Ill; Chapel Hill, NC; and Tucson, Ariz

Wound repair and regeneration is a highly complex combination of matrix destruction and reorganization. While major
hurdles remain, advances over the past generation have improved the clinician’s armamentarium in the medical and
surgical management of this problem. The purpose of this manuscript is to review the current literature regarding the
pragmatic use of three of the most commonly employed advanced therapies; namely, bioengineered tissue, negative
pressure wound therapy, and hyperbaric oxygen therapy with a focus on the near-term future of wound healing, including
stem cell therapy. ( J Vasc Surg 2010;52:59S-66S.)

Wound repair is an orchestra of highly integrated bio-
logical and molecular events of cell migration and prolifer-
ation, and of extracellular matrix deposition and remodel-
ing.1 Certain pathophysiologic and metabolic conditions
can alter this normal course of events so that healing is
impaired or delayed, resulting in chronic, nonhealing
wounds.2,3 Diabetic foot ulcers (DFUs) readily become
chronic, and the factors that delay wound healing are
multiple and relate both to diabetes and to the effects of its
complications.3 The costs associated with the healing of an
ulcer have been noted to be as high as $45,000; however,
these estimates do not include the deleterious effects on the
patient’s quality of life because of impaired mobility and
substantial loss of productivity.4 Clearly, the healing of
ulcerations in a timely manner is of central importance in
any plan for amputation prevention and limb preserva-
tion.5,6 The integration of technological advances with our
understanding of the complex cellular and biochemical
mechanisms of wound healing has led to the development
of various advanced wound healing modalities, such as
bioengineered skin and tissue equivalents, negative pres-
sure wound therapy (NPWT), and hyperbaric oxygen ther-
apy. This article examines the latest advances in wound
healing using these three therapeutic categories and as-
sesses their implications for clinical practice.
From the Rosalind Franklin University of Medicine and Science;a the
Department of Surgery, Section of Vascular Surgery, University of North
Carolina School of Medicine;b and the Department of Surgery, Southern
Arizona Limb Salvage Alliance (SALSA), University of Arizona College of
Medicine.c
Competition of interest: none.
This article is being co-published in the Journal of Vascular Surgery® and the
Journal of the American Podiatric Medical Association.
Reprint requests: Dr David G. Armstrong, Southern Arizona Limb Salvage
Alliance, University of Arizona College of Medicine, Department of
Surgery, Tucson, AZ 85724 (e-mail: armstrong@usa.net).
The editors and reviewers of this article have no relevant financial relationships
to disclose per the JVS policy that requires reviewers to decline review of any
manuscript for which they may have a competition of interest.
0741-5214/$36.00
Copyright © 2010 by the Society for Vascular Surgery and the American
Podiatric Medical Association.
doi:10.1016/j.jvs.2010.06.009
BIOENGINEERED SKIN AND DERMAL
SUBSTITUTES OR EQUIVALENTS
Cell-based technologies to deliver exogenous
growth factors to the wound bed. Autogenous and
non-autogenous skin grafts, commonly used for the heal-
ing of skin ulcerations, may be associated with a number of
limitations such as risks of immune rejection, infection
transmission,6,7 and the creation of a donor site that is at
risk of developing pain, scarring, infection, and/or delayed
healing.7 The need for a readily available, non-antigenic
tissue that possesses many of the histological and functional
characteristics of normal human skin spawned the evolu-
tion of growing living human tissues for transplantation.
Tissue engineering has revolutionized skin grafting from
the initial autograft and allograft preparations to biosyn-
thetic and tissue-engineered skin replacements and cell-
based therapies. These advanced therapies include cultured
autologous keratinocyte grafts, cultured allogeneic keratin-
ocyte grafts, autologous/allogeneic composites, acellular
collagen matrices, and cellular matrices. A number of prod-
ucts are commercially available, and many others are in
development. The ones that are currently available include
human fibroblast-derived dermal substitute, human fibro-
blast-derived temporary skin substitute, and allogeneic bi-
layered cultured skin equivalent.
Human fibroblast-derived dermal substitute.
Human fibroblast-derived dermal substitute (Dermagraft,
Advanced Biohealing Ltd, La Jolla, Calif) is composed of
fibroblasts, extracellular matrix, and a bioabsorbable scaf-
fold (Fig 1). It is produced by culturing human dermal
fibroblast cells derived from newborn foreskin tissue onto a
bioabsorbable polyglactin mesh scaffold.8 As the fibroblasts
proliferate to fill the interstices of this scaffold, they secrete
human dermal collagen, matrix proteins, growth factors,
glycosaminoglycans, and cytokines to generate a three-
dimensional, allogeneic, human dermal substitute contain-
ing metabolically active, living cells with a preferred, nearly
parallel alignment of the collagen fibers within human
dermal substitute.8 The critical dependence of the thera-
peutic properties of this living dermal implant on the recov-
ery of protein synthesis, growth factor expression, and
59S

60S Wu et al
Fig 1. Cultured human dermis in place on neuropathic wound
following transmetatarsal amputation.
angiogenesis has been demonstrated.9 Unlike human skin,
human fibroblast-derived dermal substitute does not con-
tain macrophages, lymphocytes, blood vessels, or hair fol-
licles. Human fibroblast-derived dermal substitute has
good resistance to tearing and is packaged with bovine
serum and a saline-based cryoprotectant that contains 10%
dimethyl sulfoxide (DMSO). Cryopreservation helps main-
tain cell viability and provides off-the-shelf availability.
However, because the packing medium may also contain
traces of bovine serum, human fibroblast-derived dermal
substitute is contraindicated in patients with known hyper-
sensitivity to bovine products. Human fibroblast-
derived dermal substitute is also contraindicated for use in
ulcers that have signs of clinical infection or in ulcers with
sinus tracts.
Laboratory studies suggest this bio-engineered dermal
substitute promotes the healing of chronic ulcerations via
two principal modes of action.9 First, it provides living,
human dermal fibroblasts that deposit matrix proteins and
facilitate angiogenesis.10 It also provides a preformed col-
lagen matrix, receptors, and bound growth factors that
facilitate the migration and colonization of the host’s epi-
thelial cells, which promote wound closure.9 Previous stud-
ies have shown human fibroblast-derived dermal substitute
to be most effective in treating ulcers of greater than 6
weeks duration.11 It may be possible that chronic ulcers are
deficient in many of the factors necessary for healing and are
most likely to benefit from human fibroblast-derived der-
mal substitute treatment.
Human fibroblast-derived dermal substitute is de-
signed to assist in restoration of the dermal bed in an ulcer
to improve the wound healing process and allow the pa-
tient’s own epithelial cells to migrate and close the wound.
It is approved by the United States Food and Drug Admin-
istration for the treatment of full-thickness, chronic (dura-
tion ⬎6 weeks) diabetic foot ulcers extending through the
dermis, but not involving tendon, muscle, joint capsule, or
bone.
JOURNAL OF VASCULAR SURGERY
September Supplement 2010
The efficacy of human fibroblast-derived dermal substi-
tute in the healing of full thickness chronic diabetic wounds
has been confirmed in many studies.11,12 A randomized,
controlled, multicenter trial evaluated 314 patients with
chronic diabetic foot ulcers for complete wound closure by 12
weeks and found that 30.0% (39/130) of human fibroblast-
derived dermal substitute patients healed compared with
18.3% (21/115) of control, wet-to-dry dressing patients
(P ⫽ .023).11 In addition, the group of patients who
received human fibroblast-derived dermal substitute expe-
rienced significantly fewer ulcer-related adverse events.11
Another prospective, multicenter, randomized controlled
12-week study that enrolled 28 patients with chronic dia-
betic ulcers found significantly more patients in the human
fibroblast-derived dermis group healed versus the control
group (71.4% vs 14.3%; P ⫽ .003).12 Moreover, the study
noted that patients who healed in the human fibroblast-
derived dermis group achieved wound closure significantly
faster than the control group (P ⫽ .004); the study group
also exhibited a statistically significant higher percent of
wound closure by week 12 as compared with patients in the
control arm (P ⫽ .002).12 Interestingly, the percentage of
patients who experienced an infection involving their study
wound was lower in the human fibroblast-derived dermis
group than in the control group.
One potential problem that can arise from the applica-
tion of a human dermal substitute onto an allogeneic host is
the initiation of an immune response leading to its rejec-
tion.11 Human fibroblast-derived dermis has passed exten-
sive safety testing, and to date, there has been no reported
case of rejection in clinical use. This may be secondary to
the inherent properties of human dermal substitute since it
is derived from neonatal human tissue that has undeveloped
human leukocyte antigen tissue markers.11 In addition,
dermal-derived fibroblasts are relatively non-antigenic, do not
express human leukocyte antigen-DR markers,9 and are there-
fore, not expected to cause an immune reaction.
Risk factors related to improved healing with hu-
man fibroblast-derived dermal substitute. Data from a
Phase III randomized trial were analyzed to find risk factors
related to ulcer healing.3 Of interest, age, race, diabetes
type, ulcer duration prior to enrollment, and hours of
weight-bearing were not associated with healing rate. Ini-
tial ulcer area, gender, a history of ulcer infection, and
change in hemoglobin A1c (Hgb A1c) were associated with
altered healing rates.
An initial ulcer area greater than 2 cm2 was associated
with a 1.5 times greater incidence of wound closure (P ⫽
.02). Females were 2.0 times more likely to heal than males
(P ⫽ .009). An episode of infection during the 12 weeks of
treatment was associated with a 3.4 times increased risk of
non-closure (P ⬍ .01).
In another study, Browne et al reported on the impor-
tance of controlling bacterial load prior to the use of human
fibroblast-derived dermal substitute. The authors found an
association between the bacterial load and healing rate both
before and after human fibroblast-derived dermal substi-
tute application. They recommended treatment of patients
JOURNAL OF VASCULAR SURGERY
Volume 52, Number 12S
Fig 2. Analysis of healing based on Hemoglobin A1C levels in
study of bioengineered tissue.
with combination antibiotics until the bacterial burden was
reduced to less than106 colony forming units/gram prior
to the application of living skin substitutes or growth
factors.13
The initial and terminal Hgb A1c levels did not inde-
pendently relate to wound closure. To better determine the
relationship between glucose control and wound healing,
Marston and colleagues calculated the change in Hgb A1c
between initial and 12-week levels. Patients with a decrease
in this value were expected to have better glucose control
on average than those with an increasing level. In the
control group, there was no significant difference in the rate
of healing in those with improving compared with worsen-
ing Hgb A1c. Further, the number healed in the human
fibroblast-derived dermal substitute treated group with
worsening Hgb A1c was similar to the control rates
(20.2%). However, the number of subjects that healed in
the human fibroblast-derived dermal substitute group with
an improving Hgb A1c (46.7%) was significantly higher
than in the other three groups (P ⫽ .008).3 These data are
detailed in Fig 2. Allenet et al assessed the cost-effectiveness
of human fibroblast-derived dermis in the treatment of the
diabetic foot ulcer compared with standard treatment.14
The authors developed a Markov model to simulate, over a
52-week period, the health status of a cohort of 100 pa-
tients with a diabetic foot ulcer treated either with conven-
tional therapy or with human fibroblast-derived dermis.14
They concluded that because human fibroblast-derived
dermis heals more ulcers within 52 weeks, the average cost
per healed ulcer is lower (53,522 French francs [FF] vs
56,687 FF for standard treatment).14 The incremental cost-
effectiveness of human fibroblast-derived dermis equals
38,784 FF, indicating the extra investment that the decision-
maker has to accept for an additional ulcer healed with human
fibroblast-derived dermis compared with conventional
treatment.14
Allogeneic bi-layered cultured skin equivalent.
Allogeneic bi-layered cultured skin equivalent (Apligraf;
Organogenesis Inc, Canton, Mass) is a living, biological
dressing developed from neonatal foreskin and consists of
living cells and structural proteins. Like human skin, this
allogeneic bi-layered cultured skin equivalent has both an
upper epidermal and a lower dermal layer and contains
Wu et al 61S
human skin cells.5 The lower dermal lattice combines bo-
vine type 1 collagen and cultured human neonatal dermal
fibroblasts,15 which produce additional matrix proteins and
organize the provided structural proteins. The upper epi-
dermal layer is formed by promoting human epidermal
keratinocytes to first multiply and then to differentiate to
replicate the architecture of the human epidermis5 and act
as a barrier to prevent water loss and infection.16 Allogeneic
bi-layered cultured skin equivalent has been shown to
produce all cytokines and growth factors that are produced
by the normal skin during the healing process.5 Unlike
human skin, allogeneic bi-layered cultured skin equivalent
does not contain melanocytes, Langerhans’ cells, macro-
phages, lymphocytes, or other structures such as blood
vessels, hair follicles, or sweat glands.
Although the precise mode of action is not clear, allo-
geneic bi-layered cultured skin equivalent has been quoted
to behave similarly to a partial thickness autograft in that it
provides immediate wound coverage15 and interacts with
adjacent tissue after implantation.17 Similarities between
dermal layers of the host and graft may facilitate the cross-
over activity of mediators and response to signals from both
the host and graft dermal cells.18 Allogeneic bi-layered
cultured skin equivalent has also been noted to act through
at least three modes of healing: secondary intention, persis-
tent wound closure with underlying healing, and frank graft
take.15,16 It is believed that the allogeneic bi-layered cul-
tured skin equivalent acts by both filling in the wound with
extracellular matrix and by inducing the expression and
production of numerous growth factors and mediators
such as interleukin transforming growth factors (TGF-␤),
granulocyte-macrophage colony-stimulating factor, platelet-
derived growth factor, basic fibroblast growth factor, and
cytokines that contribute to wound healing by the stimu-
lation of wound contraction and epithelization.5,16,17,19 A
study investigating the effects of dermal replacement ther-
apy on blood flow at the base of diabetic foot ulcers noted
that blood flow increased by an average of 72% in the base
of five of the seven ulcers studied.20 The changes in blood
flow observed may reflect angiogenesis in the newly formed
granulation tissue and/or vasodilatation of existing vessels,
processes that are possibly enhanced by the allogeneic
bi-layered cultured skin equivalent application.20
Allogeneic bi-layered cultured skin equivalent is pack-
aged in a sealed heavy-gauge polyethylene bag with a 10%
CO2/air atmosphere and an agarose nutrient medium. It is
contraindicated in patients with known allergies to bovine
collagen or hypersensitivity to the components of the ship-
ping medium. One of the previous inconveniences with
allogeneic bi-layered cultured skin equivalent was its need
to be shipped overnight based on date of patient applica-
tion. The newly improved shipping box with better insula-
tion and temperature maintenance now affords allogeneic
bi-layered cultured skin equivalent a 10-day shelf life and
the clinician some flexibility on the date of application.
Antiseptic agents such as Dakin’s solution, mafenide ace-
tate, scarlet red dressing, tincoban, zinc sulfate, povidone-
iodine solution, and chlorhexidine have been determined
 JOURNAL OF VASCULAR SURGERY
62S Wu et al September Supplement 2010

to be cytotoxic to allogeneic bi-layered cultured skin equiv-

alent and should not be used immediately prior to its
application.
Apligraf is the first bi-layered living skin equivalent
approved in the United States for the treatment of chronic
venous and full-thickness neuropathic diabetic foot ulcers
of greater than three weeks’ duration that extend through
the dermis but without tendon, muscle, capsule, or bone
exposure.21
In a large, multicenter, randomized, prospective clini-
cal trial, allogeneic bi-layered cultured skin equivalent was
shown to heal non-infected, non-ischemic chronic plantar
diabetic foot ulcers faster and in more patients than con-
ventional therapy.5 By 12 weeks of treatment, 56% (63/
112) of chronic diabetic foot ulcers treated with allogeneic
bi-layered cultured skin equivalent were 100% closed, com-
pared with 39% (36/96) of ulcers treated with conven-
tional therapy (debridement plus saline dressings alone and
total off-loading [P ⫽ .0026]).5 The median time to
wound closure was 65 days for diabetic foot ulcers treated
with allogeneic bi-layered cultured skin equivalent versus
90 days for ulcers treated with conventional therapy (P ⫽
.0026).5 A similar study conducted in the European Union
and Australia reported comparable results.22 The incidence
of adverse reactions was similar between the two groups,
with the exception of osteomyelitis and lower-limb ampu-
tations, both of which were noted to be less frequent in the Fig 3. Negative pressure wound therapy foam in place with con-
tinuous streaming infusion (⬙ChemoVAC⬙) modification.
allogeneic bi-layered cultured skin equivalent group.5,23 Allo-
geneic bi-layered cultured skin equivalent is well-tolerated,
appears to be immunologically inert, with no clinical evidence patient groups with chronic wounds, health care providers
of rejection by any patient.18,24 and coverage decision makers should take not only the high
Because the allogeneic bi-layered cultured skin is made cost of the biotechnology product but the total cost of care
up of viable human cells, it cannot be terminally steril- into account when deciding about the appropriate alloca-
ized.25 Safety concerns, which have been addressed, in- tion of their financial resources.28
clude the risk of possible transmission of infection, immu- Negative pressure wound therapy. Since its intro-
nogenicity, immunological graft rejection, and tumor duction in the United States in 1997, negative pressure
formation.25 The maternal blood of the neonatal donor wound therapy (NPWT) or vacuum-assisted closure has
and the working cell banks are thoroughly screened for emerged as a commonly employed option in the treatment
infectious agents, pathogens, and other contaminants.25 of complex wounds (Fig 3). The incorporation of NPWT
Allogeneic bi-layered cultured skin equivalents are of into wound treatment regimens has been advocated by
considerable cost and should therefore be reserved for many clinicians, and NPWT has been noted to help de-
chronic foot ulcers that have failed to respond to the crease the number of dressing changes, reduce the time
currently available standard care.26 Redekop et al found between debridement and definitive closure, and reduce
that treatment with allogeneic bi-layered cultured skin costs associated with a protracted course of hospital
equivalent plus good wound care resulted in a 12% reduc- stay.29,30
tion in costs over the first year of treatment compared with Armstrong and colleagues evaluated the efficacy of
good wound care alone.27 This benefit was realized after 5 NPWT to heal 31 indolent diabetic foot wounds immedi-
months, the crossover point of the two cost curves. Alloge- ately after wide surgical debridement. A cessation of ther-
neic bi-layered cultured skin equivalent use increased the apy protocol was utilized where NPWT was discontinued
amount of ulcer-free time by 1.53 months (7.78 vs 6.25), when the wound bed approached 100% coverage with
reduced the risk of amputation (6.3% vs 17.1%),27 and granulation tissue and no exposed tendon, joint capsule, or
subsequently was cost-effective in the long-term. Langer bone. They noted that 90.3% of the wounds treated with
and Rogowski assessed the cost-effectiveness of growth NPWT healed at the level of debridement without the need
factors and tissue-engineered artificial skin for treating for further bony resection in a mean 8.1 ⫾ 5.5 weeks.30 In
chronic wounds based on a review of 11 qualifying eco- a randomized trial, Eginton et al compared the wound
nomic evaluations.28 The authors noted that, although healing efficacy of NPWT and conventional moist dressings
some growth factors and tissue-engineered artificial skin to treat large diabetic foot ulcers, and found NPWT de-
products had favorable cost-effectiveness ratios in selected creased wound volume and depth significantly more than
JOURNAL OF VASCULAR SURGERY
Volume 52, Number 12S
moist gauze dressings (59% vs 0% and 49% vs 8%, respec-
tively).31
Recently published trials have further demonstrated the
wound-healing efficacy of NPWT. Blume and coworkers
compared the safety and clinical efficacy of NPWT with
advanced moist wound therapy (AMWT) to treat diabetic
foot ulcers in a multicenter, randomized, controlled trial.
They enrolled 342 subjects, 79% male, with a mean age of
58 years, who were randomized to receive either NPWT or
AMWT and standard off-loading therapy as needed.32 The
authors noted that a greater proportion of foot ulcers
achieved complete ulcer closure with NPWT (73/169;
43.2%) than AMWT (48/166; 28.9%) within the 112-day
active treatment phase (P ⫽ .007). The Kaplan-Meier
median estimate for 100% ulcer closure was 96 days (95%
confidence interval: 75.0, 114.0) for NPWT and not deter-
minable for AMWT (P ⫽ .001). The authors noted no
significant difference between the groups in treatment-
related complications at 6 months.
Similarly, a 16-week, 18-center, randomized clinical
trial conducted by Armstrong and Lavery, involving 162
diabetic patients with larger and more complex wounds
than those from previous randomized trials, found that
NPWT healed more wounds after partial foot amputation
versus the standard of care (43 [56%] vs 33 [39%]; P ⫽
.040). The authors noted that NPWT produced faster
wound-healing rates (P ⫽ .005) and faster granulation
tissue formation rates, versus standard of care, based on the
time needed to complete closure (P ⫽ .002).33 Resource
utilization for patients treated with NPWT also was evalu-
ated in this same study population. Apelqvist34 and co-
workers reported that patients randomized to the NPWT
group required fewer surgical procedures (including de-
bridement) than the control group (43 vs 120; P ⬍ .001),
fewer average number of dressing changes (41 [range,
6-140] for NPWT versus 118.0 [range, 12-226] for con-
trol MWT [P ⬍ .0001]), and fewer outpatient treatment
visits (4 [range, 0-47] in the NPWT versus 11 [range,
0-106] for control, [P ⬍ .05]). This yielded a cost savings
in excess of $12,800 compared with standard therapy.
Combined with the clinical data, these analyses provide
compelling evidence that appropriate use of NPWT is
efficacious and cost-effective in achieving healing of prop-
erly selected wounds, both on an inpatient and outpatient
basis.
Hyperbaric oxygen therapy. Hyperbaric oxygen
(HBO) has long been considered as a potential treatment
modality for complicated or recalcitrant ulcers. Oxygen has
been reported to stimulate angiogenesis, enhance fibroblast
and leukocyte function, and normalize cutaneous micro-
vascular reflexes.35,36 Clinically, HBO has been demon-
strated to improve transcutaneous pO2 in the limbs of
some patients with ischemic ulcers. Significant side ef-
fects of treatment are uncommon, but may be severe,
including barotraumatic otitis, hyperoxic seizures, and
pneumothorax.
For the treatment of DFU, one randomized study was
particularly influential in supporting use of HBO for com-
Wu et al 63S
plex wounds. Abidia and colleagues randomly assigned 18
patients with ischemic non-healing diabetic limb ulcers to
100% oxygen or air at 2.4 atmospheres for 90 minutes in a
hyperbaric chamber daily.37 In this double-blind study,
oxygen and control groups received 30 sessions after which
the outcome was measured. In the oxygen group, five of
eight ulcers were closed completely, compared to one of
the eight control ulcers (P ⫽ .027).
In another prospective study of diabetic foot ulcers,
Kalani et al enrolled 38 patients with non-healing foot
ulcers and basal transcutaneous oxygen levels in the foot
below 40 mm Hg.38 Seventeen patients were treated with
HBO for 40 to 60 sessions, and 21 were treated with
standard diabetic ulcer care. Patients were followed for 3
years. At final follow-up, 76% of patients treated with HBO
had healed their DFU, and only 12% required limb ampu-
tation. In the standard care group, 48% had healed their
foot ulcer at 3 years, and 33% required limb amputation.
In 2004, the Cochrane Collaborative reviewed hyper-
baric oxygen therapy for chronic wounds and concluded
that HBO reduces the risk of amputation for patients with
DFU and increases the chance of healing at 1 year.39
However, it was noted that these recommendations were
based on small, underpowered studies and that further
randomized studies were greatly needed to clarify the ben-
efits of this costly therapy. Addressing some of the method-
ologic concerns of previous studies, a rather robust double-
blind randomized controlled study conducted by Londahl
and coworkers42 suggested improved healing in the active
HBO group compared with placebo at 1 year in patients
suffering from complex diabetic foot wounds (52% vs 29%;
P ⫽ .03). This study used an intent-to-treat analysis for
patients with chronic (⬎3 month duration) neuropathic
and neuroischemic wounds. All received treatment in a
multiplace chamber receiving either active HBO or placebo
(compressed air).
Further work has been conducted to identify better
decision-making parameters for the use of HBO. Works
have focused on the use of transcutaneous oxygen tension
(TcPO2) as a predictive modality in selecting patients for
HBO treatment. Specifically, Grolman et al measured
TcPO2 in the ischemic limb of 36 patients breathing room
air, followed by 100% O2. They found an increase of
TcPO2 in the ischemic foot of ⬎10 torr was associated
with a healing rate of 70%, compared with a healing rate of
11% in those with an increase of ⬍10 torr.40 In a larger
study of ischemic and non-ischemic DFUs, Fife and col-
leagues evaluated the use of TcPO2 in 1144 patients. In
this study, predictive values were relatively poor, with some
patients healing despite low initial and in-chamber
TcPO2.41
While data, particularly recently, have pointed toward
HBO therapy as having some degree of potential benefit, its
cost is high. Patients often travel long distances for daily
treatments at great cost to themselves and their families.
Although reported protocols for treatment of ischemic
limb ulcers vary significantly, most involve a total cost of
$15,000 to $40,000. In an assessment for the Canadian
 JOURNAL OF VASCULAR SURGERY
64S Wu et al September Supplement 2010

government, Chuck et al from the University of Alberta

compared HBO and standard care for DFUs using a deci-
sion model and available outcomes data. They found that
the average yearly cost for HBO treated ulcers was $40,695
(Canadian) compared with $49,786 (Canadian) for stan-
dard care. They concluded that adjunctive HBO is cost-
effective compared with standard care alone.43
Currently, HBO is an option that may improve limb
preservation in a limited group of patients with complicated
ischemic and diabetic limb ulcers. Other HBO indications
reimbursed by most insurers include the treatment of inha-
lation injury, necrotizing wound infections, crush injury,
and osteoradionecrosis. Until larger randomized studies
are performed, it cannot be recommended as a primary
treatment for patients with uncomplicated diabetic or isch-
emic ulcers. But in selected more complicated cases, HBO
may have a role.

WOUND TREATMENTS ON THE HORIZON

Stem cell therapy. Marrow cells have been shown to
play an important role in the healing of cutaneous wounds.
Subsequent to dermal wounding, marrow-derived mesen-
chymal stem cells (MSC) are mobilized into the peripheral
circulation and engraft near adnexal structures in the skin.
These cells eventually differentiate into skin cells.44
Deng et al transplanted fluorescent-labeled bone mar-
row MSC into lethally irradiated mice and found that
labeled cells gave rise to stem cells and committed cells in
the skin.45 Another study found that 15% to 20% of the
dermal fibroblasts originated from the bone marrow in
a murine wound model.46 Animal studies have shown
wound healing significantly improved after injection of
MSC into the wound.47 Bauer et al found that although
extremity ischemia is a powerful stimulant for marrow stem
cell recruitment, fewer progenitor cells were able to migrate
to the ischemic wound.48 This may be a result of macro-
and microvascular disease, obstructing vascular conduits
for mobilization of MSC. Local application, topically or via
injection, of MSC would place these progenitor cells at the
site of injury, assisting in homing and delivery. Human
studies with recent small case-series transplanting autolo-
gous cultured marrow derived MSC and pure marrow
aspirate (Fig 4) have shown rapid improvement in granula-
tion and healing in chronic wounds.44,49,50
Badiavas and Falanga44 harvested bone marrow aspi-
rate from the ileum in three patients with chronic wounds
unresponsive to aggressive therapy (abdominal dehiscence,
lower extremity arterial ulcer, and lower extremity venous
ulcer) and injected the marrow aspirate into the peri-
wound tissue and applied the aspirate topically. The re-
maining aspirate was cultured and expanded in vitro and
later applied topically to the wounds in a repeat treatment.
The authors noted that, after each treatment with cultured
MSC, the wounds experienced a burst of granulation tis-
sue. Two patients healed rapidly by secondary intention;
one patient healed with the use of a skin substitute (cul-
tured fetal foreskin). They concluded that their study sup-
ported the hypothesis that bone marrow aspirate contained
Fig 4. Harvest of (A) and seeding (B) marrow-derived stem cells
on acellular matrix.
progenitor cells that can engraft into wound and accelerate
healing.
Other critical considerations. Despite the plethora
of advances, results from a myriad of published and unpub-
lished industry-sponsored, randomized trials that evaluated
the efficacy of these advanced wound healing agents have
been less than ideal and are difficult to place in perspec-
tive.5,51-53 For example, published healing rates for DFUs
treated by TCCs (total contact casts) are noted to be 80% to
90% compared with only 45% to 55% for biologic tis-
sues.54,55 Most studies either offered shoes or sandals to
study participants or allowed individual centers to select the
type of pressure relief;55 however, not one of these studies
employed irremovable offloading.
Such considerations emphasize the importance of using
advanced wound healing modalities as adjuvant therapies
that work synergistically with standard wound care regi-
mens such as routine debridement, pressure mitigation,
infection control, and provision of adequate vascularity to
the affected area. Without adhering to these important
principles, the addition of any adjunctive modality is un-
likely to result in improved healing rates.1,13 Wound bed
preparation encompasses the removal of necrotic tissue,
JOURNAL OF VASCULAR SURGERY
Volume 52, Number 12S
formation of granulation tissue, and elimination of wound
exudate.56 Brem et al found that two separate clinical and
specialty sites were able to achieve a frequency of complete
wound closure of greater than 70% within 6 months via
optimal wound preparation.56 Care for a patient with dia-
betic foot ulceration is complex, necessitating collaboration
of a multidisciplinary team to achieve treatment goals; such
a team must accurately assess and manage current wound
and patient conditions, optimally manage subsequent com-
plications, and aim to promote shorter healing time. Ad-
vanced wound healing modalities, when used appropri-
ately, may serve as useful components of the wound
management algorithm.
REFERENCES
1. Falanga V. Classifications for wound bed preparation and stimulation of
chronic wounds. Wound Repair Regen 2000;8:347-52.
2. Mustoe TA, O’Shaughnessy K, Kloeters O. Chronic wound pathogen-
esis and current treatment strategies: a unifying hypothesis. Plast Re-
constr Surg 2006;117(7 Suppl):35S-41S.
3. Marston WA; Dermagraft Diabetic Foot Ulcer Study Group. Risk
factors associated with healing chronic diabetic foot ulcers: the impor-
tance of hyperglycemia. Ostomy Wound Manage 2006;52:26-8, 30, 32
passim.
4. Paquette D, Falanga V. Leg ulcers. Clin Geriatr Med 2002;18:77-88, vi.
5. Veves A, Falanga V, Armstrong DG, Sabolinski ML; Apligraf Diabetic
Foot Ulcer Study. Graftskin, a human skin equivalent, is effective in the
management of noninfected neuropathic diabetic foot ulcers: a prospec-
tive randomized multicenter clinical trial. Diabetes Care 2001;24:
290-5.
6. Lee KH. Tissue-engineered human living skin substitutes: development
and clinical application. Yonsei Med J 2000;41:774-9.
7. Bello YM, Falabella AF, Eaglstein WH. Tissue-engineered skin. Current
status in wound healing. Am J Clin Dermatol 2001;2:305-13.
8. Marston WA. Dermagraft, a bioengineered human dermal equivalent
for the treatment of chronic nonhealing diabetic foot ulcer. Expert Rev
Med Devices 2004;1:21-31.
9. Mansbridge J, Liu K, Patch R, Symons K, Pinney E. Three-dimensional
fibroblast culture implant for the treatment of diabetic foot ulcers:
metabolic activity and therapeutic range. Tissue Eng 1998;4:403-14.
10. Mansbridge J. Skin substitutes to enhance wound healing. Expert Opin
Investig Drugs 1998;7:803-9.
11. Marston WA, Hanft J, Norwood P, Pollak R; Dermagraft Diabetic Foot
Ulcer Study Group. The efficacy and safety of Dermagraft in improving
the healing of chronic diabetic foot ulcers: results of a prospective
randomized trial. Diabetes Care 2003;26:1701-5.
12. Hanft JR, Surprenant MS. Healing of chronic foot ulcers in diabetic
patients treated with a human fibroblast-derived dermis. J Foot Ankle
Surg 2002;41:291-9.
13. Browne AC, Vearncombe M, Sibbald RG. High bacterial load in
asymptomatic diabetic patients with neurotrophic ulcers retards wound
healing after application of Dermagraft. Ostomy Wound Manage 2001;
47:44-9.
14. Allenet B, Parée F, Lebrun T, Carr L, Posnett J, Martini J, et al.
Cost-effectiveness modeling of Dermagraft for the treatment of diabetic
foot ulcers in the French context. Diabetes Metab 2000;26:125-32.
15. Zaulyanov L, Kirsner RS. A review of a bi-layered living cell treatment
(Apligraf) in the treatment of venous leg ulcers and diabetic foot ulcers.
Clin Interv Aging 2007;2:93-8.
16. De SK, Reis ED, Kerstein MD. Wound treatment with human skin
equivalent. J Am Podiatr Med Assoc 2002;92(1):19-23.
17. Trent JF, Kirsner RS. Tissue engineered skin: Apligraf, a bi-layered
living skin equivalent. Int J Clin Pract 1998;52:408-13.
18. Donohue KG, Carson P, Iriondo M, Zhou L, Saap L, Gibson K, et al.
Safety and efficacy of a bilayered skin construct in full-thickness surgical
wounds. J Dermatol 2005;32:626-31.
Wu et al 65S
19. Brem H, Balledux J, Bloom T, Kerstein MD, Hollier L. Healing of
diabetic foot ulcers and pressure ulcers with human skin equivalent: a
new paradigm in wound healing. Arch Surg 2000;135:627-34.
20. Newton DJ, Khan F, Belch JJ, Mitchell MR, Leese GP. Blood flow
changes in diabetic foot ulcers treated with dermal replacement therapy.
J Foot Ankle Surg 2002;41:233-7.
21. Introduction. Healing chronic wounds: technologic solutions for today
and tomorrow. Adv Skin Wound Care 2000;13(2 Suppl):4-5.
22. Edmonds M; European and Australian Apligraf Diabetic Foot Ulcer
Study Group. Apligraf in the treatment of neuropathic diabetic foot
ulcers. Int J Low Extrem Wounds 2009;8:11-8.
23. Steinberg JS, Edmonds M, Hurley DP Jr, King WN. Confirmatory data
from EU study supports Apligraf for the treatment of neuropathic
diabetic foot ulcers. J Am Podiatr Med Assoc 2010;100:73-7.
24. Molecule of the month: Apligraf living human skin equivalent. Drug
News Perspect 1998;11:43.
25. Dolynchuk K, Hull P, Guenther L, Sibbald RG, Brassard A, Cooling M,
et al. The role of Apligraf in the treatment of venous leg ulcers. Ostomy
Wound Manage 1999;45:34-43.
26. Fagrell B, Jorneskog G, Intaglietta M. Disturbed microvascular reactiv-
ity and shunting–a major cause for diabetic complications. Vasc Med
1999;4:125-7.
27. Redekop WK, McDonnell J, Verboom P, Lovas K, Kalo Z. The cost
effectiveness of Apligraf treatment of diabetic foot ulcers. Pharmaco-
economics 2003;21:1171-83.
28. Langer A, Rogowski W. Systematic review of economic evaluations of
human cell-derived wound care products for the treatment of venous
leg and diabetic foot ulcers. BMC Health Serv Res 2009;9:115.
29. McCallon SK, Knight CA, Valiulus JP, Cunningham MW, McCulloch
JM, Farinas LP. Vacuum-assisted closure versus saline-moistened gauze
in the healing of postoperative diabetic foot wounds. Ostomy Wound
Manage 2000;46:28-32, 34.
30. Armstrong DG, Lavery LA, Abu-Rumman P, Espensen EH, Vazquez
JR, Nixon BP, et al. Outcomes of subatmospheric pressure dressing
therapy on wounds of the diabetic foot. Ostomy Wound Manage
2002;48:64-8.
31. Eginton MT, Brown KR, Seabrook GR, Towne JB, Cambria RA. A
prospective randomized evaluation of negative-pressure wound dress-
ings for diabetic foot wounds. Ann Vasc Surg 2003;17:645-9.
32. Blume PA, Walters J, Payne W, Ayala J, Lantis J. Comparison of
negative pressure wound therapy using vacuum-assisted closure with
advanced moist wound therapy in the treatment of diabetic foot ulcers:
a multicenter randomized controlled trial. Diabetes Care 2008;31:
631-6.
33. Armstrong DG, Lavery LA. Negative pressure wound therapy after
partial diabetic foot amputation: a multicentre, randomised controlled
trial. Lancet 2005;366:1704-10.
34. Apelqvist J, Armstrong DG, Lavery LA, Boulton AJM. Resource utili-
zation and economic costs of care based on a randomized trial of
vacuum-assisted closure therapy in the treatment of diabetic foot
wounds. Am J Surg 2008;195:782-8.
35. Kuffler DP. Hyperbaric oxygen therapy: an overview. J Wound Care
2010;19:77-9.
36. Goldman RJ. Hyperbaric oxygen therapy for wound healing and limb
salvage: a systematic review. PM R 2009;1:471-89.
37. Abidia A, Laden G, Kuhan G, Johnson BF, Wilkinson AR, Renwick PM,
et al. The role of hyperbaric oxygen therapy in ischaemic diabetic lower
extremity ulcers: a double-blind randomised-controlled trial. Eur J Vasc
Endovasc Surg 2003;25:513-8.
38. Kalani M, Jorneskog G, Naderi N, Lind F, Brismar K. Hyperbaric
oxygen (HBO) therapy in treatment of diabetic foot ulcers. Long-term
follow-up. J Diabetes Complications 2002;16:153-8.
39. Kranke P, Bennett M, Roeckl-Wiedmann I, Debus S. Hyperbaric
oxygen therapy for chronic wounds. Cochrane Database Syst Rev
2004;(2):CD004123.
40. Grolman RE, Wilkerson DK, Taylor J, Allinson P, Zatina MA. Trans-
cutaneous oxygen measurements predict a beneficial response to hyper-
baric oxygen therapy in patients with nonhealing wounds and critical
limb ischemia. Am Surg 2001;67:1072-9; discussion 1080.

66S Wu et al
41. Fife CE, Buyukcakir C, Otto GH, Sheffield PJ, Warriner RA, Love TL,
et al. The predictive value of transcutaneous oxygen tension measure-
ment in diabetic lower extremity ulcers treated with hyperbaric oxygen
therapy: a retrospective analysis of 1,144 patients. Wound Repair Regen
2002;10:198-207.
42. Londahl M, Katzman P, Nilsson A, Hammarlund C. Hyperbaric oxy-
gen therapy facilitates healing of chronic foot ulcers in patients with
diabetes. Diabetes Care 2010;33:998-1003.
43. Chuck AW, Hailey D, Jacobs P, Perry DC. Cost-effectiveness and
budget impact of adjunctive hyperbaric oxygen therapy for diabetic foot
ulcers. Int J Technol Assess Health Care 2008;24:178-83.
44. Badiavas EV, Falanga V. Treatment of chronic wounds with bone
marrow-derived cells. Arch Dermatol 2003;139:510-6.
45. Deng J, Petersen BE, Steindler DA, Jorgensen ML, Laywell ED.
Mesenchymal stem cells spontaneously express neural proteins in
culture and are neurogenic after transplantation. Stem Cells 2006;24:
1054-64.
46. Fathke C, Wilson L, Hutter J, Kapoor V, Smith A, Hocking A, et al.
Contribution of bone marrow-derived cells to skin: collagen deposition
and wound repair. Stem Cells 2004;22:812-22.
47. McFarlin K, Gao X, Liu YB, Dulchavsky DS, Kwon D, Arbab AS, et al.
Bone marrow-derived mesenchymal stromal cells accelerate wound
healing in the rat. Wound Repair Regen 2006;14:471-8.
48. Bauer SM, Goldstein LJ, Bauer RJ, Chen H, Putt M, Velazquez OC.
The bone marrow-derived endothelial progenitor cell response is im-
paired in delayed wound healing from ischemia. J Vasc Surg 2006;43:
134-41.
JOURNAL OF VASCULAR SURGERY
September Supplement 2010
49. Badiavas EV, Ford D, Liu P, Kouttab N, Morgan J, Richards A, et al.
Long-term bone marrow culture and its clinical potential in chronic
wound healing. Wound Repair Regen 2007;15:856-65.
50. Falanga V, Iwamoto S, Chartier M, Yufit T, Butmarc J, Kouttab N, et al.
Autologous bone marrow-derived cultured mesenchymal stem cells
delivered in a fibrin spray accelerate healing in murine and human
cutaneous wounds. Tissue Eng 2007;13:1299-312.
51. Steed DL. Clinical evaluation of recombinant human platelet-derived
growth factor for the treatment of lower extremity diabetic ulcers.
Diabetic Ulcer Study Group. J Vasc Surg 1995;21:71-8.
52. Veves A, Sheehan P, Pham HT. A randomized, controlled trial of
Promogran (a collagen/oxidized regenerated cellulose dressing) vs
standard treatment in the management of diabetic foot ulcers. Arch
Surg 2002;137:822-7.
53. Gentzkow GD, Iwasaki SD, Hershon KS. Use of Dermagraft, a cultured
human dermis, to treat diabetic foot ulcers. Diabetes Care 1996;19:
350-4.
54. Cavanagh PR, Lipsky BA, Bradbury AW, Botek G. Treatment for
diabetic foot ulcers. Lancet 2005;366:1725-35.
55. Armstrong DG, Boulton AJ. Pressure offloading and “advanced”
wound healing: isn’t it finally time for an arranged marriage? Int J Low
Extrem Wounds 2004;3:184-7.
56. Brem H, Balledux J, Sukkarieh T, Carson P, Falanga V. Healing of
venous ulcers of long duration with a bilayered living skin substitute:
results from a general surgery and dermatology department. Dermatol
Surg 2001;27:915-9.