Ideal Dressing for STSG Donor Site – an Article Review

Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active. 

In the 2009 review (2nd reference below),  Voineskos and colleagues did a literature review of skin graft donor-site dressings.  They noted that although there is no clear evidence that moist dressings are any better overall when compared with dry dressings,  there is evidence that moist dressings tend to be less painful than dry dressings.

Donor sites take an average of 7 to 21 days to heal, depending on their size, location, and the patient's health status. 

This latest study (first article referenced below) compared Aquacel and a modified (perforated) polyurethane dressing modified (MPD).  The study is a prospective randomized double-blind clinical trial which included 50 adult patients. 
The authors state (bold emphasis is mine):

The ideal dressing should protect the wound from desiccation and at the same time permit gas exchange to accelerate reepithelialization. It should be impermeable to exogenous microorganisms, comfortable for the patient and the ward staff and associated with only minimal labor input. Moreover, the dressing should be flexible and pliable to permit conformation to irregular wound surfaces. Resistance to linear and shear stress are required as well as good tensile strength to resist fragmentation and retention of membrane fragments when removed. It should, furthermore, be adaptable to the varying dimensions of donor sites and, in spite of everything; it should also be of low cost. Existing dressing materials meet some of these criteria but fail to fulfill all of them, especially in larger donor sites.

Dornseifer and colleagues had previously (4th reference) noted that the “single disadvantage of polyurethane film dressings is an uncontrolled leakage” which they solved by modifying it by perforating the polyurethane film.  This  permits a controlled leakage into a secondary absorbent dressing.

They chose to compare this MPD to Aquacel ® (ConvaTec, Skillman, NJ, USA), a sodium carboxy-methylcellulose hydrocolloid polymer that is claimed to have a high fluid-absorptive capacity and was also described to be a new preferred donor site dressing. (5th reference)

Half of the skin graft donor sites were dressed with an application of Aquacel(R) and half with MPD.  The dressings were kept unchanged for ten days at which time they were removed and the epithelialization rate of both sites was evaluated. Pain scores were assessed according to a 0 to 5 numeric pain scale every postoperative day, as well as during dressing removal.

In this small study, MPD was found to best Aquacel ®.  More MPD donor sites completely reepithelialized by 10 days than the Aquacel ® sites (86.4% vs 54.5%).

MPD was significantly less painful until and during removal of the dressing (p < 0.001).

Pain at the donor site during the postoperative period was consistently low after wound coverage with both materials, considering that 90% of the values assessed by the six-items pain scale were equal to or less than 1 (minimal intermittent pain) at both sites.
However, when patients were asked to compare both sites, a significantly higher percentage of MPD sites were rated superior to the Aquacel® sites

Dornseifer and colleagues note the costs of the Aquacel® dressing turned out to be about four times more expensive, relating to a donor site of 8 x 20 cm2 and depending on the
respective price level.

Scarring was inconspicuous in both groups 60 days following surgery and no significant differences were detected between the MPD and Aquacel® treated donor sites.

REFERENCES

1.  The ideal split-thickness skin graft donor site dressing: a clinical comparative trial of a modified polyurethane dressing and Aquacel(R); Dornseifer, Ulf; Lonic, Daniel; Ivo Gerstung, Tristan; Herter, Frank; Max Fichter, Andreas; Holm, Charlotte; Schuster, Tibor; Ninkovic, Milomir; Plastic & Reconstructive Surgery., POST ACCEPTANCE, 15 June 2011; doi: 10.1097/PRS.0b013e3182268c02

2.  Systematic Review of Skin Graft Donor-Site Dressings; Voineskos, Sophocles H.; Ayeni, Olubimpe A.; McKnight, Leslie; Thoma, Achilleas; Plastic & Reconstructive Surgery. 124(1):298-306, July 2009; doi: 10.1097/PRS.0b013e3181a8072f

3.  The theoretically ideal donor site; Birdsell, D. C., Hein, K. S., Lindsay, R. L.; dressing. Ann Plast Surg 2: 535-537, 1979.

4.   The ideal split-thickness skin graft donor site dressing: rediscovery of polyurethane film;  Dornseifer, U., Fichter, A. M., Herter, F., et al.; Ann Plast Surg 63: 198-200, 2009.

5.  Clinical comparative study of aquacel and paraffin gauze dressing for split-skin donor site treatment; Barnea, Y., Amir, A., Leshem, D., et al.;   Ann Plast Surg 53: 132-136, 2004.

Does Negative Pressure Promote Wound Healing? -- article review

Updated 3/2017-- all links (except to my own posts) removed as many no longer active. 

There was a recent EurekAlert which caught my attention:  No healing in a vacuum. 

Negative-pressure wound therapy probably does not promote healing. This is the conclusion of Frank Peinemann and Stefan Sauerland's meta-analysis in the current edition of Deutsches Ärzteblatt International (Dtsch Arztebl Int 2011; 108[22]: 381-9).

The press release actually contained a link to a pdf file of the article (full reference and link below).

Negative-pressure wound therapy (NPWT), also known as vacuum assisted closure,  involves covering the wound with an an airtight film and an adjustable negative pressure is applied using an electronically controlled pump.  The vacuum or negative pressure drains wound exudate.   NPWT is used for chronic persistent wounds and complicated wounds.

The article by Peinemann and Sauerland is a systematic review of the literature (English and German), aimed at  evaluating wound healing and adverse events following NPWT in comparison to conventional treatment in patients with acute or chronic wounds.  From the beginning summary:

We found reports of 9 RCTs in addition to the 12 covered by earlier IQWiG reviews of this topic. Five of the 9 new trials involved NPWT systems that are not on the market. The frequency of complete wound closure is stated in only 5 of the 9 new reports; a statistically significant effect in favor of NPWT was found in only two trials.The results of 8 of the 9 new trials are hard to interpret, both because of apparent bias and because diverse types of wounds were treated.

Data analysis used complete wound closure as the primary endpoint.  This was based on the U.S. Food and Drug Administration’s (FDA) 2006 Guidance for Industry definition for complete wound closure as “skin closure without drainage or dressing requirements.”

The following dependent variables were used as secondary endpoints:
● Adverse events, such as death, secondary amputations, fistula formation, and wound infection
● Time to complete wound closure
● Reduction in wound size
● Health-related quality of life.

In the discussion section of the article, some key summaries:

Regarding the primary endpoint of “wound closure” – results were not homogenous.  The authors notes it is currently impossible to be sure that NPWT performs better than control treatments.

Regarding the secondary endpoints

– Most articles reported “time to wound closure”  occurred quicker in NPWT groups.  The authors note “However, there were considerable differences between trials in terms of the methods used to measure and evaluate wound closure; particularly problematic is the fact that no blinding was used when this endpoint was measured.”  So for now, as with the  primary endpoint, it remains undecided.

--  The results on adverse events were not homogenous and varied depending on the specific complications.   For a number of other adverse events no statistically significant difference was detected.

The authors note that most trials of NPWT were conducted in hospitals.  They make this point in regard to the FDA report (3rd reference below):

The FDA recently issued a report on six deaths and 77 other complications that were reported within a two year period in connection with NPWT . All the deaths were caused by acute hemorrhages, and known contraindications for NPWT (e.g. a large blood vessel
exposed) had clearly been overlooked. Many of the deaths occurred in outpatient care or care homes, which highlights the need to monitor therapy.

The authors conclusion:

Although NPWT may have a positive effect on wound
healing, there is no proof that it is either superior or inferior to conventional wound treatment. Further RCTs of good methodological quality are required.

REFERENCES

Peinemann F, Sauerland S: Negative pressure wound therapy—systematic review of randomized controlled trials; Dtsch Arztebl Int 2011; 108(22): 381–9; DOI: 10.3238/arztebl.2011.0381

An introduction to the use of vacuum assisted closure by Steve Thomas, PhD--World Wide Wounds (Last updated: May 2001)

FDA: Serious complications associated with negative pressure; 2009 (last updated 02/24/2011)

Caring for Horse and Donkey Bite Wounds

 Updated 3/2017--  all links (except to my own posts) removed as many no longer active.

Earlier this week this tweet from @prsjournal caught my eye

Most Popular: Management of Horse and Donkey Bite Wounds: A Series of 24 Cases: No abstract available http://bit.ly/lgNkCS

I missed this article when it came out in the June 2010 issue of the Plastic and Reconstructive Surgery Journal.  As I have covered fire ant bites, cat bites, and snake bites.  Fellow blogger Bongi has written about hippo bites.  It’s time to cover horse and donkey bites. 

Dr. Köse, Department of Plastic and Reconstructive Surgery, Harran University Hospital, Turkey and colleagues presented a retrospective evaluation of 24 patients treated for animal bites (19 horse and five donkey bites) from 2003 to 2009.  The head and neck were the most frequent bite sites (14 cases), followed by the extremities (8 cases) and the trunk (2 cases).

The article is very short, representing their personal viewpoint and experience. 

Our experience shows the safety of primary closure for horse and donkey bite wounds, provided that careful debridement and good cleansing with antibiotic prophylaxis are also performed. An acceptable aesthetic outcome can be achieved only with early primary repair and reconstructive procedures.

Dr. Köse note that horse and donkey bites often result in tissue loss wounds.  Their review of the literature (not sure how extensive) found one reported case of anaphylaxis after a horse bite and one case of a deep crush injury with hematoma, fat necrosis, and muscle rupture without an external wound in a woman bitten on her thigh by a horse.

As I shared in my post Assessing and Managing Mammal Bites – an Article Review

• Thoroughly examine patients with bites.  Especially with children, check the entire body to identify additional injuries.
  
• Examine the wound itself meticulously. It’s easy to miss things.
• Be alert for injuries to the vasculature, nerves, tendons, bones, and joints.
• Bites from large mammals can damage and even fracture bone.  Plain radiographs should be viewed after the exam.
• Large mammals who bite and shake can dislocate joints. Have patients perform active range-of-motion with joints that are near bite wounds.
• Use plain radiography to assess for retained foreign bodies and skeletal injuries. Computed tomography and magnetic resonance imaging have increased sensitivity for foreign bodies and subtle fractures.

As with all wounds, standard wound care applies.  This means copiously irrigate and debride as needed.  Bites are tetanus-prone wounds. Review the patient’s immunization records.  Give updates, etc as needed.

REFERENCE

Management of Horse and Donkey Bite Wounds: A Series of 24 Cases; Köse, Rüstü; Sögüt, Özgür; Mordeniz, Cengiz; Plastic & Reconstructive Surgery. 125(6):251e-252e, June 2010; doi: 10.1097/PRS.0b013e3181d515dd

Topical Treatment of Hypertensive Leg Ulcers – an Article Review

Updated 3/2017-- all links (except to my own posts) removed as many no longer active. 

An interesting little article in the April issue of the Archives of Dermatology (full reference below) by Senet and colleagues on the treatment of hypertensive leg ulcers with platelet-derived growth factor-BB.  Interesting, in that, it reported a negative outcome or lack of superiority for one treatment over another.

First, what is a hypertensive leg ulcer (HLR)?

According to the Graves and colleagues (second article referenced below), Martorell, a Spanish cardiologist (1906-1984) first noticed the relationship between hypertension and alterations in arterioles and leg ulcers in 1945.  Martorell called these ulcers hypertonic or hypertensive ulcers of the legs and published the first 4 cases. 

Originally, Martorell described the following diagnostic criteria:

a) Ulcer located anterolaterally on the lower legs,

b) arterial diastolic hypertension of the lower legs,

c) hyperpulsatility of the arteries of the lower legs,

d) absence of arterial calcification,

e) absence of CVI (chronic venous insufficiency),

f) symmetric lesions (either ulceration at the same time or as a result of previous ulceration of the opposite leg),

g) increased pain in horizontal position, and

h) female sex.

Graves also noted that soon after Martorell reported his 4 cases, 11 other cases were published by Hines and Farber confirming the existence of these ulcers -- thus, the ulcer is also called the "hypertensive ulcer of Hines-Farber."

Senet and colleagues note, “Hypertensive leg ulcers (HLUs), first described in the 1940s, were renamed Martorell HLUs or necrotic angiodermatitis by American and European dermatologists.”

So HLU’s are also known as “hypertensive ulcer of Hines-Farber” and as necrotic angiodermatititis.

……

Whatever it is called, HLR’s are extremely painful, superficial, rapidly spreading, necrotic wounds on the dorsolateral part of the leg which have red purpuric margins.  The pathophysiologic characteristics of HLUs include dermal and subdermal vessel arteriosclerosis, inappropriate local vasoconstriction, but no significant involvement of the large deeper vessels.

Senet and colleagues note the medical management of HLU is currently symptomatic: controlling hypertension and diabetes, wound debridement, and application of the usual dressings.  Surgical management is often skin grafts.

Senet and colleagues conduced a multicenter, randomized controlled trial from March 2004 to June 2009 to determine the effect of topical becaplermin gel on HLU healing.

Eligible participants (n=59) were randomly assigned to receive either topical becaplermin gel-BB, 0.01% (Regranex gel) or hydrogel (Duoderm Hydrogel).

For both groups, treatment began 1 week after randomization, during the second visit (week 0), and all patients received the same daily local care: wound irrigation with normal saline, application of a continuous thin layer of gel on the wound, covering with a moist saline gauze and a bandage.

Each reference wound surface was estimated on treatment day 1 by measuring wound length and width to determine the appropriate becaplermin gel or hydrogel volume to apply that was maintained throughout the study [a single 15-g tube is enough to treat a 5-cm² wound for 6 weeks (1 cm of gel/cm²/d)].

The patient or his/her caregiver was instructed on proper wound care, gel application, and wound dressing, which was continued until complete healing or for a maximum of 8 weeks.   All patients were observed through week 12.

Topical becaplermin, compared with hydrogel dressing, did not improve the complete wound closure rate (primary outcome measure) after treatment week 8 and had no significant effect on quality of life, pain, or median wound area.

Complete wound closure rates for becaplermin and hydrogel, respectively, were 18% (5 of 28 patients) and 10% (3 of 31 patients), respectively, at week 8 (an 8 percentage-point difference; 95% confidence interval [CI], –10.3 to 26.0) and 36% (10 of 28 patients) and 26% (8 of 31 patients) at week 12 (10 percentage-point difference; 95% CI, –13.6 to 33.4).

REFERENCES

1.  Topical Treatment of Hypertensive Leg Ulcers With Platelet-Derived Growth Factor-BB: A Randomized Controlled Trial; Patricia Senet; Eric Vicaut; Nathalie Beneton; Clelia Debure; Catherine Lok; Olivier Chosidow; Arch Dermatol. 2011;0(2011):archdermatol.2011.84. 

2.  Martorell Hypertensive Leg Ulcer:  Case Report and Concise Review of the Literature; Graves JW, Morris JC, Sheps SG. J Human Hypertension. 2001;15:279-283. (pdf file)

3.  Las ulcers supramalleolares por arteriolitis de las grandes hipertensas; Martorell F.;  Actas del Instituto Policlinico de Barcelona. 1945;1:6-9. (not read by me)

4.  Ulcer of the leg due to arteriosclerosis and ischemia occurring in the presence of hypertensive disease; Hines EA Jr, Farber EM.; Mayo Clin Proc. 1946;21:337-346.  (not read by me)

Reimbursement for Surgical Dressings

Updated 3/2017-- all links removed as many are no longer active and it was easier than checking each one.

I opted out of Medicare many years ago, so I could skip articles like the one referenced below.  I don’t.  

Kathleen Schaum writes a very informative article on the ins & outs of reimbursement for surgical dressings.  She gives a self-test to help you and your team assess your knowledge:

….If you pass the LCD/Article self-test, congratulate yourself for a job well done. If you do not pass the self-test, you should immediately take steps to become compliant. Let's start the self-test now.

* Do you know how to find the LCD for Surgical Dressings and the Surgical Dressing Policy Article that is pertinent to the geography that you serve?

If yes, have you printed both documents, read them, and shared them with your entire wound care team? If no, the Web sites in Table 1 will connect you with each of the DME MACs' LCDs and Articles. Remember that your wound care patients are counting on you to understand and implement a process that will meet all the LCD/Article guidelines.

* Can you correctly answer these frequently asked questions?

Unfortunately, the LCD for Surgical Dressings and its attached Article have been either forgotten by or not introduced to some modern-day wound care professionals. ……...

Q: Why do medical suppliers tell my patients with skin tears that Medicare does not cover the dressings that I order?

A. Wound dressings are covered by Medicare when they are used on a surgical wound, partial-, or full-thickness skin wound, or partial- or full-thickness burn. Dressings are not covered for skin tears, abrasions, Stage I ulcers, first-degree burns, or cutaneous fistulas unrelated to a surgical procedure.

…….

The helpful web sites given in Table 1 of the article:
CIGNA Government Services (CIGNA) – http://www.cignagovernmentservices.com
National Government Services (NGS) – http://www.ngsservices.com
National Heritage Insurance company (NHIC) – http://www.medicarehic.com
Noridian Administrative Services (Noridian) – https://www.noridianmedicare.com




REFERENCES
Can You Pass the Surgical Dressing Ordering and Documentation Test?; Schaum, Kathleen D.; Advances in Skin & Wound Care. 24(3):112-117, March 2011; doi: 10.1097/01.ASW.0000395044.66516.02