CRITICAL REVIEW

Use of Placental Membranes for the Treatment of

Chronic Diabetic Foot Ulcers
Jonathan N. Brantley* and Thomas D. Verla
Department of Surgery, Hunter Holmes McGuire VA Medical Center, Richmond, Virginia.

Jonathan N. Brantley, DPM

Significance: Chronic diabetic foot ulcers (DFUs) remain a challenge for physi-cians to
treat. High mortality rates for DFU patients have pointed to the low effectiveness of standard
care and lack of quality wound care products. The composition (collagen-rich tissue matrix
and endogenousgrowth factorsand cells) and functional properties (anti-inflammatory, anti-
bacterial, and angiogenic) of placental membranes are uniquely suited to address the needs of
chronic wounds. This led to the commercialization of placental membranes, which are now
widely available to physicians as a new advanced wound treatment option.

Recent Advances: Progress in tissue processing and preservation methods has facilitated
the development of placental products for wounds. Currently, a variety of commercial
placental products are available to physicians for the treatment of chronic DFUs and other
wounds. This review summarizes the key factors that negatively impact DFU healing
(including social factors, such as smoking, vas-cular deficiencies, hyperglycemia, and other
metabolic abnormalities), describes the structure and biology of placental membranes, and
overviews commercially available placental products for wounds and data from the most
recent DFU clinical trials utilizing commercial placental membranes.

Critical Issues: Although the effects of diabetes on wound healing are complex and not
fully understood, some of the key factors and pathways that interfere with healing have been
identified. However, a multidisciplinary approach for the as-sessment of patients with chronic
DFUs and guidelines for selection of appro-priate treatment modalities remain to be
implemented.

Future Directions: The biological properties of placental membranes show bene-fits for
the treatment of chronic DFUs, but scientific and clinical data for com-mercially available
placental products are limited. Therefore, we need (1) more randomized, controlled clinical
trials for commercial placental products; (2) studies that help to understand the timing of
placental products’ application and criteria for patient selection; and (3) studies comparing
the functional properties of different commercially available placental products.
Submitted for publication January 23, 2015.
Accepted in revised form March 23, 2015.

*Correspondence: Hunter Holmes McGuire

VA Medical Center, 1201 Broad Rock
Boulevard, Richmond, VA 23249
 To clarify the with readers a tifies and corrects
factors and success- such factors in each
path- patient.
waysnegatively
SCOPE AND SIGNIFICANCE
affectingwound To describe the
healing in fully implemented structure and
The scope of this review is: diabetic patients patient as-sessment relevant wound
and to share algorithm that iden- healing proper-
nc/4.0/) n in any ADVANCES IN
which medium, WOUND
ª Jonathan N. Brantley and Thomas D. CARE, DOI: 10.1089/wound.2015.0634
permits any provided the
Verla 2015; Published by Mary Ann VOLUME 4,
noncommer original NUMBER 9
Liebert, Inc. This Open Access article is
cial use, author(s) and
distributed under the terms of the
distri- the source are
Creative Commons Attribution
Noncommercial License
bution, and credited.
reproductio j 545
(http://creativecommons.org/licenses/by-
546 BRANTLEY AND VERLA
multidisciplinary a chronic wound
approaches for the presents.
assessment of
ties of placental diabetic patients DISCUSSION
membranes, including and implementation
amnion (AM) and chorion of DFU pre-vention Assessment of
(CM), highlighting key programs remain to factors preventing
sim-ilarities and be established. DFUs from healing
differences between them. DFUs are often
resistant to wound When addressing
therapies due to the chronic wounds,
To provide a classification
com-plicated there are multiple
of current com-mercial
diabetic wound factors that need to
placental membrane
environment that is be taken into
products and to review
charac-terized by consid-
available clinical data.
hyperglycemia,
hypoxia, and high
TRANSLATIONAL levels of proteases,
RELEVANCE bacterial antigens,
reactive oxygen eration. The
According to the American spe-cies, and algorithm for
Diabetes Association, there inflammatory assessment of high-
are currently 29.1 million cytokines. risk DFUs is
Americans with type II Scientists can uti- presented in Figure
diabetes, which represents lize current 1. A high-risk DFU
9.3% of the population.
1 knowledge is an ulcer
regarding key characterized by
Diabetic foot ulcers
factors and neuropathy and
(DFUs) are the most
micro-angiopathy.
common complication of pathways that
Patients with high-
diabetes, with an annual interfere with
risk DFU have the
incidence of 1–4% and a healing for the
devel-opment of potential to heal,
lifetime risk of 15–25%.2–4 but an assessment
novel wound
The annual cost for treating of all the com-
products that will
DFUs is estimated to be ponents on the
be able to correct
between $9 billion and $13 algorithm chart
an abnormal
billion, which puts an must be evaluated
diabetic wound
enormous fi-nancial burden for selection of the
5 environment.
on our society. It is clear right treatment
that dia-betes has negative modalities. A
effects on wound healing. description of the
CLINICAL key assessment
All diabetic patients should
be assessed for risk factors RELEVANCE parameters in-
predictive of DFUs with cluded in the
the main goal of preventing Nonhealing DFUs algorithm (Fig. 1)
DFU development and represent a serious and their influence
recurrence. The key risk medical problem. on wound healing
fac-tors of DFUs include Although multiple is provided below.
social factors, such as advanced treatment For more de-tails,
smoking and obesity; direct modalities are three books
factors, such as foot available, wound dedicated to wound
deformities; and indirect closure rates for healing and factors
factors, such as neuropathy, such wounds that can
peripheral arterial diseases, remain low. compromise it are
venous stasis diseases, and Commercial recommended.6–8
other underlying placental products
conditions. However, that are now
Neutrophils and
attempts to prevent DFUs available have the monocytes. A
often fail. This clearly potential to address
the challenges that complete blood
indicates that better count (CBC) test
with a differential panel is utilized. Antibiotics
critical for evaluating the are required to ad-
patient’s neutrophil and dress cellulitis.
mono-cyte levels. When a Cadexomer iodine
chronic wound is in the in- has been shown to
flammatory phase, often be efficacious in Social factors.
Social factors, such
both the neutrophil and the the disruption of
monocyte counts are glycocalyx in as alcohol and drug
elevated. Neutrophils are biofilm. Wounds abuse, poor
the first responders not with obvious personal hygiene,
only to the infection but denatured ECM and tobacco abuse,
also to the presence of must be debrided at are among key risk
necrotic tissue that must be both macroscopic factors that not
removed from the wound. (sharp sur-gical) only predict
Monocytes/macrophages and microscopic development and
respond to the same (enzymatic) levels. recurrence of DFUs
inflammatory stimuli. They Exoge-nous but also predict
are involved in clearance of enzymatic poor wound
apoptotic neutrophils and debridement using closure.9 Patient’s
denatured collagen, and biologics, such as educa-tion is an
they serve as a source of Santyl important step in
growth factors and pro- and (collagenase) reducing or
anti-inflammatory eliminating the
(Healthpoint, Fort
cytokines. In general, negative effects of
Worth, TX), have
elevations in the social factors for
been proven to be
differential panel are prevention and
both safe and
observed in response to successful
effica-cious. In the
cellulitis, the presence of event of wound treatment of DFUs.
biofilm and denatured All patients with
periphery
extracellular matrix diabetes are
maceration, a
(ECM), and maceration required to have
topical zinc oxide
around the pe-riphery of paste can provide primary care
the wound. An appropriate the desired drying provider
strategy to combat the supervision of their
effect.
aforementioned clinical medical condition
pathologies should be and
PLACENTAL MEMBRANES FOR CHRONIC DFUS
547
Figure 1. Treatment algorithm for the
assessment of high-risk DFU patients. This
algorithm was developed and implemented at the
Hunter Holmes McGuire VA Medical Center. The
algorithm is based on our current understanding
of key factors that can impair wound healing. All
patients with high-risk DFUs, which are
characterized by neuropathy and
microangiopathy, undergo screening before
selection of wound treatment modalities. The
purpose of this algorithm is for the
standardization of wound treatment and the
improvement of clinical outcomes. ABI, ankle-
brachial index; ABG, arterial blood gases; APSV,
ankle peak systolic velocity; BMP, basic metabolic
panel; C&S Punch Biopsy, culture and sensitivity
punch biopsy; CBC w Diff., complete blood count
with differential; CRP, C-reactive protein; DFU,
diabetic foot ulcer; ECM, extracellular matrix;
HgA1C, hemoglobin A1C; IR, interventional
radiology; LR, lactated ringers; MRI, magnetic
resonance imaging; OM, osteomyelitis; ORC,
oxidized regenerated cellulose; PDGF-BB,
platelet-derived growth factor-BB; Phase ID,
phase identification; PRFE, pulsed radio
frequency energy; PTH, parathyroid hormone;
TBI, toe-brachial index; TCC, total contact cast.
548 BRANTLEY AND VERLA
affect healing and viscosity, cellular
should be aging, and
12 increased platelet
avoided.
referrals to appropriate ag-gregation with a
specialists in a timely relative decrease in
manner. Among the the chemotac-tic,
aforementioned social phagocytic, and
Biochemistry and lysosomal activity
factors, tobacco abuse metabolic panels.
especially has a direct of cells. The effects
Biochemi-stry and are both micro- and
negative im-pact on wound metabolic panels
healing at cellular and macrovascular in
make possible the nature, but
molecular levels and mon-itoring of key
should be addressed. It is factors in patients’ microvascular
known that smoking disease may be
serum to control more critical when
doubles the complication fluctuations that
rate for patients undergoing impact wound considering the
surgery compared to that of healing. The panel chronicity of
10 wound healing. A
nonsmok-ers. Smoking referenced in hemoglobin A1c
increases the level of Figure 1 provides a test provides a
carbon mon-oxide bound to comprehensive list clinician with the
hemoglobin, thereby of critical factors, knowledge of long-
decreasing the red blood and the text below term glycemic
cells’ capacity to deliver provides a detailed control. Elevated
oxygen. The combustion description for each
product of tobacco not only factor.
has vaso-constrictive
properties but is also an
irritant to the lumen of the Glucose and hemoglobin A1c
arterial system and causes a hyperglycemia. has a negative
rebound inflammatory impact on wound
Patient’s fasting healing rates.
response.11 In addition, and nonfasting Elevated
smoking in-hibits glucose levels can hemoglobin A1c is
migration and proliferation be monitored by indicative of
of keratinocytes and the basic metabolic endothelial
fibroblasts and induces panel. dysfunctions
neutrophil and monocyte Hyperglycemia has comprising nerve
oxidative burst leading to a detrimental effect sen-sation
prolonged inflammation. on wound healing. abnormalities,
Prolonged inflammation It damages the capillary
delays collagen synthesis, endothelium of proliferation, pre-
and a lack of collagen blood vessels capillary fibrosis,
deposition leads to poor resulting in altered proteinase
tensile strength. Clinically, blood flow, activation, reactive
cigarette smoking is known increases vascular oxygen
to be associated with permeability, metabolites, and
delayed healing, wound changes vascular fibrin deposition.
infection, and dehiscence. growth factor
12
All to-gether, these
Smoking cessation must be expression and events trigger tissue
en-couraged to avoid delay leukocyte/ breakdown.
13
of wound healing. Patients monocyte adhesion, Lowering
should be counseled on the and eventually hemoglobin A1c
evidence that even short- triggers vascu-lar levels is important
term smoking cessation occlusion.
for successful
will improve wound heal- Hyperglycemia wound treatment.
leads to basement
ing.12 Nonsmokers with Interestingly, recent
membrane
wounds should be also thickening in data show that high
counseled that second-hand capillaries, levels of
smoke may negatively increased blood hemoglobin A1c do
not affect the activity of reservoirs of proteins and cell
advanced wound products intracellular membrane proteins.
con-taining living cells, antioxidants, such Third, released
supporting the use of such as reduced glu- AGE pre-cursors
products for these tathione. This modify circulating
14 decreases the blood proteins,
patients.
body’s ability to such as albumin.
Hyperglycemia impairs com-bat oxidants Complexes
wound healing by ab- and increases between AGEs and
normal activation of four susceptibility to blood proteins will
main biochemical mech- intracellular interact with AGE
anisms: (1) the polyol oxidative stress. receptors on cells
pathway, (2) formation of leading to
advanced glycation end pathological
products (AGEs), (3) the Hyperglycemia increases in
protein kinase C (PKC), triggers the inflammatory
and (4) the hexosamine formation of intra- cytokines and
pathway (Fig. 2). The main cellular AGE growth factors
enzyme of the polyol precursors, which released by macro-
pathway is aldose damage the cells by phages and other
reductase, which converts several cells, which in turn
excess glucose into sorbitol mechanisms. First, cause vas-cular
leading to osmotic stress on AGE precursors pathology.
cells. Osmotic stress bind to intracellular
induces alterations in the proteins
in-ternal cellular structures (transcription Hyperglycemia also
and arrangement of factors), lip-ids, leads to
chromatin, as well as and nucleic acids hyperactivation of
potential changes in the nu- that negatively PKC through an
clear membrane affect intra-cellular increased synthesis
influencing gene molecule of diacylgly-cerol.
transcription and functionality. PKC changes gene
nucleocytoplasmic Second, AGE expression leading
15
transport. During sorbitol precursors are to a decrease in
formation, aldose reductase released from cells endothelial nitric
utilizes high amounts of and then bind to oxide synthase and
nicotinamide adenine ECM proteins and a simultaneous
dinucleotide phosphate modify their increase in
(NADPH), which is function, thereby endothelin-1 (ET-
required to maintain disrupting signaling 1),
between matrix
PLACENTAL MEMBRANES FOR CHRONIC DFUS
549
Figure 2. Effects of hyperglycemia on wound healing. Hyperglycemia impairs wound healing by
four main biochemical mechanisms: (1) prolonged activation of the polyol pathway, (2) excessive
formation of advanced glycation end products, (3) hyperactivation of PKC, and (4) increased
activation of the hexosamine pathway. The consequences of the abnormal hyperactivation of these
pathways include vascular abnormalities, changes in gene expression and functionality of proteins,
and osmotic and oxidative stress, all of which have negative effects on wound healing. DAG,
diacylglycerol; ECM, extracellular matrix; eNOS, endothelial nitric oxide synthase; ET-1, endothelin-
1; GSH, glutathione; NADPH, nictotinamide adenine dinucleotide phosphate; NF-jB, nuclear factor-
kappaB; PAI-1, plasminogen activating factor inhibitor-1; PKC, protein kinase C. TGF-b,
transforming growth factor-beta; UDP, uridine diphosphate; VEGF, vasular endothelial growth factor.
To see this illustration in color, the reader is referred to the web version of this article at
www.liebertpub.com/wound
multiple tissues and
effects, delays wound
thereby causing microvascular including cell healing.
blood flow abnor-malities. It damage and in- Normally,
upregulates vascular endothelial creased intracellular
growth factor (VEGF) to levels that leukocyte glucose is
induce vascular per-meability. PKC- adhesion to the metabolized
induced expression of transforming endothelium, through
growth factor (TGF)-b leads to thus glycolysis, in
increased collagen and fibronectin compromising which
formation causing capillary occlu- functionality of fructose-6-
sion by thickening the basement the endothe- phosphate is
membrane. lial barrier. one of the
intermediates.
A PKC-mediated increase in However,
plasminogen acti-vating factor Activation of excess glu-
inhibitor-1 (PAI-1) inhibits fibrino- the cose triggers
lysis that leads to vascular hexosamine conversion of
occlusion. Activation of PKC also pathway repre- fructose-6-
causes an increase in nuclear factor- sents another phosphate to
kappa b (NF-jb) that triggers the mechanism by glucosamine-
expression of proinflammatory which 6-phosphate
cytokines. Additionally, there is an hyperglyce- and finally to
increase in NADPH oxidases UDP (uridine
resulting in high levels of reactive diphosphate)
oxygen species, which have N-
mia damages
acetylglucosam
ine by the enzyme occlusion. hydration and
glutamine:fructose-6-phosphate Biochemical albumin/preal
amido-transferase. N- path-ways bumin.
acetylglucosamine modifies serine affected by
and threonine residues of hyperglycemia The basic
transcription factors resulting in are overviewed metabolic
pathologic changes in gene expres- by Brownlee.
16
panel also
sion. For example, modification of facilitates the
the transcription factor specificity evaluation of
protein 1 results in increased the patient’s
expression of TGF-b1 and PAI-1, hydration
both of which lead to vascular Malnutrition: status by
550 BRANTLEY AND VERLA
a catabolic state levels of
consequently homocysteine
requiring an decrease clot-ting
monitoring the sodium increase in protein and provisional
level. Evidence of hy- intake. When matrix formation,
pernatremia provides treating a wound, along with a
insight into the patient’s 1.5 g of protein per diminished ability
potential to be classified as kilogram of body of cells to adhere,
dehydrated. All cells need weight is re- spread, and migrate
an aqueous environment to commended in a throughout the
maintain their function, and patient’s diet. With provisional matrix
dehydration harms cell adequate nu- to popu-late the
function and impedes tritional support, wound bed, thereby
wound healing. prealbumin levels causing a
should rise 2 mg/dL subsequent delay of
17 18
Albumin is responsible for (20 g/L) per day. healing.
the transportation of zinc, Supplementation
copper, calcium, and Homocysteine. with vitamin B6,
multiple other molecules Homocysteine is a folic acid, and
required for wound sulfhydryl- vitamin B12 should
healing. Albumin levels containing amino be used to
less than normal (3.5–5.0 acid formed during normalize
g/dL) indicate a potential the metabolism of homocysteine
state of malnutrition. methionine. The elevation.
However, since albumin normal level of this
has a relatively long half- metabolite is
life of 15–20 days, it is not usually < 12 lM.
the best indicator of An elevated Iron, copper, and
immediate nutritional homocysteine level zinc. Iron is
status. Prealbumin has been ( > 15 lM), critically impor-tant
shown to be a much better regardless of the for wound healing
predictor of malnutrition underlying cause, is in multiple ways.
due to its shorter 2-day a strong Mon-itoring the
half-life when compared to independent risk patient’s iron panel
albumin. A prealbumin factor for occlusive can give the
level less than normal (15– vascular disease. clinician relative
35 mg/dL) is indicative of Homocysteine has insight into the
a protein-malnourished a high affinity for patient’s capacity to
state and must be ad- fibro-nectin and initiate collagen
dressed. However, inhibits the synthesis and to
hydration status may affect interaction of deliver an ad-
the accuracy of albumin fibronectin with equate oxygen
and prealbumin measure- fibrin. The binding supply to the
ments. In overhydrated of fibronectin to compromised
patients, the values of al- fibrin is impor-tant tissue. Iron,
bumin and prealbumin can in thrombosis and ascorbic acid, and
be low, and conversely, in wound healing. oxygen assist in
dehydrated patients, an Tissue injury post-translational
erroneous elevation may be triggers a rapid hydroxylation of
observed. Therefore, activation of the proline and lysine
hydration level should be clotting cascade residues in newly
taken into consideration and the formation synthesized
when albumin/pre-albumin of a provisional collagen molecules.
levels are analyzed. matrix, the major Iron also plays a
components of role in the
which are fibrin activation of matrix
The presence of a wound and fibronectin. metalloproteinases
indicates that the body is in Ele-vated serum (MMPs), which is
important for ECM postreceptor bind- greater than 0.5
19 ing of insulin-like represent an
remodeling.
growth factor-1 acceptable degree
Copper is essential for the resulting in al- of arterial inflow.
activation of lysyl oxidase, terations in cell
21
However, arterial
cytochrome-C oxidase, and proliferation. pathology present
superoxide dismutase, in patients with
enzymes that are critical Vascular diabetic
for biogenesis of assessment. Poor complications
connective tissues, requires more
blood circulation is
mitochondrial electron comprehensive and
a major concern for
chain transfer, and reliable methods to
patients with
antioxidant defense, assess vascular
nonhealing DFUs.
respectively. Copper status distally in the
Several modalities
deficiency impairs the lower ex-tremity.
are available to
formation of collagen For example,
assess the level
fibrils by inhibition of noncompressible
and/or degree of
tropocollagen cross-linking vascular disease vessels as a result
performed by lysyl of the ever-present
and al-low
oxidase. Copper deficiency clinicians to select arterial
also decreases iron calcifications
the most
absorption, causes provide unreliable
appropriate in-
demineralization of bone, tervention to fluctuating values.
neutropenia, leucopenia, resolve vascular Recently, using
and failure of ankle peak systolic
problems.22 velocities has been
20
erythropoiesis. sug-gested for
Traditionally, an vascular
Zinc performs multiple ankle-brachial assessment and has
functions in the body. With index (ABI) and been con-sidered
regard to wound healing, toe-brachial index predictive for
zinc deficiency leads to (TBI) allow nonhealing
decreased epithelialization detection of periph- 23
DFUs. A cutoff
and fibroblast pro-liferation eral vascular
value of 35 cm/s
in the wound bed. Zinc is insufficiency. An
(average of velocity
an irreplaceable cofactor ABI of greater than
measured in the
necessary for the activation 0.7 with an upper
anterior and
of MMPs. Zinc also limit of less than posterior tibial
appears to be essential for 1.3 and/or a TBI of
arteries at the
PLACENTAL MEMBRANES FOR CHRONIC DFUS
551

membranes AM and CM,

continue from
Amnion and the edge of the
level of the ankle) was found to be chorion placenta and
structure enclose the
sensitive and specific in predicting
the healing potential of chronic amniotic fluid
DFUs. With the use of an arterial The placenta at and the fetus.
duplex ultrasound scan, an term is discoid The amniotic
estimation of how ‘‘fast’’ the blood in shape with a epithelium is a
is travelling to the lower extremity, diameter of single layer of
degree of perfusion, and subsequent 15–20 cm and flat, cuboidal,
diffusion in the low ex-tremity can a thickness of and columnar
be made. 2–3 cm. epi-thelial cells
Placental in contact with
membranes, the amniotic
Structure and biology of placental
fluid. The epithelium is attached to a be-tween the described
basement membrane, which in turn mother and the below. A
is connected to the amniotic meso- developing comparison of
derm. The basement membrane of fetus. Amnion amniotic and
the amnion is one of the thickest and chorion
membranes among all human tissue contain no chorionic
basement membranes. In the blood vessels membranes
amniotic me-soderm closest to the or nerves; composition
epithelium, an acellular compact instead, the and properties
layer is composed of collagens type nutrients it is summarized
I and III and fibronectin. Below the requires are in Table 1.
24–43
compact layer of the AM, a network sup-plied
of dispersed fibroblasts and mes- directly by
Extracellular
enchymal stem cells (MSCs) and diffusion out of
matrix of
rare macrophages are observed. A the amniotic
amnion and
spongy layer of loosely arranged fluid and/or chorion
collagen fibers separates the from the
amniotic and chor-ionic mesoderm. underlining
Collagens.
The spongy layer is loosely con- decidua. The
Collagens are
nected to the chorion, and the structure
the major
amnion can be easily separated from
structural
the chorion by blunt dissection. The of amnion and
component of
chorion is placental
overviewed by 33,4
Niknejad et al. membranes.
4,45
and by Parolini The tensile
et al.
24,25
The strength of
chorionic membrane consists of
microscopic placental
mesodermal and trophoblastic
membranes is
layers. A large and incomplete pseu-
pro-vided by
do basement membrane separates structure of
interstitial type
the chorionic mesoderm from the placental
I and III
trophoblast layer, which is in- membranes is
collagens
terdigitated extensively with the shown in
together with
decidua. Meso-dermal layers of Figure 3.
small amounts
amnion and chorion are similar in Placental
of type V, VI,
composition. The main function of membranes are
and VII
the amnion and mesodermal layer of composed of
collagens in
the chorion is to serve as a ECM, growth
the compact
protective barrier enclosing the fetus factors, and
layer of AM,
during in utero development. The tissue-resident
which is
major function of the tro-phoblast cells and are
layer is an exchange of substances
microscopi from the chorion. The chorion
c structure. consists of a mesodermal
The (stromal, fibroblastic) layer and
amnion is the trophoblast layer, which is
composed tightly connected to the
of a single maternal decidua. Amniotic
layer of and chorionic mesoderm
epithelial contains fibroblasts,
cells and a mesenchymal stem cells, and
mesoderm tissue macrophages. Both
al (also amnion and chorion are
called avascular tissues. Here, a
stromal or cross-sectional view of H&E-
fibroblastic) stained placental membranes
layer. A at term are shown (provided
loose by Osiris Therapeutics, Inc.,
Figure 3. spongy Columbia, MD). ECM,
Human ECM layer extracellular matrix; H&E,
amnion and separates hematoxylin–eosin.
chorion the amnion

552
BRANTLEY AND VERLA
Table 1. Properties of human amnion and chorion

Property
Amnion
Chorion
References

Physical

Thickness
111 – 78 lm
431 – 113 lm
26, 27
Max tensile force
0.166 (0.15 - 0.25 kg/cm)
0.117 (0.05 - 0.1 kg/cm)

Max tensile stress

2
30.2 kg/cm
2
5.9 kg/cm

Layers
Epithelial, basement membrane, compact,
Mesodermal, pseudo basement membrane,
24, 25

mesodermal, sponge
trophoblast

Tissue-resident cells
Epithelial cells, fibroblasts, mesenchymal
Fibroblasts, mesenchymal stem
25, 28

stem cells, macrophages

cells, macrophages, trophoblast cells

Cell number (average per placenta)

a
*20 million stromal
a
25–40 million stromal
29, 30

50–70 million epithelial

In utero function
Barrier, cover
Stromal layer-barrier, cover; trophoblast-material
25, 31
exchange, secretory

Extracellular matrix

Structural matrix
Collagens I, III, IV, V, VI, elastin
Collagens I, III, IV, V, VI, tropoelastin
24, 32
Glycoproteins
Fibronectin, laminins, nidogen
Fibronectin, laminins, nidogen
33
Proteoglycans
Chondroitin, dermatan sulfate, hyaluronan,
Chondroitin, dermatan sulfate, hyaluronan, decorin,
34

decorin, biglycan
biglycan, versican, perlican

b
Selected growth factors
EGF, HGF, TGF-b (1, 3), bFGF, KGF, NGF,
HGF, TGF-b1, TGF-a, bFGF, VEGF, PDGF, PIGF
35–37

VEGF, PDGF, PIGF, TGF-a

Mucin
Interferon a
38

Defensins
Defensins
39, 40

TIMPS, CTGF, IL-1RA

TIMP-1
37, 41

Groa, sICAM, IL-6, IL-8, MCP-1, MIF,

IL-6, IL-8, IL-4, SDF-1a, IL-10, GCSF
37, 42, 43

serpin E1, SDF-1a, IL-10, IL-4, G-CSF

a
Estimated based on 20 g and 25–40 g weight for wet amnion and chorion,
b 36
respectively. Most amniotic growth factors are also present in chorion.
form membrane of
heterotypic the amnion but
adjacent to the basement fibrils with also in the
45 type I and III pseudo
membrane. The basement
colla-gens, and basement
membrane consists mostly of type type VII forms membrane of
IV collagen, which serves as a anchoring the chorion,
scaffold for the as-sembly of its fibrils. Type IV suggesting that
other components: laminin, nidogen, collagen is type IV
and heparan sulfate. Collagen types present not collagen plays
V, VI, and VII in the compact layer only in the a role in the
are important for the strength of the basement develop-ment
amnion. Collagen types V and VI
and maintenance of the placental signaling
45 leading to
matrix. Type VI and XIV Laminins were
collagens are distributed throughout synthesis of first identified
other matrix as products of
placental membranes.45 The produc-
proteins. Fi- the human
tion of collagens is continued to bronectins are
term, and tissue-resident placental a glycoprotein amniotic
cells are important for the epithelial cells.
family derived Laminins are
maintenance of strength and for the from a single
repair of the amniochorionic present in the
33
gene, which by basement
tissue. alternative membrane, in
splicing can which sev-eral
form 20 subunits are
different linked together
Elastin and microfibrils. The fibronectin through
placental mem-branes have isoforms. disulfide
viscoelastic properties attributed to Fibronectins bonds.
the presence of elastin and have multiple Laminins are
microfibrils. Elastin is the binding encoded by
amorphous component of elastic domains for several
fibers, which is assembled from cells and different genes
precursor proteins named tropoe- various ma-trix and mediate
lastins. The soluble isoforms of proteins, which cell–matrix
tropoelastins are assembled outside stabilize the interactions. In
the cells into the insoluble elastic whole system amnion,
fiber. The cross-linking of elastin of cells and laminins
results in matrix. Most anchor the
cells can epithelial cells
adhere to to the
fibronectin basement
the formation of a fiber, which can
through its membrane and
be associated with fibrillin-based
RGD motif the basement
microfibrils. The microfibrils are
(Arg-Gly- membrane to
abundant in the mesenchymal layers
Asp). the underlying
of AM and CM as well as in the
33
Fibronectins stroma.
compact layer of the amnion. bind matrix Together with
proteins collagens,
Fibronectins and laminins. through laminins
Fibronectins have generalized collagen- and contribute to
distribution across the placental heparin- the strength of
mem-brane matrix. They play an binding the amnion.
33
important role in cell– matrix domains.
interactions, which initiate cell
PLACENTAL MEMBRANES FOR CHRONIC DFUS
553

Decorin is Decorin is
involved in present in skin.
lateral In decorin-
Proteoglycans and hyaluronan. organization of deficient mice,
Proteoglycans are composed of a collagen type I the tensile
protein core with one or more and III fibrils, strength of
attached, sulfated, which are skin is
glycosaminoglycan side chains. The important for decreased. This
placental membranes contain pre- placental supports the
dominantly smaller proteoglycans, membrane role of decorin
such as dec-orin and biglycan. tensile as a
strength. contributor to
the mechanical properties of tis- peptides (such cells have low
sues. Biglycan, another small as defensins, immunogenicit
proteoglycan, in-teracts with type neutrophil y. Therefore,
VI collagen in the pericellular gelatinase- the amnion can
matrix. In addition to structural associated be used across
roles, proteo-glycans are important lipocalin, and the hu-man
for cell proliferation and leukocyte
differentiation and perform, through cathelicidin) antigen (HLA)
the binding of growth factors, are expressed barrier II
essential functions in re-modeling in placental without
processes. For example, decorin and mem- matching
biglycan bind and inhibit TGF-b branes.
48–50 between donor
activity. The presence and recipient.
of TGF-b3, Tissue
HGF, and macrophages
Large amounts of hyaluronan (HA) are a cell type
are found in placental membranes, interleukin-10 that can
especially in the amnion. In potentially
contributes to trigger an
addition, HA is a major the anti-
carbohydrate component of the immune
scarring ac- 53
ECM that is present in skin, joints, tivity of reaction.
and Wharton’s jelly in the umbilical placental However, the
cord. HA provides mechanical num-ber of
membranes.51,5
support and interacts with different 2 tissue-resident
34 macrophages is
growth factors. High-molecular-
weight HA con-tributes to the anti- low, and there
inflammatory and anti-scarring are no reports
properties of placental membranes, of adverse
and recently, it has been reported Tissue- events linked
that HA also serves as a free radical resident to the presence
amniotic and of tissue
scavenger.46,47
chorionic cells macrophages
in placental
Placental membrane growth mem-branes.
factors Amnion
contains The chorion
epithelial cells consists of two
Accumulated data indicate that in layers: mesen-
that are at-
addition to ECM, placental growth chymal and
tached to the
factors play an important role in trophoblast.
basement
supporting wound healing. Different The structural
membrane and
growth factors are identified in the and cellular
form the
amnion and chorion. This list composition of
epithelial layer.
includes, but is not limited to, the
The cellular
epidermal growth factor, basic mesenchymal
composition of
fibroblast growth factor, platelet- layer of the
the
derived growth factor, VEGF, chorion is
mesenchymal
hepatocyte growth factor (HGF), similar to the
layer of the
TGF-b, and keratinocyte growth mesenchymal
35
amnion
factor. These multifunctional includes fibro- layer of the
growth factors support migration, blasts, MSCs, amnion.25
proliferation, and dif-ferentiation of and a small Fibroblasts,
fibroblasts, endothelial cells, and amount of MSCs, and
epithelial cells, which are involved tissue mac- rare macro-
in granulation tissue formation, new rophages. phages are
blood vessel formation, and Neonatal present in the
reepithelialization of wounds. In fibroblasts, mesenchymal
addition, anti-inflammatory factors epithelial cells, layer of the
(such as interleukin-10, in-terleukin- and chorion. The
1 receptor antagonist, and mesenchymal trophoblast
prostaglandin E2) and antibacterial
layer of the chorion has a different membranes predominantly
structural matrix composition: the remains to be used for the
main cell population in it is investigated, treatment of
trophoblast cells, the im- accumulated burns, and the
munogenicity of which is not clear data suggest reported use of
and remains to be addressed. This that the
31 amnion
may explain common clinical use of presence of
the amnion and rare use of the MSCs in for chronic
chorion. wound care ulcers was
products may limited to a
provide addi- few case
tional benefits. studies,
MSCs are present in all tissues in
the body, including skin, and data especially for
58–60
indicate that MSCs are important for DFUs.
Commercial With progress
cutaneous wound healing.49 A de- placental
crease in MSC number and made in the
membrane field of tissue
functionality with aging and products
diseases can explain the reduced pro-cessing
heal-ing potential in older patients The use of and
with type II diabe-tes and other preservation
54,55
placental methods, more
underlying conditions. Animal membranes for than 25
and clinical studies demonstrate the wound healing different
benefits of exogenous MSC use for has been commercial
nonhealing wounds.56 Both amnion reported for placental
and chorion are a rich source of over 100 membrane
30 57
young, potent MSCs. Although the years. products
contribution of MSCs to the wound However,
healing activities of pla-cental amnion was
554 BRANTLEY AND VERLA
are available at the present
time as a modality for
chronic wound treatment.
Preservation of placental
membranes allows for a
prolonged storage time
sufficient for full testing of
donors and final products
for communicable diseases
and makes preserved
placental mem-brane an
‘‘off the shelf,’’ available
on demand product.
However, different
processing methods may
impact the composition and
functionality of placental
membranes to varying
41,61
degrees. Most
placental membrane
products contain no viable of clinical data at
cells. They are either
dehydrated or
cryopreserved with
devitalized or
decellularized tissue.
Grafix Prime (amnion) and controlled clinical
Core chorionic
mesenchyme (Osiris
Therapeutics, Inc.,
Columbia, MD) are the
only commercial placental companies’
membrane products in the marketing materials
market that preserve both and/or website.
the structural and cellular
integrity of the amnion and
the chorion and can be
considered a true
alternative to fresh
placental membranes. A
summary of the main
commercially available
placental membrane prod- commercially
ucts is presented in Table 2. available placental
Clinical experience with
commercial placental
membrane products
Placental membranes are
regulated as human cells,
tissues, or cellular or
tissue-based EpiFix, which is a
products (HCT/P) dehydrated
under 21 CFR part amniochorion, also
1271, Section 361 called dHACM. In
of the Public total, 12 patients
Health Services were treated in
(PHS) Act. In these studies who
contrast to drugs had chronic
and devices, tissue wounds with a
allografts do not wound age > 4
require premarket weeks and of
approval, allowing various etiology. Of
for a faster 12 patients, 4 had
regulatory pathway surgical
to the market. dehiscence, 3
However, the patients had
common downside neuropathic DFUs,
of tissue allografts and 5 other patients
including placental had ve-nous leg
ulcers (VLU),
scleroderma, snake
bite, or traumatic or
membrane arterial
insufficiency
allografts is a lack
wounds.62–64
the time of
marketing. Most Three patients with
commercial neuropathic chronic
placental DFUs were
membranes do not described in the
have randomized, Shah study. The
initial wound sizes
data, and existing were 0.42, 3.42,
data are limited to 2
and 1.32 cm with a
case studies duration of 4, 7–8,
presented in and 3 months,
respectively. No
advanced wound
therapy use was
reported before the
application of
Diabetic foot EpiFix. Overall,
ulcer case after one appli-
studies. Peer- cation of EpiFix,
reviewed published two of three
case studies patients (66.7%)
utilizing reached complete
closure at 4 and 5.5
weeks post-
tissue are limited to application. The
two com-mercial patient with the
products: EpiFix 3.42 cm2 wound
(MiMedx Group, reached 50%
Mar-ietta, GA) and reduction of wound
Grafix (Osiris size 4 weeks post-
Therapeutics, Inc.). treatment.
Three case reports However, it is not
are currently reported whether
available for this patient reached
complete closure. The durability
Amniox biologics.co
Medical m/
Revitalon
www.amniox
Table 2. medical.com/
Classification of placental MedLine
current commercial tissue BioDFence www.medline.com/products/wou
placental nd-and-
membrane products
Clarix BioD, LLC
(excluding amniotic
http://biodlogics
fluid-based
.com/index.php/
products)
products/biod-
fence
Description
Preservation
Product(s) name skin-care/revitalon
Tissue source AmnioExcel
Neox Cord
Manufacturer
Amnion and Dehydrated
Company’s
Derma ASGBarrier
websites
Sciences Amnion
www.dermas AlonSource
ciences.com/ www.alonsourcegroup.com/about
-us/

Clarix Cord
cross-linked
umbilical AmnioClear
cord
Liventa
Viable placental Biosciences Group (ASG)
Cryopreserved www.liventab
Grafix Prime ioscience.co
Decellularized
Amnion m/difference.
Dehydrated
Osiris Therapeutics html
Amnio Graft Biovance
www.osiris.com/graf
Amnion Amnion
ix
BioTissue Alliqua (Celgene)
tissue
www.biotissu http://alliqua.com/products/biova
EpiFix
e.com/produc nce/
Amnion and
Grafix Core ts/amniograft. Placental Tissue
chorion
Chorionic aspx
MiMedx
www.mimedx
.com/product
s?qt-product
Amnio Guard

mesenchyme
(with
trophoblast)
Dehydrated
XWRAP
Devitalized tabs = 2#qt-
Amnion
Cryopreserved product tabs
Applied
Neox
Biologics
Amnion
www.applied
PLACENTAL MEMBRANES FOR CHRONIC DFUS
555

2
Case 2: 1.9 · 1.8 = 3.42 cm
(mean – SD)
Time to wound closure
Case 1: 4 weeks
of wound closure in long-term follow-up is not provided. 2 6.2 – 2.6 weeks
Case 3: 1.2 · 1.1 = 1.32 cm
24.5 – 49.2 (mean – SD)
The use of Grafix is reported in a retrospective single-center
study.65 The analysis included 66 patients with 67 wounds, Wound age (weeks) Case 2: Not reported
Case 1: 16 (mean – SD)
among them 27 patients with chronic DFUs, 34 patients
with VLUs, and 6 patients with other types of chronic
wounds (e.g., surgical, traumatic).
Case 3: 5.5 weeks

Twenty-three of 27 DFU patients (85.2%) pre-viously failed Case 2: 28–32

different types of advanced thera-pies, including collagen
No. of applications
matrices, skin grafts, cellular skin substitutes, topical 1
growth factors, hyperbaric oxygen therapy, and negative 3.8 (mean)
b

pressure wound therapy. The mean DFU wound size was Case 3: 12
2
3.97 cm , and the mean wound age was 24.5 weeks. By References
64
week 12, 85.2% of DFU patients (23/27) reached complete 65
Exclusion criteria
wound closure. End-stage renal
Infection; ischemia and
Key patient’s characteristics and outcomes for three DFU a
Sixty-six patients within the
cases treated with EpiFix and for 27 DFU cases treated with study with 67 wounds, including
Grafix are summarized in Table 3. failure, previous 27 DFUs, 34 VLUs, and 6 other
malnutrition were wounds.
b
Mean number of applications
for all 67 wounds.
Prospective DFU studies. Prospective DFU trials for
commercial placental membranes are limited to five studies: graft failure,
addressed before
one open label pilot study for Biovance (Celgene, Warren,
NJ), three random-ized, controlled trials (RCTs)—two Biovance is a
single center and one multicenter—for EpiFix, and one infection, decellularized, dehydrated,
multi-center RCT for Grafix. application
human amnion that can be
used in the management of
noninfected partial- and
autoimmune
full-thickness wounds.
Table 3. Summary of DFU case studies for commercial placental Fourteen patients with
membrane products
chronic refractory DFUs
sized from 1 to 49 cm2
diseases
EpiFix (MiMedx)
were enrolled in a pilot
66
Grafix (Osiris) open label study. Nine
Previous advanced therapy patients who completed
0/3 (0) the 12-week study without
23/27 (85.2) deviations were included
in the analysis. By week
failure, failed/total (%)
12, 55.5% of patients (5/9)
No. of patients
closed their wounds,
3 33.3% (3/9) showed
27
a
wound size re-duction of >
Complete wound closure, 50%, and 11.1% (1/9) had
2/3 (66.7)
Wound size 23/27 (85.2), at week 12 < 50% wound size
2
Case 1: 0.7 · 0.6 = 0.42 cm reduction. Results showed
2
3.97 – 3.08 cm closed/total (%) a benefit of the amnion for
the treatment of refractory
chronic DFUs. However,
no other studies were conducted to validate the results of Twenty patients with
this pilot study. DFUs were treated in each
arm. Overall, by week 12,
Results of three randomized trials using Epifix in the 92.5% of wounds reached
treatment of DFUs are available. The first one is a complete closure with a
versus 45% in the Apligraf
and 35% in the control
groups. No follow-up data
are avail-able at the
present time.
71

nonblinded, single-center RCT that enrolled 25 DFU mean healing time of 4.1
patients (12 in the control arm and 13 in the treatment arm). versus 2.4 weeks for the However, the results of
After 6 weeks, 92% of wounds treated with EpiFix reached biweekly and weekly these studies cannot be
70
complete wound clo-sure versus only 8% in the control group, respectively. generalized as the number
67
group, p < 0.001. Patients who did not respond to the of patients in each study
standard of care (SOC) during 12 weeks in the control The third EpiFix study was was small, and two of
group of this study were offered treatment with EpiFix. conducted at three centers three studies were
Eleven patients with a mean wound size of 4.7 cm2 and 21.1located in Virginia. It was conducted at one center.
weeks of chronicity were treated biweekly with EpiFix in an RCT com-paring One EpiFix DFU
the crossover phase. By week 12, 91% of wounds were closure rates between three multicenter study was
68 groups: control (SOC), performed at three centers
reepithelialized. Eighteen of 22 pa-tients from the 70 that are located in the same
randomized and crossover phases of the trial were followed EpiFix, and Apligraf. geographic area (Table 4).
up for 9–12 months, and 94.4% (17/18) of wounds Twenty DFU pa-tients per
69 group were enrolled. By Also, the treatment of
remained closed. patients in the control
week 6, 95% of patients in
the EpiFix group achieved group and the EpiFix
The second study, a single-center, open label, randomized complete wound closure group differs. In the
trial compared weekly versus bi-weekly EpiFix application. control arm, patients
556

BRANTLEY AND VERLA

Table 4. Summary of DFU prospective clinical studies with commercial placental products

Biovance (Celgene)

EpiFix (MiMedx)

Grafix (Osiris)

Product description
Decellularized,
Dehydrated devitalized amnion and chorion (containing trophoblast)
Cryopreserved viable

dehydrated

amnion

cross-linked
amnion

Study type
Open label
Randomized, controlled,
Randomized, controlled,
Randomized, controlled,
Randomized, controlled,

nonblinded, single center

nonblinded,
nonblinded, multicenter
single blinded,

single center

multicenter
No. of patients
14 (9 evaluated)
a
13 treatment/12 SOC
40 (20 per arm)
b
20 treatment/20 SOC
c
50 treatment/47 SOC

weekly/biweekly

No. of centers
Not reported
1 (VA)
1 (VA)
3 (VA)
20 (TX, NJ, RI, GA, OH,
(geographic locations)

MO, FL, CA, AZ, NY,

PA, AL, LA, NC)

2
Wound size (mean, cm )
Not reported
2.6 treatment/3.4 SOC
2.0 treatment/2.4 SOC
2.7 treatment/3.3 SOC
3.41 treatment/3.93 SOC
Closure rate
55.5% (week 12)
92% treatment/8% SOC
95% treatment/70% SOC
95% treatment/30% SOC
62% treatment/21% SOC

(week 6)
(week 6)
(week 6)
(week 12)
Mean number of treatments
2.3
Not reported
2.3 treatment/2.4 SOC
2.15 treatment/
6 treatment/12 SOC

not specified SOC

References
66
67
70
71
72 (results of crossover

68 (results of crossover

and follow-up are

phase reported)

included in this

69 (follow-up results

publication)

are reported)

Standard of care
Not specified
Debridement, moist dressing,
Weekly debridement,
Weekly debridement if
Weekly debridement,

compression dressing,
adaptic (nonadherent
necessary, moist dressing,
adaptic (nonadherent
daily wound dressing
dressing) followed
compression dressing,
dressing) with saline

changes performed by
by a moisture-retentive
daily wound dressing
moist gauze or Allevyn,

patient at home,
dressing Nugel and a
changes performed by
off-loading

off-loading
compressive padded
patient at home (collagen

dressing Dynaflex,
alginate and gauze),

weekly wound dressing

off-loading

d
change, off-loading

a b
Eleven SOC patients were enrolled in the open-label crossover phase and showed 91.2% complete closure at week 12. This study also had a
group (n = 20) treated with Apligraf.

c
Twenty-six SOC patients were enrolled in the open-label crossover phase and showed 67.8% probability of wound closure with a mean time to
d
closure of 42 days. EpiFix weekly or biweekly was applied with SOC.
SOC, standard of care.
received standard care. group.
had to perform daily dressing changes at home, whereas in Both groups con-sisted of
the treatment arm, dressings were changed weekly/biweekly wound debridement, In an open-label crossover
at the doctor’s office by medical personnel. Such nonadherent dress-ings, phase of the trial, 26
differences in control and treatment arms may create bias. and standard off-loading. patients who received
To generalize EpiFix findings, another multicenter study In the blinded phase, 62% standard care and in whom
with a larger number of patients is required. of Grafix patients closed the wound did not close
their wounds versus 21% within 12 weeks were
Results of a multicenter, blinded RCT are available for in the standard care group treated with Grafix weekly
Grafix, which shows significantly higher and faster wound by week 12 ( p = 0.0001). for up to an additional 12
closure rates, with fewer wound-related infections, versus After 12-week follow-up, weeks. After treatment
72 82.1% of wounds with Grafix, the proba-
SOC. A total of 97 patients from 20 centers across the
remained closed for the bility of wound closure
nation were in the trial: 50 patients with DFUs were treated
Grafix group ver-sus 70% was 67.8%, with a mean
with weekly applications of Grafix and 47 DFU patients
for the standard care time to closure of 42 days.
The results of the Grafix trial provide a good basis for summarized in Table 4. interferes with the effects
generalization as a large number of subjects were recruited of advanced therapies that
from a wide population, and Grafix was administered in a are often required for the
broad range of clinical settings. SUMMARY treatment of chronic DFUs
refractory to SOC.
Prospective DFU study designs, key patient pa-rameters, Hyperglycemia and vas-
Diabetes negatively
and outcomes for commercial placental products are cular status together with
impacts DFU healing and
wound infection, social
Comparison of the functional properties and clinical efficacy between different commercial placental membrane products is
needed.

Clinical data for commercial placental membrane products is limited. Among more than 25 placental membrane products, only
two have been evaluated in randomized, controlled clinical trials.

Advances in tissue processing and preservation techniques have resulted in the development of commercial placental
membrane products. These products represent a new advanced wound treatment modality available for nonhealing wounds.

Placental membrane (amnion and chorion) composition and biological activities are beneficial for wound
treatment, particularly for chronic, difficult-to-close wounds.

Before wound treatment, DFU patients have to be assessed for multiple factors that negatively affect wound
healing. Each factor should be addressed before wound treatment.

Chronic DFUs remain challenging to treat. Such wounds often do not respond to standard wound care treatments
and require advanced therapies.

TAKE-HOME MESSAGES

PLACENTAL MEMBRANES FOR CHRONIC DFUS

557

than 25 commercial AND FUNDING

placental membrane SOURCE
products are on the market,
factors, and malnutrition have to be evaluated in each and the number is growing This work was not funded
patient and addressed before initiation of wound treatment. rapidly. However, with a by any organizations and
A standardized algorithm for DFU assess-ment and therapy few exceptions, the ma- represents authors’
selection is re-commended for implementation at each jority of placental products personal analysis of liter-
institution, which should be a multidis-ciplinary effort of have neither scientific nor ature data.
primary care, infectious diseases, endocrinology, and clinical data to support
vascular and wound care specialists. their use. A data-dri-ven
approach should be used
AUTHOR
when selecting products
Chronic DFUs are often stalled in the inflammatory phase DISCLOSURE AND
for wound treatment.
and are character-ized by an excess of proinflammatory cy-
Future develop-ment of
GHOSTWRITING
tokines, oxygen free radicals, and proteases preventing
placental products should
wounds from heal-ing. Accumulated data indicate that pla- The opinions expressed are
include more scientific
cental membranes, including the amnion and chorion, have those of the authors and do
studies clarifying
a composition and properties that are beneficial for chronic not represent those of the
mechanisms of action,
wound treatment. The anti-inflammatory activity of Hunter Holmes McGuire
more controlled
placental membranes, in par-ticular, is critical for VA Medical Center. No
randomized clinical studies
downregulation of competing finan-cial
dem-onstrating safety and
efficacy, and side-by-side interests exist. This article
inflammation and for assistance of wound transi-tion from scientific and clinical was not written by any
the inflammatory to the regenerative phase of wound comparisons between com- writer other than the
healing. Advances in tissue preservation methods have mercially available authors.
resulted in the devel-opment of commercial placental placental products.
membrane prod-ucts, which represent a promising new ABOUT THE
wound treatment modality available to physicians. More AUTHORS
ACKNOWLEDGMENT
 Residency Program at the is a postgraduate year 3
Dr. Brantley is the Chief of Podiatric Medicine and Surgery Hunter Holmes McGuire resident at the Hunter
and the Director of Podiatric Medicine and Surgery VA Medical Center in Holmes McGuire VA
Richmond, VA. Dr. Verla Medical Center.
Frykberg RG, Zgonis T, Boulton AJ, Vileikyte L, Cummings AK, ulcers for in Wound
Armstrong DG, et al. Dia-
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Ragnarson-Tennvall G, Birnbaum HG, medicare Healing, 1st
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Singh N, Armstrong 2014;37:6
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using dehydrated human amnion/chorion
brachial
index

TGF ¼
transformin
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extremity diabetic ulcers. Int Wound J 2014 [Epub factor
ahead of print]; DOI: 10.1111/iwj.12395.

VEGF ¼
Lavery LA, Fulmer J, Shebetka KA, et al. The ef- vascular
ficacy and safety of Grafix((R)) for the treatment of endothelial
chronic diabetic foot ulcers: results of a multi-centre,
controlled, randomised, blinded, clinical trial. Int growth
Wound J 2014;11:554–560. factor VLU
¼ venous
leg ulcer
Abbreviations and Acronyms

ABI
¼ ankle-brachial index
AGE
¼ advanced glycation end product
AM
¼ amnion
CBC
¼ complete blood count
CM
¼ chorion
dHACM
¼ dehydrated amniochorion
DFU
¼ diabetic foot ulcer
ECM
¼ extracellular matrix
ET-1
¼ endothelin-1
HA
¼ hyaluronan
HGF
¼ hepatocyte growth factor
HLA
¼ human leukocyte antigen
MMP
¼ matrix metalloproteinase