. 05/04/54 1 ..2554 200 ISBN: 978-616-721774-1 :

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, , , , website website: http://mdphysio,sumhua.com, http://gotoknow.org, http://www.bloggang.com www.ccne.or.th.

" monofilament 4 " monofilament 4 ?!?. 6 8 9 6 56 57 4 4 6 8 9 3 6 1

68 (CoP) 68 4

( ) . . - - . . ( ) . . . . . . . . ( ) () (

) x 100 . (Loss Of Protective sensation), , monofilament 10 g // . . . . . . // . . // . ( ) . . . . . . .

.. // .. ( ) () ( ) x 100 . (LoPS + PathoBiomachanics) (abrasion) (blister) (shallow crater) . . . . . . - N.S.S. 0.9 % - Sofa tulle Gauze

. . . () . . . . . / / . . . . . ( ) () ( ) x 100

. // ( ) // // x 100 . / (exudates) (slough) (necrotic tissue) / / . . . . . . . . . () . . . . . / *

** *** - Betadine - N.S.S. 0.9 % ( Hydrogen peroxide) - Betadine dilute (Betadine :N.S.S 0.9 % = 1.3 ) - N.S.S 0.9 % - Sofa tulle Gauze . . . . . ( ) () ( ) x 100 . // ( )

// // x 100 // . / ( . .. . --) ( . .. . -- ) ( . ... --) (- . - ) . (- . - )

. - Type 1 % % % % - Type 2 (Insulin Resistance) / % % % - ........ ( ) . . // //

. monofilament 10 gm . () . FBS/HbA1C FBS (Fasting plasma glucose) - / / DTX (Dextrostrix) - / . / . / . HbA1C (Hemoglobin A1C) A1C - A1C < % . . // ( ) / ( # ) (x) (//) . (abrasion) (blister) (shallow crater) / (exudates) (slough) (necrotic tissue)

- (abrasion) (blister) (shallow crater) - / (exudates) (slough) (necrotic tissue) . (linear measurement) Probe/forceps (cotton swab applicator) . (Dorsalis pedis) (Tibialis posterior artery) / . . -

-

. / - (Flat Feet) - (claw toe) - (hammertoe)

claw toe

-

- (Bunion)

. -

- - - (Blister)

. - (sensory neuropathy) - (motor neuropathy) - (autonomic neuropathy) (Fissure) Monofilament

. :

: (Loss Of Protective Sensation), , monofilament 10 g : (LoPS + PathoBiomachanics) : //

.................... ............................................. ...................................................................................................................................... ........... ........ .......... // Type 1 Type 2

FBS/DTX....................... HbA1c................................. .................... : : : : : : : // : // monofilament 10 g.

Rt Lt

() 1......../................./............. 2. ........./................/............. (x) ( ) (//) / (#)

Rt Lt () ............................................................... .. ......................................................... .. 3. ........./.............../............

Rt Lt () ...................................................................... ... ................................................... ... 4. ........./............../............

Rt Lt () ..................................................................... ........................................... .

Rt Lt () ..................................................................... ... ...................................................

. . . . - - - . - - - () - . () . - - /.................................... . - - ( )

1. 2. 3. 4. 5.

1. (dorsalis pedis) (tibialis posterior artery)

2. 2+ (femoral) (popliteal)

1. 2.

3.

4. ()

5. 6. 7. 8. 9. 10. 11. - - () - - - -

- - -

- - 1 . 3 5 - -

- - - - - - 6-8

1. 2. 3. 4. 5.

1. 20 -30 2.

1 ( 10 ) 2 ()

: ()

2 ( 10 ) 1. 2 2.

3 ( 10 ) 1. 2. 2 3. 4 ( 10 ) 1. 2. 3. 5 ( 10 ) 1. 2. 3. 4. 6 ( 10 ) 1. 2. 3. 4.

7 ( 10 ) 6 2 1. 2. 3. 4. 8 (10 ) 2 9 ( 10 ) 1. 2. 3. ( 1 10 )

10 () 1 2 2 ( )

1. 2. 3. 4. 5. 6.

(http://mdphysio.sumhua.com) 1. 1.1 (Cracked Heels) fissure

Prevention and Treatments: - - - 1.2 (Corns)

Prevention and Treatments: - Corn - - - - Corns (surgical scalpel) - corn 1.3 (Calluses) ball of the foot, , (structural foot problems) (abnormal gait) (flat feet) (high arched feet) (fat pad) ball of foot

Prevention and Treatments: - Callus - Callus - Callus (surgical scalpel) - 2. / 2.1 (Claw Toes ) Flexible type: rigid type: corns , callus

Prevention and Treatments: - claw toe

- - - - 2.2 (Flat Feet) pes planus Arch Arch Flat foot

Arch Callus Corn (plantar fasciitis) Prevention and Treatments: - 10 - - (plantar fascia) (Low dye strapping)

- Arch - CallusCorn - - (Stretching exercises) 1. Towel Curl 20

2. Toe Taps 10-50

3. Calf Stretch 15-30 3

4. Achilles Stretch Achilles tendon 15-30 3 ( plantar fasciotomy) plantar fascia

2.3 (Bunions) (high-heeled shoes) ( overlapping toes)

Prevention and Treatments: - - - - - - - Steroid

3. Assessment and Management of Foot Disease in Patients with Diabetes (skin ulcer) sensory neuropathy monofilament plantar pressure distribution total-contact cast bypass grafts (Arterial reperfusion) 3.1 The Neuropathic Ulcer and The Role of Neuropathy (Sensory neuropathy) (ischemia) (infection) (Peripheral

neuropathy) 80 % 3.2 The Role of Mechanical Stress metatarsal heads claw toes 3.3 Management of Neuropathic Ulcers neuropathic ulcer (foreign bodies) (soft-tissue gas) foam contact cast 4. (Wound care) (callus) Wet dressing (2-3 ) Dry dressings iodine hydrogen peroxide Prevention of Neuropathic Ulcers calluses 30 % (Blisters) (macerated skin) felted total

(hemorrhagic calluses)

10 25 11

1. peripheral neuropathy

. peripheral vascular disease (Diabetic foot ulcer) . (Infection)

4. 2-5 5. altered biomechanical 15 14-24 65 1. 2. 3. 4. 5. 6.

7. 8.

1. (diabetic neuropathy) 2. 3. 4. 5. 6. 1. 2. 3. intermittent claudication 4. beta-block 5. Infection x-ray MRI 1.

2. (orthopedic shoes) 3. 4. recombinant growth factors bioengineered skin patches 5.1 neuropathic foot ulcers sinus-tract crepitation 2 3 deep abscesses, extensive soft-tissue infection, metastatic infection of remote sites acute Charcot's disease (teomyelitis) aerobic gram-positive cocci staphylococcus aureus, streptococci ( polymicrobial) aerobic gram-positive cocci,

gram-negative bacilli (e.g., Escherichia coli, klebsiella species, and proteus species), anaerobes (e.g., bacteroides species and peptostreptococcus) coagulase-negative staphylococci, enterococci, corynebacterium species Superficial swabs colonizing infecting organisms Infecting organisms Superficial swab Needle aspiration sensitivity osteomyelitis bone specimens percutaneous biopsy surgical excision osteomyelitis sensitive specific diabetic osteoarthropathy osteomyelitis Technetium bone scans sensitive Indium-111-labeled leukocyte scanning radionuclide study probe sensitivity probe osteomyelitis probe osteomyelitis probe acute osteomyelitis

specimens - non-limb-threatening - limb-threatening - or life-threatening Aminoglycosides Fluoroquinolones empirical treatment gram-positive anaerobic . 10-12 pedal osteomyelitis technetium bone scans pedal bone 4-6 (digital or ray amputation) 2-3 tarsal or calcaneal osteomyelitis, 6. Surgical Aspects

(Limb-threatening infections) systemic infection 2-3 60 % 46% . Atherosclerotic occlusion distal tibial and peroneal arteries foot vessels dorsalis pedis artery 7. Orthosis : Orthosis 1. correct alignment 2. relieve Pressure 7.1 Flat foot

7.2 High Arch

7.3 Change weight pad

7.4 Heel Pad - - Heel spur : - Plantar Fasciitis - Archilles Problem

7.5 Total Support Orthosis:Insole

1. History HbA1c,FBS 2. Skin condition problem 2.1

2.2 - Ingrown nail

- Hematoma

2.3

2.4 Callus ,corn, Blister Callus Corn Corn Callus ball of foot, , , hard corn Central core Soft corn

Callus Corn Callus (Slide) Callus Corn Corn

3. Neurological Assessment 3.1 Sensory Neuropathy Monofilament 10 g 4 ADA (American Diabetic Association)

3.2 Motor Neuropathy Intrinsic muscle Claw toes

3.3 Autonomic Nervous System Dysfunction

4. Vascular Assessment 4.1 (Dorsalis Pedis) 4.2 (Posterior Tibial)

5. Ulcer Assessment

( ) (Wagner Grade) 6. Deformity

7. Arch of foot assessment

7.1 Check weight bearing

7.2 Podoscope

7.3 Pes Cavus :high arch

7.4 Pes Planus:Flat foot

8. Charcot Foot acute Charcot foot (cellulitis) (deep venous thrombosis) Charchot foot , Charchot foot Charcot foot sensory neuropathy,Arteriovenous shunt ( autonomic neuropathy),

(microtrauma)

Off - loading Treatment offloading technique 1. total non weight bearing: , (Crutches), (Wheel chair) 2. total contact casting:

3. removable walking braces with rocker bottom soles:

4. Patellar-tendeon bearing brace Acute Charcot Foot total contact cast cast Patellar-tendeon bearing brace 6-24 Charcot Fracture

9. (Wound Debridement) Bacteroides species, Clostridium perfringens gas gangrene

auto-amputate

Pressure sore with Necrotic Cap 10. 1. 2. 3. (**) 4. Wagner Grade 10.1 Superficial ulcer. Wagner Grade 1 subcutaneous fat

layer. (Superficial infection ) cellulitis

Wagner Grade 2 ,, deep abscess (osteomyelitis)

Wagner Grade 3 , (osteomyelitis), joint sepsis deep plantar space infections deep plantar space abscesses, necrotizing fasciitis tendon sheath infections

Wagner Grade 4 , ,

Wagner Grade 5 -Unsalvagable Gangrene

10.2 Chronic wounds Chronic wound Acute wound

11. The foot

of a diabetic patient that has the potential risk of pathologic consequences, including infection, ulceration, and/or destruction of deep tissues associated with neurologic abnormalities, various degrees of peripheral vascular disease, and/or metabolic complications of diabetes in the lower limb. 1. Prevent limb loss: 2. Prevention of ulceration and recurrence: 3. Early recognition and treatment of diabetic foot complications: 4. Maintain quality of life: (Risk Factor for ulceration) 1. Peripheral sensory neuropathy: 2. Structural foot deformity: 3. Trauma and improperly fitted shoes: 4. History prior ulcers/amputations: 5. Prolonged pressures: 6. Limited joint mobility: 7. Uncontrolled hyperglycemia: 8. Blindness/partial sight: 9. Chronic renal disease: Neuropathy Sensory Neuropathy, Motor Neuropathy, Autonomic Neuropathy Neuropathic Ulcer Peripheral Sensory Neuropathy

Motor neuropathy Anterior crural muscle Intrinsic Muscle

Autonomic Neuropathy sympathetic failure, arteriovenous shunting, microvascular thermoregulatory dysfunction tissue perfusion microvascular

( ) (epidermal cells) (dermal cells) (extracellular matrix: ECM) (angiogenesis) (cytokines) (growth factors) (Harding, Morris, & Patel, 2002) (Harding, Morris, & Patel, 2002) (Bale & Jones, 1997) (Singer & Clark, 1999; Schultz, et al, 2003; Jones, Bale, & Harding, 2004) 4 (Bale & Jones, 2006; Keast & Orsted, 1998; Jones, Bale, & Harding, 2004; Beitz, 2005) 1 (Hemostasis) endothelial cells ECM (cell migration) (Singer & Clark, 1999) (vasoconstriction) chemical mediators histamine, serotonin adenosine triphosphate (ATP) (Bale & Jones, 2006) (Bale & Jones, 2006) factor XII (Hageman factor) (clot formation) (Jones, Bale, & Harding, 2004) (Singer & Clark, 1999) fibrinolysis (Jones, Bale, & Harding, 2004)

2 (Inflammation) fibrin clot prostaglandins activated complement proteins (capillary permeability) plasma inflammatory exudate (Bale & Jones, 2006) 2 neutrophil macrophage ( monocyte) (Jones, Bale, & Harding, 2004) neutrophil monocyte chemotactic factors (Bale & Jones, 2006) Neutrophil (immune cell) (Medina, Scott, Ghahary, & Tredget, 2005) (Harding, Morris, & Patel, 2002) 24 48 (Harding, Morris, & Patel, 2002) (phagocytosis) neutrophil 3 (Jones, Bale, & Harding, 2004) Monocyte macrophage 2 3 (Jones, Bale, & Harding, 2004) pathogenic organisms (tissue debris) (Bale & Jones, 2006) macrophage biological regulators cytokines growth factors, bioactive lipid products proteolytic enzymes macrophage platelet-derived growth factor (PDGF), tumor necrosis factor , transforming growth factor insulin growth factor 1 (Cooper, Yu, Hennessey, Ko, & Robson, 1994 cited in Harding, Morris, & Patel, 2002) cytokines PDGF, transforming growth factor (TGF) epidermal growth factor (EGF) PDGF (granulation tissue) TGF epithelialization TGF ( chemotaxis

fibroblasts

(angiogenesis) EGF neovascularization fibroblasts macrophages Basic fibroblast growth factor (angiogenesis) (Jones, Bale, & Harding, 2004) 3 (Proliferation or Granulation) 3 2 3 (granulation tissue) matrix fibrin, fibronectin, collagens, proteoglycans, glycosaminoglycans (GAGs) glycoprotein fibroblast (Jones, Bale, & Harding, 2004) growth factors PDGF TGF1 extracellular-matrix molecules (Singer & Clark, 1999) fibroblast proteoglycans (glue-like ground substance) fiber fibronectin framework ground substance (Bale & Jones, 2006) ECM (Singer & Clark, 1999) (hypoxic) (Bale & Jones, 2006) matrix matrix matrix metalloproteinases (MMPs) plasminogen activators (Harding, Morris, & Patel, 2002) coenzyme (cross-linking of fibers) (tensile strength) (Rigby, 1992 cited in Bale & Jones, 1997)

2 (epithelialization) (wound contraction) epithelialization epithelium hair follicles epithelium (migration) epithelium epithelial cells contact inhibition myofibroblast inflammatory mediators (Bale & Jones, 2006) 4 (Remodeling or Maturation) 3 (Bale & Jones, 2006) 1 (Jones, Bale, & Harding, 2004) (Jones, Bale, & Harding, 2004) (Bale & Jones, 2006) (tensile strength) (Jones, Bale, & Harding, 2004) fibroblast (Bale & Jones, 2006)

2 (Harding, Morris, & Patel, 2002; Hess & Kirsner, 2003; Medina, Scott, Ghahary, & Tredget, 2005; Bale & Jones, 2006) 1. (local factors)

(tissue maceration) (mechanical trauma) (iatrogenic) 2. (systemic factors) Glucocorticoid steroids (uremia) (Medina, Scott, Ghahary, & Tredget, 2005) (Ayello & Cuddigan, 2004) (Sholar & Stadelmann, 2003) (Bates-Jensen, 1999) (Jones, Bale, & Harding, 2004) (epithelial hyperplasia) fibrosis (capillary proliferation) (Vaalamo, Weckroth, Puolakkainen, Kere, Saarinen, Lauharanta, & Saarialho-Kere, 1996)

(Bates-Jensen, 1999) (systems review and physical examination considerations) 1. (infection and immunosuppression)

(erythema) (induration) (purulent exudate) (bacterial colony count) 105 organisms/ml (infection) bacterial colony count 105 organisms/ml (Bates-Jensen, 1999) 2. (cardiovascular and respiratory systems) (metabolic waste products) (tissue perfusion) (sacral area) (fatigue) pulse oximetry (pulmonary function tests) 3. (peripheral vascular system) (capillary refill) 2 (range of motion) (dorsalis pedis pulse) (posterior tibial pulse) ankle brachial index (ABI) Doppler device (systolic blood pressure) brachial artery dorsalis pedis ABI 0.08 (debridement)

(compression therapy) (Bates-Jensen, 1999) 4. (gastrointestinal and genitourinary systems) () ( ) (BatesJensen, 1999) 5. (neurologic and musculoskeletal systems) (tremors) (Bates-Jensen, 1999) 6. (endocrine system) fasting blood sugar 140 mg/dl glycosylated hemoglobin (HgbA1C) 7 (Bates-Jensen, 1999)

(Krasner, 2001 cited in Price, 2005) (model of chronic wound pain) 3 1) cyclic acute wound pain 2) non-cyclic acute wound pain (intermittent manipulation of the wound)

3) chronic wound pain (persistent pain) pain scale 0 10 0 10 visual analog scale (Bates-Jensen, 1999)

1. (location) (Baranoski & Ayello, 2004) (sacrum) 2 (medial lateral malleolus) (Bates-Jensen, 1999) 2. (wound size) (Baranoski & Ayello, 2004) (linear measurement) (wound tracing) (Bates-Jensen, 1999) (Baranoski & Ayello, 2004) (cotton swab applicator) 3. (wound stage or classification) Agency for Health Care Policy and Research (AHCPR) (Bergstrom et al, 1994 cited in Bates-Jensen, 1999) 4 1 (stage I)

2 (stage II) (partial-thickness skin loss) / (abrasion) (blister) (shallow crater) 3 (stage III) (full-thickness skin loss) (subcutaneous) fascia 4 (stage IV) (full-thickness skin loss) (sinus tract) 4. (wound edge) 5. exudate (exudate type and amount) exudate (serum) (cell debris) leukocytes serous serosanguineous sanguinous (bloody) 6. (surrounding tissue condition) (maceration) exudate 7. (granulation tissue and epithelialization)

8. (wound bed) slough (necrotic tissue) eschar

(Krasner, 1999) 1. (wound bed preparation) (Falanga, 2003; Hess & Kirsner, 2003) (Schultz, Mozingo, Romanelli, & Claxton, 2005) (Falanga, 2003) 4 TIME T (tissue) I (infection and inflammation) M (moisture imbalance) E (edge of wound)

(Templeton, 2004; Schultz, Mozingo, Romanelli, & Claxton, 2005) TIME 1.1 (Beitz, 2005) (debridement technique) (Hess & Kirsner, 2003) (Beitz, 2005) - (surgical or sharp) - (mechanical) wet-to-dry dressings saline maceration (hydrotherapy) - (chemical) Hypochlorites Dakins solution Hydrogen peroxide

air

embolism granulation Povidone iodine slough fibroblasts Cadexomer iodine Iodosorb Iodoflex fibroblasts - (autolytic) Hydrocolloids Hydrogel Alginates, Foam, Hydrofiber moisture vapor permeable cellulitis - (enzymatic) Collagenase (Syntyl), Papain-urea (Accuzyme) Papain-urea and chlorophyllin (Panafil) cellulitis

granulation Papain-urea latex - (biotherapeutic) maggot debridement therapy biosurgery (sterile maggots) Lucilia sericata proteolytic enzymes (osteomyelitis) - (negative-pressure dressings) (Vacuum-Assisted Closure : VAC) granulation slough eschar enteric fistula 1.2 inflammatory cytokines protease ativity growth factor (Schultz, Mozingo, Romanelli, & Claxton, 2005) (contamination) colonization critical colonization (wound infection) (systemic infection) 105 organisms/ml (Ayello & Cuddigan, 2004) (iodine) (leg ulcers) (bacterial load)

1.2 cytokines macrophages (Quatresooz, Henry, Paquet, Pierard-Franchimont, Harding, & Pierard, 2003) 1.3 (Harding, Morris, & Patel, 2002) (Hess & Kirsner, 2003) MMPs (Ayello & Cuddigan, 2004) exudate matrix (Mendes et al, 1999 cited in Hess & Kirsner, 2003) (topical therapies) (Hess & Kirsner, 2003) (maceration) (Schultz, Mozingo, Romanelli, & Claxton, 2005) (Ayello & Cuddigan, 2004) (compression therapy) (Hess & Kirsner, 2003) 1.4 keratinocytes (Schultz, Mozingo, Romanelli, & Claxton, 2005) bioengineered skin substitutes, growth factor/cytokine preparations MMPs inhibitors 2. (Fowler, 2003)

(Price, 2005) (cyclic acute wound pain) 30 60 2002) (soft silicone) (Krasner,

maceration (Fowler, 2003) silicone mesh contact layer (gel) skin protectant pastes (Queen, Woo, Schulz, & Sibbald, 2003) (non-cyclic acute wound pain) (topical anesthetics) 4% lidocaine solution, 2% lidocaine gel 1% lidocaine solution (Krasner, 2002) polyvinyl alcohol (PVA) soft foam sponge, nonadherent oil-emulsion type dressing, contact layer, thin layer of amorphous hydrogel calcium alginate petrolatum gauze 48 normal saline 10 30 cc. 15 30 (Krasner, 2002) chronic wound pain (persistent pain) (Fowler, 2003)

(Price, 3.

2005)

(Hurd, 2004) (Demling & Leslie, 2001 cited in Hurd, 2004) - 0.8 1.0 gm/kg 30 cc/kg/day 30 Kcal/kg/day - 1 2 (1 2 ) 1.2 1.5 gm/kg 35 cc/kg/day 35 Kcal/kg/day - 3 4 1.5 2.0 gm/kg 35 - 40 cc/kg/day 40 Kcal/kg/day - 4 3.0 gm/kg 40 cc/kg/day 40 Kcal/kg/day - 2.0 3.0 gm/kg 40 cc/kg/day 35 - 40 Kcal/kg 4. (Baharestani, 2004) (Fowler, 2003

(Baharestani, 2004) (wound cleansing) (wound irrigation) (topical antimicrobial agents) metronidazole activated charcoal (Fowler, 2003)

54

.

1. 2. 3. 4.

() 1. 1.1 1.2 1.3

2.

3. 4.

5.

6.

.

2. 3. 4. 5.

(dorsalis pedis) (tibialis posterior artery) 2+ (femoral) (popliteal)

1. 2. 3. 4. ( ) 5. 6. 7. 8.

9. - - () - - - - - - -

- - 1 . 3 5 - -

-

- - - - - 6-8 1. 2. 3. 4. 5.

1. 20 -30 2.

: () 1 ( 10 ) 2 ()

2 ( 10 ) 1. 2 2.

3 ( 10 ) 1. 2. 2 3.

4 ( 10 ) 1. 2. 3.

5 ( 10 ) 1. 2. 3. 4.

6 ( 10 ) 1. 2. 3. 4.

7 ( 10 ) 6 2 1. 2. 3. 4.

8 (10 ) 2

9 ( 10 ) 1. 2. 3. ( 1 10 )

10 () 1 2 2

( )

" monfilament 4 " ( ) monofilament 4 American Diabetic Association:ADA Monofilament 4 (Big toe) 1, 3, 5 4 4 Impairment (Neuropathy) 10 4 10 Impairment of Protective sensation Loss of Protective sensation

4 Dr.Paul Brand Dr.Frichy 20 70 80 4 Dr.Price ( ) 4

deformities Claw toe Loss of Protective sensation

1.7 monofilament

monofilament 4

( ) guild line 4 * Monofilament 10 * , * * 1 (Normal)

monofilament (Sensation intact, no deformity and good intrinsic muscle power)

2 1 2 (Risky group)

monofilament (loss of protective sensation and poor intrinsic muscle power. but no deformities)

( protective sensation )

6 3

monofilament (loss of protective sensation and poor intrinsic muscle power and deformities can be seen.)

(claw toe) (Bunion)

3 4 (Very high risk)

(numbness and have history of ulcer or amputation, Charcot or fracture bone of foot.)

2 (Charcot foot)

1 ( )

?!?. (. ) (Corn) "" .. () 2

1. 2. 40% (Collomack), (Duofilm), (Free zone)

20 1-2 1. 2. 3.

( ) 1. (gauze dressing) 2. Impregnated gauze dressing 3. Semipermieable film dressing 4. Hydrogel 5. Hydrocolloid 6. Semipermeable Foams 7. Hypercellular Dressing 8. Hydro selective Dressing 9. Alginate Dressings 10. Hydrofiber 1. (gauze dressing)

2.

Impregnated gauze dressing primary dressing (granulation, epithelialization wound)

3. Semipermieable film dressing polyurethane O2 CO2

4. Hydrogel propylene glycol 20% 80% , impregnateed gauze autolytic debridement (slough, necrotic tissue)

5. Hydrocolloid (Hydrophillic) gelatin, pectin, carboxymethylcellulose Autolytic debridement (sheet) (paste)

6. Semipermeable Foams Polyurethane foam Hydrophillic hydrophobic Autolytic debridement

7. Hypercellular Dressing Polyurethane Polyurethane hydrophobic

8. Hydro selective Dressing Polyurethane Matrix Sodium polyacrylate Hydro selective Dressing Polyurethane Film O2

9. Alginate Dressings calcium sodium alginate (Sheet) (ropes)

10. Hydrofiber 100% (Sodium carboxymethylcellulose )

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