Treatment of nonhealing ulcers with allografts
Introduction
Wounds in the lower extremities represent a medical and surgical dilemma of global proportions. Consider these statistics:
- 1.
Venous ulcers, the most common type of leg ulcers, account for an estimated 70% to 90% of the cases. Recurrence is high, and the estimated cost of treating one episode can exceed $40,000.1
- 2.
Approximately 17 million people in the United States have diabetes, with more than 1 million cases diagnosed in 2000.2 Nonhealing foot ulcers represent a major cause of morbidity, immobility, and lower extremity amputation in the diabetic population.3 Amputation remains 15% more likely in individuals with diabetes.4 The estimated total cost of wound management exceeds $7 billion per year, with expected increases as the population ages.5
- 3.
The National Pressure Ulcer Advisory Panel reports wide ranges of prevalence among patients in the United States. Best estimates suggest that 2.5 million pressure ulcers require treatment annually in the hospital setting, with total annual costs of hospital-acquired pressure ulcers estimated at $2.2 to $3.6 billion.6
Clinicians treat many other chronic wound pathologies, including those related to arterial insufficiency, trauma, vasculitis, infection, pyoderma gangrenosum, and sickle cell disease. Additional etiologies include cryofibrinogenemia, cryglobulinemia, homocystinemia, rheumatoid arthritis, scleroderma, Buerger's disease, and calciphylaxis, among others. Wound care specialists also remain challenged by patients presenting with factitial wounds.
Unfortunately, the past few decades show little improvement in preventing morbidity and disability from chronic wounds, despite often-heroic efforts on the part of wound care professionals.7 Clinicians must seek out novel innovations to stimulate and/or accelerate wound healing.
Practitioners traditionally use skin allografts on burn patients for temporary wound coverage. In addition, allografts mitigate pain and aid in wound-bed preparation before placement of autografts. Research demonstrates many other applications in wound healing supporting the use of allografts as a true biologic dressing. Recently discovered nuisances unique to chronic wounds make allografts a formidable alternative as wound-bed preparation emerges as the standard of care for these lesions. Diagnosis and treatment of underlying wound etiologies remains essential. Intervention through a multidisciplinary approach using accepted algorithms helps reduce the extensive morbidity and expense associated with these lesions.
The following review presents the rationale for incorporating skin allografts into the wound healing algorithm, including discussions about chronic wound biochemistry, current applications, combination therapies, and case studies. The treatment of complicated wounds, including those with exposed tendon and bone, continues to represent an important adjunctive therapy and remains the focus of this text.
Section snippets
Rationale for the clinical use of cadaveric allograft
Allograft or homograft skin is tissue transplanted from a different individual within the same species, whereas autograft refers to skin taken from the same individual and transplanted from one part of the body to another.
The ideal wound dressing possesses several key characteristics, including adherence, water vapor transport, elasticity, creation of bacterial barrier, absence of toxicity and antigenicity, antisepsis, hemostatic activity, ease of application and removal, a long shelf life,
Conclusions
Wounds of all types and varieties are increasing at alarming rates, fostering creative therapies to promote healing. Cadaveric allograft represents the gold standard for adjunctive treatment of burns, yet research and clinical practice reveal that this therapy may be advantageous in other scenarios. Many wounds may benefit from allograft usage, including those created by venous disease, diabetes, pressure, trauma, vasculitis, and calciphylaxis, among others.
Allograft is an ideal dressing
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