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Figures 1–4 illustrate the wound pre- and post-debridement and BMA extraction, and the application and coverage with xenograft of the BMA. The outer nonadherent and gauze dressings over the xenograft were kept intact for approximately 7 days or until their first postoperative visit, which was ± 2 days. Patients were scheduled to be seen at the wound clinic weekly and had wound measurements taken for 12 weeks or until wound closure, whichever occurred first. The rate of wound improvement and/or failure was documented at each visit only if the xenograft was displaced and the wound was visually examined. If no significant decrease in wound size was recorded (at least 0.5 cm after 6 weeks following surgery), then other therapies were considered to prevent further deterioration or infection.

Results

  The study consisted of 8 patients with lower extremity wounds secondary to past burns, vasculitic disease, and venous insufficiency, although secondary diagnosis included trauma, lupus, pyoderma gangrenosum, and/or lymphedema. Age, wound etiology, related comorbidities, wound size, treatments utilized, and surgeries performed for each patient are listed in Table 1. Patients were treated with local dressings before surgery, as well as after surgery, if the xenograft became displaced. Three of the eight patients showed a gradual decrease in wound size over the following few months. One of the three patients had a left saphenous vein radiofrequency ablation per vascular recommendations 3 months following the BMA due to her significant varicosities and vascular disease. Two patients showed progressive increase in wound size several months following the procedure. The remaining three patients showed no significant improvement with < 0.5 cm reduction in wound size after 6 weeks; therefore, alternative therapies were utilized. Two patients proceeded with the application of living skin substitutes to aid in wound closure, and one patient had split-thickness skin grafts placed over bilateral venous ulcers in addition to hyperbaric oxygen therapy.

Discussion

  Autologous adult bone marrow-derived stem cells are known to assist with the tissue repair process by secreting large amounts of growth factors and cytokines. They are capable of differentiating into multiple cell types including endothelium, liver, muscle, skin, bone, cartilage, brain, fibroblasts, and keratinocytes.²⁰ Deng et al²¹ showed that the fluorescent labeled mesenchymal cells in mice gave rise to stem cells in the skin. In 2008, Rogers et al²² injected bone marrow aspirate topically into the wound periphery in three patients with differing etiologies and suggested that this procedure is a useful and safe adjunct to achieve wound closure. These ulcers healed in 47, 50, and 60 days, respectively.²² Badiavas et al²³ achieved similar results in three patients who had complete closure of their yearlong ulcers with use of BMA and cultured cells. All healed within 3 months; however, one patient required a bioengineered skin (Apligraf®, Organogenesis, Canton, MA).²³ In 2007, Badiavas et al²⁴ conducted another study injecting BMA into the wounds of 4 subjects but only one healed completely. Our patient review showed wound size reduction in only three of the eight patients without any patient’s attaining closure in the 12 weeks postoperative period. Patients were routinely followed for up to 6 months.