Compression therapy in mixed ulcers increases venous output and arterial perfusion

Venous Leg Ulcers: The Need to Incorporate Age-Friendly 4M's in Management

Venous leg ulcers develop due to a complex set of conditions routed in lower extremity edema and inflammation. Even though older adults are disproportionally affected by these wounds, the guidelines discuss best practices without keeping in mind the age-friendly 4M's-what Matters Most, Mobility, Medications, and Mentation/Mood. This article reviews the management and treatment of venous leg ulcers, but with a geriatric medicine focus. Compression therapy, mobility optimization, and social isolation reduction are highlighted for our older adult population.

Haemodynamic effect of a leg compression bandage on the distal posterior tibial artery using 4D flow magnetic resonance imaging: A quantitative study

The uncertainty concerning the physiological effects of compression bandaging on the peripheral blood flow is a challenge for healthcare professionals. The main objective was to determine the haemodynamic impact on the distal posterior tibial artery after the application of a high-compression leg multicomponent bandaging system using 4D flow magnetic resonance imaging. Leg dominance disparities of the posterior tibial artery before and after the application of the compressive bandage were also analysed. Twenty-eight healthy female volunteers were recruited (mean: 25.71, standard deviation: 4.74 years old) through a non-probability convenience sampling. The 4D flow magnetic resonance imaging of the distal tibial posterior artery was performed in all participants, first under standard resting conditions and after the application of a compression bandage in the leg. When the strong compressive bandage was applied, the area of the assessed artery decreased by 14.2%, whilst the average speed increased by 19.6% and the flow rate increased by 184.8%. There were differences between the haemodynamic parameters of both legs according to dominance, being statistically significantly lower in the dominant leg. The application of strong compressive bandaging significantly increases the arterial flow and mean velocity in the distal segment of the posterior tibial artery, in healthy volunteers by 4D flow magnetic resonance imaging. In this study, leg dominance influenced some of the haemodynamic parameters. According to the results, leg compression bandages cannot be contraindicated in vascular ulcers with arterial compromise.

Development of a New Adjustable Compression Garment (McBoooon) Made of Non-Stretch Self-Adhesive Fabric

Objectives: To assess the physical features and compression characteristics of a newly developed adjustable compression garment, McBoooon (Mc). Methods: Twelve healthy volunteers were recruited to assess the compression characteristics. The interface pressure (IP) was continuously measured to calculate the static (SSI) and dynamic stiffness indices (DSI). Additionally, the peak flow velocity (PV) of the popliteal vein during ankle dorsiflexion was measured using ultrasonography. Each parameter was compared between ASHIKA stockings (AS), Mc applied at the same resting pressure as AS (Mc1), and Mc applied at a resting pressure approximately twice that of Mc1 (Mc2). Results: SSI and DSI were significantly different, increasing in the order AS < Mc1 < Mc2 (p <0.01). Although the PV was significantly higher in the compression group than in the control group (p <0.05), no significant differences were found among the three groups. Conclusion: The physical features and compression characteristics of Mc were clarified. The high stiffness of this garment improves the adherence to compression therapy and contributes to the treatment of chronic venous insufficiency.

Development of a Tissue Oxygenation Flow-Based Index Toward Discerning the Healing Status in Diabetic Foot Ulcers

Objective: The objective of this study is to characterize breath-hold (BH)-induced oxygenation changes in diabetic foot ulcers (DFUs) and develop an oxygenation flow index (OFI) to discern nonhealing from healing DFUs. Approach: The imaging approach utilizes an innovative BH stimulus that induces vasoconstriction and measures for altering oxygenation flow in and around the tissues of DFUs and controls. The modified Beer-Lambert law was utilized to calculate hemoglobin-based spatiotemporal oxygenation maps in terms of oxygen saturation. Results: We found controls had synchronous BH-induced oxygenation changes across the dorsal (OFI: 29.0%) and plantar (OFI: 57.6%) aspects of the foot. Nonhealing DFUs, however, had less synchronous BH-induced oxygenation changes (OFI <28%). In addition, two complicated healing DFU cases, or cases with underlying issues or poor long-term healing outcomes, were observed to have OFIs <28%. Innovation: An OFI was developed to differentiate nonhealing DFUs from healing DFUs using a single, noncontact, near-infrared optical scanner for spatiotemporal oxygenation monitoring. The OFI has potential to provide immediate feedback on the microcirculation in DFUs, through hemoglobin-based oxygenation parameters. Conclusion: A preliminary threshold (OFI <28%) could differentiate nonhealing and complicated DFUs from healing DFUs. The overall oxygenation flow pattern was less synchronous (or the OFI value reduced) in the nonwound areas of the feet that were nonhealing. In other words, the reduced OFI value (<28%) in the entire foot, excluding the wound region is a possible indicator that the wound may not heal.

Current challenges in the prevention and management of post-thrombotic syndrome-towards improved prevention

Post-thrombotic syndrome (PTS) is a common and potentially debilitating complication of deep vein thrombosis (DVT), affecting up to 50% of DVT patients. The consequence of this chronic condition includes reduced quality of life, increased use of the healthcare system and decreased productivity. The societal impact of this condition is projected to increase, given our ageing population and increased burden of thrombotic diseases. Despite significant recent advances in our understanding of PTS, many unanswered questions remain. Currently, there are few effective and proven options for established PTS; hence, the emphasis should be on instituting effective prevention to reduce the progression to PTS. Effective anticoagulation lowers the risk of PTS, with direct oral anticoagulants appearing to outperform vitamin-K antagonists. However, the evidence for elastic compression stockings and endovascular thrombolysis or thrombectomy techniques remains unclear. Accurate identification of individuals at high risk of developing PTS may also improve the targeting of preventative interventions. This review will examine the current body of evidence regarding PTS, with a focus on preventative strategies as well as novel biomarkers.

Compression therapy in dermatology

Compression therapy is a conservative therapy that can be used in many patients with dermatological conditions, especially those associated with edema. In addition to its well-established use in venous and lymphatic disorders, there is increasing evidence that compression therapy supports the healing of inflammatory dermatoses. The presence of edema, regardless of its etiology, is an indication for the use of compression therapy. Nowadays, a variety of materials and treatment options are available for compression therapy, each with their own advantages and disadvantages. Often, compression therapy with low resting pressures is sufficient for effective therapy and is better tolerated by patients. The main contraindications to compression therapy are advanced peripheral arterial disease and decompensated heart failure. Individual factors and economic considerations should be taken into account when deciding on compression therapy with the patient. Patient self-management should be encouraged whenever possible. This requires education and support tools.

Kompressionstherapie in der Dermatologie

Die Kompressionstherapie ist eine konservative Therapie, die bei vielen Patienten mit dermatologischen Krankheiten durchgeführt werden kann, insbesondere wenn diese mit Ödemen assoziiert sind. Neben den wissenschaftlich sehr gut belegten Indikationen bei venösen und lymphatischen Erkrankungen, gibt es auch zunehmend wissenschaftliche Hinweise, dass durch die Kompressionstherapie die Abheilung entzündlicher Dermatosen unterstützt wird. Wenn Ödeme vorliegen, handelt es sich, unabhängig von deren Genese, um einen Einsatz im Rahmen der Zulassung der Kompressionstherapie.

Für die Kompressionstherapie stehen heute verschiedene Materialien und Versorgungsoptionen mit systemspezifischen Vor‐ und Nachteilen zur Verfügung. Oft ist eine Kompressionstherapie mit niedrigen Ruhedruckwerten für einen Therapieerfolg ausreichend und wird von den Patienten besser toleriert. Als wichtigste Kontraindikationen der Kompressionstherapie sind die fortgeschrittene periphere arterielle Verschlusskrankheit und die dekompensierte Herzinsuffizienz zu beachten.

Bei der gemeinsam mit dem Patienten getroffenen Entscheidung für eine Kompressionstherapie, sollten individuelle Faktoren und wirtschaftliche Aspekte berücksichtigt werden. Wann immer möglich, ist ein Selbstmanagement des Patienten zu unterstützen. Hierfür sind Edukation und Hilfsmittel erforderlich.

Compression therapy in peripheral artery disease: a literature review

OBJECTIVE

Our objective is to examine the pathophysiology of oedema in the ischaemic and post-revascularised limb, compare compression stockings to pneumatic compression devices, and summarise compression regimens in patients with severe peripheral artery disease (PAD) without revascularisation, after revascularisation, and in mixed arterial and venous disease.

METHOD

A scoping literature review of the aforementioned topics was carried out using PubMed.

RESULTS

Compression therapy has been shown to increase blood flow and aid in wound healing through a variety of mechanisms. Several studies suggest that intermittent pneumatic compression (IPC) devices can be used to treat critical limb ischaemia in patients without surgical options. Additionally, compression stockings may have a role in preventing oedema after peripheral artery bypass surgery, thereby diminishing pain and reducing the risk of surgical wound dehiscence.

CONCLUSION

Oedema may occur in the ischaemic limb after revascularisation surgery, as well as in combination with venous disease. Clinicians should not fear using compression therapy in PAD.

Compression Therapy in Dermatology

Purpose of Review

The compression therapy provides valuable support during management of vascular and inflammatory lower leg skin disorders. The review outlines the mechanism of action and the treatment options available with indications for use in wound management and general dermatology.

Recent Findings

Atypical wounds such as pyoderma gangrenosum, cutaneous vasculitis and other inflammatory skin diseases may benefit from the use of compression therapy. Adherence to treatment is always a challenging aspects for patients and caregiver, but modern technologies and specific materials have improved the compliance during treatment.

Summary

Compression therapy is a main option in vascular ulcer management. The technology provided by different devices together with new methods of bandaging application have increased the outcomes and acceptability from patients. Physicians should be aware of the advantages provided by compression therapy in skin diseases.

Sclerotherapy of lower limb veins: Indications, contraindications and treatment strategies to prevent complications - A consensus document of the International Union of Phlebology-2023

BACKGROUND

Sclerotherapy is a non-invasive procedure commonly used to treat superficial venous disease, vascular malformations and other ectatic vascular lesions. While extremely rare, sclerotherapy may be complicated by serious adverse events.

OBJECTIVES

To categorise contraindications to sclerotherapy based on the available scientific evidence.

METHODS

An international, multi-disciplinary panel of phlebologists reviewed the available scientific evidence and developed consensus where evidence was lacking or limited.

RESULTS

Absolute Contraindications to sclerotherapy where the risk of harm would outweigh any benefits include known hypersensitivity to sclerosing agents; acute venous thromboembolism (VTE); severe neurological or cardiac adverse events complicating a previous sclerotherapy treatment; severe acute systemic illness or infection; and critical limb ischaemia. Relative Contraindications to sclerotherapy where the potential benefits of the proposed treatment would outweigh the risk of harm or the risks may be mitigated by other measures include pregnancy, postpartum and breastfeeding; hypercoagulable states with risk of VTE; risk of neurological adverse events; risk of cardiac adverse events and poorly controlled chronic systemic illness. Conditions and circumstances where Warnings and Precautions should be considered before proceeding with sclerotherapy include risk of cutaneous necrosis or cosmetic complications such as pigmentation and telangiectatic matting; intake of medications such as the oral contraceptive and other exogenous oestrogens, disulfiram and minocycline; and psychosocial factors and psychiatric comorbidities that may increase the risk of adverse events or compromise optimal treatment outcomes.

CONCLUSIONS

Sclerotherapy can achieve safe clinical outcomes provided that (1) patient-related risk factors and in particular all material risks are (1a) adequately identified and the risk benefit ratio is clearly and openly discussed with treatment candidates within a reasonable timeframe prior to the actual procedure; (1b) when an individual is not a suitable candidate for the proposed intervention, conservative treatment options including the option of 'no intervention as a treatment option' are discussed; (1c) complex cases are referred for treatment in controlled and standardised settings and by practitioners with more expertise in the field; (1d) only suitable individuals with no absolute contraindications or those with relative contraindications where the benefits outweigh the risks are offered intervention; (1e) if proceeding with intervention, appropriate prophylactic measures and other risk-mitigating strategies are adopted and appropriate follow-up is organised; and (2) procedure-related risk factors are minimised by ensuring the treating physicians (2a) have adequate training in general phlebology with additional training in duplex ultrasound, procedural phlebology and in particular sclerotherapy; (2b) maintain their knowledge and competency over time and (2c) review and optimise their treatment strategies and techniques on a regular basis to keep up with the ongoing progress in medical technology and contemporary scientific evidence.

[The term mixed leg ulcer should no longer be used today]

A wound on the lower legs of patients with chronic venous insufficiency (CVI) and peripheral arterial disease (PAD) is today usually referred to as a mixed leg ulcer. This does not take into account the different stages of the diseases and, thus, their pathophysiological relevance. In everyday clinical practice, this often leads, among other things, to these patients not receiving compression therapy. The multidisciplinary professional association Initiative Chronische Wunden (ICW) e. V., therefore, recommends that this undifferentiated and misleading term should no longer be used. Instead, a leg ulcer with advanced CVI and concomitant PAD in stage I-IIb according to Fontaine or Rutherford category 0-3 should be classified as a venous leg ulcer, while a leg ulcer with advanced PAD in stage III or IV according to Fontaine or Rutherford category 4-6 and advanced CVI is termed an arteriovenous leg ulcer. A leg ulcer in advanced PAD stage IV according to Fontaine or Rutherford category 5 or 6 without advanced CVI is called an arterial leg ulcer. Other relevant comorbidities with an influence on wound healing should also be described separately.

Clinical Efficacy and Safety of Long-Term Compression in Patients with Mixed Arterial and Venous Etiology Ulcers in the Leg

Elastic compressions are standard treatment for leg ulcers of venous etiology. The effect of compressions on ulcers of mixed (arterial or venous) etiology, however, has rarely been studied. The objective of this study was to evaluate the variation in transcutaneous oxygen pressure (TcPO2) in patients with ulcers of mixed arterial or venous etiology treated with 1 month of compression. This prospective cohort study was conducted at a university hospital in France. Patient eligibility was for those attending a consultation of a work-up of a leg ulcer of mixed arterial-venous etiology lasting at least 4 to 6 weeks. Compressions were prescribed according to the hemodynamic status and were evaluated by the ankle-brachial index and toe-brachial index using a decision-making algorithm based on French national guidelines. Quality of life was assessed using the Short-Form 36-Item (SF-36) questionnaire. In total, 32 patients were included between September 30, 2018 and May 31, 2019. A difference was observed between TcPO2 before compression (49.3 ± 13.01 mm Hg) and after 1 month (51.2 ± 15.05 mm Hg), average change 1.9 ± 2.04 mm Hg ( p  = 0.025). The average ulcer size prior to compression was 49 ± 102 cm ² versus 37 ± 94 cm ² after 1 month of effective compression, corresponding to a reduction of 12 ± 8 cm ² ( p  < 0.001). There was a reduction in the bodily pain dimension of the SF-36. Compressions adapted to the hemodynamic status led to an increase in TcPO2, a reduction in wound size, and an improvement to bodily pain in patients with leg ulcers of mixed arterial-venous etiology.

High-Intensity, Low-Frequency Pulsed Electromagnetic Field as an Odd Treatment in a Patient with Mixed Foot Ulcer: A Case Report

Lower-extremity ulcers are associated with an increasing prevalence and significant economic and social costs. To date, there is no high-quality evidence related to an optimal treatment algorithm. A multimodal approach is needed particularly in patients with comorbidity and polytherapy. Herein, we report the case of a 94-year-old Caucasian female with comorbidity and polytherapy who was admitted to our observation for a history (1 year) of chronic painful malleolar mixed ulcer. After clinical evaluation, she was treated with a twice daily pain relief therapy and with a weekly diamagnetic therapy protocol plus a local treatment. During the clinical examination, we documented a statistically significant improvement in both pain (VAS score from 8 to 2 p < 0.01) and foot ulcer (surface reduction from 6 cm × 4 cm to 2 cm × 2 cm, p < 0.01) at the sixth week of combined treatment. The ulcer completely healed at the ninth week. This is the first study to document the effect of diamagnetic therapy as an add-on therapy in the management of wound healing. In conclusion, even if high-quality evidence is still lacking, diamagnetic therapy might represent an interesting option as an add-on treatment for ulcer.

Venous Leg Ulcers: A Review of Published Assessment and Treatment Algorithms

Significance: Chronic venous disease (CVD) is prevalent in the aging population and leads to venous leg ulcers (VLUs). These wounds can last and recur for years, significantly impacting quality of life. A large body of literature exists on CVD and VLU diagnosis and treatment. Multiple algorithms, guidelines, and consensus documents have been published on this topic, highlighting the importance of this issue in clinical practice. However, these documents are not fully aligned with each other. Recent Advances: The latest update of the internationally used classification system for CVD was recently published. Our review aims to summarize the existing information to provide an educational tool for clinicians new to this topic, and to highlight the commonalities between the published recommendations. Critical issues: VLUs need to be treated with consideration for the extent of venous disease present in the patient. This requires a good understanding of the various components involved and the possible additional concomitant conditions by the first-line clinician who encounters the patient. A multidisciplinary team is necessary for a successful overall treatment plan, and this plan should be tailored to each patient's specific needs and lifestyle. Future Directions: Compression is still the mainstay of treatment for CVD and VLUs. Compression is needed long term, but it does not suffice by itself to prevent recurrences without interventional correction. Venous intervention should be offered early to prevent or slow disease progression and reduce recurrence.

Compression bandages or stockings versus no compression for treating venous leg ulcers

BACKGROUND

Leg ulcers are open skin wounds on the lower leg that can last weeks, months or even years. Most leg ulcers are the result of venous diseases. First-line treatment options often include the use of compression bandages or stockings.

OBJECTIVES

To assess the effects of using compression bandages or stockings, compared with no compression, on the healing of venous leg ulcers in any setting and population.

SEARCH METHODS

In June 2020 we searched the Cochrane Wounds Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE (including In-Process & Other Non-Indexed Citations), Ovid Embase and EBSCO CINAHL Plus. We also searched clinical trials registries for ongoing and unpublished studies, and scanned reference lists of relevant included studies as well as reviews, meta-analyses and health technology reports to identify additional studies. There were no restrictions by language, date of publication or study setting.

SELECTION CRITERIA

We included randomised controlled trials that compared any types of compression bandages or stockings with no compression in participants with venous leg ulcers in any setting.

DATA COLLECTION AND ANALYSIS

At least two review authors independently assessed studies using predetermined inclusion criteria. We carried out data extraction, and risk-of-bias assessment using the Cochrane risk-of-bias tool. We assessed the certainty of the evidence according to GRADE methodology.

MAIN RESULTS

We included 14 studies (1391 participants) in the review. Most studies were small (median study sample size: 51 participants). Participants were recruited from acute-care settings, outpatient settings and community settings, and a large proportion (65.9%; 917/1391) of participants had a confirmed history or clinical evidence of chronic venous disease, a confirmed cause of chronic venous insufficiency, or an ankle pressure/brachial pressure ratio of greater than 0.8 or 0.9. The average age of participants ranged from 58.0 to 76.5 years (median: 70.1 years). The average duration of their leg ulcers ranged from 9.0 weeks to 31.6 months (median: 22.0 months), and a large proportion of participants (64.8%; 901/1391) had ulcers with an area between 5 and 20 cm². Studies had a median follow-up of 12 weeks. Compression bandages or stockings applied included short-stretch bandage, four-layer compression bandage, and Unna's boot (a type of inelastic gauze bandage impregnated with zinc oxide), and comparator groups used included 'usual care', pharmacological treatment, a variety of dressings, and a variety of treatments where some participants received compression (but it was not the norm). Of the 14 included studies, 10 (71.4%) presented findings which we consider to be at high overall risk of bias. Primary outcomes There is moderate-certainty evidence (downgraded once for risk of bias) (1) that there is probably a shorter time to complete healing of venous leg ulcers in people wearing compression bandages or stockings compared with those not wearing compression (pooled hazard ratio for time-to-complete healing 2.17, 95% confidence interval (CI) 1.52 to 3.10; I² = 59%; 5 studies, 733 participants); and (2) that people treated using compression bandages or stockings are more likely to experience complete ulcer healing within 12 months compared with people with no compression (10 studies, 1215 participants): risk ratio for complete healing 1.77, 95% CI 1.41 to 2.21; I² = 65% (8 studies with analysable data, 1120 participants); synthesis without meta-analysis suggests more completely-healed ulcers in compression bandages or stockings than in no compression (2 studies without analysable data, 95 participants). It is uncertain whether there is any difference in rates of adverse events between using compression bandages or stockings and no compression (very low-certainty evidence; 3 studies, 585 participants). Secondary outcomes Moderate-certainty evidence suggests that people using compression bandages or stockings probably have a lower mean pain score than those not using compression (four studies with 859 participants and another study with 69 ulcers): pooled mean difference -1.39, 95% CI -1.79 to -0.98; I² = 65% (two studies with 426 participants and another study with 69 ulcers having analysable data); synthesis without meta-analysis suggests a reduction in leg ulcer pain in compression bandages or stockings, compared with no compression (two studies without analysable data, 433 participants). Compression bandages or stockings versus no compression may improve disease-specific quality of life, but not all aspects of general health status during the follow-up of 12 weeks to 12 months (four studies with 859 participants; low-certainty evidence). It is uncertain if the use of compression bandages or stockings is more cost-effective than not using them (three studies with 486 participants; very low-certainty evidence).

AUTHORS' CONCLUSIONS

If using compression bandages or stockings, people with venous leg ulcers probably experience complete wound healing more quickly, and more people have wounds completely healed. The use of compression bandages or stockings probably reduces pain and may improve disease-specific quality of life. There is uncertainty about adverse effects, and cost effectiveness. Future research should focus on comparing alternative bandages and stockings with the primary endpoint of time to complete wound healing alongside adverse events including pain score, and health-related quality of life, and should incorporate cost-effectiveness analysis where possible. Future studies should adhere to international standards of trial conduct and reporting.

Wounds in chronic leg oedema

Wounds and chronic oedema are common disorders, but rarely studied together. The objective of this cross-sectional study was to investigate the point-prevalence and risk factors of wounds on the leg, in chronic leg oedema. Forty sites in nine countries were included. Of 7077 patients with chronic leg oedema, 12.70% had wounds. Independent risk factors were: peripheral arterial disease (odds ratio (OR) 4.87, 95% confidence intervals (CI) 3.63-6.52), cellulitis within the past 12 months (OR 2.69, 95% CI 2.25-3.21), secondary lymphoedema (OR 2.64, 95% CI 1.93-3.60), being male (OR 2.08, 95% CI 1.78-2.44), being over 85 years of age (OR 1.80, 95% CI 1.23-2.62), underweight (OR 1.79, 95% CI 1.14-2.79), bed bound (OR 1.79, 95% CI 1.01-3.16), chair bound (OR 1.52, 95% CI 1.18-1.97), diabetes (OR 1.47, 95% CI 1.23-1.77), and walking with aid (OR 1·41, 95% CI 1.17-1.69). 43.22% of those with wounds had clinically defined well-controlled oedema, associated with a significantly lower risk of wounds (OR 0.50, 95% CI 0.42-0.58, P < .001). Hard/fibrotic tissue (OR 1.71, 95% CI 1.19-2.48), and a positive Stemmers sign (OR 1.57, 95% CI 1.05-2.35) were associated with wounds. The study reinforces the importance of measures to control oedema, as controlled swelling was associated with a 50% lower risk of wounds.

Multicomponent compression system use in patients with chronic venous insufficiency: a real-life prospective study

OBJECTIVE

Compression therapy is the cornerstone of therapeutic management of patients with chronic venous insufficiency (CVI). This study aimed to evaluate the efficacy and safety of a multicomponent compression system in an unselected population of patients with CVI problems under real-life conditions.

METHOD

A prospective, multicentre, observational study with a multicomponent two-bandage compression system (UrgoK2, Laboratoires Urgo, France) was conducted in 103 centres in Germany. Main outcomes included wound healing rate, wound healing progression, assessment of oedema and ankle mobility, local tolerability and acceptance of the compression therapy.

RESULTS

A total of 702 patients with venous leg ulcers (VLU) and/or with lower limb oedema due to CVI were treated with the evaluated system for a mean (±standard deviation) duration of 27±17 days. By the last visit, 30.9% of wounds had healed and 61.8% had improved. Limb oedema was resolved in 66.7% of patients and an improvement of ankle mobility was reported in 44.2% of patients. The skin condition under the compression therapy was also considered as improved in 73.9% of patients and a substantial reduction of pain was achieved, both in number of patients reporting pain and in pain intensity. Compression therapy with the evaluated system was 'very well' or 'well' tolerated and 'very well' or 'well' accepted by >95% of patients. These positive outcomes were in line with the general opinion of physicians on the evaluated compression bandages, which were judged 'very useful' or 'useful' for >96.6% of patients. Similar results were reported regardless of the treated condition, VLU and/or limb oedema.

CONCLUSION

Real-life data documented in this large observational study of non-selected patients receiving compression therapy in daily practice confirm the benefits and safety profile of the evaluated compression system. This study also confirms the high-level of performance and acceptability of the system, regardless of the characteristics of the wounds or patients at initiation of the treatment. The data support the use of this multicomponent compression system as one first-line intervention in patients with symptoms caused by CVI.

Modified compression therapy in mixed arterial-venous leg ulcers: An integrative review

Leg ulcers remain an increased burden to healthcare cost and morbidity in modern society. While most leg ulcers are venous in origin, recognition and prompt identification of concomitant arterial occlusive disease is critical to determine underlying aetiology and subsequent management. This integrative review presents the current evidence to establish the role of modified compression therapy (MCT) in treatment of mixed arterial venous leg ulcers (MAVLU). A literature search was conducted using the electronic databases CINAHL, MEDLINE, PUBMED, and Embase. Ten studies met the eligibility criteria and were subsequently analysed. Our review concludes that MCT, with compression pressures between 20 and 30 mmHg, can promote healing in MAVLU with moderate arterial insufficiency (0.5 ≤ ABPI ≤0.8). If ABPI is <0.5, MCT can be considered once restoration of acceptable ABPI is achieved. Intolerance, lack of response or further deterioration of disease within 3 months should prompt further arterial imaging and intervention. MCT is generally well tolerated with no adverse outcomes reported. A holistic yet individualised approach is vital in order to account for all factors influencing this patient-led decision-making process, ultimately ensuring effective treatment, which improves patient's quality of life and reduces socioeconomic burden of the disease.

Compression therapy in venous diseases: physical assumptions and clinical effects

Compression therapy (CT) is an established treatment method in chronic venous disease. Despite years of clinical experience, choosing the optimum compression therapy, including grade and pressure distribution, which determine the efficacy of treatment poses a challenge. The paper discusses CT physical assumptions (stiffness, elasticity, static and dynamic stiffness indices), clinical effects and contraindications to CT.

Compression Therapy Is Not Contraindicated in Diabetic Patients with Venous or Mixed Leg Ulcer

The aim of this study was to investigate if compression therapy (CT) can be safely applied in diabetic patients with Venous Leg Ulcers (VLU), even when a moderate arterial impairment (defined by an Ankle-Brachial Pressure Index 0.5–0.8) occurs as in mixed leg ulcers (MLU). Materials and methods: in one of our previous publications we compared the outcomes of two groups of patients with recalcitrant leg ulcers. Seventy-one patients were affected by mixed venous and arterial impairment and 109 by isolated venous disease. Both groups were treated by tailored inelastic CT (with compression pressure <40 mm Hg in patients with MLU and >60 mm Hg in patients with VLU) and ultrasound guided foam sclerotherapy (UGFS) of the superficial incompetent veins with the reflux directed to the ulcer bed. In the present sub analysis of the same patients we compared the healing time of 107 non-diabetic patients (NDP), 69 with VLU and 38 with MLU) with the healing time of 73 diabetic patients (DP), 40 with VLU and 33 with MLU. Results: Twenty-five patients were lost at follow up. The results refer to 155 patients who completed the treatment protocol. In the VLU group median healing time was 25 weeks for NDP and 28 weeks in DP (p = 0.09). In the MLU group median healing time was 27 weeks for NDP and 29 weeks for DP (p = −0.19). Conclusions: when providing leg ulcer treatment by means of tailored compression regimen and foam sclerotherapy for superficial venous refluxes, diabetes has only a minor or no effect on the healing time of recalcitrant VLU or MLU.

Safety of medical compression stockings in patients with diabetes mellitus or peripheral arterial disease

INTRODUCTION

Compression therapy is highly effective in the treatment of many venous diseases, including leg edema. However, its relevance in patients with peripheral arterial disease (PAD) or diabetes mellitus is critically discussed. The aim of the present study was to assess the influence of compression therapy on microperfusion and its safety in patients with PAD or diabetes mellitus.

RESEARCH DESIGN AND METHODS

A prospective analysis of 94 consecutive patients (44 patients with diabetes, 45 patients with PAD and 5 healthy controls) undergoing medical compression therapy was performed. Microperfusion was assessed by a combined method of white light tissue spectrometry and laser Doppler flowmetry under medical compression therapy (classes I and II), in different body positions (supine, sitting, standing and elevated position of the leg) and at different locations (great toe, lateral ankle and calf).

RESULTS

During the entire study, no compression-related adverse events occurred. Evaluation of microcirculation parameters (oxygen saturation of hemoglobin and flow) at the different locations and in sitting and standing positions (patients with diabetes and PAD) under compression therapy classes I and II revealed no tendency for reduced microperfusion in both groups. In contrast, in the elevated leg position, all mean perfusion values decreased in the PAD and diabetes groups. However, the same effect was seen in the healthy subgroup.

CONCLUSIONS

In consideration of the present inclusion criteria, use of medical compression stockings is safe and feasible in patients with diabetes or PAD. This study did not find relevant impairment of microperfusion parameters under compression therapy in these patient subgroups in physiologic body positions.

TRIAL REGISTRATION NUMBER

NCT03384758.

Risks and contraindications of medical compression treatment - A critical reappraisal. An international consensus statement

Objectives

Medical compression therapy is used for non-invasive treatment of venous and lymphatic diseases. Medical compression therapy-associated adverse events and contraindications have been reported, although some contraindications are theoretically based. This consensus statement provides recommendations on medical compression therapy risks and contraindications.

Methods

A systematic literature search of medical compression therapy publications reporting adverse events up until November 2017 was performed. A consensus panel comprising 15 international experts critically reviewed the publications and formulated the recommendations.

Results

Sixty-two publications reporting medical compression therapy adverse events were identified. The consensus panel issued 21 recommendations on medical compression therapy contraindications and adverse event risk mitigation, in addition to reviewing medical compression therapy use in borderline indications. The most frequently reported non-severe medical compression therapy-associated adverse events included skin irritation, discomfort and pain. Very rare but severe adverse events, including soft tissue and nerve injury, were also identified.

Conclusion

This consensus statement summarises published medical compression therapy-associated adverse events and contraindications, and provides guidance on medical compression therapy. Severe medical compression therapy-associated adverse events are very rarely encountered if compression is used correctly and contraindications are considered.

The Ears of a Hippopotamus: Quality of Venous Leg Ulcer Care in Gauteng, South Africa

OBJECTIVE

To describe venous ulcer care and wound care practices in Gauteng, a province of South Africa, according to the Donabedian structure-process-outcome quality improvement model.

METHODS

Forty-eight facilities were selected randomly from public and private wound care practices in Gauteng. Structured interviews were conducted with care providers via questionnaire to assess the structural aspects of the Donabedian model. Within these facilities, investigators randomly selected 160 patient files and extracted data using a checklist to assess processes implemented and outcomes reached for patients who had previously presented with lower-leg venous ulcers.

RESULTS

Facilities lack the necessary equipment to perform vital assessments. Handheld Dopplers were available in 66% (n = 48) of the facilities. Sixty-one percent (n = 48) of the personnel at the facilities indicated that they had no formal wound care training. Although the majority of files (92%, n = 147) indicated that an assessment tool was used, many elements were not evaluated comprehensively according to the best available evidence. Aspects such as smoking, body mass index, and anemia were assessed in fewer than 30% of the patients. Distinguishing between superficial and deep infection and the accompanying overuse of antimicrobials and antibiotics were among the challenges identified. Further, 71% of patients received compression therapy, although the ankle-brachial pressure index of only 30% of patients was known. In 27 cases (17%), the outcome was amputation.

CONCLUSIONS

From this survey, it is evident that not all clinicians providing wound care in Gauteng are adequately trained or fully implementing best practice guidelines, and the consequences are detrimental to patients, particularly in terms of amputation. This article highlights the need for improved legislation and regulation for practitioners who deliver wound care services.

Hyperelastic Properties of Platinum Cured Silicones and its Applications in Active Compression

This paper presents the fundamental research of design, development, and evaluation of an active compression system consisting of silicone based inflatable mini-bladders, which could be used in applying radial pressure for the treatment of venous disease. The use of mini-bladders will nullify the effect of radius of curvature and provide a higher resolution to the pressure distribution. They are designed with two elastomeric layers and inflation is limited only to one side. The mini-bladders apply a radial force onto the treated surface when inflated, and the pressure inside mini-bladders could be measured using the concept of back pressure, which provides the flexibility to inflate mini-bladders to a predefined pressure. The 3-D deformation profile of the mini-bladders was analysed using finite element method (FEM) and FEM simulations were validated with experimental data, which showed good agreement within pressure region required for the treatment of venous disease. Finally, the pressure transmission characteristics of mini-bladders were evaluated on a biofidellic lower leg surrogate and the results have shown that the mini-bladders could apply a uniform pressure irrespective of the location on the leg with a 60%–70% of inlet pressure successfully transmitted onto the leg surface, while 40%–50% was available after the fat layers.

Examining risk factors and preventive treatments for first venous leg ulceration: A cohort study

BACKGROUND

Large studies that examine risk factors for first occurrence of venous leg ulcerations are needed to guide management.

OBJECTIVE

To investigate factors associated with development of first occurrence of venous leg ulcerations.

METHODS

A retrospective cohort study using a validated national commercial claims database of patients with venous insufficiency. Subjects were followed to determine whether they developed first occurrence of venous leg ulcerations, and risk and protective factors were analyzed.

RESULTS

Adjusted hazard ratio (AHR) for comorbidities demonstrated an increased risk in men (AHR 1.838; 95% confidence interval [CI] 1.798-1.880), older age (45-54 years: AHR 1.316, 95% CI 1.276-1.358; 55-64 years, AHR 1.596, 95% CI 1.546-1.648), history of nonvenous leg ulceration (AHR 3.923; 95% CI 3.699-4.161), anticoagulant use (AHR 1.199; 95% CI 1.152-1.249), antihypertensive use (AHR 1.067; 95% CI 1.040-1.093), and preexisting venous insufficiency including chronic venous insufficiency (AHR 1.244; 95% CI 1.193-1.298), edema (AHR 1.224; 95% CI 1.193-1.256), and chronic venous hypertension (AHR 1.671; 95% CI 1.440-1.939). Possible protective factors were having venous surgery (AHR 0.454; 95% CI 0.442-0.467), using compression stockings (AHR 0.728; 95% CI 0.705-0.753), using prescribed statin medications (AHR 0.721; 95% CI 0.700-0.743), and using pain medications (AHR 0.779; 95% CI 0.757-0.777).

LIMITATIONS

Risk of misclassification, given the use of International Classification of Diseases, Ninth Revision codes. Possible confounding factors such as body mass index could not be adequately controlled with these codes.

CONCLUSION

The new evidence presented supports a paradigm shift toward venous leg ulceration prevention.

Introducing the British Lymphology Society position paper on ankle brachial pressure index

Prompt application of appropriate compression therapy is essential for effective treatment of lymphoedema. However, it is accepted that prior to the application of compression to the lower limbs, either with bandaging or compression garments, patients should demonstrate a satisfactory vascular status, as assessed via axillary brachial pressure index (ABPI). Unfortunately, the presence of peripheral oedema may render a reading impossible or grossly inaccurate. Relying solely on ABPI assessment is potentially harmful to patients, who may be denied appropriate treatment or experience complications and deterioration of their condition due to delayed treatment. The British Lymphology Society recognises a need to focus more on clinical assessment skills to determine vascular status, rather than relying on ABPI alone. Thus, the Society has developed guidance and a practical tool to support clinical decision-making and enhance practitioner confidence in the safe application of compression therapy in the absence of ABPI.

Global guidelines trends and controversies in lower limb venous and lymphatic disease: Narrative literature revision and experts' opinions following the vWINter international meeting in Phlebology, Lymphology & Aesthetics, 23-25 January 2019

Guidelines are fundamental in addressing everyday clinical indications and in reporting the current evidence-based data of related scientific investigations. At the same time, a spatial and temporal issue can limit their value. Indeed, variability in the recommendations can be found both among the same nation different scientific societies and among different nations/continents. On the other side, Garcia already published in 2014 data showing how, after three years in average, one out of five recommendations gets outdated (Martinez Garcia LM, Sanabria AJ, Garcia Alvarez E, et al. The validity of recommendations from clinical guidelines: a survival analysis. CMAJ 2014;186(16):1211–1219). The present document reports a narrative literature revision on the major international recommendations in lower limb venous and lymphatic disease management, focusing on the different countries’ guidelines, trends and controversies from all the continents, while identifying new evidence-based data potentially influencing future guidelines. World renowned experts’ opinions are also provided. The document has been written following the recorded round tables scientific discussions held at the vWINter international meeting (22–26 January 2019; Cortina d’Ampezzo, Italy) and the pre- and post-meeting literature search performed by the leading experts.

Compression therapy in venous diseases: current forms of compression materials and techniques

Compression therapy (CT) is an established treatment method in chronic venous disease (CVD). The paper presents information on different CT forms with indications and contraindications based on expert consensuses from recent years. A high prevalence of CVD implies continuous development of compression materials, systems and techniques as well as measurement methods. The article aims at reviewing available literature on the development of compression therapy techniques.

Cadaveric Skin Grafts May Greatly Increase the Healing Rate of Recalcitrant Ulcers When Used Both Alone and in Combination With Split-Thickness Skin Grafts

BACKGROUND

Leg ulcers that do not heal despite appropriate treatment are defined as recalcitrant ulcers. Large surface area, depth, and long duration represent some of most important factors impeding ulcer healing. After sharp debridement, dermal substitutes including skin from cadaver donors may increase the healing rate of recalcitrant ulcers reducing the risk of scar formation and recurrence.

OBJECTIVE

Assessing if, after sharp debridement, dermal substitutes including skin from cadaver donors may increase the healing rate of recalcitrant ulcers reducing the risk of scar formation and recurrence.

PATIENTS AND METHODS

Among patients admitted to our hospital for all types of chronic leg ulcers, we retrospectively reviewed the records of patients affected by recalcitrant ulcers (surface greater than 100 cm, tissue loss involving epidermis, dermis, and subcutaneous tissue, duration longer than 1 year, and showing no healing tendency). After sharp debridement, the ulcers were covered by allografts with strict follow-up after discharge. Multiple allografts were performed when necessary, and a final autograft was applied in case of incomplete healing.

RESULTS

The records of 414 patients were analyzed. Forty-three patients were lost at follow-up, and the remaining 371 healed after 765 grafting procedures. In 163 patients, the ulcers healed by means of a final autograft. In all the remaining cases, allograft led to ulcer healing.

CONCLUSION

Allografts represent an effective treatment option in case of recalcitrant, large, deep and long-lasting leg ulcers.

[Importance of adequate pressure in compression therapy : Basis for successful treatment]

BACKGROUND

The pressure exerted by a compression device on a part of the body corresponds to the dosage of the compression therapy. Therefore, the pressure course under compression materials should be investigated in different clinical situations.

MATERIAL AND METHODS

Pressure measurements were carried out under different compression materials in lying, standing and walking positions within the framework of training, self-experimentation and in patients with venous leg ulcers.

RESULTS

The results showed that the pressure varied considerably depending on the material used, the firmness of application, the local configuration (body position) and the time interval between applications. A loss of pressure occurred under each compression therapy, especially under inelastic short-stretch material, mainly due to movement and edema reduction. This pressure loss is decisive for the timing of dressing changes and a reason for the good tolerance of high-pressure levels in mobile patients.

CONCLUSION

Low pressures are particularly suitable for edema reduction. Hemodynamic effects require higher pressures (60-80 mmHg). For this purpose, inelastic materials are preferred which enable lower pressures when lying down (40-60 mmHg). As compression bandages are too loosely applied by many users, pressure indicators on bandages or adaptive bandages with templates are helpful to apply the material with the correct pressure. As a consequence of these findings it is postulated that, at least in studies comparing different compression media, pressure measurements should be carried out in the future, whereby the measuring point and body position should be documented.

A near-infrared spectroscopy-assisted test discriminates patients with peripheral arterial disease and venous insufficiency with changes of foot oxygenation following light elastic compression therapy

Background: Elastic compression therapy (CT) in patients with peripheral artery disease (PAD) and chronic venous insufficiency (CVI) may compromise arterial perfusion. We evaluated the feasibility of a toe-flexion test, which quantifies dynamic foot perfusion by near-infrared spectroscopy (NIRS), for the assessment of hemodynamic sustainability of CT in PAD patients with CVI. Patients and methods: In this prospective observational study, PAD patients aged 50-85 with combined CVI at CEAP stages II-IV were studied. The ankle-brachial index (ABI) was measured, and foot perfusion was determined after 10 consecutive toe-flexion movements with NIRS sensors placed on the dorsum of each foot. Knee-high open-toe compression stockings were applied, and the degree of compression was measured. Toflex-area was determined by calculating the area under the curve of the oxygenated hemoglobin track recorded by NIRS. A toflex-area reduction > 20 % following CT was arbitrarily defined to identify limbs of patients with improved foot perfusion. These subjects received CT to be worn and a diary to report adherence and symptoms. Results: Forty-seven PAD patients (74 ± 9 years; ABI 0.67 ± 0.24) with CVI were enrolled. For all legs, superimposable toflex-areas were observed for the first two attempts (ICC 0.92). Following application of CT (17 ± 2 mmHg), the toflex-area improved (from -162 ± 110 a.u. to -112 ± 104 a.u.; p < .001). Sixty-two limbs (n = 32 patients) exhibited improved foot perfusion after CT, with a mean variation of 80 ± 47 a.u., while 32 limbs (n = 23 patients) showed stable or worsened values. In a regression model, favorable variations in toflex-area after CT were linked to a worse baseline toflex-area (R² = 0.18; p < 0.001; r_partial = -0.42) while the percentage improvement directly correlated with CEAP class (p = 0.033). Conclusions: The NIRS-assisted test, which is feasible in a laboratory context, objectively discriminates the hemodynamic tolerability of the treatment and identifies subjects with combined PAD and CVI with improved perfusion after CT, in spite of the presence of PAD.

Controlling compression bandaging pressure in leg ulcer research trials: A summary of the literature

Compression bandaging remains the ‘gold standard’ intervention for the treatment of venous leg ulcers. Numerous studies have investigated the effect of a large variety of compression bandaging techniques and materials on venous leg ulcer healing. However, the majority of these studies failed to monitor both actual bandage application pressures and the bandaging competency of participating clinicians. A series of literature searches to explore the methods, practices, recommendations and results of monitoring compression bandaging pressures in leg ulcer research trials were undertaken. This included investigating the reliability and validity of sub-bandage pressure monitors and the degree to which compression bandaging achieves the recommended sub-bandage pressure. The literature revealed inconsistencies regarding the monitoring of sub-bandage pressure and in sub-bandage pressures produced by clinicians. This creates difficulties when comparing study outcomes and attempting to develop evidence-based practice recommendations.

Compression therapy in lymphedema: Between past and recent scientific data

Aim

To extrapolate and discuss the scientific data on compression in lymphedema treatment, so to review old and innovative concepts about pressure, stiffness and other interplaying factors related to its efficacy and comfort.

Material and methods

Narrative review based on search in Medline/Google Scholar through key-words related to compression in lymphedema.

Results

Currently available literature lacks relevant details about data on protocol, devices, techniques, interface pressure, stiffness, as well as biases are represented by the different descriptions to present the outcomes. More recent evidence from adjustable wrap devices and elastic garments question the need for high pressure (especially for the upper limb) and stiffness in lymphedema treatment.

Conclusions

At present time a very strong compression pressure exerted by material with high stiffness seem to be questionable in lymphedema treatment. A low pressure provides the best outcomes in arm lymphedema, while a pressure in the range of 40–60 mm Hg seems to provide higher efficacy in lower limb lymphedema, provided it is maintained overtime. A high stiffness seems to be unnecessary to treat chronic edema. Future clinical trials, including proper description of treatment methodology and adequate investigating instrumental tools, are awaited to possibly corroborate the conclusive outcomes of our review.

Development of an accurate nursing program based on function in chronic venous leg ulcers: protocol for matching function status with nursing interventions using the Delphi survey

Objective

Venous leg ulceration (VLU) is one of the complications of lower extremity venous reflux and reflux disorder of severe diseases, with many adverse effects on patient’s work and life. Nowadays, more and more patients with VLU accept wound care in community setting. Clinical nurses generally take care of the patients based on their own experiences. Healing in VLU is an incredibly complex process, which puzzles even experts. The majority of general nurses do not have this level of expertise, especially those nurses serving in community. Function is the basis of nursing activities. Patients always show different clinical manifestations and self-care abilities due to various function states, which cannot be reflected completely by the existing nursing practice. How to describe nursing practice standardized in order to demonstrate the effectiveness of interventions and facilitate interdisciplinary communication is another urgent problem. Therefore, the aim of this project is to develop an accurate nursing program based on function in chronic venous leg ulcers, which can both satisfy the needs of patients and promote nursing revolution.

Methods

This study will use International Classification of Functioning Disability and Health as a framework to choose suitable functions and to filter function classification standards of chronic venous leg ulcers through evidence-based systematic research. Nursing interventions related to VLU are selected based on Nursing Interventions Classification, adding other nursing activities by methods of evidence-based systematic review and clinical observation. Then, nursing interventions and function status are matched through steering committee. Finally, the Delphi survey method is adopted to make nursing program native and scientific.

Conclusions

This study is expected to be very significant and meaningful in using standardized nursing terminology. The nursing program established could better meet the needs of both patients with chronic venous leg ulcers and clinical nurses, promoting the development of wound specialist and standardized nursing language.

The Static Stiffness Index: an important parameter to characterise compression therapy in vivo

The compression pressure, which corresponds to the dosage of compression therapy, has been widely neglected up to now, not only concerning scientific literature, but also in clinical practice. It is evident that compression pressures in the upright position and during walking are clinically more relevant than just the resting pressure. The Static Stiffness Index (SSI), which is the difference between standing and resting pressure, is a valuable parameter characterising the efficacy of a specific compression product to narrow/occlude the venous lumen. This is a prerequisite for reducing venous reflux and exerting a massaging effect necessary to improve the venous pumping function during movement. This article provides an overview of the recent literature on the SSI, which supports the recommendations of the International Compression Club. In addition, it aims to provide an insight on the importance of the SSI in daily practice, as an educational tool as well as in defining the properties of applied compression therapy in clinical research.

Reduced incidence of vein occlusion and postthrombotic syndrome after immediate compression for deep vein thrombosis

Thus far, the association between residual vein occlusion and immediate compression therapy and postthrombotic syndrome is undetermined. Therefore, we investigated whether compression therapy immediately after diagnosis of deep vein thrombosis affects the occurrence of residual vein obstruction (RVO), and whether the presence of RVO is associated with postthrombotic syndrome and recurrent venous thromboembolism. In a prespecified substudy within the IDEAL (individualized duration of elastic compression therapy against long-term duration of therapy for prevention of postthrombotic syndrome) deep vein thrombosis (DVT) study, 592 adult patients from 10 academic and nonacademic centers across The Netherlands, with objectively confirmed proximal DVT of the leg, received no compression or acute compression within 24 hours of diagnosis of DVT with either multilayer bandaging or compression hosiery (pressure, 35 mm Hg). Presence of RVO and recurrent venous thromboembolism was confirmed with compression ultrasonography and incidence of postthrombotic syndrome as a Villalta score of at least 5 at 6 and 24 months. The average time from diagnosis until assessment of RVO was 5.3 (standard deviation, 1.9) months. A significantly lower percentage of patients who did receive compression therapy immediately after DVT had RVO (46.3% vs 66.7%; odds ratio, 0.46; 95% confidence interval, 0.27-0.80; P = .005). Postthrombotic syndrome was less prevalent in patients without RVO (46.0% vs 54.0%; odds ratio, 0.65; 95% confidence interval, 0.46-0.92; P = .013). Recurrent venous thrombosis showed no significant association with RVO. Immediate compression should therefore be offered to all patients with acute DVT of the leg, irrespective of severity of complaints. This study was registered at ClinicalTrials.gov (NCT01429714) and the Dutch Trial registry in November 2010 (NTR2597).

Management of Patients With Venous Leg Ulcers: Challenges and Current Best Practice

Introduction It is well documented that the prevalence of venous leg ulcers (VLUs) is increasing, coinciding with an ageing population. Accurate global prevalence of VLUs is difficult to estimate due to the range of methodologies used in studies and accuracy of reporting. (1) Venous ulceration is the most common type of leg ulceration and a significant clinical problem, affecting approximately 1% of the population and 3% of people over 80 years of age (2) in westernised countries. Moreover, the global prevalence of VLUs is predicted to escalate dramatically, as people are living longer, often with multiple comorbidities. Recent figures on the prevalence of VLUs are based on a small number of studies, conducted in Western countries, and the evidence is weak. However, it is estimated that 93% of VLUs will heal in 12 months, and 7% remain unhealed after five years. (3) Furthermore, the recurrence rate within 3 months after wound closure is as high as 70%. (4) (-6) Thus, cost-effective adjunct evidence-based treatment strategies and services are needed to help prevent these ulcers, facilitate healing when they occur and prevent recurrence. The impact of a VLU represents social, personal, financial and psychological costs on the individual and further economic drain on the health-care system. This brings the challenge of providing a standardised leg ulcer service which delivers evidence-based treatment for the patient and their ulcer. It is recognised there are variations in practice and barriers preventing the implementation of best practice. There are patients not receiving appropriate and timely treatment in the initial development of VLUs, effective management of their VLU and preventing recurrence once the VLU has healed. Health-care professionals (HCPs) and organisations must have confidence in the development process of clinical practice guidelines and have ownership of these guidelines to ensure those of the highest quality guide their practice. These systematic judgments can assist in policy development, and decision making, improve communication, reduce errors and improve patient outcomes. There is an abundance of studies and guidelines that are available and regularly updated, however, there is still variation in the quality of the services offered to patients with a VLU. There are also variations in the evidence and some recommendations contradict each other, which can cause confusion and be a barrier to implementation. (7) The difference in health-care organisational structures, management support and the responsibility of VLU management can vary in different countries, often causing confusion and a barrier to seeking treatment. These factors further complicate the guideline implementation process, which is generally known to be a challenge with many diseases. (8).