Pathophysiology of venous ulcers: surgical implications, review, and update

Use of fetal bovine dermal repair scaffold in diabetic foot ulcers with recidivism: an open-label prospective clinical study

OBJECTIVE

This study aimed to establish the effectiveness of fetal bovine dermal scaffold (FBDS) application with multilayer offloading (standard of care) over that of traditional therapies in the treatment of diabetic foot ulcers (DFUs).

METHOD

Patients from a single centre in South Florida, US were recruited for this research. All patients underwent a run-in period of standardised care and vascular testing to determine and control the ability to heal. Patients were placed in multilayer offloading total contact cast (TCC) systems with application of FBDS every four weeks. Wound measurements and efficacy of offloading were monitored weekly.

RESULTS

In an older population with diabetes and above-normal body mass index (BMI), use of FBDS was successful in wound closure, with average time to closure of 7.85 weeks for the 20 patients in this study. It should be noted that surface wound area was reduced by approximately 40% by week 4 and by almost 83% by week 9. Follow-up at three and six months showed no residual or recurrent ulcerations in this study population for 19/20 patients.

CONCLUSION

Total wound closure of hard-to-heal DFUs in this patient series study was achieved with local surgical debridement, TCC offloading and application(s) of a FBDS in older patients with above-normal BMI and in wounds of >4 weeks non-progressive healing. Furthermore, at three and six months, 19/20 patients' wounds remained closed and did not re-ulcerate.

A Review of the Microcirculation in Skin in Patients With Chronic Venous Insufficiency: The Problem and the Evidence Available for Therapeutic Options

Impairment of the cutaneous microcirculation is a major predisposing factor in inflammation and ulceration in patients with chronic venous insufficiency (CVI). Increase of capillary filtration rate predisposes to the formation of edema. Local lymphedema is a complication of CVI, often underdiagnosed. This review is focused on CVI but excludes the complication of ulceration. Treatment of microcirculatory dysfunction can be done by pharmacologic intervention or compression therapy or using a combination of both. This review is focused on drugs that have been evaluated by randomized prospective controlled trials. The following compounds are discussed: horse chestnut seed extracts, flavonoids, red vine leaves extracts, total triterpenic fraction of Centella asiatica (L), prociadins, calcium dobesilate, and pentoxifylline. The microcirculatory effects of compression therapy using bandages or stockings are also reviewed. The major microcirculatory effects that have been shown are the reduction of capillary filtration rate and improvements in levels of transcutaneous partial pressures of oxygen and carbon dioxide (TcPO2 and TcPCO2). Available data suggest that a combination of pharmacologic and compression therapy may have some additive effects.

Effective use of negative pressure wound therapy provides quick wound-bed preparation and complete graft take in the management of chronic venous ulcers

Venous ulcers are characterised by longstanding and recurrent loss of skin integrity. Once occurred, healing is slow and recurrence is high because of inappropriate conditions of the wound bed. This study involves 20 patients with chronic venous ulcers at least 6 weeks of duration treated with negative pressure wound therapy (NPWT). Patients underwent a radical debridement of all devitalised tissues in the first operation. After adequate haemostasis, silver-impregnated polyurethane foam was applied. Once the wounds were determined to be clean and adequate granulation tissue formation was achieved, split-thickness skin grafts were applied. Black polyurethane foam was applied over them. All wounds completely healed without the need for further debridement or regrafting. The mean number of silver-impregnated foam dressing changes prior to grafting was 2·9 (one to eight changes). The mean number of NPWT foam changes was 2·6 after skin grafting (two to five changes). Two patients who did not use conservative treatments for chronic venous insufficiency (CVI) after discharge from the hospital had recurrence of venous ulcers in the follow-up period. Application of NPWT provides quick wound-bed preparation and complete graft take in venous ulcer treatment.

Shave therapy for chronic venous ulcers: a guideline for surgical management and postoperative wound care

This article presents a practice-oriented concept in the treatment of chronic venous ulcers with accompanying lipodermatosclerosis by shave therapy. Besides the indication for shave therapy, we focus on the operative technique and important therapy during postoperative convalescence time.

Venous ulcer: epidemiology, physiopathology, diagnosis and treatment

This review discusses the epidemiology, pathogenesis, diagnosis and current therapeutic options for venous ulcer. Venous ulcer is a severe clinical manifestation of chronic venous insufficiency (CVI). It is responsible for about 70% of chronic ulcers of the lower limbs. The high prevalence of venous ulcer has a significant socioeconomic impact in terms of medical care, days off work and reduced quality of life. Long-term therapeutics are needed to heal venous ulcers and recurrence is quite common, ranging from 54 to 78%. Thrombophlebitis and trauma with long-term immobilization predisposing to deep venous thrombosis are important risk factors for CVI and venous ulcer. The most recent theories about pathogenesis of venous ulcer have associated it with microcirculatory abnormalities and generation of an inflammatory response. Management of venous leg ulcers is based on understanding the pathogenesis. In recent years novel therapeutic approaches for venous ulcers have offered valuable tools for the management of patients with this disorder.

A review of the microbiology, antibiotic usage and resistance in chronic skin wounds

Chronic leg and foot wounds represent an increasing burden to healthcare systems as the age of the population increases. The deep dermal tissues of all chronic wounds harbour microorganisms, however, the precise interaction between microbes in the wounds and impaired healing is unknown. With regard to antibiotic therapy, there is a lack of evidence concerning its effectiveness, optimal regimens or clinical indications for treatment. Despite this lack of evidence, antibiotics are frequently a feature of the management of chronic wounds and these patients receive significantly more antibiotic prescriptions (both systemic and topical) than age and sex-matched patients. Current guidelines for antibiotic prescribing for such wounds are often based on expert opinion rather than scientific fact and may present difficulties in interpretation and implementation to the clinician. Although the increasing prevalence of antibiotic resistance is widely recognized, the relationships between antibiotic resistance, chronic wound microbiology and rationales for antibiotic therapy have yet to be determined. This review discusses the role of microbes in chronic wounds from a clinical perspective with particular focus on the occurrence of bacteria and their impact on such wounds. The evidence and role of antibiotics in the treatment of such wounds are outlined and current practice of antibiotic usage for chronic wounds in the primary care setting described. The implications of antibiotic usage with regard to antibiotic resistance are also considered.

Age-related changes in wound healing

Evidence for age-related effects on wound healing have been derived for the most part from empirical observations without adjustment for confounders other than age. Age-related changes in the structure and function of the skin do occur. Some of these changes result from chronic solar radiation exposure rather than chronological age per se. The tensile strength of wounds, accumulation of wound healing factors and rate of wound closure have all been examined in relation to chronological aging. However, the clinical impact of these changes in acute wound healing appears to be small. Poor healing in chronic wounds is more often related to comorbid conditions rather than age alone. Since the majority of these chronic wounds occur in elderly populations, this has contributed to the conclusion that aging itself may influence healing. Progress in understanding the role that growth factors play in wound healing and the ability to synthesise adequate quantities of these factors for clinical use has led to clinical trials evaluating their use in wound healing. The results of these studies, with the possible exception of those in diabetic wounds, have been disappointing. Insight into the wound healing process indicates that growth factors interact during wound healing in a sequential and orderly process. Improved wound healing may require different clinical designs or the use of these factors in a precisely timed sequential administration.