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Current Insights On Using Amniotic Membranes For Wounds
After decades of use in other healthcare disciplines, amniotic membrane modalities are showing promise in the podiatric arena. These experts tackle the subject of using amniotic membrane products to facilitate wound healing, discuss using amniotic membranes in place of split thickness skin grafts and offer additional insights on dressing choices.
Q:
What has been your experience with the use of amniotic membrane grafts for wound closure?
A:
For the past few years, Kazu Suzuki, DPM, CWS, been using amniotic membrane grafts along with skin substitute grafts for wound closure. He has used EpiFix (MiMedx Group), Grafix (Osiris Therapeutics) and AmnioClear (Liventa Bioscience). In Dr. Suzuki’s experience, he has found that human amniotic membrane grafts are as effective, if not better, than older skin substitute grafts from animal sources (porcine, bovine, etc.). He cites conflicting research comparing EpiFix and Apligraf (Organogenesis) but has found they are both equally effective in wound closure.1
“Amniotic membranes do provide a great scaffolding effect as an intact matrix for wound closure,” notes Eric Lullove, DPM. “They are loaded with growth factors and extracellular matrix so they do provide for a nice framework of tissue for the host environment to help ‘kickstart’ the healing process in a delayed or chronic wound.”
For Jennifer Swan, DPM, amniotic membranes have been a “wonderful” addition to the selection of products and options for the treatment of wounds. With the use of amniotic products, she has been able to get wounds to heal with fewer applications and has noted a faster healing time in comparison to non-amniotic products. In addition, Dr. Swan has seen a reduction in scar tissue and pain when using amniotic tissue, citing “great success.”
Q:
Do you have any experience with the injectable form of amniotic membrane fluid and grafts?
A:
Citing a pilot study he authored in 2015, Dr. Lullove notes that injectable amniotic membrane can provide a great framework for torn structures and anatomic areas that may preclude smooth incorporation of a graft tissue the clinician would place on the wound.2
“The injectable forms of these tissues are a great resource for physicians to deal with any number of chronic inflammatory conditions,” notes Dr. Lullove.
Although Dr. Suzuki does not have a personal experience with the injectable form of amniotic membrane, he is aware of the products and their indications. As the amniotic membrane grafts are so effective in wound closure, he suspects that grafts may have the same kind of positive therapeutic effect if he injected them around the wound. However, Dr. Suzuki acknowledges the problem that insurance companies do not reimburse the injectable form at this time.
Both Dr. Suzuki and Dr. Swan know doctors who offer amniotic membrane fluid injection for various chronic inflammatory ailments such as plantar fasciitis. Dr. Suzuki notes a scientific poster at the Symposium on Advanced Wound Care Fall 2015 (SAWC Fall) conference, which advocated injection of EpiFix into the heel for chronic plantar fasciitis.3 He believes it is similar to platelet-rich plasma injection in the sports medicine arena but cautions that more research is necessary with a sufficiently powered randomized controlled study to figure out the modality’s therapeutic effect for this condition.
Q:
When you have decided to use an amniotic membrane graft instead of a skin substitute graft, how do you choose which amniotic membrane graft to use?
A:
Drs. Swan and Suzuki note the importance of insurance coverage in selecting a graft. Dr. Swan says insurance companies have yet to come to the table with appropriate coverage for most skin substitutes when physicians are dealing with postoperative wound dehiscence.
“It has been quite frustrating that the insurance companies have not seen the value in getting these wounds to heal as quickly as possible with these advanced amniotic products,” says Dr. Swan. She says studies in press will hopefully provide evidence-based medicine to convince the insurance companies of the value and benefit of amniotic tissue.
As amniotic membrane grafts are substantially more expensive than older grafts of animal origin, Dr. Suzuki points out the necessity of verifying the patient’s insurance information in order to prevent lost reimbursement on each graft application. As he notes, that verification is more important for larger wounds as larger size amniotic grafts are disproportionately more expensive in comparison to smaller grafts.
Dr. Lullove bases the decision to choose amniotic grafts over other grafts on the type of injury, the depth of the wound/injury and the exact purpose for which he will use a cellular tissue product. As he notes, there are more than 60 cellular tissue products, including amniotic membranes, on the market and each one of those products is very specific in its function at the time of implantation or placement.
For example, Dr. Lullove may need more of a dermal scaffolding versus a membrane and notes the difference is wholly dependent on the patient.
Q:
When do you choose amniotic membrane grafts over split-thickness skin grafts?
A:
For Dr. Suzuki, the decision depends on therapeutic goals and wound size. As amniotic membrane grafts often come in sizes as large as 5 cm2, he may choose a split-thickness skin graft (STSG) if the wound is substantially bigger than that size. Also, for patients over 80 or sicker patients with multiple comorbidities (end-stage renal disease, cancer, poor appetite, etc.), Dr. Suzuki may choose an amniotic membrane graft as patients may not be able to heal the split-thickness graft harvest site. He suspects that amniotic membrane grafts may be more effective in closing wounds than split-thickness skin grafts because of various growth factors within these graft materials.
When patients have autoimmune diseases, are high-risk healers due to steroids, arteriovenous disease, non-adherence, or are not adequate surgical candidates, Dr. Lullove says amniotic allograft is a better option than a split-thickness skin graft. He reserves STSG for patients who are good candidates for wound healing based on skin perfusion pressures, ankle brachial index and a lack of metabolic disease. Dr. Lullove notes amniotic membrane allografts are ideal for the non-surgical candidate or for patients who are too “risky” to take to the OR.
Dr. Swan typically chooses amniotic membranes over STSGs whenever possible. Most of the time, her choice depends on insurance coverage but she also notes that if the patient has extremely fragile skin that may not do well with the creation of a secondary wound, amniotic membrane might be a better choice.
Q:
What is your choice of fixation and secondary dressings over amniotic grafts?
A:
Dr. Suzuki uses the same method as he does for any other skin substitute or STSG. If applying secondary dressings in the OR, he may use a staple gun or 3-0 vicryl, saying they are easier to remove. In the office setting, Dr. Suzuki may use Steri-Strips (3M) or Mepitel (Mölnlycke Health Care) or similar silicone-adhesive mesh to secure the graft to the wound. As for the secondary dressing, he prefers to use something non-adherent and antimicrobial, such as Xeroform (DeRoyal), Cutimed Sorbact (BSN Medical) or a silicone foam dressing, such as Mepilex Ag (Mölnlycke Health Care).
Dr. Swan uses Prolene sutures (Ethicon) to suture in the amniotic tissue. Her secondary dressing consists of Adaptic (Systagenix) or another type of non-adhesive dressing with a subsequent compression dressing using 4x4 gauze dressing, cast padding and an Ace wrap. If the patient has a lot of edema, she will use a Jones compressive dressing. In addition, if there is any concern for drainage, Dr. Swan will also use an absorptive foam dressing after the non-adherent layer.
Dr. Suzuki’s methods may change based on the shape, size, location and drainage amount of each wound. He recalls a device rep once telling him not to use antimicrobial dressings over the amniotic membrane graft but he has not observed any detrimental effect thus far when doing so.
Dr. Lullove is in private practice in Boca Raton, Fla. He is a Staff Physician at West Boca Medical Center in Boca Raton and the Medical Director at the West Boca Center for Wound Healing. Dr. Lullove is a Fellow of the American College of Certified Wound Specialists. He is on the Association for the Advancement of Wound Care (AAWC) Board of Directors as the Podiatric Physician Board Member and is the Liaision for the AAWC to the Alliance of Wound Care Stakeholders.
Dr. Suzuki is the Medical Director of the Tower Wound Care Center at the Cedars-Sinai Medical Towers. He is also on the medical staff of the Cedars-Sinai Medical Center in Los Angeles and is a Visiting Professor at the Tokyo Medical and Dental University in Tokyo. Dr. Suzuki can be reached via e-mail at Kazu.Suzuki@CSHS.org .
Dr. Swan is in private practice at the Orthopedic Foot and Ankle Center in Westerville, Ohio.
References
- Zelen CM, Gould T, Serene TE, et al. A prospective, randomised, controlled, multi-centre comparative effectiveness study of healing using dehydrated human amnion/chorion membrane allograft, bioengineered skin substitute or standard of care for treatment of chronic lower extremity diabetic ulcers. Int Wound J. 2015; 12(6):724-32.
- Lullove E. A flowable placental tissue matrix allograft in lower extremity injuries: a pilot study. Cureus. 2015; 7(6):e275.
- Tallis R, Ahrens A. Description of technique for implantation of dehydrated human amnion/chorion membrane allograft for the treatment of plantar fasciitis. Poster presentation, Symposium on Advanced Wound Care (SAWC) Fall, Sept. 26-28, 2015, Las Vegas, NV.
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