**6. Several adjuvant and devices in the management of hard-to-heal wounds**

In this section, several adjuvant and devices are presented, including growth factor, bioengineered tissues, and a negative pressure system, which are combined for the improved clinical treatment of complex wounds. 24)

Firstly, several growth factors have been used clinically to prepare favorable wound beds. Of these growth factors, basic fibroblast growth factor (bFGF) is the only angiogenic cytokine currently available in Japan.39) Treatment with bFGF allows chronic ulcers to heal more quickly (Figure 18). 40) Secondly, artificial dermis, which is composed of atelocollagen sponge and a silicone membrane, is beneficial for these wounds because of its unique characteristics (Figure 19). Atelocollagen sponge allows the early infiltration of mononuclear cells and fibroblasts, leading to the rapid resolution of inflammatory reactions and more favorable growth of granulation tissue. On the other hand, the silicone membrane protects against a loss of fluid, protein, and electrolytes, which helps maintain a suitable environment for wound healing. 41, 42) Formerly, resurfacing tendon- or bone-exposed wounds required vascularized flaps, showing high morbidity at the donor site, skilful micro- or plastic surgeons, microsurgical instruments, and much time, because a free skin graft would not take on unfavorable wound beds, such as in the presence of infected granulation and low-vascular tissues. 41) Artificial dermis is beneficial for the reconstruction of these wounds because it promotes the early infiltration of mononuclear cells and fibroblasts and better growth of connective tissue strands and epithelium. 41-43)

Complex Wounds in Patients Receiving Hemodialysis 139

Collagen sponge

Fibroblasts and capillaries infiltrate

Silicone membrane

Free skin graft

removal

Collagen sponge is absorbed, and abundant granulation tissue develops over the wound

Free skin grafting is performed over the

prepared suitable wound bed

Fig. 19. Treatment of a full-thickness skin defect ulcer using artificial dermis.

into the collagen sponge

Silicone membrane

Fig. 18. (A) A 63-year-old female suffered from a tendon-exposed wound due to instillation into the subcutaneous tissue of the ankle. She had received hemodialysis because of chronic glomerulonephritis for 4 years. (B) Three weeks after wound bed preparation with basic fibroblast growth factor. Abundant granulation tissue suitable for free skin grafting was observed. The wound completely resurfaced after skin grafting.

Fig. 18. (A) A 63-year-old female suffered from a tendon-exposed wound due to instillation into the subcutaneous tissue of the ankle. She had received hemodialysis because of chronic glomerulonephritis for 4 years. (B) Three weeks after wound bed preparation with basic fibroblast growth factor. Abundant granulation tissue suitable for free skin grafting was

observed. The wound completely resurfaced after skin grafting.

A

B

Fig. 19. Treatment of a full-thickness skin defect ulcer using artificial dermis.

Complex Wounds in Patients Receiving Hemodialysis 141

Fig. 21. (A) The photograph shows an infected wound in a patient receiving HD because of DM at the initial examination. (B) A favorable wound bed did not develop, although cleansing and wet-to-dry dressing were continued for 2 weeks after debridement. (C) The

wound became clean and favorable for free skin grafting 2 weeks after the start of combination treatment using bFGF and artificial dermis. (D) The resurfaced wound 2

months after skin grafting.

Marks reported that dermal wounds treated with collagen sponge seeded with fibroblasts or coated with bFGF show an increased level of reepithelialization, indicating that this method facilitates early dermal and epidermal wound healing. 44 45) Consequently, this method improves complex wounds and quickly prepares a favorable wound bed (Figures 20, 21).

Fig. 20. (A) The photograph shows an unsatisfactory wound bed in a patient receiving HD because of DM at the initial examination. (B) A favorable wound bed did not develop, although cleansing and wet-to-dry dressing were continued for 2 weeks after debridement. (C) The wound became clean and a wound bed had developed 2 weeks after the start of combination treatment using bFGF and artificial dermis. (D) A favorable wound bed was prepared after 3 weeks of combination treatment. (E) The resurfaced wound 2 weeks after skin grafting.

Marks reported that dermal wounds treated with collagen sponge seeded with fibroblasts or coated with bFGF show an increased level of reepithelialization, indicating that this method facilitates early dermal and epidermal wound healing. 44 45) Consequently, this method improves complex wounds and quickly prepares a favorable wound bed (Figures

Fig. 20. (A) The photograph shows an unsatisfactory wound bed in a patient receiving HD because of DM at the initial examination. (B) A favorable wound bed did not develop, although cleansing and wet-to-dry dressing were continued for 2 weeks after debridement. (C) The wound became clean and a wound bed had developed 2 weeks after the start of combination treatment using bFGF and artificial dermis. (D) A favorable wound bed was prepared after 3 weeks of combination treatment. (E) The resurfaced wound 2 weeks after

20, 21).

skin grafting.

Fig. 21. (A) The photograph shows an infected wound in a patient receiving HD because of DM at the initial examination. (B) A favorable wound bed did not develop, although cleansing and wet-to-dry dressing were continued for 2 weeks after debridement. (C) The wound became clean and favorable for free skin grafting 2 weeks after the start of combination treatment using bFGF and artificial dermis. (D) The resurfaced wound 2 months after skin grafting.

Complex Wounds in Patients Receiving Hemodialysis 143

Fig. 24. (A) The photograph shows a complex wound in a patient receiving HD because of DM at the initial examination. He was also diagnosed with ASO. (B) He underwent amputation of toes 2-5, and the metacarpal bones were exposed. (C) Artificial dermis was applied on the wound. (D) Combined treatment of negative pressure wound therapy and artificial dermis was performed. (E) A favorable wound bed was prepared after 3 weeks of

Patients receiving HD because of DM are likely to show more severe and rapidly developing complex wounds. They usually require immediate debridement before blood

[1] Akita S, Akino K, Imaizumi T, et al. The quality of pediatric burn scars is improved by

[2] Attinger CE, Janis JE, Steinberg J, Schwartz J, Al-Attar A, Couch K.Clinical approach to

early administration of basic fibroblast growth factor.J Burn Care Res. 2006;27:333-

wounds: débridement and wound bed preparation including the use of dressings and wound-healing adjuvants. Plast Reconstr Surg. 2006 Jun;117(7 Suppl):72S-109S.

this combination treatment.

access shunts become infected.

**7. Conclusion** 

**8. References** 

8.

Thirdly, negative pressure using a vacuum system has been proposed for speeding up treatment. A negative pressure wound therapy (NPWT) system is emerging as an acceptable option in patients with non-healing wounds of the foot, ankle, and lower limb46). Negative pressure wound therapy is a technique used to promote healing in acute or chronic wounds. A vacuum source is used to create sub-atmospheric pressure (125 mm Hg) in the local wound environment 47, 48). A dressing, containing a drainage tube, is fitted to the contours of the wound and sealed with a transparent film. The tube is connected to a vacuum source, turning an open wound into a controlled, closed wound while removing excess fluid from the wound bed to enhance circulation and remove waste from the lymphatic system (Figure 22) 49). It could be used effectively to prepare ulcers for closure via split-skin grafting or secondary closure in good time. We usually perform wound bed preparation with a combination of these therapies for improved clinical treatment of complex wounds (Figures 23), 24).

Fig. 22. Treatment of a full-thickness skin defect ulcer using artificial dermis.

Fig. 23. (A) The photograph shows a necrotic wound of toes 1-3 in a patient receiving HD because of DM at the initial examination. He was also diagnosed ASO. He underwent amputation of toes 1-3, and the wound was sutured. (B) However, he developed a complex ulcer because of wound dehiscence. (C) Negative pressure wound therapy was performed. (D) Wound contraction was noted 2 weeks later. (E) The wound bed had closed completely 1 month later.

Thirdly, negative pressure using a vacuum system has been proposed for speeding up treatment. A negative pressure wound therapy (NPWT) system is emerging as an acceptable option in patients with non-healing wounds of the foot, ankle, and lower limb46). Negative pressure wound therapy is a technique used to promote healing in acute or chronic wounds. A vacuum source is used to create sub-atmospheric pressure (125 mm Hg) in the local wound environment 47, 48). A dressing, containing a drainage tube, is fitted to the contours of the wound and sealed with a transparent film. The tube is connected to a vacuum source, turning an open wound into a controlled, closed wound while removing excess fluid from the wound bed to enhance circulation and remove waste from the lymphatic system (Figure 22) 49). It could be used effectively to prepare ulcers for closure via split-skin grafting or secondary closure in good time. We usually perform wound bed preparation with a combination of these therapies for improved clinical treatment of complex wounds (Figures

Fig. 22. Treatment of a full-thickness skin defect ulcer using artificial dermis.

Fig. 23. (A) The photograph shows a necrotic wound of toes 1-3 in a patient receiving HD because of DM at the initial examination. He was also diagnosed ASO. He underwent amputation of toes 1-3, and the wound was sutured. (B) However, he developed a complex ulcer because of wound dehiscence. (C) Negative pressure wound therapy was performed. (D) Wound contraction was noted 2 weeks later. (E) The wound bed had closed completely

23), 24).

1 month later.

Fig. 24. (A) The photograph shows a complex wound in a patient receiving HD because of DM at the initial examination. He was also diagnosed with ASO. (B) He underwent amputation of toes 2-5, and the metacarpal bones were exposed. (C) Artificial dermis was applied on the wound. (D) Combined treatment of negative pressure wound therapy and artificial dermis was performed. (E) A favorable wound bed was prepared after 3 weeks of this combination treatment.
