title: Prevention of amputation caused by rheumatic diseases following a novel therapy of exposing bone marrow, occlusive dressing and subsequent epidermal grafting.
abstract: BACKGROUND
  Wounds with exposed bones caused by rheumatic diseases commonly result in amputation despite progress in our understanding of wound-healing mechanisms.
  
  
  OBJECTIVE
  To determine whether an experimental therapy of bone marrow exposure, an occlusive dressing and subsequent grafting of epidermal sheets accelerates healing and reduces the need for amputation in patients with rheumatic diseases.
  
  
  METHODS
  Fifteen patients, including those with rheumatoid arthritis or systemic sclerosis, who had wounds with exposed bones were treated either with the standard procedure, consisting of local wound care, debridement with a scalpel, bed rest and parenteral antibiotics (n = 8), or with a newly developed experimental procedure (n = 7). In that new procedure, the affected bone was initially exposed by debridement with a scalpel, followed by partial excision with a bone scraper until bleeding was observed from the exposed bone. The lesions were immediately covered with an occlusive dressing, and were eventually treated with epidermal grafts obtained from suction blisters.
  
  
  RESULTS
  A comparison with standard therapy demonstrated that the time needed for wound healing was similar, but that the newly developed combination therapy reduced the risk of amputation (P = 0.020). No skin ulcers or erosions were observed for at least 1 year in five of seven patients (72%) due to the adoption of stable palmoplantar-type characteristics in grafts derived from the trunk epidermis.
  
  
  CONCLUSIONS
  Our study indicates that exposure of bone marrow cells plus an occlusive dressing accelerates the healing of skin ulcers at least partly through the preparation of a healthy well-granulated wound bed and that subsequent epidermal grafting achieves site-specific differentiation through epithelial-mesenchymal interactions.
authors.affiliation: Department of Dermatology, Graduate School of Medicine Osaka University, 2-2 Yamada-oka, Suita-shi, Osaka 565-0871, Japan.
authors.forename: Y
authors.initials: Y
authors.lastname: Yamaguchi
authors.forename: Y
authors.initials: Y
authors.lastname: Sumikawa
authors.forename: S
authors.initials: S
authors.lastname: Yoshida
authors.forename: T
authors.initials: T
authors.lastname: Kubo
authors.forename: K
authors.initials: K
authors.lastname: Yoshikawa
authors.forename: S
authors.initials: S
authors.lastname: Itami
mesh_terms: D000328:Adult; D000368:Aged; D000671:Amputation, Surgical; D001172:Arthritis, Rheumatoid / Q000503:physiopathology / Q000601:surgery / Q000628:therapy; D001853:Bone Marrow / Q000503:physiopathology / Q000601:surgery*; D001854:Bone Marrow Cells / Q000502:physiology; D004817:Epidermis / Q000503:physiopathology / Q000637:transplantation*; D005260:Female; D005385:Fingers; D006801:Humans; D008297:Male; D008875:Middle Aged; D009779:Occlusive Dressings; D012216:Rheumatic Diseases / Q000503:physiopathology / Q000601:surgery / Q000628:therapy*; D012595:Scleroderma, Systemic / Q000503:physiopathology / Q000601:surgery / Q000628:therapy; D012867:Skin / Q000503:physiopathology; D012883:Skin Ulcer / Q000503:physiopathology / Q000601:surgery / Q000628:therapy; D013997:Time Factors; D014034:Toes; D016896:Treatment Outcome; D014945:Wound Healing / Q000502:physiology*