^1,2Post SR, ²Associate Professor, Department of Surgery, Dr Shankarrao Chavan Government Medical College, {GMC}, Vishnupuri, Nanded, INDIA.

Email: omkarmatele@gmail.com  

Table 1: Age distribution

Table 2: Site affected

Wound size was measured at baseline-Day 1 for all patients. The change in wound size was calculated from baseline (Day 1) and last day of measurement, i.e.; Day 28 and in patients who underwent Split skin grafting (SSG) before 28 days it was calculated one day prior to SSG. The change in wound size from baseline (Day 1) was assessed and day28. There was significant change in wound size between Group A and Group B with greater decrease in wound size at day 28. In Group A (PAPAINUREA), the average percentage decrease in wound size at Day 28 was 36% compared to 20.6% in Group B (PI).

Table 3: Wound Size

In Group A (PAPAINUREA), the mean duration for Day of appearance of Granulation tissue was 3.529± 0.85 days. In Group B (PI), the mean duration for day of appearance of Granulation tissue was 7.26 ± 1.8 days, difference was statistically significant (p < 0.001). In Group A (PAPAINUREA), the mean duration for day of appearance of Epithelialization was 7.68± 1.80 days. In Group B (PI), the mean duration for day of appearance of Epithelialization was 13.32 ± 2.46 days, difference was statistically significant (p < 0.001). In Group A (PAPAINUREA), the mean duration for day of Periwound Erythema Resolution was 4.52 ± 1.10 days. In Group B (PI), the mean duration for day of Periwound Erythema Resolution was 7.72 ± 1.21 days, difference was statistically significant (p < 0.001). In Group A (PAPAINUREA), the mean duration for day of Periwound Edema Resolution was 6.60 ± 1.5 days. In Group B (PI), the mean duration for day of Periwound Edema Resolution was 10.52 ± 1.69 days, difference was statistically significant (p < 0.001). In Group A (PAPAINUREA), the mean duration for day of Wound Disinfection (Culture negative) was 7.56 ± 1.84 days. In Group B (PI), the mean duration for day of Wound Disinfection (Culture negative) was 10.16 ± 2.11days, difference was statistically significant (p < 0.001). In Group A (PAPAINUREA), the mean duration of hospitalisation was 10.64 ±2.65 days. In Group B (PI), the mean duration of hospitalisation was 13.16 ± 2.64 days, difference was statistically significant (p < 0.001).

Table 4: General characteristics

The commonest organism on Culture sensitivity taken on day 1 for all patients was Staphylococcus aureus – 24 patients, Enterococci – 13 patients, no growth in 6 patients.

Table 5: Organism on C/S

In Group B (PI) 58.00 % of cases underwent SSG before 28days 42 % of subjects underwent SSG after 28 days. In Group A (PI), 78.43 % of cases underwent SSG . SSG before 28days 21.56 % of subjects underwent SSG after 28days. Difference between group A and group B was statistically significant (p = 0.02).

Table 6: Split skin Grafting

There was a significant bivariate relationship between age, DM, group and wound procedures (debridement, fasciotomy) on wound healing outcomes. In Group A, patients in whom was Papain-Urea used and in patients who underwent procedures (debridement, fasciotomy), we found that there was earlier appearance of epithelialization, earlier resolution of periwound erythema and periwound edema and Early wound disinfection with rapid decrease in wound size significantly.

Table 7: Pearson Correlations

**. Correlation is significant at the 0.01 level (2-tailed).

DISCUSSION

In present study the mean age of patients was 48.08 ±13.08. When this mean age compared in both groups A and B, the mean age in both groups was nearly same (Group A: 49.23 ± 11.76 and Group B: 48.36 ± 14.42). Gerstein AD et al.⁸ stated in his study that age-related differences in wound healing have been clearly documented. Although the elderly can heal most wounds, they have a slower healing process. Eaglstein WH⁹ mentioned in his study that the inflammatory response is decreased with age, and undoubtedly this bears on some of the alterations in healing. The proliferative phase traditionally includes cell migration, proliferation, and maturation, all of which are changed with age. In our study, when correlation of age with wound healing and decrease in wound size was calculated, there was positive correlation between in these factors which justify the statements of above mentioned studies. In present study, patients presented with co-morbidities in both groups were same (28% in group A and 30% in group B). And in both groups, Diabetes Mellitus was most common co-morbidity noted (12 % in group A and 18 % in group B). Beyene RT et al.¹⁰ mentioned in his study that preexisting diagnoses may significantly alter, delay, or inhibit normal wound healing. This is most commonly seen with chronic disorders, such as diabetes and renal failure, but also occurs secondary to aging and substance abuse. Less commonly, genetic or inflammatory disorders are the cause of delayed wound healing. In our study, when correlation of co-morbidities (DM) with wound healing and decrease in wound size was calculated, there was weak or no correlation and negative correlation respectively between in these factors. Mendiola-So M et al.70. mentioned about the sites of common foot ulcers in DM patients. Most common sites: plantar surface of foot (metatarsal heads and midfoot), toes (dorsal interphalangeal joints or distal tip). The Pathogenesis was DFUs frequently caused by repetitive injury to an insensate or vascular compromised foot. In our study also foot and leg is common site of ulcer occurrence and most common morbidity was DM. The mean decrease in wound size in Group A was 36% whereas 20.6% in Group B. Alvarez OM et al., ¹ mentioned in his study that Papain-urea also appeared to be more effective in promoting granulation tissue and in our study the mean duration (in days) for appearance of Granulation tissue in group A (Papain-urea) was less than PI. Dalla P et al.,¹² compared efficacy of SOS versus PI in post C- section wounds, showed that 88% had granulation by day 5 in SOS group compared to 80% in PI group and by day 10 there was granulation in all patients. In our study time taken for granulation tissue formation with PI treatment was less than the study conducted by Dalla P et al. The mean duration (in days) for appearance of Epithelial tissue in group A was 4.529 ± 1.10 days whereas in Group B was 7.72 ± 1.21 days. There was significant difference between Group A and Group B on for day of appearance of epithelial tissue. Dalla P et al.,¹² mentioned in his study that in 12% patients 5 days were required for resolution of erythema. Dalla P et al.,¹² conducted a study on 218 patients suffering from chronic diabetic foot ulcers 110 patients were treated with SOS and 108 patients with povidone iodine. The mean healing time in PI group was 58 ± 20 which is much higher than when compared to our study with both groups (group A and group B). The mean duration (in days) of stay at hospital stay in group A was 10.64 ± 2.65 days whereas in Group B 13.16 ± 2.64was. There was significant difference between Group A and Group B on for day of appearance of epithelial tissue. The overall most common organism found on bacteriological culture was Staphylococcus aureus (23.76%) followed by Enterococci (12.87%) (Table no. 13) which is similar to a study conducted Chittoria RK et al.¹³ in which also Staph aureus was the commonest organism on culture. In patients where Papain urea was used and in patients who underwent procedures (debridement, fasciotomy), we found that there was earlier appearance of epithelialization, earlier resolution of periwound erythema and periwound edema and Early wound disinfection with rapid decrease in wound size significantly.

CONCLUSION

There was shorter duration of hospital stay, earlier wound disinfection and a greater number of patients who underwent earlier skin grafting in papain urea group. The results were statistically significant and in favour of papain urea. Thus we conclude that use of papain urea is highly recommended as compared to povidone iodine in management of non-healing ulcers.

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