Search

One of the most common types of skin breakdown in ageing populations is skin tears. The International Skin Tear Advisory Panel advocates for special attention to be paid to dressing selection related to skin tear management. The panel recommends choosing dressings that will promote the maintenance of moisture balance, suit the local wound environment, protect peri‐wound skin, control or manage exudate and infection, and optimise caregiver time. It is paramount that dressings protect the fragile nature of the skin associated with those who at heightened risk for skin tear development. To compare the effectiveness of soft silicone dressings (a contact layer and/or foam) for the healing of skin tears with local practices that do not include soft silicone dressings. The study was a pragmatic randomised controlled prospective study. One hundred and twenty‐six individuals from two long‐term care facilities in Ontario Canada who presented with skin tears were randomised into the treatment group using either soft silicone dressings (a contact layer and/or foam) or the control group using non‐adhesive dressings. The current study demonstrated that 96.9% (n = 63) of skin tears in the treatment group healed over a 3‐week period compared with 34.4% (n = 21) in the control group. The proportion of wound healing experienced at week 2 was 89.2% (n = 58) in the treatment group compared with 27.9% (n = 17) in the control group. There was a significantly greater reduction in wound surface area relative to baseline in the treatment group (2.9 cm2) compared with the control group (0.6 cm2) (χ 2 = 21.792 P

The aim of this study was to summarise the clinical evidence supporting almost 40 years of topical cadexomer iodine (CIOD) use in wound bed preparation by removing barriers to healing such as exudate, slough, bioburden, and infection and allowing chronic wound progression. A systematic review was conducted (Embase/PubMed, November 2020) to identify relevant comparative studies meeting inclusion criteria. Meta‐analyses were performed using a fixed‐effects (I 2

Chronic wounds are still regarded as a serious public health concern, which are on the increase mainly due to the changes in life styles and aging of the human population. There are different types of chronic wounds, each of which requires slightly different treatment strategies. Nevertheless, wound bed preparation is included in treatment of all types of chronic wounds and involves tissue debridement, inflammation, and infection control, as well as moisture balance and epithelial edge advancement. Maggot therapy (MT) is a form of biological debridement which involves the application of live medical grade Lucilia sericata (Meigen, 1826) (Diptera: Calliphoridae) larvae. Whereas it was initially thought to act mainly through debridement, today MT is known to influence all four overlapping physiological phases of wound repair: homeostasis, inflammation, proliferation, and remodelling/maturing. During MT, medical-grade larvae are applied either freely or enclosed in tea-bag like devices (biobag) inside the wounds, which suggests that larva excretion/secretion (ES) products can facilitate the healing processes directly without the need of direct contact with the larvae. This review summarizes the relevant literature on ES-mediated effects on the cellular responses involved in wound healing.

For nearly two decades, Negative Pressure Wound Therapy (NPWT) has been used for temporary wound coverage as well as wound bed preparation. The addition of instillation and dwell time as an adjunct to NPWT (NPWTi-d) enables wound bed cleaning and improved wound bed granulation. Thirty patients with different types of colonised wounds (traumatic, surgical, and chronic) were treated with NPWTi-d using saline for instillation. Patient data, microbiological data and wound characteristics were collected and analysed. Endpoints were bacterial decontamination (count and type), effect on wound bed granulation, and successful reconstruction. Additionally, subgroup analyses for traumatic, surgical, and chronic wounds as well as patients pretreated with conventional NPWT or isolated gram-positive or negative germs were performed. NPWTi-d was applied on average for 13 days with a total hospitalisation time of 51 days. After NPWTi-d, decontaminated wounds were detected in 23% of cases. The number of different bacteria as well as bacterial count could be significantly reduced from 2.38 to 1.16 and 3.9 to 1.3, respectively. This was similar for all subgroups except surgical wounds, in which NPWTi-d did not lead to a significant reduction of the bacterial count. NPWTi-d resulted in a significant stimulation of granulation tissue. Successful reconstruction was achieved in 90% of cases. NPWTi-d enabled wound pre-conditioning by powerfully reducing or decontaminating the bacterial load and spectrum in most of the wounds. The wound bed integrity was re-established to prepare successful reconstruction.

Appropriate and effective wound cleaning represents an important process that is necessary for preparing the wound for improved wound healing and for helping to dislodge biofilms. Wound cleaning is of paramount importance to wound bed preparation for helping to enhance wound healing. Surfactant applications in wound care may represent an important area in the cleaning continuum. However, understanding of the role and significance of surfactants in wound cleansing, biofilm prevention and control, and enhancing cellular viability and proliferation is currently lacking. Despite this, some recent evidence on poloxamer‐based surfactants where the surfactants are present in high concentration have been shown to have an important role to play in biofilm management; matrix metalloproteinase modulation; reducing inflammation; and enhancing cellular proliferation, behaviour, and viability. Consequently, this review aims to discuss the role, mode of action, and clinical significance of the use of medically accepted surfactants, with a focus on concentrated poloxamer‐based surfactants, to wound healing but, more specifically, the role they may play in biofilm management and effects on cellular repair.

In stalled, chronic wounds, more aggressive and proactive wound closure efforts are needed. We describe adjunctive use of epidermal grafting in patients with chronic wounds. Wound bed preparation consisted of surgical necrotectomy or sharp debridement, hyperbaric oxygen therapy, negative pressure wound therapy, compression therapy, platelet-rich plasma therapy and/or heparan sulphate agents. Epidermal grafts were harvested from the patient's thigh and applied to the wound. Wound and donor site healing was monitored. A total of 78 patients (average age = 64·1 ± 15·6 years) were included in the study. Common comorbidities included hypertension (47·4%), venous insufficiency (37·2%) and obesity (28·2%). Average wound duration was 13·2 months (range: 0·3-180 months). The most common wound types were dehiscence (29·5%), radiation ulcer (24·4%) and venous ulcer (17·9%). Total time from epidermal grafting to wound closure was 10·0 ± 7·3 weeks. Of the 78 wounds, 66 (84·6%) reached full wound closure (49 3 months, 1 without time data). Of 78 wounds, 10 (12·8%) underwent partial wound healing, while 2 wounds (2/78; 2·6%) remained unhealed. These results suggest that wound surface reduction can be achieved by proactive early application of biological therapies and epidermal skin grafts, which may help decrease time to wound healing.

While the overwhelming majority of wounds heal rapidly, a significant proportion fail to progress through the wound-healing process. These resultant chronic wounds cause considerable morbidity and are costly to treat. Wound bed preparation, summarised by the TIME (Tissue, Inflammation/infection, Moisture imbalance, Epithelial edge advancement) concept, is a systematic approach for assessing chronic wounds. Each of these components needs to be addressed and optimised to improve the chances of successful wound closure. We present an up-to-date literature review of the most important recent aspects of wound bed preparation. While there are many novel therapies that are available to the treating clinician, often, there are limited data on which to assess their clinical value, and a lack of appreciation for adequate wound bed preparation needed before expensive therapy is used to heal a wound.

Burn and blast injuries are frequently complicated by invasive infections, which lead to poor wound healing, delay in treatment, disability, or death. Traditional approach centers on early debridement, fluid resuscitation, and adjunct intravenous antibiotics. These modalities often prove inadequate in burns, where compromised local vasculature limits the tissue penetration of systemic antibiotics. Here, we demonstrate the treatment of infected burns with topical delivery of ultrahigh concentrations of antibiotics. Standardized burns were inoculated with Staphylococcus aureus or Pseudomonas aeruginosa. After debridement, burns were treated with either gentamicin (2 mg/mL) or minocycline (1 mg/mL) at concentrations greater than 1,000 times the minimum inhibitory concentration. Amount of bacteria was quantified in tissue biopsies and wound fluid following treatment. After six days of gentamicin or minocycline treatment, S. aureus counts decreased from 4.2 to 0.31 and 0.72 log CFU/g in tissue, respectively. Similarly, P. aeruginosa counts decreased from 2.5 to 0.0 and 1.5 log CFU/g in tissue, respectively. Counts of both S. aureus and P. aeruginosa remained at a baseline of 0.0 log CFU/mL in wound fluid for both treatment groups. The findings here demonstrate that super-therapeutic concentrations of antibiotics delivered topically can rapidly reduce bacterial counts in infected full-thickness porcine burns. This treatment approach may aid wound bed preparation and accelerate time to grafting.

The outcome of management of diabetic foot ulcers remains a challenge, and there remains continuing uncertainty concerning optimal approaches to management. It is for these reasons that in 2008 and 2012, the International Working Group of the Diabetic Foot (IWGDF) working group on wound healing published systematic reviews of the evidence to inform protocols for routine care and to highlight areas, which should be considered for further study. The same working group has now updated this review by considering papers on the interventions to improve the healing of chronic ulcers published between June 2010 and June 2014. Methodological quality of selected studies was independently assessed by two reviewers using Scottish Intercollegiate Guidelines Network criteria. Selected studies fell into the following ten categories: sharp debridement and wound bed preparation with larvae or hydrotherapy; wound bed preparation using antiseptics, applications and dressing products; resection of the chronic wound; oxygen and other gases, compression or negative pressure therapy; products designed to correct aspects of wound biochemistry and cell biology associated with impaired wound healing; application of cells, including platelets and stem cells; bioengineered skin and skin grafts; electrical, electromagnetic, lasers, shockwaves and ultrasound and other systemic therapies, which did not fit in the aforementioned categories. Heterogeneity of studies prevented pooled analysis of results. Of the 2161 papers identified, 30 were selected for grading following full text review. The present report is an update of the earlier IWGDF systematic reviews, and the conclusion is similar: that with the possible exception of negative pressure wound therapy in post-operative wounds, there is little published evidence to justify the use of newer therapies. Analysis of the evidence continues to present difficulties in this field as controlled studies remain few and the majority continue to be of poor methodological quality.

Wound bed preparation (WBP) is an integral part of the care programme for chronic wounds. The acronym TIME is used in the context of WBP and describes four barriers to healing in chronic wounds; namely, dead Tissue, Infection and inflammation, Moisture imbalance and a non-migrating Edge. Larval debridement therapy (LDT) stems from observations that larvae of the blowfly Lucilia sericata clean wounds of debris. Subsequent clinical studies have proven debriding efficacy, which is likely to occur as a result of enzymatically active alimentary products released by the insect. The antimicrobial, anti-inflammatory and wound healing activities of LDT have also been investigated, predominantly in a pre-clinical context. This review summarises the findings of investigations into the molecular mechanisms of LDT and places these in context with the clinical concept of WBP and TIME. It is clear from these findings that biotherapy with L. sericata conforms with TIME, through the enzymatic removal of dead tissue and its associated biofilm, coupled with the secretion of defined antimicrobial peptides. This biotherapeutic impact on the wound serves to reduce inflammation, with an associated capacity for an indirect effect on moisture imbalance. Furthermore, larval serine proteinases have the capacity to alter fibroblast behaviour in a manner conducive to the formation of granulation tissue.

Wound bed preparation is the management of a wound in order to accelerate endogenous healing or to facilitate the effectiveness of split-skin grafting. The formation of a healthy wound bed is a prerequisite to the use of advanced wound care products. Unless this is achieved, even the most sophisticated and expensive materials are unlikely to function correctly. An attempt has been made to use 3% citric acid ointment for wound bed preparation to prepare wound for grafting in five cases of wounds with large raw areas infected with multiple antibiotic-resistant bacteria.

Background Stringent control of proteolytic activity represents a major therapeutic approach for wound-bed preparation. Objectives We tested whether a protease-modulating polyacrylate- (PA-) containing hydrogel resulted in a more efficient wound-bed preparation of venous leg ulcers when compared to an amorphous hydrogel without known protease-modulating properties. Methods Patients were randomized to the polyacrylate-based hydrogel (n = 34) or to an amorphous hydrogel (n = 41). Wound beds were evaluated by three blinded experts using photographs taken on days 0, 7 and 14. Results After 14 days of treatment there was an absolute decrease in fibrin and necrotic tissue of 37.6 ± 29.9 percentage points in the PA-based hydrogel group and by 16.8 ± 23.0 percentage points in the amorphous hydrogel group. The absolute increase in the proportion of ulcer area covered by granulation tissue was 36.0 ± 27.4 percentage points in the PA-based hydrogel group and 14.5 ± 22.0 percentage points in the control group. The differences between the groups were significant (decrease in fibrin and necrotic tissue P = 0.004 and increase in granulation tissue P = 0.0005, respectively). Conclusion In particular, long-standing wounds profited from the treatment with the PA-based hydrogel. These data suggest that PA-based hydrogel dressings can stimulate normalization of the wound environment, particularly in hard-to-heal ulcers.

Negative pressure wound therapy (NPWT) has emerged as a cutting-edge technology and provides an alternative solution to the problem of wounds. This study was undertaken to assess the efficacy of this technique in the treatment of chronic wounds. A prospective clinical study was used to evaluate our experience in use of NPWT in the healing of pressure ulcers and chronic wounds over 2 years. The primary end point of the study group was the time taken for appearance of healthy granulation tissue and full reepithelialisation without drainage. All patients with sepsis were excluded from the study. The statistical analysis of the data was carried out. Of the 60 patients studied, 41 had associated comorbidities including diabetes mellitus. The commonest site of occurrence was the lower limb. Coverage in the form of a flap was required at presentation in 63·33% of patients. However, after initiation of NPWT, none of them required the procedure and they healed spontaneously either by secondary intention or by skin grafting. The time taken for appearance of healthy granulation tissue was 14·36 ± 4·24 days. Complete healing of wounds occurred by 33·1 ± 10·22 days. There was a statistically significant difference in the volume of the wounds before and after the intervention (P = 0·000). Complications resulting from NPWT were minimal. This technique is an excellent adjunct to surgical debridement.

Summary The number of patients suffering from chronic wound healing disorders in Germany alone is estimated to be 2.5–4 million. Therapy related expenses reach 5–8 billion Euros annually. This number is partially caused by costly dressing changes due to non-standardized approaches and the application of non-evidence-based topical wound therapies. The purpose of this paper is to elucidate a straightforward principle for the management of chronic wounds, and to review the available evidence for the particular therapy options. The T.I.M.E.-principle (Tissue management, Inflammation and infection control, Moisture balance, Epithelial [edge] advancement) was chosen as a systematic strategy for wound bed preparation. Literature was retrieved from the PubMed and Cochrane Library databases and subjected to selective analysis. Topical wound management should be carried out according to a standardized principle and should further be synchronized to the phases of wound healing. Despite the broad implementation of these products in clinical practice, often no benefit exists in the rate of healing, when evaluated in meta-analyses or systematic reviews. This insufficient evidence is additionally limited by varying study designs. In case of non-superiority, the results suggest to prefer relatively inexpensive wound dressings over expensive alternatives. Arbitrary endpoints to prove the effectiveness of wound dressings, contribute to the random use of such therapies. Defining rational endpoints for future studies as well as the deployment of structured therapy strategies will be essential for the economical and evidence-based management of chronic wounds.

Debridement is integral to wound bed preparation by removing devitalised tissue, foreign material, senescent cells, phenotypically abnormal/dysfunctional cells (cellular burden) and bacteria sequestrum (biofilm). While the body of evidence to substantiate the benefits of debridement is growing, little is known about the cost-effectiveness of each debridement method. The purpose of this analysis was to compare cost-effectiveness of various debridement methods and clinical outcomes to help inform clinicians and policy makers of the cost-effectiveness associated with the various types of therapies and the impact they can have on the Canadian health care system. Results indicated that sharp debridement was the most cost-effective followed by enzymatic debridement method.

Debridement is a crucial component of wound management. Traditionally, several types of wound debridement techniques have been used in clinical practice such as autolytic, enzymatic, biodebridement, mechanical, conservative sharp and surgical. Various factors determine the method of choice for debridement for a particular wound such as suitability to the patient, the type of wound, its anatomical location and the extent of debridement required. Recently developed products are beginning to challenge traditional techniques that are currently used in wound bed preparation. The purpose of this review was to critically evaluate the current evidence behind the use of these newer techniques in clinical practice. There is some evidence to suggest that low frequency ultrasound therapy may improve healing rates in patients with venous ulcers and diabetic foot ulcers. Hydrosurgery debridement is quick and precise, but the current evidence is limited and further studies are underway. Debridement using a monofilament polyester fibre pad and plasma-mediated bipolar radiofrequency ablation are both very new techniques. The initial evidence is limited, and further studies are warranted to confirm their role in management of chronic wounds.

Summary Aim: To evaluate the evidence on the impact of different debridement techniques on healing and their efficacy in the treatment of leg ulcers. Methods: Web-based search (PubMed) for trials investigating surgical, enzymatic, autolytic, osmotic, ultrasound-assisted, and biosurgical wound debridement on leg ulcers with regard to healing and efficacy. Results: Both surgical and hydrosurgical methods proved to be effective debridement techniques. For conventional surgical debridement, a significantly greater reduction of the wound surface area and a higher healing rate were reported. Studies on autolytic, osmotic, and enzymatic wound debridement showed effective debridement for krill enzymes, dextranomer and manuka honey. Only for manuka honey was there a significantly greater reduction of the wound surface area compared to standard treatment. One study comparing fibrinolysin/DNAse with placebo and one comparing autolytic with enzymatic debridement showed no significant differences between the respective techniques. Trials on ultrasound-assisted wound debridement reported a positive impact on healing. A significant wound surface area reduction was demonstrated in one of them. Maggot therapy led to effective debridement. The largest trial showed no significantly improved healing. Conclusions: Further studies are needed to strengthen the evidence for a significant impact of wound debridement on the healing of leg ulcers.

Negative pressure (wound) therapy, synonymous with topical negative pressure or vacuum therapy mainly cited as branded VAC® (vacuum-assisted closure) therapy, is a mode of therapy used to encourage wound healing. It is used both as primary treatment of chronic and complex wounds and as an adjunct for temporary closure and wound bed preparation preceding surgical procedures such as skin grafts and flap surgery. The device has come into wide and successful use, although the physiological basis of its effect is not yet fully understood, and with a delay, increasingly evidence-based data become available. A meta-analysis was made of peer-reviewed publications (PubMed-Medline) chosen on the basis of inclusion of the terms randomized clinical trial, vacuum-assisted closure, and topical negative pressure. Scientific data were evaluated from experimental animal studies, randomized clinical trials, observations of clinical applications, and case reports on all known effects of VAC therapy. Systematic analysis of the data shows efficacy concerning induction of wound healing mechanisms, especially in the early stage. Increased perfusion can be considered proven. Data analysis shows positive efficacy for treatment of infection. Although this therapy appears effective and its superiority to conventional techniques has been demonstrated, there are still some critical votes concerning efficacy. Because its mechanisms of action remain unclear, and because there is still some gap between evidence-based data and the excellent clinical results, further prospective, randomized, blinded studies are needed. Even so, we conclude that vacuum therapy, used when indicated and especially by experienced surgeons, is an excellent tool to support wound healing.

The outcome of management of diabetic foot ulcers is poor, and there is continuing uncertainty concerning optimal approaches to management. It was for these reasons that in 2006 the International Working Group of the Diabetic Foot (IWGDF) working group on wound healing undertook a systematic review of the evidence to inform protocols for routine care and to highlight areas which should be considered for further study. The same working group has now updated this review by considering papers on the interventions to improve the healing of chronic ulcers published between December 2006 and June 2010. Methodological quality of selected studies was independently assessed by two reviewers using Scottish Intercollegiate Guidelines Network criteria. Selected studies fell into the following ten categories: sharp debridement and wound bed preparation with larvae and hydrotherapy; wound bed preparation using antiseptics, applications and dressing products; resection of the chronic wound; hyperbaric oxygen therapy (HBOT); compression or negative pressure therapy; products designed to correct aspects of wound biochemistry and cell biology associated with impaired wound healing; application of cells, including platelets and stem cells; bioengineered skin and skin grafts; electrical, electromagnetic, lasers, shockwaves and ultrasound; other systemic therapies which did not fit in the above categories. Heterogeneity of studies prevented pooled analysis of results. Of the 1322 papers identified, 43 were selected for grading following full text review. The present report is an update of the earlier IWGDF systematic review, but the conclusion is similar: that with the exception of HBOT and, possibly, negative pressure wound therapy, there is little published evidence to justify the use of newer therapies. This echoes the conclusion of a recent Cochrane review and the systematic review undertaken by the National Institute for Health and Clinical Excellence Guidelines Committee in the UK. Analysis of evidence presents considerable difficulties in this field particularly as controlled studies are few and the majority are of poor methodological quality.

Venous ulcers are characterised by longstanding and recurrent loss of skin integrity. Once occurred, healing is slow and recurrence is high because of inappropriate conditions of the wound bed. This study involves 20 patients with chronic venous ulcers at least 6 weeks of duration treated with negative pressure wound therapy (NPWT). Patients underwent a radical debridement of all devitalised tissues in the first operation. After adequate haemostasis, silver-impregnated polyurethane foam was applied. Once the wounds were determined to be clean and adequate granulation tissue formation was achieved, split-thickness skin grafts were applied. Black polyurethane foam was applied over them. All wounds completely healed without the need for further debridement or regrafting. The mean number of silver-impregnated foam dressing changes prior to grafting was 2·9 (one to eight changes). The mean number of NPWT foam changes was 2·6 after skin grafting (two to five changes). Two patients who did not use conservative treatments for chronic venous insufficiency (CVI) after discharge from the hospital had recurrence of venous ulcers in the follow-up period. Application of NPWT provides quick wound-bed preparation and complete graft take in venous ulcer treatment.

Patients with massive venous stasis ulcers that have very high bacterial burdens represent some of the most difficult wounds to manage. The vacuum-assisted closure (VAC) device is known to optimise wound bed preparation; however, these patients have too high a bacterial burden for simple VAC application to facilitate this function. We present the application of the VAC with instillation of dilute Dakins solution as a way of bacterial eradication in these patients. Five patients with venous stasis ulcers greater than 200 cm(2) that were colonised with greater than 10(5) bacteria were treated with the VAC instill for 10 days with 12.5% Dakins solution, instilled for 10 minutes every hour. Two patients had multi-drug-resistant pseudomonas, three with MRSA. All the five had negative quantitative cultures, prior to split thickness skin graft with 100% take and complete healing at 1 year. Adequate delivery of bactericidal agents to the infected tissue can be very difficult, especially while promoting tissue growth. By providing a single delivery system for a bactericidal agent for a short period of time followed by a growth stimulating therapy, the VAC instill provides a unique combination that appears to maximise wound bed preparation.

MIST ultrasound, a recently FDA-cleared noncontact ultrasound therapy, was utilized prospectively in an IRB-approved trial for the treatment of recalcitrant wounds of various etiologies. Twenty-nine wounds from 23 patients were studied. Inclusion criteria included wounds greater than 4 weeks duration with no evidence of clinical improvement (>15% area reduction) over the prior 2 weeks before enrollment. The wounds were required to be free from clinical signs of infection. After an initial debridement and wash-out period, patients were treated 3 times a week with MIST for 4 minute treatment applications. Dressing regimens were left up to the investigator as dictated by wound conditions. The primary endpoint is complete healing. Data will be presented looking at MIST-derived healing, as defined by complete healing using MIST therapy all the way to closure. MIST-assisted healing, as defined by MIST therapy for wound bed preparation followed by an alternative means of closure will also be presented. “Overall healing” defined by the combination of the two prior groups will complete the outcomes report, as this reflects a more “real-world” clinical application for the technology. Wound dynamics, Kaplan Meier survival plots and laser Doppler imaging estimations of angiogenesis will all be presented. Acknowledgment: This study was supported with a grant from Celleration Inc., Eden Prairie, MN.

The understanding of bioengineered tissue has evolved over the past 5 years. Now considered “cell therapy,” bioengineered tissue can provide a nonhealing wound with the appropriate complement of cytokines, growth factors, and healthy cells to promote the patient’s healing process. As clinicians have gained experience with Apligraf*, the process of wound bed preparation has proven to be a critical step in order to achieve optimal outcomes with the tissue construct. Recently, the investigators have evaluated a novel device, MIST† ultrasound , recently FDA cleared for the cleansing and debriding of wounds. A subgroup from a total of 23 patients in a research trial using MIST therapy for nonhealing wounds received an Apligraf as part of their treatment regimen. The'bioengineered tissue remained intact for a full 4 weeks postapplication and the appearance of the graft was quite different than our prior experience with the product. On removal of the wound/graft eschar, patients had achieved complete epithelialization. This report describes the patients who underwent this combination of technologies along with wound photographs, measurements and patient histories. As we learn more about the biochemistry of healing we are able to “look” at how we combine and use advanced wound care technologies. Acknowledgments: This study was supported from a grant from Celleration Inc. Product notation: * Apligraf® is a registered trademark of Novartis, Inc., East Hanover, NJ © 2004 Organogenesis, Inc., Canton, MA † MIST™ ultrasound is a registered trademark of Celleration Inc., Eden Prairie, MN.

Chronic wounds have traditionally been treated by conservative means. It was Winter's moist wound healing research, in 1962, that stimulated a proliferation of a moist interactive dressing technologies. Even considering this advancement in thinking, chronic wounds continue to be a problem for many clinicians. An increasing delineation of the science of healing in the past 20 years has redefined the way in which we both evaluate and treat wounds. This scientific understanding has raised wound care from the clinical problem arena to that of clinical specialty, where many now cross refer patients to specialists in this field. Wound bed preparation (WBP) has played a significant role in this change in practice. The concept has changed an 'art' of switching at random from one dressing to another, into a clinical science. WBP has come to the forefront as a major educational aid to help others develop appropriate treatment of the underlying disease causing the wound and patient requirements. The concept of WBP evolved over the recent years, becoming more and more sophisticated with time. Recent adaptations have brought together many of the current components. This article proposes yet another element of WBP, that of 'oxygen balance'.

Wound clinics are seeing an increase in the number of ‘complex’ wounds, which arise as the result of the interaction between multiple coexisting systemic pathologies, environmental factors and local wound factors. These complex wounds require an approach to diagnosis and management that can encapsulate all these factors. Unified wound assessment approaches such as HEIDI (History, Examination, Investigations, Diagnosis and management plan), wound bed preparation and applied wound management systems are essential to reach a definitive diagnosis and to ensure that management is agreed between the various clinical specialities that may be involved. A series of case histories is presented that illustrate the benefits of a unified approach to wound management. Results of a study into the cost‐effectiveness of an improved foam dressing are presented, and the problems of demonstrating the ability to make long‐term savings through short‐term expenditure are discussed.

Zinc is an essential trace element in the human body and its importance in health and disease is appreciated. It serves as a cofactor in numerous transcription factors and enzyme systems including zinc-dependent matrix metalloproteinases that augment autodebridement and keratinocyte migration during wound repair. Zinc confers resistance to epithelial apoptosis through cytoprotection against reactive oxygen species and bacterial toxins possibly through antioxidant activity of the cysteine-rich metallothioneins. Zinc deficiency of hereditary or dietary cause can lead to pathological changes and delayed wound healing. Oral zinc supplementation may be beneficial in treating zinc-deficient leg ulcer patients, but its therapeutic place in surgical patients needs further clarification. Topical administration of zinc appears to be superior to oral therapy due to its action in reducing superinfections and necrotic material via enhanced local defense systems and collagenolytic activity, and the sustained release of zinc ions that stimulates epithelialization of wounds in normozincemic individuals. Zinc oxide in paste bandages (Unna boot) protects and soothes inflamed peri-ulcer skin. Zinc is transported through the skin from these formulations, although the systemic effects seem insignificant. We present here the first comprehensive account of zinc in wound management in relation to current concepts of wound bed preparation and the wound-healing cascade. This review article suggests that topical zinc therapy is underappreciated even though clinical evidence emphasizes its importance in autodebridement, anti-infective action, and promotion of epithelialization.

The availability of different types of wound dressings has increased in the last decade. Wound care practitioners have at their disposal an extensive range of dressings. Emerging dressing types include interactive/bioactive dressings and tissue-engineered skin substitutes. There is no one dressing that is suitable for the management of all types of chronic wounds and few are suited for the treatment of a single wound during all stages of the healing cycle. Successful wound management depends on an understanding of the healing process combined with knowledge of the properties of the various dressings available. Without such knowledge and careful assessment of all the factors that effect healing, dressing selection is likely to be arbitrary and ineffective, wasteful both in terms of time and physical resources. This article is an overview of some of the first-line and second-line interactive/bioactive dressings available. A synopsis of wound assessment and wound bed preparation will aid in choosing the appropriate dressings. It will also touch on advanced technologies including tissue-engineered skin substitutes. J Pharm Pract Res 2006; 36: 318-24.

Current concepts of wound healing acknowledge the essential role of wound bed preparation in achieving a wound with good healing potential. Critical to wound bed preparation is the removal of necrosis, unhealthy tissue, foreign matter, and infection. One of the accepted methods of wound bed preparation is surgery. The high-power parallel waterjet is a new surgical device, which allows the operator to remove very precisely undesirable tissue and debris with maximal preservation of viable tissue. A retrospective study was performed to evaluate the efficacy, safety, and economic impact of using this technique of surgical debridement. Forty patients who had waterjet debridements were compared with 22 patients with matched wounds who had conventional surgical debridement. The waterjet group had significantly fewer procedures (p

Wound management encompasses a number of disciplines. As new concepts and innovative technologies develop within this exciting field, it is important to share them in spite of the divergence of clinical perspectives between the expert disciplines. One such divergence exists between surgeons and nonsurgical wound specialists. As a result, there is a need to develop a common language between these two groups. How can we develop a common language that unites surgical expertise within medical wound management? One route may be through the principles of wound bed preparation, which we believe have great potential for the communication of effective surgical techniques. Another is through sharing our concepts of surgical debridement as it is applied to different wounds by a variety of surgical disciplines. In this monograph, we try to bring these two themes together. We discuss how wound bed preparation has added to our understanding of the pathophysiology of the nonhealing wound and has provided us with some general clinical concepts. We discuss what role debridement, and then specifically surgical debridement, has to play within wound bed preparation, before analyzing the importance of surgical debridement in tissue preservation and the control of infection. We finally look at ongoing work that examines the cost of various surgical debridement techniques. We will also review a new hydrosurgery system (VERSAJET, Smith and Nephew, Hull, UK), which we believe has an important role to play in the surgical preparation of the wound. We also expect that this paper will remind our medical colleagues about the critical role played by surgery in wound management.

Scalp necrosis is rare in patients with giant cell arteritis. Here, we report the case of an 81‐year‐old woman who presented with a management problem that required a truly multidisciplinary approach to treatment. A combined approach of effective wound bed preparation with selective debridement, prolonged antimicrobial therapy, corticosteroid use and careful dressing choices resulted in a successful outcome in a potentially disastrous situation.

Debridement is defined as the removal of non-vital tissue from wounds. In chronic wounds, debridement means the elimination of necrosis as well as the clearing away of wound dressings, foreign bodies, and other non-vital substances. Sufficient debridement represents one basic prerequisite for a non-delayed wound-healing process. In addition to treating the causal factors for delayed wound healing, debridement should be the first step in an adequate phase-adapted wound-bed preparation for chronic wounds. This report aims to review the different options available in the execution of debridement in chronic wounds. The following therapeutic measures are available for the debridement of chronic wounds: surgery, maggot therapy, laser, ultrasound, hydrotherapy, wet-to-dry method, autolysis, proteolytic enzymes, osmotic or chemical debridement. There is no single correct debridement for all patients! Patients are individuals and therefore different methods of debridement may make sense. Which therapeutic option is chosen is determined by multiple factors. Moreover, depending on the wound milieu, the successive application of different methods can be useful.

Topical negative pressure (TNP) therapy has emerged as a high‐technology, microprocessor‐controlled physical wound‐healing modality. Complex effects at the wound–dressing interface following application of a controlled vacuum force have been documented. These include changes on a microscopic, molecular level and on a macroscopic, tissue level: interstitial fluid flow and exudate management, oedema reduction, effects on wound perfusion, protease profiles, growth factor and cytokine expression and cellular activity, all leading to enhanced granulation tissue formation and improved wound‐healing parameters. Primary indications for clinical use have been documented and include traumatic wounds, open abdominal wounds, infected sternotomy wounds, wound bed preparation, complex diabetic wounds and skin‐graft fixation. Whilst this therapy now forms an essential part of the wound healing armamentarium, extensive clinical trials are recommended to confirm efficacy and delineate its optimum use.

Management of chronic wounds has progressed from merely assessing the status of a wound to understanding the underlying molecular and cellular abnormalities that prevent the wound from healing. The concept of wound bed preparation has simultaneously evolved to provide a systematic approach to removing these barriers to natural healing and enhancing the effects of advanced therapies. This brief review of wound bed preparation traces the development of these concepts and explains how to apply systematic wound management using the TIME acronym - tissue (non viable or deficient), infection/inflammation, moisture (imbalance) and edge (non advancing or undermined).

Over the past 30 years as caregivers, clinicians have been exposed to a plethora of new advanced wound dressings. The moist wound care revolution began in the 1970s with the introduction of film and hydrocolloid dressings, and today these are the traditional types of dressings of the advanced dressing categories. Wound-healing science has progressed significantly over the same period, as a result of intense clinical and scientific research around these product introductions. Today, the clinician understands moist wound healing, occlusion, cost effectiveness, wound bed preparation and MMP activity to name but a few of the many concepts in wound care that have flourished as a result of technology and product advancement. This review article presents a condensed history of dressing development over the past 30 years. However, in addition, such advancement is discussed in respect to its adoption in different parts of the world. The largest single markets of the world are generally the United States of America and Europe; as such, the development of both practice and technology generally begins there. Much has been written about these markets in previous review articles. For the purposes of this review, the development of wound care and the maturing of practice is discussed in respect to Canada, Japan and Australia representing smaller geographical areas where the development has been more recent but nonetheless significant.

The addition of hydrosurgery into our surgical armamentarium will aim to revolutionize surgical wound debridement. Hydrosurgery (Versajet1) utilizes a high pressure fine saline jet delivered via a compact hand-piece to debride, irrigate and remove debri simultaneously. The hydrosurgery system is minimally invasive enabling debridement at the bedside, with minimal haemorrhage and analgesic requirements2. Its applications range from debridement of traumatic and non-traumatic wounds (acute and chronic), wound lavage, debridement of variable thickness burns, wound bed preparation prior to skin grafting, and flap recontouring. Complex infected wounds (necrotising fasciitis) may also be debrided with potential maximal preservation of adjacent neurovasculature and viable tissues. We present five cases involving the use of the Versajet for the debridement of three diabetic foot wounds, one venous ulcer, and one traumatic chest wound. All hydro-debridements were performed at the bedside with an average procedure time of 23 minutes (15–40 minutes), an average analgesic requirement of 10 mg morphine (5–15 mg), and with minimal encountered blood losses (including two patients on Coumarin). Only a single ward debridement procedure was required to achieve a healthy wound bed in all five patients. The Versajet enables debridement and wound bed preparation that is efficient, minimally invasive, and cost effective with reductions in hospital stay.

Aim: Recently advocated concept of wound bed preparation (WBP) has systematically concreted the critical components of wound care, including debridement, bacterial balance, and management of exudate. We succeed in experiences by topical pharmaceutical therapy combined with WBP. We aimed to demonstrate availability of the wound management. Methods: Since 1999, 18 exteriorized-bone patients with deep soft tissue defects were treated with this treatment. Our procedure was composed of four steps; 1) Resection or debridement, 2) Wound cleansing (soaking foot and hand in the hot bath with antibacterial carbonated agent), 3) Topical medication: basic fibroblast growth factor (Trafermin; KAKEN, Tokyo) and bucladecine sodium (Actocin ointment; Daiichi Pharmaceu. Co. Ltd, Tokyo), and 4) Dressing. Results: The average time for whole coverage of the exposed-bone area with healthy granulation was 23 ± 13( median;19, range; 7–47) days after surgical treatment (the 1st step). The average time for complete epithelization was 72 ± 42 (55, 26–150) days in the patients who had not undergone skin graft. For minor amputations of diabetic feet the healing time until complete epithelization was 65 ± 46 (44, 26–150) days on an average. Conclusions: We concluded that the integrated approach mobilizing commercial available products for wound healing under optimally prepared environment offers advantage of facilitating the efficacy of exogenous therapeutic measures on condition that endogenous regeneration has been accelerated.