WundForum. Summaries of selected articles published in the journal HARTMANN WundForum. A publication of the HARTMANN GROUP Issue 3/2008 Volume 15

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1 WundForum A publication of the HARTMANN GROUP Issue 3/2008 Volume 15 Inhibition of metalloproteinase activity in chronic wounds using TenderWet with polyacrylate Use of TenderWet in chronic problem wounds The role of local ozone therapy in the healing of leg ulcers Practical aspects of local wound therapy: the wound dressing (II) Summaries of selected articles published in the journal HARTMANN WundForum

2 Smola, Hans Inhibition of matrix metalloproteinase activity in chronic wounds using TenderWet with polyacrylate (Inhibition von Matrix-Metalloproteasen-Aktivität in chronischen Wunden durch TenderWet mit Polyacrylat-Superabsorber) HARTMANN WundForum, 3/2008, vol. 15, WundForum Das Magazin für Wundheilung und Wundbehandlung Heft 3/ Jahrgang Forschung Inhibition von MMPs in chronischen Wunden durch TenderWet Kasuistik TenderWet active in der Anwendung bei Problemwunden Titelthema Wundheilungskomplikationen nach Endoprothetik Praxiswissen Rolle der lokalen Ozontherapie in der Abheilung von Beinulzera This report summarises the results of research groups of the University of Cologne, Germany, on the role of metalloproteinases in persistent inflammation and the ability of TenderWet to bind metalloproteinases to its superabsorbent polyacrylate particles. The processes that characterise physiologic wound healing have been thoroughly studied and described at the cellular and molecular levels; further improvements with therapy are not considered possible. In contrast, in pathologically altered wound situations, several different factors disrupt the local wound healing process and impair the normally occurring wound healing phases. These are predominantly uncontrolled inflammatory reactions that impair formation of granulation tissue and epithelial wound closure. The inflammatory phase is characterised by the presence of granulocytes and macrophages in the wound area, which both inactivate bacteria and xenobiotics and release cytokines and proteinases. Proteinases can be divided into various groups, of which matrix metalloproteinases are a large subgroup. To digest enzymes, matrix metalloproteinases must be activated in a process which has not previously been fully understood. Matrix metalloproteinases degrade dead and damaged constituents of the extracellular matrix. This process represents the first cleansing of the wound, which lasts approximately three days. In chronic wound healing with persistent tissue damage, granulocytes and macrophages continually migrate to the wound area. This causes an excess of inflammatory cytokine release, which in turn increases the production of matrix metalloproteinases. The balance between tissue remodelling and tissue destruction is thereby shifted in favour of destruction and healing fails to occur. The optimal stages of wound healing can only resume when the inflammatory loop of excessive matrix metalloproteinase activity is broken. This study presents evidence that altering the local, unphysiologic wound environment is possible using TenderWet. TenderWet especially blocks matrix metalloproteinase activity as matrix metalloproteinases adheres to TenderWet s superabsorbent polyacrylate core. Thus, each wound dressing change removes a large amount of excessive proteinase activity and wound physiology can return to normal. Clinically, this can be seen through the rapid formation and promotion of granulation tissue. ISSN B F

3 Meuleneire, Frans Use of TenderWet active in chronic problem wounds (TenderWet active in der Anwendung bei chronischen Problemwunden) HARTMANN WundForum 3/2008, vol. 15, In this article, the author presents three case reports from the hospital setting involving the treatment of chronic wounds predominantly with TenderWet active: venous leg ulcer, pressure ulcer on the back, and decubitus ulcer on the buttocks. Venous leg ulcer A therapeutic concept implemented in this indication was the application of TenderWet together with a compression bandage. This procedure was effective in overcoming the stagnation in wound healing and bringing the ulcer to healing in approximately 3 months. 1a 1b Pressure ulcer on the back A black necrosis had grown from a dark blue spot. The necrosis was softened for 3 weeks with a hydrogel dressing until it slowly came off. Further removal of the necrosis was performed with a scalpel and by cleansing with TenderWet active cavity. The pressure ulcer was tamponaded with TenderWet active cavity. The foam dressing PermaFoam comfort was applied as a secondary dressing; this effectively absorbed excess exudate and provided the patient with a good degree of comfort. 1c 1d 1e 1f Decubitus ulcer on the buttocks At the start of treatment, the necrosis was softened with a hydrogel for easier removal and the wound margins were covered with a hydrocolloid dressing. Once the necrosis was clearly detached and reduced in size, TenderWet active was used for further wound cleansing. Wound dressings were changed once daily. For these skin wounds which had spread to the bone, wound cleansing with TenderWet active required 3 weeks. Since the cause of a decubitus ulcer is a continuous, local pressure on a limited skin area, complete and continuous relief of pressure was provided as causal treatment. Local treatment with TenderWet active was continued with success even in the granulation phase, and a clear reduction in size of the wound cavity was observed after only one month. Case 1: Venous leg ulcer Figure 1a. Condition of the venous ulcer at the start of treatment with TenderWet. Figures 1b-e. Further progress of treatment with TenderWet and continuous compression therapy. TenderWet proved to be a suitable wound dressing even under a compression bandage. Figure 1f. Condition of the ulcer at approximately 3 months; the ulcer was fully healed 14 days later.

4 Dalicho, Stephan, J. Tautenhahn, O. Jannasch et al. The role of local ozone therapy in the healing of leg ulcers (Rolle der lokalen Ozontherapie in der Abheilung von Beinulzera) HARTMANN WundForum 3/2008, vol. 15, In a pilot study, the biological and clinical therapeutic effect of local ozone therapy was examined in ten patients. Use of the technique was limited to treatment of peripheral leg ulcers of various causes. Ozone treatment was carried out after removing the systemic and local factors which impaired wound healing. This was achieved through a combination of wound debridement, rheologic infusion therapy and, in some cases, extensive vascular reconstructive surgery. Modern wound dressings were also applied. Ozone therapy was performed for an average of 43.5 days, on both an ambulatory and an inpatient basis. Therapy was performed 2 to 4 times per week for 10 minutes each. Wound dressings were applied according to the stage of healing absorbent foam dressings (e.g. PermaFoam) and later hydrocolloid (e.g. Hydrocoll) or hydrogel (e.g. Hydrosorb) wound dressings. Ozone treatment was stopped upon closure of the wound. In five of the ten treated patients, wound treatment could be completed within the observation time (average 41 days, range 24 to 72 days). In four patients, the treatment interval was less than 8 weeks. The remaining five cases, all with long wound histories, showed clear tendency to reduction in size of the wound. Therapeuic uses of ozone Type of application Systemic (autologous transfusions) Rectal ozone insufflation Local ozone-oxygen gas treatment Subcutaneous/ intracutaneous/ intramuscular injection Intra-articular injection Medical use Peripheral arterial occlusion Impaired cerebral blood flow Visual or auditory (tinnitus) disturbances due to impaired blood flow Viral infections Acne Allergies Chemotherapy adjuvant Immunostimulant Ulcerative colitis Proctitis stage I and II Anal fistula Anal fissures (Systemic use) Chronic or superinfected wounds Skin lesions Burns Eye injury Oral disinfection Herpes zoster Analgesia Neural therapy Rheumatic diseases Arthrosis Joint injury Chronic joint diseases Table 1 As well as stimulating the immune system, ozone is effective against several factors of a disrupted microcirculation. Therefore, patients with chronic peripheral ulcers of various causes could profit from local treatment with ozone. The wounds were all clearly reduced in size or even brought to healing, including ulcers exacerbated by arterial haemorrhage and problem wounds which had undergone a long pretreatment.

5 Lang, Friedhelm Practical aspects of local wound therapy: the wound dressing (II) (Praktische Aspekte der lokalen Wundtherapie: der Wundverband (II)) HARTMANN WundForum, 3/2008, vol. 15, The first part of this series of articles, Practical aspects of local wound therapy (see HARTMANN WundForum 2/2008) described the general principles and the preparation of wound dressings and bandage changes. The second part describes three important procedures in local wound therapy: inspection of the wound, debridement or cleansing of the wound, and control of infection. If these measures are not adequately carried out, further delays in healing can be expected. Inspection of the wound A colour scheme developed by W. Westehof et al. can be helpful in assessing wounds. The colour scheme uses black/yellow for the cleansing stage or for persistent tissue damage (black for necrosis, yellow for the purulent, fibrinous, greasy coating), red for the granulation phase, and pink for the epithelialisation phase. Debridement / cleansing To bring a chronic wound to healing, the initial causes should first be considered and then the wound should be freed as fast as possible from necrosis and coatings which disturb wound healing. This should be performed using appropriate cleansing techniques, such as surgical, physical and enzymatic debridement. As each method reaches the goal of debridement in a very different fashion, it is necessary to determine selection criteria and consider the suitability of the method to the indication. Colour scheme for the assessment of the wound condition (Westerhof et al.) Figure 1. Cleansing stage: black-yellow Support of the body s own external cleansing is urgently required e.g. surgical removal of necrosis, softening of the coating with moist wound dressings, etc. Granulation phase: bright red Formation of granulation tissue proceeds well maintain a moist wound environment with wound dressing, protect the wound from drying out and from secondary infection. orange Formation of granulation tissue stagnates Review treatment, possible disturbing factors such as impaired blood flow, pressure, malnutrition, etc. Epithelialisation phase: pink Spontaneous epithelialisation occurs at the wound margins promote with moist wound treatment.

6 Debridement Overview of procedures Table 2. Surgical Characteristics Advantages Problems Removal of necrosis and fibrin coating using scalpel, scissors, sharp spoon or laser under operative conditions, inpatient or ambulatory selective, little damage to healthy tissue efficient and fastest suppression of infection most thorough initial cleansing, reducing the duration of wound healing requirement for anaesthesia with inadequate hospital care, potentially painful for the patient, danger of bleeding Physical Softening and removal of necrosis and fibrin coatings through moist wound treatment using hydroactive wound dressings selective, as only damaged tissue is softened and removed moist wound environment is gentle to cells safe and free of side effects simple to perform, even in outpatient setting causes little or no pains time-intensive, which in certain wound conditions can result in risks (spread of infection, especially in arterial and diabetic ulceration) Enzymatic Removal of fibrin coatings and thinner necrotic layers (less compact necroses) by various enzyme preparations with the correct choice of preparation according to the wound condition, efficient removal of the coatings not as fast and selective as surgical debridement, therefore carries possible risks similar to those of physical debridement. undesired effects are possible when not used for appropriate indications Infection control The most important obstacle to wound healing is infection. Various pathologic agents induce specific tissue reactions which affect the clinical picture of the infection. The most reliable diagnostic tool is bacterial spectrum- and resistance testing, which is also required for constructing an antibiogram. Swabs are taken from the deep part of the wound and from the wound edges, as infectious agents concentrate in these sites. Depending on the clinical condition, a count of 105 organisms per gram of tissue is a general indication that an infection requires therapy. PAUL HARTMANN AG Heidenheim Germany Visit us in the internet: