The Combined Benefit of Negative Pressure Therapy (N.P.T.), Elemental Silver Contact Layer, and Bilayered Living Skin Equivalent (L.S.E.) in the Treatment of Chronic Hard to Heal Lower Extremity Wounds.

Carl Van Gils, DPM, MS,
LeAn Stark MS, APRN, CFNP, CWOCN,
Brenda Forbes RN BSN CDE,
Dixie Regional Medical Wound Clinic, St. George, UT

Problem: Closure of chronic lower extremity wounds is often more challenging due to existing co-morbidities. Complicating factors such as chronic steroid use, vascular disease, and MRSA colonization deter wound healing and encourage resistance to typically reliable wound healing techniques. These hard to heal wounds Invite further complications Including Infection, pain, disability, and amputation. Often these patients are not candidates for split thickness skin grafting for hesitation to create a new wound. However, bllayered living skin equivalents (loS.E.) may be prone to failure If heavy wound exudate cannot be well controlled.

Purpose: To accelerate the wound healing process in chronic hard to heal wounds and to decrease pain, infection, and wound exudate.

Methodology: We present our first six patients of an on-going trial utilizing the combined benefits of negative pressure therapy (N.P.T.), a silver contact dressing, and bllayered living skin equivalent (L.S.E.). Painful lower extremity wounds of traumatic etiology with co-morbidities including chronic steroid use, poor healing potential and vascular disease were chosen. N.P.T was performed with an elemental sliver coated contact dressing with 400 micron porus foam at 75~100 mm Hg for an average of 14 days. Once a sufficient granulation wound base was achieved, the patient underwent LS.E placement. N.P.T with sof~foam at 125mm Hg continues for an additional 6.7 days over the silver contact dressing and the LS.E.

Results: 6 of 6 patients were successful In achieving goals of wound closure, decreased pain, and decreased infection.

Conclusion: The combination of N.P.T, elemental silver contact dressing, and L.S.E. in colonized hard to heal chronic wounds produces an accelerated wound healing potential. Patient education and compliance in this sophisticated method are key Issues for successful outcome.

*Negative Pressure Therapy; VAC by KCI
  Elemental Silver Contact Layer; Silverlon by Argentum Medical LLC.
  Bi layered Living Skin Equivalent; Apligraf by Novartis

Technique

• Treatment begins with sharp debridement, Silverlon, and compression.
• KCI Wound VAC is added shortly thereafter
  • Silverlon is placed directly to the wound bed with 2-3cm overlap
  • Black Wound VAC sponge is placed over the Silverlon cut to fit the wound. VAC setting us usually 100-125mmHg continuous
• 1-3 weeks later, Apligraf (graftskin) is added
  • Primary dressing of Mepitel and Silverlon
  • Covered by Wound VAC's white sponge at 125mmHg continuous.
• The VAC is discontinued 1-2 weeks after Apligraf application.
• Weekly dressings continue with Silverlon and Compression until wound is healed.

Case 1

54 year old male with 30 year history of steroid dependant COPD and Asthma; he also has peripheral neuropathy, hypertension, CAD with history of MI, and history of slow healing wounds. He has been self-treating a traumatic leg wound for 3-4 weeks.

10/3/01 admit 4.7 x 6.0 x 1.8 cm 10/17/01 Silverlon & Debridement 4.1 x 4.9 x 1.1 cm 11/12/01 Silverlon & Wound Vac 4.0 x 4.7 x 0.7 cm

12/10/01 s/p Silverlon VAC and Apligraf 0.6 x 1.0 cm 12/31/01 Healed at 3 months

Case 2

73 year old woman with chronic steroid dependent asthma, hypertension, bilateral venous stasis disease, and history of phlebitis. Has 3 month old painful leg wound that originated from an insect bite and has failed conventional therapy.

6/11/01 s/p Debridement s/p 12 days of Wound VAC	6/11/01 Application of Apligraf Continue VAC and Silverlon Reduced pain
7/2/01 s/p apligraf & VAC Cont. Silverlon and Dynaflex Reduced pain	8/28/01 Healed at 3 months

Case 3

68 year old woman with chronic steroid dependent rheumatoid arthritis, Sjogren Syndrome, osteoporosis, and iron deficiency anemia presents with a traumatic painful leg ulcer.

11/26/01 Admit 9.9 x 8.5 cm	11/29/01 s/p debridement. Application of Apligraf.
11/29/01 Apligraf, Silverlon, VAC	12/03/01 1st dressing change; reduced pain Excellent apligraf "take" Went on to rapid healing

Case 4

82 year old woman with diabetes, peripheral vascular disease, and neuropathy. Ulcer developed from thermal injury (electric blanket). Failed to respond to conventional treatment.

1/12/02 Necrotic Diabetic Heel Ulcer 5.1 x 7.0 cm	1/12/02 s/p Debridement. Pre-Apligraf, Silverlon, Wound Vac
1/14/02 2 days s/p apligraf Silverlon, Wound Vac Excellent Apligraf "take"	4/10/02 s/p 2nd Apligraf, Silverlon, Wound Vac 2.1 x 2.0 cm

 

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