Stepwise surgical technique used to treat recalcitrant pretibial ulcerations: a case series.

INTRODUCTION: Pretibial lacerations resulting from trauma may evolve into chronic wounds with worsening infections without treatment. There is a limited amount of literature on the presentation and treatment of recalcitrant pretibial ulcerations. OBJECTIVE: This study aims to provide a review of surgical treatment methodology that successfully managed recalcitrant pretibial ulcerations. MATERIALS AND METHODS: The authors conducted a retrospective case review of patients with pretibial ulcerations. All wounds underwent aggressive debridement in the operative setting. Next, the wounds were fenestrated with a needle before placing one application of an antimicrobial acellular dermal tissue matrix derived from fetal bovine dermis, which was tightly adhered onto the wound bed. All wounds received a uniform multilayer compression dressing. RESULTS: Three patients with pretibial ulcerations were included in this study. Each wound was a result of mechanical trauma and deteriorated into a refractory ulceration despite initial conservative treatment for more than 6 months. All ulcers exhibited local infection of cellulitis, hematoma, and a collection of purulent fluid. None of the wounds had any signs of radiographic osteomyelitis. The application of the allograft following debridement and fenestration led to wound volume reduction by 75%, 66.7%, and 50% in 3 patients in 28 days. All wounds healed successfully within 4 months. CONCLUSIONS: The combination of a fenestration method and an antimicrobial fetal bovine dermal matrix successfully healed recalcitrant pretibial ulcerations in high-risk patients.

Antimicrobial Peptides Secreted From Human Cryopreserved Viable Amniotic Membrane Contribute to its Antibacterial Activity.

Chronic wounds remain a large problem in the field of medicine and are often associated with risk of infection and amputation. Recently, a commercially available human cryopreserved viable amniotic membrane (hCVAM) has been shown to effectively promote wound closure and reduce wound-related infections. A sprevious study indicates that hCVAM can inhibit the growth of bacteria associated with chronic wounds. In the present study, we investigated the mechanism of hCVAM antimicrobial activity. Our data demonstrate that antimicrobial activities against common pathogens in chronic wounds such as P.aeruginosa, S.aureus and Methicillin-resistant S.aureus (MRSA) are mediated via the secretion of soluble factors by viable cells in hCVAM and that these factors are proteins in nature. Further, we show that genes for antimicrobial peptides (AMPs) including human beta-defensins (HBDs) are expressed by hCVAM and that expression levels positively correlate with antimicrobial activity of hCVAM. At the protein level, our data indicate that HBD2 and HBD3 are secreted by hCVAM and directly contribute to its activity against P. aeruginosa. These data provide evidence that soluble factors including AMPs are hCVAM antimicrobial agents and are consistent with a role for AMPs in mediating antimicrobial properties of the membrane.

Understanding the Impact of Preservation Methods on the Integrity and Functionality of Placental Allografts.

INTRODUCTION: Human placental membranes (hPMs) have a long history in treating burns and wounds. The composition of hPMs includes structural matrix, growth factors, and neonatal cells, all of which contribute to their regenerative potential. However, most hPM products are devitalized after dehydration and irradiation. We compared the functionality of single-layer viable cryopreserved human amniotic membrane (vCHAM) with multilayer devitalized dehydrated human amnion/chorion membrane (dHACM) in wound-relevant models to determine the effect of different processing methods on hPMs. METHODS: Viable cryopreserved human amniotic membrane and dHACM were compared with fresh hPM for structural integrity and viability. Viable cell persistence in vCHAM over time was evaluated in vitro and in vivo in a diabetic chronic wound mouse model. Proliferation of cells within fresh hPM and vCHAM was evaluated with bromodeoxyuridine and Ki-67 staining, and proliferation of isolated cells in culture was evaluated. Growth factor release over time and in vitro response to chronic wound stimuli (tumor necrosis factor α, lipopolysaccharide, and hypoxia) were used to compare the functionality of vCHAM and dHACM. RESULTS: The structure and thickness of fresh hPM were retained in vCHAM but were compromised in dHACM. Similar to fresh hPM, vCHAM contained viable cells, whereas dHACM did not. Cells in vCHAM remained viable after 4 and 7 days in culture and in an in vitro chronic wound environment and after 4 and 8 days in vivo after application to a mouse chronic wound. Staining for bromodeoxyuridine and Ki-67 did not reveal proliferative cells within fresh hPM and vCHAM. However, isolated cells proliferated in culture. Viable cryopreserved human amniotic membrane increased platelet-derived growth factor BB, hepatocyte growth factor, and epidermal growth factor levels over time and responded to chronic wound stimuli in vitro by significantly increasing levels of vascular endothelial growth factor and prostaglandin E2. Dehydrated human amnion/chorion membrane showed no significant accumulation of growth factors and did not respond to chronic wound stimuli. CONCLUSIONS: These results indicate that vCHAM retains intact, native matrix, and viable, active cells and responds to chronic wound stimuli in vitro. The inclusion of multiple layers of hPM does not compensate for structural degradation and loss of viability caused by dehydration as evidenced by a lack of functional response by dHACM. The clinical significance of these results remains to be answered.

Angiogenic Potential of Cryopreserved Amniotic Membrane Is Enhanced Through Retention of All Tissue Components in Their Native State.

Objective: Chronic wounds have inadequate microvasculature (or blood vessels), resulting in poor healing. Both fresh human amniotic membrane (hAM) containing viable cells and devitalized hAM have been shown to stimulate angiogenesis in chronic wounds. However, the importance of retaining viable endogenous cells on the angiogenic activity of hAM remains unknown. To understand their role, we compared the angiogenic potential of intact cryopreserved hAM containing viable cells (int-hAM) with devitalized cryopreserved hAM (dev-hAM). Approach: The effects of conditioned medium (CM) derived from int-hAM and dev-hAM on endothelial cell migration and tube formation were compared. Int-hAM and dev-hAM CM and tissues were tested for key angiogenic factors, such as vascular endothelial growth factor (VEGF), basic fibroblast growth factor (bFGF), and platelet-derived growth factor-BB (PDGF-BB) after 7 days in culture. The role of VEGF in int-hAM-mediated tube formation was analyzed through inhibition of its activity by anti-VEGF antibody. Results: CM from int-hAM showed greater endothelial cell recruitment and tube formation compared with dev-hAM. Significantly higher levels of VEGF were detected in int-hAM CM after 1 week compared with dev-hAM CM. Int-hAM tissue also had significantly greater expression of VEGF and bFGF relative to dev-hAM. A similar trend was observed for PDGF-BB. Neutralization of VEGF in int-hAM CM significantly inhibited tube formation compared with int-hAM CM alone. Innovation and Conclusion: Preservation of all native hAM components, including viable endogenous cells, enhances the angiogenic effect of cryopreserved hAM. This effect is mediated through higher levels of angiogenic factors, especially VEGF, produced by int-hAM.

Retention of Endogenous Viable Cells Enhances the Anti-Inflammatory Activity of Cryopreserved Amnion.

Objective: Human amniotic membrane (hAM) has been used to treat wounds for more than 100 years. However, widespread use of fresh hAM has been limited due to its short shelf life and safety concerns. To overcome these concerns, different preservation methods have been introduced. The majority of these methods result in devitalized hAM (dev-hAM). Recently, we developed a cryopreservation method that retains all hAM components intact (int-hAM), including viable endogenous cells. To understand the advantages of retaining viable cells in preserved hAM, we compared the anti-inflammatory properties of int-hAM and dev-hAM. Approach: The tissue composition of int-hAM and dev-hAM was compared with fresh hAM through histology and cell viability analysis. We also evaluated the ability of int-hAM and dev-hAM to regulate tumor necrosis factor-α (TNF-α), interleukin-1α (IL-1α), and IL-10 release when co-cultured with immune cells; to produce prostaglandin E2 (PGE2) on TNF-α stimulation; and to inhibit proteases. Results: Int-hAM maintained the structural and cellular integrity of fresh hAM. Int-hAM had >80% cell viability post-thaw and remained viable for at least a week in culture. Viable cells were not detected in dev-hAM. Compared with dev-hAM, int-hAM showed significantly greater downregulation of TNF-α and IL-1α, upregulation of PGE2 and IL-10, and stronger inhibition of collagenase. Innovation and Conclusion: A new cryopreservation method has been developed to retain all native components of hAM. For the first time, we show that viable endogenous cells significantly augment the anti-inflammatory activity of cryopreserved hAM.

Soluble Factors Released by Endogenous Viable Cells Enhance the Antioxidant and Chemoattractive Activities of Cryopreserved Amniotic Membrane.

Objective: Regulation of oxidative stress and recruitment of key cell types are activities of human amniotic membrane (hAM) that contribute to its benefits for wound treatment. Progress in tissue preservation has led to commercialization of hAM. The majority of hAM products are devitalized with various degrees of matrix alteration. Data show the importance of hAM matrix preservation, but little is known about the advantages of retaining viable endogenous cells. In this study, we compared the antioxidant and chemoattractive properties of viable intact cryopreserved hAM (int-hAM) and devitalized cryopreserved hAM (dev-hAM) to determine the benefits of cell preservation. Approach: We evaluated the ability of int-hAM and dev-hAM to protect fibroblasts from oxidant-induced cell damage, to suppress oxidants, and to recruit fibroblasts and keratinocytes in vitro. Results: Both the int-hAM-derived conditioned medium (CM) and the int-hAM tissue rescued significantly more fibroblasts from oxidant-induced damage than dev-hAM (844% and 93% more, respectively). The int-hAM CM showed a 202% greater antioxidant capacity than dev-hAM. The int-hAM CM enhanced the recruitment of fibroblasts and normal and diseased keratinocytes to a greater extent than dev-hAM (1,555%, 315%, and 151% greater, respectively). Innovation and Conclusion: Int-hAM, in which all native components are preserved, including endogenous viable cells, demonstrated a significantly greater antioxidant and fibroblast and keratinocyte chemoattractive potential compared to dev-hAM, in which viable cells are destroyed. The release of soluble factors that protect fibroblasts from oxidative injury by hAM containing viable cells is a mechanism of hAM antioxidant activity, which is a novel finding of this study.

Natural cardiac extracellular matrix hydrogels for cultivation of human stem cell-derived cardiomyocytes.

Biomaterial scaffolds made of natural and synthetic materials are designed to serve as a structural and informational template for cell attachment and tissue formation. The use of native extracellular matrix (ECM) is of special interest for the culture of cardiac stem and progenitor cells due to the presence of intrinsic regulatory factors regulating cardiac function. We describe here how to obtain native ECM hydrogels from porcine hearts for the culture of human embryonic, induced pluripotent, and somatic stem cells for cardiac tissue engineering and regenerative medicine applications.