The use of image processing in the evaluation of diabetic foot ulcer granulation after treatment with advanced-platelet rich fibrin + hyaluronic acid

Introduction: It is difficult to objectively assess wound healing process as characteristics of different types of wounds vary markedly. Reliable and valid photograph wound assessment tools to assess wound appearance is critical to provide objective measurement for clinical trials. Objective: This study aims to describe the use of digital image analysis system, ImageJ to objectively measure wound area, red granulation tissue, and granulation index for diabetic foot ulcer (DFU). Methods: Images were taken from an open label randomized controlled trial of DFU patients with wound duration ≥3 months, Wagner-2 and ulcer size < 40 cm2. at Koja and Gatot Soebroto Hospital, Jakarta, Indonesia from July 2019 to April 2020. The study was approved by the ethics committee of the Faculty of Medicine Universitas Indonesia ID 0855/UN2.F1/ETIK/2018. A total of thirty subjects were recruited, after receiving informed consent, and were randomized into three groups of ten, each group receiving different intervention of topical autologous platelet rich fibrin (A-PRF), A-PRF and Hyaluronic Acid (HA) or 0.9% NaCl solution (control). All patients underwent strict glycemic control and debridement. Images were taken at baseline, day 3, day 7 dan day 14. Wound area, granulation area, granulation index and their corresponding changes over time were measured with ImageJ software. Statistical analyses were performed using SPSS version 20. Results: In A-PRF +HA group, there was no significant increase (p=0.597) of delta percentage in wound area on day-0 (8.4 cm2) today-7 (35.8 cm2) compared with PRF on day-0 (12.8 cm2) today-7 (34.4 cm2 ) and control on day-0 (14.6 cm2) today-7 (34.7 cm2 ) . Meanwhile, there was a significant increase (p=0.035) of delta percentage granulation area on day-0 (1.4 cm2) today-7 (2.4 cm2) compared with PRF on day-0 (0.4 cm2) today-7 (1.0 cm2 ) and control on day-0 (0.2 cm2) today-7 (0.7 cm2 ). There was also a significant increase (p=0.049) of delta percentage granulation index on day-0 (26.0%) to day-7 (57.7% ) compared with PRF on day-0 (12.5% cm2) today-7 (50.9% ) and control on day-0 (12.8%) to day-7 (39.9% ). Conclusion: ImageJ provides a reliable and valid tool of measurement to assess wound healing process in diabetic foot ulcer use granulation area measurement and granulation index method.