Section: CME Category: Wound Care

Results of a Comparative Effectiveness Study of Healing

Charles Zelen, DPM

Charles M Zelen, DPM discusses the use of amniotic membrane for wound healing. Dr Zelen reviews multiple studies that support its use, not only for diabetic foot ulcers, but for chronic venous ulcers and plantar fasciitis as well.

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Goals and Objectives
  1. Discuss the benefits of using amniotic membrane for wound healing
  2. Understand the comparative effectiveness study and discuss the outcomes
  3. Discuss the use of dHACM for chronic venous ulcer
  4. Discuss the use of dHACM for chronic plantar fasciitis
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    Release Date: 03/16/2018 Expiration Date: 12/31/2020

  • Author
  • Charles Zelen, DPM

    Podiatry Section Chief
    Dept of Orthopedics
    Carilion Roanoke Memorial
    HCA Lewis Gale Hospital
    Director, Professional Education and Research Institute

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    Charles Zelen has disclosed that he serves on the Biomet Trauma Speaker's Bureau.

  • Lecture Transcript
  • Male Speaker: What we’re going to talk about today is a little bit on amniotic membrane. You’re gonna hear a lot on amniotic membrane over the next few days. I’d like to point to you. The most important thing to look at is the data. In other words, peer-reviewed, published, randomized controlled trials really show the importance of that type of level one evidence when you’re looking at which products to use and which products to consider for diabetic wounds in your practice. We’ve done a number of studies for our sponsor, MiMedx. And we’re going to go over some of those studies today as well as just a general review on the amniotic membrane. So why amniotic membrane? Believe it or not, amniotic membrane has been around since the early 1900s. The literature actually shows that it reduces inflammation, reduces scar formation. It’s immunologically privileged and it contains essential growth factors. The patients, the way that we get the amniotic membrane is they’re actually referred from OB gynecologists usually for scheduled caesarian sections only. All the tissues from all the different companies have provide the amniotic membrane. It’s all extensively tested to ensure that there is no disease process either viral or bacterial in any of the products. dHACM or what we did our study on, it’s a non-vascular tissue comprised of the most innermost layer of the placenta and consist of a single layer which is attached to a basement membrane. Histological evaluation actually shows in the combined amnion and chorion. There’s a large amounts of collagen of different types in there, both in the amnion and chorion. You could see the histological slide on the right hand side. In the specific amnion and chorion that I’m speaking on today in presenting the studies, they have actually showed a total of 57 preserved growth factors, cytokines and chemokines that are actually present and that this just briefly shows it on the left and right slides. Now the important thing to know is there are a lot of different products that are out there that are amnion only, chorion, amnion chorion in umbilical cord, but it’s really the combination of the amnion and chorion alone that have 100% of the growth factors. In the amnion alone, it’s only about 20% of the growth factors versus the chorion which has about 80%. So it’s really the two together that provide those 57 growth factors that I mentioned previously. You can see a little bit here on the bottom of the slide all the different growth factors and endothelial growth factor, platelet derived growth factor, vascular endothelial growth factor and you can see the percentages. And really only a smaller percent are in the amnion and it’s really the amnion and chorion together that get you the full 57 growth factors that are present in the dHACM that we study. Again, as we mentioned, not all products are equal. This is just a little histological slide. You can see on the left hand side the dHACM that we actually studied in our studies that I’ll be going over. Then you can see some of the different other products that are amnion only. You could see that they’ll only have a slice of the material, the amnion only about 20% of those growth factors. So what is it really that the dHACM does or the dehydrated human amnion and chorion? Think of it with all those growth factors. It actually helps the different cell layers proliferate. It helps our different cells migrate, proliferate, and produce all the growth factors that we need to heal our wounds. So let’s take a little bit of a look at the evidence. All the randomized control trials that were done in regards to this specific dHACM that we studied which is EpiFix. So way back, give a little bit of history, in 2011, somebody showed up at my door and presented to me, why don’t you consider putting dehydrated human amnion and chorion in diabetic foot wounds? I really never heard a whole lot about it and I did give it a try. In the patients that I tried it on, some really sick diabetic and diabetic and rheumatoid patients, I actually found that the patients healed very quickly. So I was enticed in the technology and we embarked on our first trial which was a randomized controlled trial where we looked at a dehydrated human amnion and chorion versus standard of care and this was published in the International Wound Journal in 2013. And basically we had two arms. We had a surgical debridement arm with standard of care and then we had the same surgical debridement with every other week application of dHACM.


    And what we found is when we ran the study out, it’s only 25 patients, we were IRB approved to 80. The statistic were just absolutely remarkable. We actually found that it’s six weeks, all but one of the patients completely healed with dHACM versus the standard of care arm where only one patient is healed. At this point we were so statistically significant. We halted the trial and we reported our data. What we then did is we took all the patients that failed standard of care and the right thing to do is usually when we do a study, we’ll usually ask the folks that are sponsoring the study. If the folks that are in the standard of care arm once they exit, if they can receive at least free grafts so everybody gets a chance to heal. So every one of the patients that failed in standard of care were actually given free grafts and that free graft was applied every other week. This is our crossover section. What we found in the crossover section was of those patients that didn’t heal, the 11 patients in their original standard of care trial, 10 out of those 11 patients were 91% healed. So in our first study we had 90% of the patients healed. And in the retrospect of crossover study of the 11 patients that did not heal with standard of care, 10 out of 11 actually did heal when receiving the dHACM graft. All of those, the 91% healed again within the 12 week period of time. So these are just a couple of cases. This is your quintessential typical diabetic ulcer. The ulcers in our studies ranged anywhere from one centimeter all the way up to 25 centimeters squared. This is an example of a standard very difficult to heal ulcer on the plantar aspect of the hallux. This patient exited standard of care at six weeks. And then after receiving the EpiFix, just one graft, healed up quickly. We also did a retrospect to follow up at 9 to 12 months and this patient remained completely healed. Here’s a much bigger wound and this will kind of show you the real power of the dHACM. You can see that heal wound looks pretty nasty when it was entered into standard of care. They exited at six weeks. He also was actually bigger at six weeks. It was much cleaner after receiving weekly surgical debridement and a Fibracol alginate. We started applying the EpiFix at week seven and the crossover. By week 16 they were completely healed. 13 months later had remained healed at the end of the study. So our third study, we wanted to look back. One of the things Medicare looks at and one of the things we should look at as podiatrist and surgeons is what happens to these patients after you get them healed? So what we did is we took a long term look at 9 to 12 months to see what actually happened to that group of patients in the original study and the crossover study. 18 of the 22 patients that healed did return for follow up. We only had one diabetic foot wound reopen and 17 actually remained healed. For the audience to know, each and every one of the patients that were actually in the trials when they exited did receive appropriate diabetic shoe gear and did receive appropriate diabetic inserts after they exited the trial. So with good diabetic foot care, shoes and insoles, 94.4%remained completely healed at 9 to 12 months. So what we found in the study is that applying EpiFix or dHACM every other week actually healed greater than 90% of the wounds prospectively and also in the crossover group. So our big question is if it works very well every other week, what would actually happen if we applied the product weekly? Because remember, you’re putting 57 growth factors in these diabetic wounds. So if you’re doing it every other week, obviously doing it weekly may actually work better. So we did have a study that was published in International Wound Journal in 2014. This was a prospective study where we looked at weekly versus biweekly application of dehydrated human amnion and chorion. Basically what we wanted to find out is if applying weekly worked better than applying every other week. There was no standard of care arm in this. It was WIRB approved. It was done at a research center between September 2012 and October of 2013. All diabetic patients with foot wounds greater than four weeks were allowed to participate. They had to be none infected. They were all diabetic and they all had to have at least four weeks of conservative treatment. And inclusion and exclusion criteria were typical for all diabetic foot trials whether they’d be phase two, phase three or post market. Obviously the patients couldn’t have an active Charcot foot. They had to have adequate blood supply. They couldn't be in renal failure and they also had to be between one and 25 centimeters square.


    And we had a two week run-in period. The importance of the run-in period is you want all the ulcers into the study to be the same. Because those that have been receiving standard of care before they enter, the standard of care could be very different. Some could be receiving a silver product. Some could be receiving an alginate. Some could be receiving a cream. So there’s a two week run-in period where everybody receives a CAMboot. Everybody receives weekly debridement and everybody receives the same non-silver collagen alginate. And any wound that improved greater than 20% was excluded from being randomized. So we had a total of 40 patients in this study. We found that we would be powered to at least a see a difference [coughs] between the two groups if we look at 40 patients. So the 40 patients, 20 received weekly application and 20 received biweekly application in a one to one ratio. We did use wound size appropriate grafts. One of the things that you’re going to see today, at least in many of the different products that are out there, is they’re making smaller and smaller grafts with an attempt to at least save Medicare, Medicaid and the insurer’s money. Because the average diabetic foot ulcer is only about 1.2 centimeters squared. So it’s important to have size specific grafts. Each patient was debrided weekly. A non-adherent dressing was placed on top of the dHACM. And then on top of that a compressive three layer, two-layer wrap. And all the wounds were offloaded with the CAMboot. They had weekly follow-up visits and we did measurements and debridements each week. And the patients were seen for up to total of 12 weeks or one week after complete healing. And the primary outcome was meantime to healing and the secondary outcome was patients healed at four, six, and 12 weeks and the number of grafts that were used. Interestingly enough, most of the time you’ll actually find in these randomized studies, both groups are completely identical. Ironically the weekly group had a statistically significantly higher hemoglobin A1C. So you might think if they had poor control of their sugars, they might not do quite as well. Well actually what happened was the opposite. It would be exactly what you would expect by applying the growth factor weekly. Those that received the dHACM every other week healed at an average of 4.1 weeks. Whereas those that received it weekly healed at 2.4 weeks. So you could actually heal 40% quicker if the dHACM was applied weekly. So this is something important for each of you to see that actually applying the biologic in a weekly fashion, the patients could get healed quicker. But guess what, we didn’t use anymore grafts in either group. So you could actually get healed 40% quicker by applying it weekly but you wouldn’t necessarily use any additional grafts to do so. So the rates of healing as you can see, greater than 90% of the patients healed in the two groups, whether you provided it weekly or biweekly. You just healed a lot quicker if you applied the biologic or the dHACM each week. Here are just a couple of cases. This is just an example of a patient with a very common mid metatarsal, plantar metatarsal ulcer. They entered. And after a couple weekly applications they were completely healed with the dHACM. Here’s another patient with the distal hallux ulcer. And after two biweekly applications, healed up completely with the dHACM. So you ask the question. We’ve done studies and we’ve proved in a randomized control model that the dHACM works against standard of care. We’ve proved that weekly application works better than every other week. So what’s the next thing that you have to do logically? And then the next thing that you have to do logically is do a comparison trial where you have standard of care, you have the dHACM and then you have another products to compare it to which will give you probably the most valid data of all. So we chose Apligraft which has been around for a long time. It’s been around for over 16 years. We use that in our comparative trial. So our next trial was a 12-week multicenter prospective, randomized, controlled, comparative effect of this trial. We had the same two week run-in period where the folks received weekly debridement, daily dressing changes, and offloading with the CAMboot. 60 patients were randomized with our interim data analysis, 20 in standard of care which received a Fibracol alginate, 20 did receive the dHACM and 20 received the bioengineered skin or the Apligraft. Again, the inclusion-exclusion criteria are very similar to all phase two and phase three and post market diabetic foot trials. Patients have to be in reasonable control of their sugars. They can’t be in renal failure. They can’t have an active Charcot or infection. Of course the wound can’t go down to tendon or bone. All the wounds have to be between one and 25 centimeters squared.


    In these groups, everything was completely the same. There was no statistically significant difference in any of the groups, whether it be age, smoking, location, size of the ulcer and median duration. All were statistically the same. And the study outcomes were quite remarkable. If you look at four and six weeks, at six weeks the dHACM or the EpiFix healed 95%of the wounds versus the bioengineered skin that healed only 45% and the control or the standard of care which healed only about 35% of the wounds. You can see that the power of the dHACM, the amniotic membrane, hence the reason why you’ll hear so many lectures on the amniotic membrane over the next few days. It works and it works very effectively and it works very quickly. So you can see by the red bar on the graft the mean percent wound heal vary per week. The dHACM healed very quickly. The bioengineered skin, it’s not that it didn’t heal. It just healed at a much slower rate as you can see by the blue curve. And then the green curve you can see standard of care, did what we expect. Helped out a little bit and then kind of went right down. Now as far as trajectory of healing, if you look on the right hand side of the graft, you can see with the dHACM or the amniotic membrane, it’s reliable healing. In almost all the wounds, you can see that even after just the very first graft, healing occurred extremely quickly whereas in the left hand side and the trajectory, the Apligraft was kind of all over the place. It did help the wounds make some progress but really it didn’t have the same reliable trajectory of healing that the dehydrated human amnion and chorion did. When we look at the Kaplan and Meier analysis, the superiority of the dHACM over the Apligraft and the standard of care, again you can see on the red graft just how quickly and how reliably the dHACM healed the wounds versus the Apligraft and the standard of care. The meantime to healing or the median time to healing with the dHACM was only 13 days versus the bioengineered skin at 49 days and the standard of care at 49 days. The P value was incredibly significant. Now also another thing you want to look at is product utilization because that’s something that Medicare, Medicaid, RVAs are looking at. You can see that the total number of grafts actually purchased for the study for the dHACM was only 43 versus the bioengineered skin, 124 pieces. As far as centimeters squared because the dHACM comes in size appropriate grafts, where the bioengineered skin only comes in one size, 154 centimeter squared for the dHACM versus 5400 for the bioengineered skin. Total actual centimeters applied, 68.2 for the dHACM versus 159 for the bioengineered skin, which made a huge difference in costs. The total cost of the grafts for the study, the entire study was only $33,000 for the EpiFix or the dHACM versus $184,000 for the bioengineered skin. The average cost to closure was only $1,600 for the amniotic membrane versus a very large $9,200 for the bioengineered skin. So the cost to closure, there was a huge almost four times difference between using the placenta versus using the bioengineered skin. So just in a little conclusion, we’re actually able to show in a randomized controlled comparative model that at a period of six weeks of time, 95% of the wounds are closed with the dehydrated human amnion and chorion versus only 46% of the wounds receiving the bioengineered skin. And the cost difference was absolutely enormous. $184,000 was spent on the bioengineered skin versus only $33,000 for the placenta or the EpiFix, making cost to closure a very small $1,600 for the amniotic membrane but a total of $9,216. One of the critiques that we did receive from the trial was why not a larger end? Why not looking at fore foot to rear foot? I’ll just give you guys a little sneak peak that the study did not end at 60 patients. So stayed tuned for the final analysis of this data that you’ll be seeing very soon with a much larger end. So we did look at some other studies. Dr. Tom Serena, one of my partners, and [Dr. Wo Lee] [19:47] who we do work with. Dr. Serena did a controlled venous leg trial of 84 patients. Looking at a compression therapy alone versus compression therapy combined with application of the placental membrane either one or two applications.


    I’ll move through this quickly because I’m slowly running out of time and I’d like to get to my plantar fasciitis trial as well. But the groups again were relatively the same in the venous leg trial. We looked at a total of patients where one group, one third received compression-only therapy and two groups actually received the placental membrane. One group received one application of the placenta and one group received two applications of the placenta. The inclusion exclusion criteria are similar to any other venous leg trial, whether it be phase two, phase three or post market. And what we looked at as I mentioned to you is the folks have actually randomized into the trial. Had to have a chronic venous leg ulcer that was resistant to conservative treatment. Once the patients were randomized, all patients received compressive therapy. But out of the three groups, two groups received the dHACM, one received one application and the second group received two applications. And what we looked at in the trial is a surrogate marker of 40% healing of these wounds in a period of time of four weeks. And again, what we found was is that the two groups that received the dHACM helped heal reliably. You can see the mean percent wound reduction in size with either one or two applications of the dHACM versus just the compression therapy only. There was a statistically significant difference. And taking a look at the number of patients that had a greater than 40% wound area closure in four weeks, 62% that either received one or two applications of the dHACM versus only half, 32% in the compression therapy group and that was statistically significant. Now what I want you to bear in mind here is in this venous leg trial, the dehydrated human amnion and chorion was not applied every week or every other week. These folks only received one or two applications but yet still healed or improved by 40% twice as many of the wounds. So our very last trial, what I’ll conclude within my last two minutes, is in addition to helping venous leg wounds and diabetic foot wounds, amniotic membrane is also very powerful for orthopedics as well. And we did do a study using the AmnioFix which is a micronized version or a particulate version of the human amnion and chorion and it can be used for injections in tendonitis, fasciitis. It can also be used at the periphery of ulcers and for bursitis, neuritis and capsulitis. We did a prospective, randomized, blinded, comparative study of injectable human amnion and chorion in the treatment of plantar fasciitis. My co-investigators, Attila Poka, Chief of the Orthopedic Education at Grant Medical Center. And James Andrews whose the President of the Andrews Institute and the orthopedic surgeon for the red skins. And what we wanted to do is we wanted to examine the efficacy of micronized dHACM in the suspension of saline for an injectable treatment for refractory plantar fasciitis. This was a western IRB approved trial where we had three groups. One group that was injected with saline and one group that was injected with a small amount of 40 milligrams of the dHACM and one with the much larger group that received the hundred milligrams of the dHACM. One shot only for folks that had resistant plantar fasciitis. The three groups were very similar. It was a total of 45 patients. The average age, female versus male, BMI, and the time they had their plantar fasciitis symptoms was all the same. It was a little bit greater than 20 weeks and all had failed reasonable conservative treatment. And what we’re able to show is over the period of the study, we actually looked at AOFAS hindfoot scale scores and you can see a gigantic difference than those that received either the 40 or the 100 milligrams of the micronized one injection alone in saline versus just a simple saline injection. The other outcomes that we looked at, we did look at the Wong-Baker faces pain scale score and you can also see that with both – of the amniotic membrane, there was an incredible improvement in the Wong-Baker faces score that was statistically significant. We looked at quality metrics validated SF36 and we looked at both the physical and the mental component scores, both of which were statistically significant improved with either dose of 40 milligrams or 100 milligrams of the amniotic membrane shots. So we’re actually able to prove in a prospective comparative randomized trial that injectable amniotic membrane is very effective for the most common thing we see in the podiatric office which is plantar fasciitis. So the big thing that I ask you in my five seconds that are left is show me the science.


    Anytime anyone comes to your door and shows you an amniotic membrane product or another biologic product, you want to see randomized controlled IRB approved trials. That is the most powerful data. That shows you if the product actually works. So I would encourage you if you’re not using amniotic membrane in your practices now or at your veteran’s location, highly consider the dHACM that we discussed today both for your diabetic wound care and also for your orthopedic needs. Thank you very much.