INTRODUCTION: Non-healing wounds can pose a medical challenge as in the case of vasculopathic venostasis resulting in a surgical ulcer. When traditional approaches to wound care fail, an amniotic patch containing mesenchymal stem cells may present a viable solution for therapeutic and efficient wound care.
BACKGROUND: Morselized amniotic AlphaPATCH patches contain concentrated molecules of PGE2, WNT4, and GDF-11, which have angiogenic, trophic, and anti-inflammatory effects on tissues that may be useful in the efficient healing of wounds.
AIM – CASE REPORT: We present a case of a severe non-healing surgical wound with sympathetic effusion in a 78- year-old male who underwent a right total knee arthroplasty procedure.
MATERIALS AND METHODS: In the OR, the joint effusion was drained, and 65cc of bloody synovial fluid was removed from the patient’s right knee. STAT gram stain of the aspirate revealed negative results. The wound was then debrided and irrigated with three liters of double antibiotic solution under pulse lavage. Two dry amniotic AlphaPATCH patches (4cm x 4cm) were placed over the wound with Acticoat applied on top.
RESULTS: At the two-week follow-up visit (following the incision and drainage of the wound dehiscence and application of the amniotic AlphaPATCH patches), a central scab formed in the middle of the wound dehiscence area (figure B). At the four-week follow-up visit, the wound dehiscence area completely scabbed over with no open areas left (figure C). At the eight-week follow-up visit, the scab had just fallen off, and the wound was healing well with immature skin representing the size of a penny (figure D). At the ten-week follow-up visit, the wound was completely healed (figure E).
DISCUSSION/CONCLUSION: Morselized amniotic AlphaPATCH patches containing mesenchymal stem cells can successfully treat non-healing wounds and offer a viable and more effective alternative to current traditional means of wound care management.
Wound healing is a complex process whereby multiple cell types, growth factors, and extra-cellular proteins interact to repair a disruption in the dermal and epidermal layers of the skin. In some cases, the mechanism behind said repair fails to restore the integrity of the injured tissue in a timely manner, delaying the progression of inflammatory, proliferative, and remodeling phases of healing. The resulting chronic, non-healing wound is vulnerable to infection, may cause pain, reduce quality of life, and become a burden on the healthcare system. Non-healing wounds, frequently seen in older patients, are associated with certain conditions such as diabetes, obesity, and rheumatoid arthritis, but may also occur following acute trauma or surgical intervention[4, 5]. It is estimated that 1-2% of patients in developed countries will experience non-healing wounds in their lifetime, and certain types of chronic wounds are estimated to account for billions of dollars of treatment costs in the United States.
An adequate progression of wound healing[1, 7, 8] begins with the secretion of growth factors such as Transforming Growth Factor beta (TGF-β), as well as Fibroblast (FGF), Endothelial (EGF), Platelet Derived (PDGF) and Vascular Endothelial (VEGF) Growth Factors. Neutrophils attracted by PDGF signals clear excess bacteria at the site with the aid of monocytes – later transformed to macrophages. Macrophages regulate the production of TGF-β, which in turn stimulates migration and proliferation of fibroblasts as well as epithelialization. Extracellular matrix and granulation tissue begin forming as fibroblasts secrete fibronectin and collagen precursors concurrently with VEGF-stimulated angiogenesis which carries oxygen and nutrients to the injured site. Finally, the collagen structure in the wound area matures and reassembles into a tighter structure with greater tensile strength. An interruption or delay at any stage of this complex process results in a non-healing wound[2, 13, 14].
The first line of treatment for non-healing wounds is to keep the injured area clean and to debride any infected or necrotic tissue; antibiotics may be prescribed to address bacterial infection. Certain types of chronic wounds can be treated with compression therapy or with negative pressure wound devices, whereby a vacuum drains wound fluid and increases blood flood to the area. In the case of more unmanageable non-healing wounds, a skin graft may be considered[16, 17]: an autologous transplant is less likely to be rejected but is limited by the size of the wound and the extent of available healthy tissue to replace the damaged one. Conversely, an allograft from cadaveric skin may cover a larger area but can trigger an immune reaction against the donor tissue. Tissue bioengineering represents another viable alternative for non-healing wounds[18-20], whereby in vitro-grown cells are placed on an artificial scaffold (often collagen-based) at the wound site to encourage cell migration to the site and tissue repair, eventually restoring functionality to the area. However, this high-cost technique cannot fully replicate the biological and cellular characteristics of true skin, notably with regards to angiogenesis at the wound site, and has not been shown to be significantly more efficient than other treatments. Standard treatment for wound care still fails in an estimated 50% of cases.
Cell therapy has emerged as a non-invasive, viable alternative for treating non-healing wounds, particularly using mesenchymal stem cells (MSCs). MSCs are pluripotent cells capable of differentiation into various cell types, and may be isolated from bone marrow, adipose tissue, umbilical cord, placenta and embryonic tissue. MSCs have a trophic effect that stimulates tissue
repair and angiogenesis, as well as the ability to move towards damaged tissue and to regulate inflammation at the site. The immunomodulatory properties of MSCs (MHC I+, MHC II-, CD40-, CD80-, CD86- and CD44+, Cd73+, CD90+, CD105+) prevent immunosuppression and allow recruitment of more macrophages, thereby stimulating the release of TGF-β, EGF, FGF, PDGF, and VEGF among others[14, 24, 26]. The angiogenic, anti-inflammatory, and trophic effects of MSCs, therefore, hasten the progression of healing and remodeling and yield many applications in clinical settings.
MSCs have been used to treat non-healing wounds[27, 28], notably Bone Marrow-derived MSCs, with reports of full healing at 21 days, complete healing within 8 weeks, no wound recurrence, and other improvements[32, 33], Similarly, adipose-derived MSCs have yielded satisfactory outcomes for non-healing wounds[34, 35]. Amniotic products and umbilical chord tissue rich in MSCs may also be used for wound and burn treatments. These products are more accessible, larger in numbers, and hold more proliferative capacity[37, 38] relative to adult MSCs. Furthermore, since this neonatal tissue is disposed of after birth, it does not present the ethical problems associated with the use of embryonic material. Of particular interest is amnion, the inner-membrane holding the embryo sac[39, 40]. This tissue may be cryo-preserved after birth to retain the qualities of amniotic membrane and the growth factors secreted in the amniotic environment such as prostaglandin and WNT4 (which reduce inflammation and promote healing). Amniotic membrane dressing has been shown to perform significantly better than conventional treatment. One study reports 81% epithelialization in 2 weeks, no infection in 80% of cases, drop in exudation, healthy granulation tissue, and decrease of pain. In another study, wound closure was greater than 40% with a reduction in mean size in the group treated with amniotic membrane compared to the control group treated with compression therapy.
This case report presents a patient with a non-healing wound following a knee replacement surgery. This rare complication of arthroplasty[44, 45] is estimated to occur in 0.33% of cases in the 30 days following an operation, and 5.3% of cases need subsequent surgeries in the following 2 years.
A 78-year-old male with history of prostate cancer, COPD, and smoking a pack of cigarettes daily (for four decades) presented for a follow-up visit in the clinic 17 days status post right total knee arthroplasty. During this visit, dermal staples were removed from the surgical incision. The mid portion of the patient’s incision showed some wound dehiscence, representing the same location in which the patient reported a previous sebaceous cyst “that had to heal from the inside out.” As antibiotic prophylaxis, Cleocin 300 mg was prescribed to be taken four times daily while Talwin was prescribed one tablet every four hours as needed for pain control. The dehisced area was thoroughly cleaned with alcohol and triple antibiotic while the remainder of the wound was Steri-Stripped.
One week later, the patient presented to the clinic for follow-up of the wound dehiscence. Upon physical examination, the wound appeared macerated and white with initial signs of necrosis. The wound was cleaned with alcohol and compressed with Ace bandage. The patient has continued to take Cleocin antibiotic regimen.
Eleven days later, the patient returned to the clinic to recheck the wound. The wound showed slow healing with no significant drainage. To expedite the healing process, three Monocryl sutures were used to close the wound.
One week later (or 1-1/2 months status post total knee arthroplasty), the patient returned to the clinic reporting that the three sutures popped out while he flexed his knee during physical therapy. The non-healing wound displayed a sympathetic effusion consistent with vasculopathic venostasis resulting in a surgical ulcer. The wound, however, was not erythematous, hot, or tender to palpation. The patient was scheduled the following day in the OR for drainage of joint effusion with gram stain, knee wound irrigation with pulse lavage, and application of amniotic dry patch to wound.
The right lower extremity was sterilely prepped and draped in the usual fashion, roughly two months status post total knee arthroplasty. The joint effusion was drained, and 65cc of bloody synovial fluid was removed from the patient’s right knee. STAT gram stain of the aspirate revealed negative results. The wound was then debrided and irrigated with three liters of double antibiotic solution under pulse lavage. Two dry amniotic AlphaPATCH patches (4cm x 4cm) were placed over the wound with Acticoat applied on top. Then 4×4’s, Webril, and Ace wrap were applied to the knee. The patient tolerated the procedure well and was transferred to the recovery room in stable condition.
At the two-week follow-up visit (following the incision and drainage of the wound dehiscence and application of the amniotic AlphaPATCH patches), a central scab has formed in the middle of the wound dehiscence area (figure B). At the four-week follow-up visit, the wound dehiscence area has completely scabbed over with no open areas left (figure C). At the eight-week follow-up visit, the scab has just fallen off, and the wound is healing well with immature skin representing the size of a penny (figure D). At the ten-week follow-up visit, the wound has completely healed (figure E), patient demonstrated full knee ROM (120 degrees of flexion and 180 degrees of extension), and patient has been released from orthopaedic care.
Although the 78-year-old patient demonstrated excellent results in ROM and overall decreased pain levels following right total knee arthroplasty, the non-healing status of the surgical wound at even six weeks status post surgery posed great concern. The vasculopathic venostasis resulting in a surgical ulcer left very little option than to perform dehiscence wound irrigation with pulse lavage and to apply amniotic AlphaPATCH dry patches to the wound following confirmation of gram negative status of the aspirate.
The amniotic AlphaPATCH patch, a morselized amniotic tissue allograft, contains the molecules PGE2, WNT4, and GDF-11. Mesenchymal stem cells (MSCs) secrete PGE2, or Prostaglandin E2, in response to injury. This molecule inhibits fibrosis by way of limiting fibroblast proliferation, migration, collagen secretion, and transforming growth factor (TGF)-induced myofibroblast that can spur fibroblast proliferation. PGE2 also enhances the wound healing process and angiogenesis. WNT4, a protein, drives wound healing by way of wound re-epithelialization and cell proliferation. The creation of new tissue materializes by multiple methods including new blood vessel formation, a critical element for normal wound healing. GDF-11, or growth/differentiation factor 11, has been identified as one of the key molecules propelling the regeneration of skeletal muscle, cardiac muscle, and nervous tissue in aged mice as a result of heterochronic parabiosis, a procedure used to connect the circulatory system of a young mouse to that of an older mouse.
The two (MSC-based) amniotic AlphaPATCH patches applied on the patient’s wound dramatically accelerated the wound healing process. The dehisced surgical wound that showed no sign of healing after 1-1/2 months post total knee replacement surgery, demonstrated a central scab formation in the middle of the wound dehiscence area (figure B) only after two weeks of AlphaPATCH patch application. After eight more weeks, the wound was completely healed and the patient was released from orthopaedic care to assume high levels of physical activity and activities of daily living. Although more studies are warranted to further substantiate the therapeutic benefits of this treatment, we suggest unreservedly that amniotic AlphaPATCH patch embodies a viable and more effective alternative to current traditional means of wound care management.
- Gurtner, G.C., et al., Wound repair and regeneration. Nature, 2008. 453(7193): p. 314-21.
- Harding, K.G., H.L. Morris, and G.K. Patel, Science, medicine and the future: healing chronic wounds. BMJ, 2002. 324(7330): p. 160-3.
- Sen, C.K., et al., Human skin wounds: a major and snowballing threat to public health and the economy. Wound Repair Regen, 2009. 17(6): p. 763-71.
- Carlson, M.A., Acute wound failure. Surg Clin North Am, 1997. 77(3): p. 607-36.
- Pierpont, Y.N., et al., Obesity and surgical wound healing: a current review. ISRN Obes, 2014. 2014: p. 638936.
- Gottrup, F., A specialized wound-healing center concept: importance of a multidisciplinary department structure and surgical treatment facilities in the treatment of chronic wounds. Am J Surg, 2004. 187(5A): p. 38S-43S.
- Stadelmann, W.K., A.G. Digenis, and G.R. Tobin, Physiology and healing dynamics of chronic cutaneous wounds. Am J Surg, 1998. 176(2A Suppl): p. 26S-38S.
- Evans, N.D., et al., Epithelial mechanobiology, skin wound healing, and the stem cell niche. J Mech Behav Biomed Mater, 2013. 28: p. 397-409.
- Ramirez, H., S.B. Patel, and I. Pastar, The Role of TGFbeta Signaling in Wound Epithelialization. Adv Wound Care (New Rochelle), 2014. 3(7): p. 482-491.
- Menendez-Menendez, Y., et al., Adult Stem Cell Therapy in Chronic Wound Healing. J Stem Cell Res Ther, 2014. 4(162): p. 2.
- Koh, T.J. and L.A. DiPietro, Inflammation and wound healing: the role of the macrophage. Expert Rev Mol Med, 2011. 13: p. e23.
- Demidova-Rice, T.N., J.T. Durham, and I.M. Herman, Wound Healing Angiogenesis: Innovations and Challenges in Acute and Chronic Wound Healing. Adv Wound Care (New Rochelle), 2012. 1(1): p. 17-22.
- Cha, J. and V. Falanga, Stem cells in cutaneous wound healing. Clin Dermatol, 2007. 25(1): p. 73-8.
- Maxson, S., et al., Concise review: role of mesenchymal stem cells in wound repair. Stem Cells Transl Med, 2012. 1(2): p. 142-9.
- Murphy, P.S. and G.R. Evans, Advances in wound healing: a review of current wound healing products. Plast Surg Int, 2012. 2012: p. 190436.
- Tsourdi, E., et al., Current aspects in the pathophysiology and treatment of chronic wounds in diabetes mellitus. Biomed Res Int, 2013. 2013: p. 385641.
- Sun, B.K., Z. Siprashvili, and P.A. Khavari, Advances in skin grafting and treatment of cutaneous wounds. Science, 2014. 346(6212): p. 941-5.
- Shevchenko, R.V., S.L. James, and S.E. James, A review of tissue-engineered skin bioconstructs available for skin reconstruction. J R Soc Interface, 2010. 7(43): p. 229-58.
- MacNeil, S., Progress and opportunities for tissue-engineered skin. Nature, 2007. 445(7130): p. 874-80.
- Metcalfe, A.D. and M.W. Ferguson, Tissue engineering of replacement skin: the crossroads of biomaterials, wound healing, embryonic development, stem cells and regeneration. J R Soc Interface, 2007. 4(14): p. 413-37.
- Jadlowiec, C., et al., Stem cell therapy for critical limb ischemia: what can we learn from cell therapy for chronic wounds? Vascular, 2012. 20(5): p. 284-9.
- Jackson, L., et al., Adult mesenchymal stem cells: differentiation potential and therapeutic applications. J Postgrad Med, 2007. 53(2): p. 121-7.
- Pittenger, M.F., et al., Multilineage potential of adult human mesenchymal stem cells. Science, 1999. 284(5411): p. 143-7.
- Chen, L., et al., Paracrine factors of mesenchymal stem cells recruit macrophages and endothelial lineage cells and enhance wound healing. PLoS One, 2008. 3(4): p. e1886.
- Chamberlain, G., et al., Concise review: mesenchymal stem cells: their phenotype, differentiation capacity, immunological features, and potential for homing. Stem Cells, 2007. 25(11): p. 2739-49.
- Gnecchi, M., et al., Paracrine mechanisms in adult stem cell signaling and therapy. Circ Res, 2008. 103(11): p. 1204-19.
- Hocking, A.M. and N.S. Gibran, Mesenchymal stem cells: paracrine signaling and differentiation during cutaneous wound repair. Exp Cell Res, 2010. 316(14): p. 2213-9.
- Hanson, S.E., M.L. Bentz, and P. Hematti, Mesenchymal stem cell therapy for nonhealing cutaneous wounds. Plast Reconstr Surg, 2010. 125(2): p. 510-6.
- Badiavas, E.V. and V. Falanga, Treatment of chronic wounds with bone marrow-derived cells. Arch Dermatol, 2003. 139(4): p. 510-6.
- Sarasua, J.G., et al., Treatment of pressure ulcers with autologous bone marrow nuclear cells in patients with spinal cord injury. J Spinal Cord Med, 2011. 34(3): p. 301-7.
- Falanga, V., et al., Autologous bone marrow-derived cultured mesenchymal stem cells delivered in a fibrin spray accelerate healing in murine and human cutaneous wounds. Tissue Eng, 2007. 13(6): p. 1299-312.
- Dash, N.R., et al., Targeting nonhealing ulcers of lower extremity in human through autologous bone marrow-derived mesenchymal stem cells. Rejuvenation Res, 2009. 12(5): p. 359-66.
- Yoshikawa, T., et al., Wound therapy by marrow mesenchymal cell transplantation. Plast Reconstr Surg, 2008. 121(3): p. 860-77.
- van den Broek, L.J., et al., Differential response of human adipose tissue-derived mesenchymal stem cells, dermal fibroblasts, and keratinocytes to burn wound exudates: potential role of skin-specific chemokine CCL27. Tissue Eng Part A, 2014. 20(1-2): p. 197-209.
- Garcia-Olmo, D., et al., A phase I clinical trial of the treatment of Crohn’s fistula by adipose mesenchymal stem cell transplantation. Dis Colon Rectum, 2005. 48(7): p. 1416-23.
- Hass, R., et al., Different populations and sources of human mesenchymal stem cells (MSC): A comparison of adult and neonatal tissue-derived MSC. Cell Commun Signal, 2011. 9: p. 12.
- Barlow, S., et al., Comparison of human placenta- and bone marrow-derived multipotent mesenchymal stem cells. Stem Cells Dev, 2008. 17(6): p. 1095-107.
- Baksh, D., R. Yao, and R.S. Tuan, Comparison of proliferative and multilineage differentiation potential of human mesenchymal stem cells derived from umbilical cord and bone marrow. Stem Cells, 2007. 25(6): p. 1384-92.
- Alviano, F., et al., Term Amniotic membrane is a high throughput source for multipotent Mesenchymal Stem Cells with the ability to differentiate into endothelial cells in vitro. BMC Dev Biol, 2007. 7: p. 11.
- Delo, D.M., et al., Amniotic fluid and placental stem cells. Methods Enzymol, 2006. 419: p. 426-38.
- Mermet, I., et al., Use of amniotic membrane transplantation in the treatment of venous leg ulcers. Wound Repair and Regeneration, 2007. 15(4): p. 459-464.
- Hanumanthappa, M.B. and S. Gopinathan, Amniotic membrane dressing versus conventional dressing in lower limb Varicose ulcer: A prospective comparative study. International Journal of Biological & Medical Research, 2012. 3(3).
- Serena, T.E., et al., A multicenter, randomized, controlled clinical trial evaluating the use of dehydrated human amnion/chorion membrane allografts and multilayer compression therapy vs. multilayer compression therapy alone in the treatment of venous leg ulcers. Wound Repair and Regeneration, 2014. 22(6): p. 688-693.
- Healy, W.L., et al., Complications of total knee arthroplasty: standardized list and definitions of the Knee Society. Clin Orthop Relat Res, 2013. 471(1): p. 215-20.
- Winiarsky, R., P. Barth, and P. Lotke, Total knee arthroplasty in morbidly obese patients. J Bone Joint Surg Am, 1998. 80(12): p. 1770-4.
- Galat, D.D., et al., Surgical treatment of early wound complications following primary total knee arthroplasty. J Bone Joint Surg Am, 2009. 91(1): p. 48-54.
- Bozyk PD1, Moore BB. Prostaglandin E2 and the pathogenesis of pulmonary fibrosis. Am J Respir Cell Mol Biol. 2011 Sep;45(3):445-52.
- Syeda MM1, Jing X, Mirza RH, Yu H, Sellers RS, Chi Y. Prostaglandin transporter modulates wound healing in diabetes by regulating prostaglandin induced angiogenesis. Am J Pathol. 2012Jul;181(1):334-46.
- Zhang B1,Wang M, GongA, Zhang X,Wu X, Zhu Y, Shi H,Wu L, ZhuW, Qian H, Xu W. Huc MSC-exosome mediated -Wnt4 signaling is required for cutaneous wound healing. Stem Cells. 2014 Jun 25.
- Labus MB1, Stirk CM, Thompson WD, Melvin WT. Expression of Wnt genes in early wound healing. Wound Repair Regen. 1998 Jan-Feb;6(1):58-64
- Mendelsohn AR, Larrick J. Systemic factors mediate reversible age-associated brain dysfunction. Rejuvenation Res. 2014 Nov 16.