Article 1
How to Select an Extracellular Matrix for Wound Repair: A Comprehensive Review. Stetkevich S, Gupta M, Simman R, Jackson SE. Eplasty. 2023 Aug 23;23e51.
Extracellular matrix (ECM) products were first pioneered in 1930 with the aim to accelerate healing, minimize scarring, and reduce pain. Since their inception, the number of products available for physicians to choose from has grown substantially. This study represents a systematic review of 71 PubMed articles published on ECM products and their applications since 2000. The studies included reviewed and compared allografts, bioengineered matrices, xenografts, and acellular fish skin products. They conclude all products provide some benefit in terms of wound healing compared to healing by secondary intention alone. They report certain benefits specific to each class of products. They find allografts promote revascularization and provide an antimicrobial barrier. Bioengineered matrices and xenografts have benefit in terms of antimicrobial activity and low immunogenicity, as well as the fact that they are easy to apply and readily available. Acellularized fish skin products appear to have all of the listed benefits in terms of wound healing but may be more costly or difficult to attain.
This study is a comprehensive review of many of the most commonly available ECM products commercially available for use in a variety of wound types and provides a starting point for clinicians looking to compare these products for incorporation into their practice. This study however is limited by the quality of papers available for review; much of the research on these products is limited to publications with low sample size and a lack of research directly comparing products. Additionally, though many different types of wounds are included in this research, the authors note the studies seemed to favor a predominance of burn wounds.
Article 2
Use of a Synthetic Dermal Matrix for Reconstruction of 55 Patients with Nongraftable Wounds and Management of Complications. Concannon E, Damkat-Thomas L, Rose E, Coghlan P, Solanki N, Wagstaff M. J Burn Care Res. 2023 Jul 5;44(4):894-904.
This study is a retrospective review of Biodegradable Temporizing Matrix (BTM) to 55 wounds deemed non-graftable due to exposed bone, tendon, or neurovascular structures. The authors excluded no patients that met this criteria in order to provide the most robust and diverse study population. Wound etiologies included burn >20% TBSA, non-burn traumatic wounds, infection, ischemic injury, and oncologic reconstructions. The mean time from BTM application to delamination and split thickness skin graft was 46 days. This study notes a complication rate of 47% with 35% reoperation rate, predominantly due to BTM or STSG loss. Though higher than the reported complication rate in the literature, they attribute this to the complexity of wounds studied rather than an innate factor of the BTM itself. There was no statistical significance between early (<7 days) or late (>7 days) application of BTM from time of initial injury or wound etiology in terms of complication rate (X2 [1, n=55] = 0.36776, P = 0.5442). Complications studied included BTM loss, STSG loss, infection, tendon adhesion, and hematoma. Most reoperations for these complications were considered minor procedures.
This study is limited by its retrospective nature. However, given that prior studies have established effectiveness of BTM in progressing wound healing, this study gives insight into the nuances of its use for a variety of wounds and specific complications to be aware of given the nature of the wound being treated. Oncologic wounds requiring subsequent radiation treatment may be more at risk for BTM loss while vascular wounds may be at higher risk of eventual STSG loss despite good BTM incorporation. However, their outcomes support use of BTM in the reconstruction ladder for complex wounds of varying etiologies, with the caveat that complications and multiple surgeries should be expected in these cases.
Article 3
Systematic Review and Meta-Analysis of Biodegradable Temporizing Matrix Application for Complex Wound Reconstruction. Grande PK, Hill D, McElfresh J, et al. J Burn Care Res. 2025 Jan 24;46(1):82-89.
Biodegradable temporizing matrix (BTM) is a synthetic dermal template that was created to reconstruct a wide variety of complex wounds. BTM can be used to reconstruct large and diverse wounds, varied comorbidities, and can be used in the presence of infection. Many of these studies are limited by sample size. This study was designed as a systemic review to determine the breadth and success of BTM for complex wound closure. Any published paper on BTM outcomes in human wounds were included. The outcome measures included: use of vacuum assisted closure devices, incidence of infection, time to BTM, time to split thickness skin graft (STSG), BTM take, and STSG survival. A total of 194 studies were pulled from four databases, of which 77 were removed as duplicates. 116 studies were then assessed as meeting inclusion criteria for the study. Of these 116 studies, 24 studies were appropriate for inclusion in the review. Half of these studies were single person case reports. Only 4 were prospective case studies. There were no available randomized control trials. The studies included were published between 2015 and 2022. The most common injury treated with BTM was burns and acute surgical wounds. BTM was used to cover a variety of exposed structures including bone, fat, perichondrium, tendon, muscle, and periosteum. Most patients (76.6%) did not experience post-operative infections. Of the 23.4% who experience post-operative infections, the most common organizers were Enterobacter spp, Pseudomonas aeruginosa, Streptococcus pyogenes, and Staphylococcus spp. Despite local infection the BTM maintained integration and resulted in STSG survival. The mean time to BTM application was 7.2 days. Time to STSG was on average 34 days. BTM has been described to take 2-3 weeks to integrate and revascularize in the tissue bed. The time to STSG demonstrates the stability of BTM in the wound bed prior to STSG. Eighty-four percent of patients have >95% BTM take within the wound beds and 96.1% survival of STSG following BTM delamination.
BTM is a fully synthetic dermal matrix that provides versatility for reconstruction. BTM is composed of 2mm thick biodegradable polyurethane foam with open cell foam and sealed membrane side. BTM can act as a pseudo-dermis preventing water loss and minimizing contracture. BTM requires a two-stage procedure comprised of BTM application followed by delamination and STSG. Wounds that were open longer prior to BTM application had a higher incidence of wound infection overall. The BTM survival was not influenced by infection in the wound bed. The survival of the STSG following BTM did not differ between infected and non-infected wound beds, which may represent publication bias. There is an absence of randomized control trials for BTM, which limits the strength of this systemic review. There are a high number of single-case studies included in this systemic review, which may lead to publication bias. Overall, BTM is a versatile and diverse tool for wound coverage. Moving forward, randomized control trials should be performed to assess the data further.
Article 4
Wound Healing with Spray-On Autologous Skin Grafting compared with standard care in patients with large diabetes related foot wounds: an open-label randomized controlled trial. Manning L, Ferreira IB, Gittings P, et al. Int Wound J. 2022 Mar;19(3):470-481.
Diabetes related foot ulcers have high morbidity and mortality, which include episodes of infection, lengthy hospitalization, prolonged antibiotic therapy, and major amputations. Poor outcomes have continued despite increasing awareness, technological advances, and social burden. This randomized control trial aimed to assess the benefit of spray-on skin (ReCell) as a superior and cost-effective management strategy for these foot wounds. This was a six-month open label randomized controlled trial of spray-on skin compared to standard of care at two hospitals and outpatient clinics in Australia from July 2018 through November 2019. Participants were: >18 years, type 1 or 2 diabetes mellitus, and had a wound area >6cm2, suitable for administration of spray on skin, no further debridement or amputation planned, and adequately vascularized wound bed, and able to follow up with community nursing services. The wound beds were prepared with low frequency ultrasonic debridement, then the patients received: spray-on skin with primary dressing for 5 days or standard of care after low-frequency ultrasonic debridement. The primary outcome measure was complete healing (full epithelization) of the wound within 26 weeks lasting for at least 2 weeks. 254 patients were screened into the study, and 45 participants with 49 eligible foot wounds screened into the study participated. Of these 49 wounds, 24 wounds received spray-on skin and 25 the standard of care. A total of 32 (65.3%) index wounds were completely healed at 6 months, including 16 of 24 (66.7%) in the spray-on skin group and 16 of 25 (64.0%) in the standard care group (p = 0.845). Forty-two of these 49 wounds were able to be assessed at 12 months. Of these 42 wounds, 36 total healed at 12 months. 18 wounds in each group were considered healed at the 12-month end point. There was no significant difference in the treatment arms (P> 0.999). There were no significant differences in mobility, self-care, activities, or anxiety/depression between the groups. The overall community nursing costs associated with the groups was higher in the standard of care group compared to the spray-on skin group (p=0.034).
There was no evidence that spray-on skin had a statistically significant difference compared to standard of care for large well-vascularized diabetes related foot wounds. In this study though, the rate of complete healing achieved in the control group was considerably higher than expected when compared to prior observational data (64% vs. 45%). This can partially be contributed to the high proportion of wounds recruited following debridement or minor amputations, so the wounds were effectively a post-surgical wound bed. The wounds selected were well-vascularized with at least one-vessel run-off confirmed by radiologic evidence or clinical examination. Access to trials for wound care interventions can be limited by frequency of visits and access to trial centers without need for regular travel.
