Venous leg ulcerations: a treatment update

Medical device-related pressure injury from compression therapy

The use of compression therapy is known to be effective in the management of patients with venous leg ulceration and is commonly recommended as a first-line treatment. A rare but known complication of compression therapy is pressure damage to the limb, also referred to as bandage damage, which should be categorised as a medical device-related pressure injury. Patients should receive a comprehensive, holistic assessment before any compression therapy is applied. Risk factors for compression therapy injury include peripheral arterial disease, older age, fragile skin, pronounced bony prominences or tendons, calf atrophy, foot drop, neuropathy/absent sensation, limited movement, cognitive impairment and receiving end of life care. Risks can be mitigated through a variety of approaches, and practitioners should be aware that these can change depending on the patient's condition. A community improvement initiative, illustrated with a case study, introduced a clinical pathway that can facilitate the identification and management of patients who are at risk of developing pressure injuries as a result of compression therapy.

Stress-memory polymeric filaments for advanced compression therapy

Revelation of stress-memory behavior in smart polymeric filaments and its implications for compression stockings for advanced compression management.

Liquid transmission characteristics of padding bandages under pressure

Padding is an essential component in a multilayer compression bandaging system, used inside the compression bandage through which substantial amount of pressure is exerted on the limb of patient for treatment of venous leg ulcers. As a result, the liquid transmission behavior of padding is also critical in managing body fluids or sweat exuded from the affected limb, reducing the excessive moisture build-up around the wound and thereby ensuring comfort to and hence a better compliance from the patients. This study investigates the in-plane fluid transport characteristics of needle-punched nonwoven padding bandages. It first reviewed the existing studies related to the problems, and discussed their limits and possible improvements in dealing with complex fluid transport issues in textile porous media. The measurement of fluid transport under different pressure levels was then done using a newly designed apparatus capable of simultaneously tracing the liquid in-plane spreading along different directions, and obtaining several transport characteristics of a testing sample, e.g. the liquid flow anisotropy, the rate of movement, the area of wet surface with time, etc. Also the effects of several important factors, such as the levels of pressure applied, the specimen bulk density, and needling density of the padding products, have been experimentally investigated. In addition, based on an extended Lucas-Washburn theory, we calculated the liquid flow distance, both instantaneous speed and a more useful time-averaged speed v(av) at any given direction, and also defined a flow anisotropy index I(A) as a convenient parameter to represent the material flow anisotropy. The applications of v(av) and I(A) to actual samples have demonstrated the usefulness of these parameters in characterizing the flow nature and behavior of the materials.

Skin grafting for venous leg ulcers

BACKGROUND

Venous leg ulceration is a recurrent, chronic, disabling condition. It affects up to one in 100 people at some time in their lives. Standard treatments are simple dressings and compression bandages or stockings. Sometimes, despite treatment, ulcers remain open for months or years. Sometimes skin grafts are used to stimulate healing. These may be taken, or grown into a dressing, from the patient's own uninjured skin (autografts), or applied as a sheet of bioengineered skin grown from donor cells (allograft). Preserved skin from other animals, such as pigs, has also been used (xenografts).

OBJECTIVES

To assess the effect of skin grafts for treating venous leg ulcers.

SEARCH METHODS

For this update we modified the search strategies and conducted searches of The Cochrane Wounds Group Specialised Register (searched 27 July 2012); The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 7); Ovid MEDLINE (2008 to July Week 3 2012); Ovid MEDLINE (In-Process & Other Non-Indexed Citations, July 26, 2012); Ovid EMBASE (2008 to 2012 Week 29); and EBSCO CINAHL (2008 to 26 July 2012). We did not apply date or language restrictions.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of skin grafts in the treatment of venous leg ulcers.

DATA COLLECTION AND ANALYSIS

Two review authors independently undertook data extraction and assessment of study quality.

MAIN RESULTS

For this update of the review, we identified one new trial, bringing the total to 17 trials (1034 participants) - all of which were generally at moderate or high risk of bias. In 12 trials participants also received compression bandaging.Eleven trials compared a graft with standard care in which no graft was used. Two of these trials (102 participants) compared a dressing with an autograft; three trials (80 participants) compared frozen allografts with dressings, and two trials (45 participants) compared fresh allografts with dressings. Two trials (345 participants) compared tissue-engineered skin (bilayer artificial skin) with a dressing. In two trials (97 participants) a single-layer dermal replacement was compared with standard care.Six trials compared alternative skin grafting techniques. The first trial (92 participants) compared autografts with frozen allograft, a second (51 participants) compared a pinch graft (autograft) with porcine dermis (xenograft), the third (110 participants) compared growth-arrested human keratinocytes and fibroblasts with placebo, the fourth (10 participants) compared an autograft delivered on porcine pads with an autograft delivered on porcine gelatin microbeads, the fifth trial (92 participants) compared a meshed graft with a cultured keratinocyte autograft, and the sixth trial (50 participants) compared a frozen keratinocyte allograft with a lyophilised (freeze-dried) keratinocyte allografts.Significantly more ulcers healed when treated with bilayer artificial skin than with dressings. There was insufficient evidence from the other trials to determine whether other types of skin grafting increased the healing of venous ulcers.

AUTHORS' CONCLUSIONS

Bilayer artificial skin, used in conjunction with compression bandaging, increases venous ulcer healing compared with a simple dressing plus compression. Further research is needed to assess whether other forms of skin grafts increase ulcer healing.