Outcomes of an Esterified Hyaluronic Acid Matrix in the Treatment of Chronic Lower Extremity Wounds

A Case Series

Timothy Cheung, MS; Zachary Laidley, BS; Jacob Jones, BS; Stephanie Wu, DPM, MS


Wounds. 2018;30(12):367-371. 

In This Article

Abstract and Introduction


Objective: This case series evaluates the outcomes of persons with chronic lower extremity wounds treated with an esterified hyaluronic acid matrix (EHAM).

Materials and Methods: Data were abstracted from 12 consecutive patients with a total of 14 evaluated chronic wounds (12 [100%] men, mean age 58.72 years) presenting for care at a multidisciplinary wound care center. Nine of the 12 patients had diabetes. The mean wound duration was 39.2 weeks. All patients received surgical wound debridement and were started on therapy consisting of weekly to biweekly applications of the EHAM with a nonadherent, moisture-retentive dressing until complete epithelialization was achieved. Outcomes evaluated included time to complete wound closure and proportion of patients achieving wound closure in 20 weeks.

Results: In total, 85.7% of wounds measuring a mean of 2.32 cm2 healed in the 20-week evaluation period. Of those that healed, healing took place in a mean of 8.9 weeks.

Conclusions: A regimen of moist wound healing using an EHAM, which provides a scaffold for in-growing cells, may be a useful adjunct in the treatment of chronic, noninfected, nonischemic wounds.


Wound healing is a global medical concern complicated by challenges such as obesity, type 2 diabetes, and an overwhelmingly aging population. A common complication of lower extremity wounds is chronicity. If left untreated, a chronic wound can lead to infections, hospitalizations, amputations, and their associated costs. Billions of dollars are spent treating chronic wounds annually in the United States alone.[1] Moreover, the loss of productivity and diminished quality of life mounts a priceless emotional toll on the individuals affected and the family members caring for them.

Normal wound healing begins with blood clotting and inflammation, which often characterize an acute injury. Following the inflammatory phase, the wound progresses toward the proliferative and eventual reepithelization and remodeling phases. These later events are characterized by fibroblastic migration and proliferation, extracellular matrix (ECM) synthesis and organization, and angiogenesis. The ECM is produced by increased fibroblastic production of glycoproteins, proteoglycans, collagen fibers, and glycosaminoglycans such as hyaluronic acid (HA).[2] However, in a chronic wound, the healing phases are either stunted or redundant.[3] Thus, a goal of chronic wound treatment is to progress the healing process to facilitate complete healing.

There have been many attempted treatments to target chronic healing, specifically ECM production and organization. The ECM allows the exchange of nutrients and wastes as well as provides a scaffold for host immune cells to migrate to tissues to eliminate pathogens and progress cell turnover. Of the ECM components, hyaluronan is the most conserved and hygroscopic. As the principal component of ECM, HA is involved in cell division and tissue formation. Consequently, HA plays many important roles in tissue healing. It has been shown that HA attenuates the inflammatory response and contributes to the production of granulation tissue, increased production of proteoglycans and glycosaminoglycans, and neoangiogenesis.[4–9] During remodeling, HA contributes to reepithelization and organized deposition of collagen fibers.[10] Naturally, the healing properties of HA and the need for more advanced wound healing dressings led to the design of various treatment modalities capitalizing on HA derivatives.[11]

Esterified hyaluronic acid matrix (EHAM; Hyalomatrix Wound Matrix; Medline Industries Inc, Mundelein, IL) is comprised of a HA-derived matrix coupled with a layer of medical-grade silicone. The silicone layer controls water vapor loss, avoiding an excessive loss of fluids, and acts as a semipermeable barrier to external agents. The purpose of this case series is to evaluate outcomes of chronic lower extremity wounds treated with EHAM.