A multidisciplinary approach using mechanical ultrasound debridement, platelet rich plasma, hyperbaric oxygen therapy, electrical stimulation, and skin grafts was used to treat 398 patients with chronic wounds over 32,161 procedures. Most wounds were traumatic, venous, rheumatic, or mixed vascular insufficiency. After treatment, 72% of wounds healed or improved, with venous, rheumatic, and mixed wounds responding best. Ischemic wounds responded least. The approach was found to enhance healing over standard care.

1. Multidisciplinary approach for the enhancement of healing in selected problem wounds
K. Hoxha1, P. Baroni1, E. Bondioli2, D. Melandri2,
P. Longobardi1, I. Tomasini3
1-Centro iperbarico Ravenna; 2-Burn Centre and Regional Skin Bank, Bufalini Hospital, AUSL Cesena; 3 -Blood Transfusion Service, S.M. delle Croci Hospital AUSL Ravenna
Contact: Klarida Hoxha, Centro iperbarico, via Augusto Torre 3, 48124 Ravenna. Tel. 0039-0544-500152,
email: k.hoxha@iperbaricoravenna.it

2. Objectives
To verify if a multidisciplinary approach allows the enhancement of healing in selected problem wounds better than the benchmarking
Etiology
% reduction in wound area at 4 week as predictor of healing
Venous Leg ulcer
> 28.79% at 4 weeks will heal at 24 weeks
Diabetic Foot Ulcer
> 50% at 4 weeks will heal at 12 weeks
Surgical Wound
50% at 2 weeks will heal at 3 weeks
Pressure Ulcer
> 50% after 2 weeks

3. At Hyperbaric Center of Ravenna, in 2013, 398 patients with cutaneous wound were treated for a total of 32,161 Wound Care procedures.
Inclusion criteria:
−ulcer present for > 6 weeks;
−size from 5 cm2 to the whole leg circumference;
−Falanga score ≥ B2.
The etiology was:
–traumatic (38%),
–venous stasis (22%),
–mixed vascular insufficiency (14%), rheumatic (14%),
–pressure (7%),
–arterial insufficiency (6%).
Methods

4. What treatment involves
•Mechanical ultrasound debridement
•Homologous Platelet Rich Plasma (PRP) was prepared and activated, at clinical use, in 1:1 ratio with gluconate calcium and thrombin on a support of modulating matrix proteases. The final product, so gelled, was topically applied once a week for 4 weeks.

5. HBOT
(20 sessions in a multiplace chamber at 254 kPa with a FiO2 in mask > 0.9, for 90 minutes, 5 days per week)
What treatment involves
FREMS Frequency Rhythmic Electrical Modulation System, 20 sessions, 1 per day, 5 days per week

6. What treatment involves
Allograft once every two weeks for three times.
The evaluation was carried out every week (measurement
of ulcer area with Visitrak®, transcutaneous oximetry, photography and clinical examination).

7. Why this choice: PRP
Selected problem wounds have poor expression of Trx-1, HIF-1 >> stem cells CD133 (endothelium) and CD34 (blood vessels).
PRP activated, release over 300 GFs.
PDGF and TGF-β stimulates proliferation of fibroblasts and production of extracellular matrix.
PRP / platelet gel enhance wound healing and survival rate of skin grafts.
Hom DB & al. Laryngoscope. 2003 Sep;113(9):1566-71

8. HBOT improves the systemic factors that impair healing. Criteria for the appropriate indication to HBOT depend on the patient rather than cutaneous ulcer.
induces platelet activation and protein release.
Shaw FL & al., Clin Biochem. 2009 Apr;42(6):467-76
Why this choice: HBOT

9. increases stem cells in the circulation; their ability to get to the wound and cause the vasculogenesis
HBOT improves the healing (in animals) induced by the administration of GFs in the wound bed
Thom SR & al., Wound Repair Regen. 2011 Mar-Apr;19(2):149-61.
Why this choice: HBOT

10. Why this choice: FREMS
•Positive, significant effect on pain reduction (VAS)
•significant acceleration of the wound-healing process compared with conventional treatments (PUSH tool total index).
Electrical stimulation as adjuvant treatment for chronic leg ulcers of different aetiology: an RCT. Magnoni C, Rossi E, Fiorentini C, Baggio A, Ferrari B, Alberto G. J Wound Care. 2013 Oct;22(10):525-6, 528-33.

11. Results
Skin wound
Healed
(%)
Improved (%)
Stationary (%)
Drop out (%)
Traumatic
6,2
22,4
10,4
-
Venous
80,5
12,2
4,9
2,4
Rheumatic
72
24
-
4
Mixed (Vascular)
69,2
30,8
-
-
Pressure
57,1
28,6
14,3
-
Ischemic
33,3
-
66,7
-
•Most of the wounds healed or improved (reduced by 72%, Falanga score A2) after eight weeks from the inclusion.
•Arterial insufficiency (ischemic) ulcers had less benefit.
•There were no side effects.

12. Conclusion
Our experience suggests clinical efficacy of multidisciplinary approach for the enhancement of healing in selected problem wounds.

13. Pasquale Longobardi
Master Med. Subacquea Iperbarica, Scuola Superiore S. Anna (Pisa)
www.iperbaricoravennablog.it k.hoxha@iperbaricoravenna.it