One-Stage Closure of Venous Ulcers with Matriderm and Split-Thickness Skin Grafts

1. Abstract Venous ulcers are important cause of chronic wounds with high hospitalization costs associated. Compression therapy alone, as the mainstay treatment, often fails to completely close large ulcers which require surgery. Bi-layered constructs of dermal matrix and split-thickness skin-graft are already widely used in burns, scar resurfacing, traumatic wounds and diabetic ulcer, but rarely in venous ulcers and only in a two-stage procedure. We report two cases of large venous ulcers treated with Matriderm and split-thickness skin grafts in a one stage procedure, associated with compression therapy. Graft take at day 5 was 100%. Follow-ups were performed at 2 weeks, 1 month, 3 months and 6 months and showed no signs of recurrence. The observational data obtained suggest that Matriderm can be successfully used in a one-stage procedure to close large venous ulcers with reduced hospitalization costs. 2. Introduction Venous ulcers, as a severe manifestation of chronic venous insufficiency, represent a rising cause of chronic wounds in the aging population. It is estimated that venous ulcers account for about 70% of chronic ulcers of the lower limb, with a recurrence rate ranging from 54% to 78% and high hospitalization costs [1]. Damage to the superficial/deep vein valves impair venous return which leads to increased venous pressure, compromising the oxygen supply and resulting ultimately in an ulcer. The venous ulcer abounds in proteases which destroy the extracellular matrix impeaching cellular adhesion and angiogenesis. As a consequence, the ulcer remains in the inflammatory phase of wound healing. Clinically, the ulcer is accompanied by edema, exudate, pain and bad smell which may have a negative impact on the patient’s quality of life, limiting mobility and causing personal hygiene problems and psychological issues. Poor prognostic factors include besides large ulcers (>10 cm2), tissue fibrosis, peripheral arterial disease, duration longer than 12 weeks, high body mass index and advanced age [2]. The treatment options available are various, with different level of evidence: compression therapy (level A), pentoxifiline associated with compression therapy (level A), calf muscle exercise (level B), electrical stimulation therapy (level B), venous surgery (level B), limb elevation (level C), hyperbaric oxygen (level C), sclerotherapy (level D), protein nutritional supplementation with protein (level E) and skin grafts (level E). Although skin grafts do not have a high level of evidence in the treatment of venous ulcers, often compression therapy (the first line treatment) and local wound care cannot close completely some ulcers, especially those associated with poor prognostic factors. In such cases, skin grafting is required in order to achieve wound closure and since there is a deficiency of extracellular matrix, artificial acellular dermal matrix might be beneficial. There are many