A Retrospective Clinical Review of Extracellular Matrices for Tissue Reconstruction: Equine Pericardium as a Biological Covering
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Abstract: Complex wounds frequently undergo surgical excision and grafting in an attempt to optimize the wound environment and to facilitate wound closure. Individuals who have not responded to conventional non-surgical therapies and dressings may not be good candidates for autologous grafting. A fully flexible, cross-linked, acellular equine pericardium biological xenograft was used to address difficult-to-treat and recalcitrant wounds of the lower extremity. Twenty-four complex wounds of varying etiology, including diabetic, venous, trauma, vasculitic, and post-surgical wounds underwent surgical debridement and xenograft application. The individual results were reviewed in a retrospective study over an 18-month period. The duration of the wounds ranged between 3 months to 2 years. The average time to wound closure was 5.96 weeks. The median time to closure was 6 weeks. No significant adverse events were noted. The data review suggests the use of equine pericardium as a xenograft and biological cover may significantly benefit patients with difficult-to-heal wounds. Additional animal and clinical studies are in progress to help understand the mechanism of action of the xenograft in the clinical environment.
Address correspondence to:
Gerit Mulder, DPM, MS, FAPWCA
UCSD Medical Center
200 West Arbor Drive
First Floor, Suite 4
San Diego, CA 92103
Phone: 303-733-4181
Email: gmulder@ucsd.edu
A variety of treatment modalities are available for the treatment of difficult to treat wounds.1 Topical dressings, ointments, drugs, devices, and other external products offer varying benefits depending on the nature of the wound environment. Regardless of modality, creating an environment that will optimize the wound environment by facilitating cellular activity may be of significant benefit in promoting wound closure.2
Biological matrices may consist of allogenic, xenogenic, or chemical constructs that act as temporary matrices that are eventually replaced by host tissue. While not containing living cells or antigenic materials, these products provide a structure for cell migration and activity that is absent in many full-thickness defects.
This retrospective clinical review examined results from 24 complex wounds treated with an acellular equine pericardium on patients with known barriers to tissue repair and wound closure. The primary purpose of the review was to determine potential benefits of this particular xenograft to assist in the development of future studies that would support continued use and help explain the mechanism of action leading to positive results and wound closure in wounds otherwise recalcitrant to other therapies, since little data are currently available on the clinical and scientific basis of acellular mechanisms of action in the clinical setting. Similarities and differences with other acellular materials are discussed and contrasted.
The data reviewed include wounds of varying etiology: diabetic, venous, trauma, post-surgical, vasculitic, and autoimmune. The primary consideration of this retrospective study was not with wound etiology, rather it was with the overall physical presentation of the wound, previous attempts at wound closure, failure to attain wound closure, and host as well as wound response to the xenograft. Secondary factors reviewed included reduction of pain, decreased wound dressings and daily treatments, and overall acceptance by the patient. The patients reviewed were all treated over an 18-month period with an initial application of non-fenestrated equine pericardium biomatrix (Unite® Biomatrix, Synovis Life Technologies, St. Paul, MN). The compilation of 24 patients is intended to provide a broad overview of possible applications.
Equine pericardium biomatrix.
1. Fonder MA, Lazarus GS, Cowan DA, Aronson-Cook B, Kohli AR, Mamelak AJ. Treating the chronic wound: A practical approach to the care of nonhealing wounds and wound care dressings. J Am Acad Dermatol. 2008;58(2):185–206.
2. Yager DR, Kulina RA, Gilman LA. Wound fluids: a window into the wound environment? Int J Low Extrem Wounds. 2007;6(4):262–272.
3. Nataraj C, Ritter G, Dumas S, Helfer FD, Brunelle J, Sander TW. Extracellular wound matrices: novel stabilization and sterilization method for collagen-based biologic wound dressing. WOUNDS. 2007;19(6):148–156.
4. Zaulyanov L, Kirsner RS. A review of a bi-layered living cell treatment (Apligraf) in the treatment of venous leg ulcers and diabetic foot ulcers. Clin Interv Aging. 2007:2(1):93–98.
5. Ballas CB, Davidson JM. Delayed wound healing in aged rats is associated with increased collagen gel remodeling and contraction by skin fibroblast, not with differences in apoptotic or myofibroblast cell populations. Wound Repair Regen. 2001;9(3):223–237.
6. Dalton SJ, Whiting CV, Bailey JR, Mitchell DC, Tarlton JF. Mechanisms of chronic skin ulceration linking lactate, transforming growth factor-beta, vascular endothelial growth factor, collagen remodeling, collagen stability, and defective angiogenesis. J Invest Dermatol. 2007;127(4):958–968.
7. Grinnell F, Ho CH, Wysocki A. Degradation of fibronectin and vitronectin in chronic wound fluid: analysis by cell blotting, immunoblotting, and cell adhesion assays. J Invest Dermatol. 1992;98(4):410–416.
8. Lineen E, Namias N. Biologic dressing in burns. J Craniofac Surg. 2008;19(4):923–928.
9. Wang JF, Olson ME, Reno CR, Kulyk W, Wright JB, Hart DA. Molecular and cell biology of skin wound healing in a pig model. Connect Tissue Res. 2000;41(3):195–211.
10. Agren MS, Werthén M. The extracellular matrix in wound healing: a closer look at therapeutics for chronic wounds. Int J Low Extrem Wounds. 2007;6(2):82–97.
11. Blakytny R, Jude E. The molecular biology of chronic wounds and delayed healing in diabetes. Diabet Med. 2006;23(6):594–608.
12. Buinewicz B, Rosen B. Acellular cadaveric dermis (AlloDerm): a new alternative for abdominal hernia repair. Ann Plast Surg. 2004;52(2):188–194.
13. Rubin L, Schweitzer S. The use of acellular biologic tissue patches in foot and ankle surgery. Clin Podiatr Med Surg. 2005;22(4):533–552.
14. Bachman S, Ramshaw B. Prosthetic material in ventral hernia repair: how do I choose? Surg Clin North Am. 2008;88(1):101–112.
15. Anson JA, Marchand EP. Bovine pericardium for dural grafts: clinical results in 35 patients. Neurosurgery. 1996;39(4):764–768.
16. Winters CL, Brigido SA, Liden BA, Simmons M, Hartman JF, Wright ML. A multicenter study involving the use of a human acellular dermal regenerative tissue matrix for the treatment of diabetic lower extremity wounds. Adv Skin Wound Care. 2008;21(8):375–381.
17. Veves A, Falanga V, Armstrong DG, Sabolinski ML. Graftskin, a human skin equivalent, is effective in the management of noninfected neuropathic diabetic foot ulcers: a prospective randomized multicenter clinical trial. Diabetes Care. 2001;24(2):290–295.
18. Mostow EN, Haraway GD, Dalsing M, Hodde JP, King D. Effectiveness of an extracellular matrix graft (OASIS Wound Matrix) in the treatment of chronic leg ulcers: a randomized clinical trial. J Vasc Surg. 2005;41(5):837–843.
19. Falanga V, Sabolinski M. A bilayered living skin construct (APLIGRAF) accelerates complete closure of hard to heal venous ulcers. Wound Repair Regen. 1999;7(4):201–207.
20. Wiegand C, Abel M, Ruth P, Hipler UC. Influence of the collagen origin on the binding affinity for neutrophil elastase. Abstract presented at: 18th Conference of the European Wound Management Association (EWMA); May 14–16, 2008; Lisbon, Portugal.
