Composite Skin Grafting with Human Acellular Dermal Matrix Scaffold for Treatment of Diabetic Foot Ulcers: A Randomized Controlled Trial

Accepted Manuscript Composite Skin Grafting with Human Acellular Dermal Matrix Scaffold for Treatment of Diabetic Foot Ulcers: A Randomized Controlled Trial Zhicheng Hu, MD, PhD, Jiayuan Zhu, MD, PhD, Xiaoling Cao, MD, Chufen Chen, BN, Shuting Li, BN, Dong Guo, MD, Jian Zhang, MD, Peng Liu, MD, Fen Shi, MD, Bing Tang, MD, PhD PII:

S1072-7515(16)00219-2

DOI:

10.1016/j.jamcollsurg.2016.02.023

Reference:

ACS 8260

To appear in:

Journal of the American College of Surgeons

Received Date: 1 December 2015 Revised Date:

17 February 2016

Accepted Date: 23 February 2016

Please cite this article as: Hu Z, Zhu J, Cao X, Chen C, Li S, Guo D, Zhang J, Liu P, Shi F, Tang B, Composite Skin Grafting with Human Acellular Dermal Matrix Scaffold for Treatment of Diabetic Foot Ulcers: A Randomized Controlled Trial, Journal of the American College of Surgeons (2016), doi: 10.1016/j.jamcollsurg.2016.02.023. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

ACCEPTED MANUSCRIPT Composite Skin Grafting with Human Acellular Dermal Matrix Scaffold for Treatment of Diabetic Foot Ulcers: A Randomized Controlled Trial

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Zhicheng Hu1*, MD, PhD, Jiayuan Zhu1*, MD, PhD, Xiaoling Cao1*, MD, Chufen Chen1, BN, Shuting Li2, BN, Dong Guo3, MD, Jian Zhang1, MD, Peng Liu1, MD, Fen Shi1, MD, Bing Tang1, MD, PhD 1

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Department of Burn Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, People’s Republic of China (Hu, Zhu, Cao, Chen, Liu, Zhang, Shi, Tang) 2 Department of Plastic Reconstructive Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, People’s Republic of China (Li) 3 Department of Plastic Surgery, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510030, People’s Republic of China (Guo)

*Drs Zhicheng Hu, Jiayuan Zhu and Xiaoling Cao contributed equally to this study

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Corresponding Author: Bing Tang, MD, PhD Department of Burn Surgery, The First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan Road II, Guangzhou 510080, China Tel: 86-20-87755766-8235, Fax: 86-20-87755766-8276 E-mail: [email protected]

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Disclosure Information: Nothing to disclose.

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Support: This work was supported by: the National Natural Science Foundation of China to Bing Tang (81571908), Jiayuan Zhu (81272096 and 81471875), and Zhicheng Hu (81501675); Guangdong Provincial Natural Science Foundation to Bing Tang (2014A030313099), and Zhicheng Hu (2014A030310117); Guangzhou City Science and Technology Program to Jiayuan Zhu (1561000117); and the Sun Yat-sen University Clinical Research 5010 Program to Jiayuan Zhu (2013001) Registration of Clinical Trials Trial registry name: Japan Primary Registries Network (JPRN), UMIN Clinical Trials Registry; Registration identification number: UMIN000013225; URL for the registry: http://www.umin.ac.jp/ctr

Running Head: Composite skin grafting for diabetic ulcer 1

ACCEPTED MANUSCRIPT Abstract Background: Composite split-thickness skin grafting (STSG) with acellular dermal matrix (ADM) has been successfully used in burn injuries and trauma, but its use in treating diabetic

safety of composite STSG with ADM in the treatment of DFUs.

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foot ulcers (DFUs) has to date, not been reported. This study investigated the efficacy and

Study Design: Fifty-two patients with DFUs were randomized divided into experimental and control groups. Patients in the experiment group received compositing STSG over ADM; the

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control group received STSG alone. The primary endpoint was the recurrence rate 12 months after grafting. The secondary endpoint was the healing quality of grafted site by Manchester

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Scar Scale (MSS), and the percentages of subjects that achieved complete wound and complications.

Results: The number of patients suffering from recurrence was significantly less in the experiment group compared to control group (4.3% vs 22.7%; p=0.02). The autografted sites

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of the experimental group had better appearance with lower MSS scores [9 (8, 10.25) vs 11 (10, 12); p=0.006]. The rates of complete wound closure by weeks 2, 4, and 8 were similar, as were the rate of complications by post-grafting week 4 (38.5% vs 26.9%; p=0.38).

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Conclusions: Composite STSG over an ADM scaffold provide an effective method to treat

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DFUs, with lower recurrence rate and better physical attributes compared with the traditional STSG method. Complete wound closure and complication rates were comparable between these methods.

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ACCEPTED MANUSCRIPT Keywords: diabetic foot ulcers; acellular dermal matrix scaffold; skin graft; wound bed preparation

Abbreviations and Acronyms

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ABIs = ankle brachial indices ADM = acellular dermal matrix DFUs= diabetic foot ulcers

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ITT = intention-to-treat

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STSG = split-thickness skin grafting

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MSS = Manchester Scar Scale,

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ACCEPTED MANUSCRIPT INTRODUCTION Nowadays, there are an estimated 382 million people living with diabetes disclosed by the International Diabetes Federation (IDF) Diabetes Atlas (Sixth Edition). By the end of 2013, diabetes will have resulted 5.1 million deaths and cost $548 billion in healthcare spending.

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Patients with diabetes mellitus have a 15%–25% chance of developing diabetic foot ulcers (DFUs) during their lifetime and a 50%–70% recurrence rate over the ensuing 5 years.1,2 Standard care for DFUs involves systemic glucose control, ensuring adequate perfusion,

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debridement of nonviable tissue, off-loading, control of infection, local wound care and patient education, all administered by a multidisciplinary team. However, even with the best

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standard of care, only 24-30% of DFUs will heal within 12 to 20 weeks.3 In a large study carried out in European specialized foot centers, 23% of patients with diabetes and a foot ulcer lost at least part of their foot, despite intensive treatment.4

Timely closure and healing are crucial in order to prevent infection, maintain physical

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function, and minimize the cost and morbidities associated with DFUs.5-7 Currently, the recommended first-line treatment for DFUs is split-thickness skin graft (STSG).8-11 STSG has a high rate of success with wound closure.12-17 but there remains a high risk of graft skin loss

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of ulcers.18

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with this treatment, and low tolerance to friction and pressure, which may lead to recurrence

Bioengineered skin constructs have shown considerable improvement in closure of DFUs.19 However, grafted skin did not survive well due to the particularly refractory nature of diabetic wounds, occasionally leaving an extra skin graft in donor sites. The acellular dermal matrix (ADM) has recently become a novel alternative. ADM is a bioprosthetic mesh; a mixture of dermal elastin and collagen that is free of cellular components, which has been confirmed safe and effective for tissue repair. Once repopulated by host cells and revascularized by surrounding host tissue, ADM may lead to lower infection rates than for 4

ACCEPTED MANUSCRIPT synthetic meshes.20 In addition, the bioscaffold has been shown to promote cell migrating, proliferating, and vascularization, and therefore accelerating wound healing.21 ADM therapy on DFUs has been demonstrated to be effective, with no significant infective graft-related complications.22-24 However, ADM has only been used as a covering material rather than

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implantable material. Another study has shown that ADM combined with traditional STSG produced lasting results, with minimal recurrence of scar contractures after burns.25 Nevertheless, some studies have suggested a statistically significant higher rate of seroma and

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infection in ADM-based breast reconstruction versus techniques without ADM.26-27

Previously, we successfully treated deep facial and extremity burns by employing

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composite razor-thin skin autografts on top of ADM, which provided a thickness similar to that of STSG therapy, without excessive scars or subsequent contracture.28,29 In addition, ADM and skin autografts used separately has been reported for the treatment of DFUs.9, 30 Therefore, in this study, we examined the clinical outcomes of composite ADM and STSG in

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treatment of DFUs, in order to clarify whether ADM had the capacity to prepare the wound bed and increase the survival rate of skin graft. METHODS

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Ethical considerations

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For the randomized controlled trial, we prospectively recruited patients from September 2010 to November 2013 (Fig. 1) in the First Affiliated Hospital of Sun Yat-sen University. This study was approved by the Institutional Review Board of First Affiliated Hospital of Sun Yat-sen University and all subjects provided written informed consent. The trial has been registered with the University Hospital Medical Information Network (UMIN) Clinical Trials Registry (registration number: UMIN000013225, http://www.umin.ac.jp/ctr). Study population The study’s inclusion criteria were: patients ≥18 years old; diagnosed type 1 or type 2 5

ACCEPTED MANUSCRIPT diabetes; DFUs lasting ≥4 weeks,31, 32 stage 2 or 3 by Wagner’s scale, >3 cm2; absence of vascular reconstruction (ankle brachial indices between 0.7 and 1.2); and with skin grafting indicated.18, 33, 34 Excluded were patients with medical conditions that would impair wound healing (e.g., malignancy, autoimmune disease) or a high anesthesiology risk; using

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corticosteroids or immunosuppressant; or with uncontrolled hyperglycemia (preoperative HbA1c >12.0%, 108 mmol/mol); or with neuropathy related to spinal lesions, cerebral infarction, Guillain-Barre syndrome, severe vasculopathy and drug-induced toxicity.

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Randomization and masking

The sample size was calculation based on detecting a 30% difference in recurrence, with a

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power of 80% at the two-sided 0.05 α level. Accordingly, it was estimated that ≥22 patients were required in each arm of the study, and 15% of participants might be lost to follow-up. Thus, we calculated a target sample size of 26 participants in each arm (52 participants in total).

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The subjects were randomized into an experimental group (human ADM scaffold + STSG; n=26) and a control group (STSG; n=26). The randomization was accomplished by using sequentially numbered, opaque, sealed envelopes, which were generated randomly by the

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statistician before enrollment to avoid selection bias. Clinical physicians or study nurses

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enrolled participants. Surgical procedure

In both groups, all the patients received standard care for DFUs before operating, including patient education, systemic glucose control, off-loading, keeping a moist environment through dressing change, debridement, infection control, local wound care and adequate circulation.35,36 In the experimental group, surgical procedures were performed as followings. Wounds were debrided and thoroughly irrigated. All necrotic or infected tissues were removed until 6

ACCEPTED MANUSCRIPT normal tissues were visible (Fig. 2A). Normal tissues are herein defined as the absence of obvious necrosis tissues or desiccation, with fresh bleeding.37 Hemostasis was achieved with bipolar electrocautery (Covidien, Mansfield, MA). Commercialized human allograft ADM was purchased from Jie-Ya Life Tissue Engineering

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(Beijing, China),29 which was approved by the Chinese State Food and Drug Administration for transplantation. ADM was implanted onto the debrided wounds as a scaffold and covering (Fig. 2B). Vaseline gauze (Jelonet®; Smith & Nephew Medical, Hull, UK) was used as the

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primary dressing, placed directly over the ADM, and the wound was bandaged with sterile bolster dressing. The secretions and blood in the wound beds were cleared away.

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On postoperative day 3, we first changed the dressing to assess the adhesion of ADM and wound condition of granulation tissue. The dressing was changed every two days until the wound bed showed healthy, well-vascularized granulation, at which time the STSG was performed. For all of the subjects, wounds were completely redebrided to remove crusts and

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nonviable tissue at the time of skin grafting, and a wound swab culture was also obtained at this time. The interval between these two surgeries was 13.9±3.1 days. After curettage and ADM (Fig. 2C), we measured the recipient site and harvested

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razor-thin sheet skin autografts matching the wound size (0.25-0.30 mm) with a Zimmer

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dermatome (Zimmer Orthopaedic Surgical Products, Dover, Ohio) from the anterolateral side of uninjured thighs, and then implanted onto the wound (Fig. 2D). The edge of the autografted skin was shaped to form a closed and continuous junction, and secured with suture or medical adhesive glue (Guangzhou Baiyun Medical Adhesive, China). The wound was bandaged with Vaseline gauze as primary dressing and pressure bandages (Nylexogrip; Laboratories Urgo, Chenover, France). The control group received traditional STSG. Briefly, after wound debridement and the cessation of bleeding, we measured the recipient size and harvested razor-thin sheet skin 7

ACCEPTED MANUSCRIPT autografts matching the wound size (0.25-0.30 mm) with a Zimmer dermatome from the anterolateral side of uninjured thigh, and then implanted onto the wound. The edge of the autografted skin was shape to form a closed and continuous junction, and further secured with sutures or medical adhesive glue. The wound was bandaged with Vaseline gauze as

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primary dressing and pressure bandages. Postoperative care

The affected lower extremities were elevated to keep them from bearing weight, and standard

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care was performed to keep them clean. We changed the dressing at post-graft day 5, to evaluate the skin graft, and then changed the dressing every 2 days until complete wound

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closure. Vaseline gauze was used as the primary dressing, and then conventional dressings were used after every observation. Pressure garments were prescribed for the patients for ≥3 months after wound healing. At weeks 2, 4 and 8 after grafting, wound closure was evaluated, and complications such as hematomas, liquefaction, necrosis and infection were noted.

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Patients were followed for 12 months after grafting surgery to estimate the physical appearance, quality of healing and recurrence rate (Fig. 2E, F). Evaluation of wound healing

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The primary endpoint for efficacy was the incidence of ulcer recurrence at the 12-month post-grafting follow-up. Secondary endpoints of the study consisted of the quality of

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autografted sites evaluated by Manchester Scar Scale (MSS),38 with total scores from 5 (best) to 18 (worst) for color, margins, contour, texture and appearance. Also included as secondary endpoints were; the percentage of subjects who achieved complete wound healing by weeks 2, 4 and 8 post-grafting (i.e., full re-epithelialization without any requirement for dressing),39 time to achieve complete wound closure, and treatment-related complications. Independent assessments were made by two experienced surgeons who were blinded to the treatment groups. Serial wound images were captured with a digital camera and were reviewed 8

ACCEPTED MANUSCRIPT separately by a blinded expert in wound care. Statistical analysis All data were analyzed based on intention-to-treat (ITT). Continuous demographic variables are presented as mean ± standard deviation, and one-way analysis of variance was used to

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determine statistical significance when data were normally distributed. Pearson’s chi-square analysis was used to compare categorical information. Kaplan–Meier survivorship analysis (product limit plot) was used to assess wound healing according to the rate of complete

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wound closure without regrafting or amputation. The log rank test was used to identify significant differences between survival curves. As appropriate, the rate of complete wound

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closure and the complications rate between the two groups were analyzed by chi-squared or Fisher’s exact tests. In addition, MSS scores are presented as median (interquartile range) values and analyzed by Mann-Whitney U method. All the data were analyzed using the SPSS 16.0 statistical software (IBM, Armonk, New York, USA). The level of significance was p

RESULTS

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<0 .05 (two sided).

Fifty-six patients were enrolled in this prospective study between September 2010 and

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November 2013. Three patients did not meet the inclusion criteria and one declined to

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participate: all four patients were deemed screen failures. The remaining fifty-two patients underwent randomization. Two patients did not receive treatments and one patient was lost during follow-up, but all patients were included in the ITT analysis (Fig. 1). Demographics, duration of diabetes, wound duration, ankle brachial indices (ABIs), wound inducement, location and size, the outcomes of treatment and clinical follow-up data were shown in the Table 1. The 2 groups were comparable in age, gender, diabetic duration, wound duration, ABIs, and wound inducement, location and size. Thirty-two male and twenty female patients were 9

ACCEPTED MANUSCRIPT included with the mean age was 64.0 years (range 41 to 88 years), 66.6±12.7 years (range 41 to 83 years) in experiment group and 61.7±12.1 years (range 41 to 88 years) in control group, respectively. The wound size of all the patients was 27.7 cm2 (range 5 to 112 cm2), specifically, 32.1 ± 22.2 cm2 in the experimental group and 28.6 ± 25.2 cm2 in the control.

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Overall, pressure was the predominate cause of wound inducement, that is 24 of 52 (46.2%). The Plantar was the predilection site (14 of 52 [26.9%]) in both groups.

The recurrence rate during the follow-up period was significantly lower in the

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experimental group compared with the control group (1 of 23 [4.3%] vs 5 of 22 [22.7%]; p = 0.02). Patients with recurrence underwent secondary surgical interventions. The median

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(interquartile range) MSS scores were lower in the experimental group (9 [8, 10.25]) than the control group (11 [10, 12]; p = 0.006; Fig. 3).

At weeks 2, 4, and 8 post-grafting, the rates of complete wound closure in the experimental group were 46.2%, 69.2%, and 88.5%, respectively, which were not

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significantly different from those of the control group (61.5%, 76.9%, and 84.6%) at each timepoint (p > 0.05; Fig. 4). At weeks 2 and 4, the Kaplan-Meier median estimate for the time of complete wound closure of the 2 groups were comparable (p = 0.053 and p = 0.096,

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respectively), and were also similar at 8 weeks (experimental, 17 [95% CI 13.7 to 20.3];

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control 13 [95% CI 11.7 to 14.3]; p = 0.20, Fig. 5). Except for the 3 patients who withdrew, in the experimental group the patients who did not achieve complete wound closure by week 8 received regrafting. In the control group, one patient received amputation and 2 patients were regrafted. The 2 groups were similar with regard to the incidence rates of post-grafting complications such as hematoma, infection, liquefaction, and necrosis (experimental, 38.5%; control, 26.9%; p=0.38; Table 2). No patient in the experimental group experienced a rejection response to ADM, and the 10

ACCEPTED MANUSCRIPT graft area showed no obvious pigmentation; graft margin scars were inconspicuous (Fig. 2E, 2F). DISCUSSION The purpose of this prospective study was to compare the effectiveness of STSG with or

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without human ADM scaffold on wound healing in DFUs. The combination of human ADM scaffold and STSG (experimental group) achieved a significantly lower recurrence rate and better quality of healing in treating DFUs, compared with the traditional STSG treatment

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(control group). The autografted sites of the experimental group had a better appearance with lower MSS scores. In addition, the two treatments were statistically comparable on safety

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assessment. These results confirmed that the combination of human ADM scaffold and STSG provide a safe and effective treatment for repairing DFUs.

In this study, we found that although the healing rate of experiment group was no different from the control group, 8 weeks after grafting there was a trend in the experimental

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group toward an improved rate of healing. ADM retains the three-dimensional structure of extracellular matrix and its effective constituents. The latter include hyaluronic acid, proteoglycans, fibronectin and other matrix related factors such as basic fibroblast growth

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factor and transforming growth factors.37 These facilitate angiogenesis and migration of

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keratinocytes, melanocytes and other cell types to provide the ideal microenvironment for wound repair. In addition, they provide an efficient structure for cell adhesion, proliferation and differentiation.21 ADM meets the requirements of wound bed preparation, changing the pathological healing into physiological healing and creating an optimal wound-healing microenvironment.40 Therefore, ADM facilitates granular tissue formation and creates a suitable recipient wound bed for the following skin graft. In the present study when skin grafting was performed, the local wound environment induced dermal regeneration and facilitated the adoption of the graft skin. In the early stage, ADM is considered a foreign body 11

ACCEPTED MANUSCRIPT and may affect survival of the graft and thus the healing rate. Nevertheless, ADM creates a better wound bed microenvironment, increasing the healing rate in the later stage. This may explain the trend towards a higher healing rate in the group given the combination of ADM and STSG.

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Another important advantage of composite skin grafting is that ADM as the scaffold in the wound bed does not need to be removed during the second operation, but can continue to facilitate wound healing and skin graft acceptance. This differs from other heterogeneous

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dermal matrices, such as some bioengineered grafts, which are xenografts and have been shown to induce an inflammatory reaction in both animal models and in humans,41,42 and

directly composite skin graft.

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which, due to the particularity refractory diabetic wound, lowers the healing rate of the

The elastic fiber structure of the ADM has excellent resilience for prevention of scar formation.43 At the same time, the ADM has significant hemostatic properties and thus may [18]

. Indeed, there were only two

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reduce the risk of hematoma formation under grafted skin patients with hematoma formation in the experiment group.

Skin autografting on the top of an ADM scaffold could enhance mechanical strength and

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provide a suitable thickness graft skin without increasing complications.44 This could help

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with mobilization of patients. From the findings in our study, the pressure and excessive friction of all the subjects accounted for 46.2% (24/52) and 32.7% (17/52) respectively, and together, are cumulatively 78.9%. Thus, the skin graft area showed better abrasion resistance and lower recurrence in our study. In this study, the postoperative dressing protocol in the patients is to apply an ointment-impregnated gauze to the graft site, followed by treatment with pressure garments such as negative-pressure wound therapy (CuraVAC system, 100-125mmHg) and pressure bandaging applied to the graft site.45 In fact, appropriate pressure on the graft site is necessary 12

ACCEPTED MANUSCRIPT for the survival of grafted skin, and pressure garments did not appear to cause any severe ischemic complications despite possible arterial insufficiency. One potential issue that may limit the application of the combined grafting method is that the two procedures prolong the recovery process compared with STSG alone, and two

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operations also increase the financial burden for patients. However, the first stage is similar to debridement surgery, and is not significantly expensive. In order to obtain better treatment outcomes, it is acceptable that a little longer time is needed to prepare the wound.

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CONCLUSIONS

In summary, combining STSG on top of an ADM scaffold surgery is a safe, effective and

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favorable option for treating DFUs. It may improve the quality of life of patients with DFUs by reducing the risk of amputation and recurrence. Acknowledgements

The authors thank Yuan-ting Liu M.D. from the School of Public Health of Sun Yat-sen

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University of China for her support in randomizing patients and statistical analyses.

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http:

//www.fda.gov/downloads/Drugs/GuidanceComplianceRegulatoryInformation/Guidance s/ucm071324.pdf 17

ACCEPTED MANUSCRIPT 40. Schultz GS, Sibbald RG, Falanga V, et al. Wound bed preparation: a systematic approach to wound management. Wound Repair Regen 2003;11(Suppl 1):S1-S28. 41. Malcarney HL, Bonar F, Murrell GA. Early inflammatory reaction after rotator cuff repair with a porcine small intestine submucosal implant: a report of 4 cases. Am J Sports

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Med 2005; 33: 907–911.

42. Zheng MH, Chen J, Kirilak Y, et al. Porcine small intestine submucosa (SIS) is not an acellular collagenous matrix and contains porcine DNA: possible implications in human

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implantation. J Biomed Mater Res B Appl Biomater 2005; 73: 61-67.

43. Cuono C, Langdon R, McGuire J. Use of cultured epidermal autografts and dermal

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allografts as skin replacement after burn injury. Lancet 1986; 1: 1123-1124. 44. Campbell KT, Burns NK, Ensor J, et al. Metrics of cellular and vascular infiltration of human acellular dermal matrix in ventral hernia repairs. Plast Reconstr Surg 2012; 129: 888–896.

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45. Yi JW, Kim JK. Prospective randomized comparison of scar appearances between cograft of acellular dermal matrix with autologous split-thickness skin and autologous split-thickness skin graft alone for full-thickness skin defects of the extremities. Plast

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Reconstr Surg 2015;135(3): e609- e616

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ACCEPTED MANUSCRIPT Table 1. Patient Demographics and Wound Characteristics Control group (n=26)

p Value

66.6±12.7

61.7±12.1

0.740

15/11

17/9

0.569

HbA1c, %, mean±SD

9.8±1.5

10.2±1.1

HbA1c, mmol/mol, mean±SD

84±4.5

88±4.3

Sex, male/female, n

Type of diabetic (I/II), n

0/26 15.0±8.7

Wound duration, weeks, mean±SD

29.4±41.7

ABIs, mmHg, mean±SD

1.0±0.2

Inducement, n (%) Pressure Excessive friction

0.535

25.0±33.9

0.470

0.9±0.2

0.438

13 (50.0)

11 (42.3)

9 (34.6)

8 (30.8)

4 (15.4)

5 (19.2)

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Traumatic Unknown

11.8±7.8

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Diabetic duration, y, mean±SD

0 (0)

2 (7.7)

6 (23.1)

4 (15.4)

7 (26.9)

6 (23.1)

7 (26.9)

7 (26.9)

Forefoot

2 (7.7)

5 (19.2)

Heel

4 (15.4)

4 (15.4)

32.1±22.2

28.6±25.2

Locations, n (%)

Dorsum

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Ankle

Size, cm2, mean±SD

0.273

0/26

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Age, y, mean±SD

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Experiment group (n=26)

Characteristic

0.638

0.811

0.566

ABIs, ankle brachial indices

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ACCEPTED MANUSCRIPT Table 2. Complication Analysis

Complication

Experiment group (n=26)*

Control group (n=26) †

%

n

%

Infection

2

7.7

3

11.5

Hematoma

2

7.7

1

Liquefaction

3

11.5

2

Necrosis

5

19.2

2

Overall

10

38.5

3.8

1.0

7.7

1.0

7.7

0.42

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*

1.0

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n

p Value

7

26.9

0.38

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One patients had two complications and six had one complication. Fisher’s exact test.

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2 patients had 2 complications and 8 had 1 complication.

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ACCEPTED MANUSCRIPT Figure Legends

Figure 1. CONSORT flow diagram.

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Figure 2. A 60-year-old male patient with diabetic foot ulcer. (A) A large (approximately 72 cm2), 126 week-old diabetic foot ulcer on the dorsum of the left foot. (B) Wound debridement and acellular dermal matrix scaffold covered. (C) Ten days after acellular dermal matrix

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sheet. (E) Postoperative month 3 and (F) month 33.

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scaffold covered and prepared for skin graft. (D) Grafting of split-thickness autologous skin

Fig 3. Manchester Scar Scale (MSS) score differences in the experimental and control groups by Mann-Whitney U analysis. (p=0.006)

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Fig 4. Patients achieved complete wound closure in post-grafting week 2, 4, and 8 between experiment (ADM skin) and control groups. There was no significant difference in the incidence of complete wound closure at any of the time points between the two treatment

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groups. ADM, acellular dermal matrix

Fig 5. Kaplan–Meier estimates of time taken to achieve complete wound closure in acellular dermal matrix (ADM) skin and control groups within 8 weeks (p =0.20, log-rank test).

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ACCEPTED MANUSCRIPT Precis This trial compared clinical outcomes of using conventional STSGs with and without an accompanying acellular dermal matrix (ADM) in diabetic foot ulcer treatment. The results showed that composite split-thickness skin grafting with ADM provide an effective method to

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treat diabetic foot ulcers with lower recurrence rate and better physical attributes.

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