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

Recent advancements in natural polymers-based self-healing nano-materials for wound dressing

The field of wound healing has witnessed remarkable progress in recent years, driven by the pursuit of advanced wound dressings. Traditional dressing materials have limitations like poor biocompatibility, nonbiodegradability, inadequate moisture management, poor breathability, lack of inherent therapeutic properties, and environmental impacts. There is a compelling demand for innovative solutions to transcend the constraints of conventional dressing materials for optimal wound care. In this extensive review, the therapeutic potential of natural polymers as the foundation for the development of self-healing nano-materials, specifically for wound dressing applications, has been elucidated. Natural polymers offer a multitude of advantages, possessing exceptional biocompatibility, biodegradability, and bioactivity. The intricate engineering strategies employed to fabricate these polymers into nanostructures, thereby imparting enhanced mechanical robustness, flexibility, critical for efficacious wound management has been expounded. By harnessing the inherent properties of natural polymers, including chitosan, alginate, collagen, hyaluronic acid, and so on, and integrating the concept of self-healing materials, a comprehensive overview of the cutting-edge research in this emerging field is presented in the review. Furthermore, the inherent self-healing attributes of these materials, wherein they exhibit innate capabilities to autonomously rectify any damage or disruption upon exposure to moisture or body fluids, reducing frequent dressing replacements have also been explored. This review consolidates the existing knowledge landscape, accentuating the benefits and challenges associated with these pioneering materials while concurrently paving the way for future investigations and translational applications in the realm of wound healing.

Managing venous leg ulceration: variance and variety

Frameworks of care have been developed to enhance and standardise care for those with venous leg ulcers. Community nurses are faced with an array of frameworks and guidance documents on which to base their care. This article outlines and discusses variations in the information provided within the body of evidence relating to the care of venous leg ulcers. It is based on the findings of ongoing study for a PhD thesis.

Updates on Recent Clinical Assessment of Commercial Chronic Wound Care Products

Impaired wound healing after trauma, disorders, and surgeries impact millions of people globally every year. Dysregulation in orchestrated healing mechanisms and underlying medical complications make chronic wound management extremely challenging. Besides standard-of-care treatments including broad spectrum antibiotics and wound-debridement, novel adjuvant therapies are clinically tested and commercialized. These include topical agents, skin substitutes, growth factor delivery, and stem cell therapies. With a goal to overcome factors playing pivotal role in delayed wound healing, researchers are exploring novel approaches to elicit desirable healing outcomes in chronic wounds. Although recent innovations in wound care products, therapies, and devices are extensively reviewed in past, a comprehensive review summarizing their clinical outcomes is surprisingly lacking. Herein, this work reviews the commercially available wound care products and their performance in clinical trials to provide a statistically comprehensive understanding of their safety and efficacy. The performance and suitability of various commercial wound care platforms, including xenogeneic and allogenic products, wound care devices, and novel biomaterials, are discussed for chronic wounds. The current clinical evaluation will provide a comprehensive understanding of the benefits and drawbacks of the most-recent approaches and will enable researchers and healthcare providers to develop next-generation technologies for chronic wound management.

The effect of wound electrical stimulation in venous leg ulcer healing-a systematic review

OBJECTIVE

The benefit of using electric stimulation therapy (EST) to heal venous leg ulcers (VLUs) is not well established. The main aim of this systematic review was to evaluate the effects of ulcer EST in VLU healing.

METHODS

A systematic search of the literature was conducted using the databases PubMed, Scopus, and Web of Science and included original studies that reported VLU healing after EST. The inclusion criteria were at least two surface electrodes placed on or near the wound or a planar probe covering the ulcer area to be treated. The Cochrane risk of bias tool for randomized control trials (RCTs) and Joanna Briggs Institute critical appraisal checklist for case series were used to evaluate the risk of bias.

RESULTS

This review included eight RCTs and three case series involving a total of 724 limbs in 716 patients with VLUs. The mean patient age was 64.2 years (95% confidence interval, 62.3-66.2), and 46.2% (95% confidence interval, 41.2%-50.4%) were men. The active electrode was placed on the wound with the passive electrode placed on healthy skin (n = 6), the two electrodes were placed on either side of the wound edges (n = 4), or a planar probe was used (n = 1). The pulsed current was the most used waveform (n = 9). The change in the ulcer size was the main method used to determine ulcer healing (n = 8), followed by the ulcer healing rate (n = 6), exudate levels (n = 4), and the time to healing (n = 3). Five RCTs detected a statistically significant improvement in at least one VLU healing outcome, after EST compared with the control group. In two of these, EST was better than the control but only for patients who had not undergone surgical treatment of VLU.

CONCLUSIONS

The findings from the present systematic review support the use of EST to accelerate wound healing of VLUs, especially for patients who are not surgical candidates. However, the significant variation in electric stimulation protocols represents an important limitation to its use and should be addressed in future studies.

Topical Hyperbaric Oxygen Therapy Versus Local Ozone Therapy in Healing of Venous Leg Ulcers

BACKGROUND

the treatment of venous leg ulcers still poses a difficult interdisciplinary medical problem. The aim of this study was to compare the therapeutic efficacy of local hyperbaric oxygen therapy with local ozone therapy in the treatment of venous leg ulcers.

MATERIALS

this study included 114 patients; 60 males (52.63%) and 54 females (47.36%) of ages ranging between 39 and 88 years (mean age: 68.9 ± 9.8 years) with venous leg ulcers, who underwent topical hyperbaric oxygen therapy (group I) and local ozone therapy (group II). In each of the study groups, the patients underwent 30 therapeutic procedures lasting 30 min each. The progress in wound healing was evaluated by computerized planimetry, and the intensity of pain was assessed with the use of the Visual Analogue Scale (VAS).

RESULTS

in both groups of treated patients, a statistically significant (p = 0.000001) reduction in the area of treated ulcers was achieved. In group I, the wound area decreased by an average of 69.67 ± 22.52%, from 7.55 ± 2.99 cm² to 2.78 ± 2.43 cm², and in group II, by an average of 41.33 ± 21.31%, from 7.36 ± 2.82 cm² to 4.62 ± 2.76 cm². In both groups of patients, a statistically significant (p = 0.000001) reduction in the intensity of pain ailments was observed: in group I, by an average of 0.55 ± 0.54 points, and in group II, by an average of 2.33 ± 0.82 points on the VAS scale.

CONCLUSIONS

local hyperbaric oxygen therapy and local ozone therapy cause a statistically significant reduction in the surface area of venous leg ulcers as well as in the intensity of pain. Better results were observed after the application of local hyperbaric oxygen therapy procedures.

Venous leg ulcers and prevalence of surgically correctable reflux disease in a national registry

BACKGROUND

Chronic venous disorders are common, with varicose veins occurring in ∼40% of the population. Venous leg ulcers affect 1% to 2% of the population, with the prevalence increasing ≤4% for those aged >65 years. Both conditions are expensive and together are responsible for ≤2% of the annual healthcare budget expenditure of Western societies. The ESCHAR (effect of surgery and compression on healing and recurrence) and EVRA (early venous reflux ablation) trials demonstrated that surgical correction of superficial venous reflux reduced ulcer recurrence, resulted in faster healing times (EVRA), and was proved cost-effective. Largescale data regarding patients with chronic venous leg ulcers presenting to venous centers with treatable superficial venous insufficiency has not been previously reported. Our study was designed to evaluate the percentage of patients with leg ulcers presenting to dedicated vein centers who were found to have surgically correctable superficial venous insufficiency.

METHODS

The American Vein & Lymphatic Society Patient Reported Outcome Venous Registry began collecting data in 2014 and is one of two national registries focused on chronic venous disorders. The database was queried first for the presence of an ulcer using the CEAP (clinical, etiologic, anatomic, pathophysiologic) classification (C6 status). These de-identified data were further correlated by crossing the number of ulcers for the same limb using the revised venous clinical severity score (rVCSS). The demographics, index duplex ultrasound details, and rVCSS features for ulcer duration and compression use were analyzed. Once the presence of an ulcer had been validated by CEAP and rVCSS, the population was divided into groups according to the ultrasound-reported anatomic pathology (eg, normal, reflux, obstruction, reflux plus obstruction). The query was directed toward all patients seeking a venous evaluation at participating centers from January 2018 through January 2022.

RESULTS

More than 270,000 unique patient records were reviewed. Of the 270,000 records, 163,027 (60%) had had duplex ultrasound scans available, for 1794 unique patients (1879 limbs), representing 1.1% with a leg wound. Of these patients, 55.4% were men and 44.6% were women. Group S included patients with isolated superficial pathology (n = 1291; 68.7%). Group M included patients with mixed superficial and deep pathology (n = 238; 12.7%). Group D included patients with isolated deep vein pathology (n = 58; 3.1%). Finally, group N included patients with leg wounds but no venous pathology (n = 292; 15.5%). The rVCSSs for groups S and M were significantly higher than those for group N. In group S, the dominant patterns involved the great saphenous vein (GSV) above the knee (54.8%), the small saphenous vein (30.7%), and the anterior accessory GSV (14.4%). The frequency of single, double, and triple axial vein reflux identified 1.45 vessels eligible for ablation treatment per limb. In group M, the dominant patterns involved the GSV above the knee (61.7%), the small saphenous vein (26.2%), and the anterior accessory GSV (12.1%), for 1.52 axial segments per limb. Of the 84.4% of venous ulcer patients, duplex ultrasound analysis revealed that 97% of this large subset had had surgically correctable disease.

CONCLUSIONS

The American Vein & Lymphatic Society Patient Reported Outcome Venous Registry demonstrated that 85% of the leg wounds in the present study were venous in origin and 97% possessed surgically correctable disease. Our findings support early referral to dedicated vein centers with appropriate venous reflux management as a part of the multidisciplinary team caring for patients with venous leg ulcers.

INFLUENCE OF THE AMOUNT OF COMPRESSION ON VENOUS AND ARTERIAL BLOOD FLOW VELOCITY AND SKIN MICROCIRCULATION OF THE LOWER EXTREMITY

OBJECTIVE

The aim: To determine the effect of compression on the venous and arterial velocity of the main blood flow of the lower limb and the skin microcirculation of the rear part of the foot.

PATIENTS AND METHODS

Materials and methods: 20 healthy subjects participated in this study: 11 men 11 (55%) men and 9 (45%) girls. The ankle brachial index (ABI), femoropop¬liteal index, femoral arterial blood flow velocity (AFV), venous blood flow velocity (VFV), transcutaneous oxygen pressure (tcPO2) and carbon dioxide pressure (tcPCO2) were measured. After the general measurements were taken, the tire was inflated to 10 mm Hg under general basic conditions and kept for three minutes. The experiment ended when no decrease in tcPO2 was observed between two consecutive pressure levels.

RESULTS

Results: The average tire pressure to reach physiological zero was 80 mm Hg. for all participants. At 10 mmHg significant changes in indicators were found by 19% (p=0.0001). tcPCO2 values increased significantly at 10 mmHg (p=0.0319) and continued to increase until the end of the study. It was established that its values increased by 14% compared to the input data (p=0.0005).

CONCLUSION

Conclusions: At the maximum compression of 60 mmHg the arterial blood flow rate decreased by 5.5 times (p=0.0001). TcPCO2 increases significantly when compressed by 10 mm Hg also in parallel with the decrease in the regional perfusion index, which begins at an external compression of 40 mm Hg, which is evidence of the deterioration of the perfusion of the skin of the anterior part of the foot in healthy subjects.

Impact of compression on velocity of venous and arterial main blood flow and cutaneous microcirculation of the lower extremity

Objective. To study the impact of compression on velocity of venous and arterial main blood flow of the lower extremity, as well as cutaneous microcirculation in the back part of the foot in healthy individuals and patients with decompensated forms of varicose disease and postthrombophlebitis syndrome. Materials and methods. In the investigation 56 individuals took part and divided into three groups: Group I – 20 healthy persons; Group II – 15 patients with varicose disease in decompensated stage; Group III– 21 patients with decompensated stage of postthrombophlebitis syndrome. In all participants of the investigation the index of ankle–brachial pressure, deep–femoro–popliteal index, the regional perfusion index, transcutaneous partial pressure of oxygen and partial pressure of carbon dioxide, the arterial blood flow velocity in femoral artery and of venous blood flow distally from sapheno–femoral junction were measured before and after application of elastic medical knitwear of various Class of compression or the cuff pressure. Results. In the Class III compression in patients of Group III the transcutaneously registered indices crossing have occurred between partial pressure of oxygen and carbon dioxide, accompanied by domination of the carbon dioxide partial pressure over the oxygen partial pressure while further enhancement of the compression Class. In patients of Group II this tendency was observed while application of Class IV compression only. At the investigation beginning the values of partial pressure of carbon dioxide registered were higher in the Group III patients, than in the patients of Group II (p=0.0001). Conclusion. While application of the Class III compression the velocity of the hip venous blood flow, comparing with its initial values, have lowered at average by 78% in patients of Group II and at average in 7.4 times in the patients of |Group III (p=0.0001). It is affordable in patients, suffering decompensated postthrombophlebitic syndrome, to apply the elastic compression of Classes I–II, while in those, having varicose disease in decompensated stage, – the elastic compression of Classes III and iV as well.

Incidence of Recurrent Venous Ulcer in Patients Treated at an Outpatient Clinic: Historical Cohort

The recurrence of venous ulcers is the wound reopening after a period of completed epithelisation of a previous ulcer due to exposure to causal factors and lack of prevention. Venous ulcers have a high recurrence rate that may increase through the years. Epidemiological evidence on its incidence and risk factors is scarce due to the lack of patient follow-up in outpatient clinics and adherence to treatment after healing. The objective was to analyze the incidence of venous ulcers recurrency in outpatients and the risk factors for its occurrence. It is an observational historical cohort with retrospective data collection, performed through electronic medical records. Setting: private health insurance outpatient clinic. The participants were adult patients with healed venous ulcers. Incidence of venous ulcer recurrence was calculated within individuals with healed ulcers from 2014 and 2018 with a follow-up of at least one year. Bivariate analysis and logistic regression were used to explore risk factors considering demographic, clinical, and wound-related variables. As a result, sixty-five (65) of the 134 patients with healed venous ulcers had a recurrence, leading to an incidence of 48.5%, with a mean onset time of 230.1 (SD 267) days. Patients with recurrent venous ulcers were primarily women (39/48.1%), with a mean age of 64 (SD 15.5) years, 57 (50.8%) had some comorbidity, with systemic arterial hypertension as the most frequent (47/51%). Obesity (15/88.2%) increased the risk of venous ulcers recurrence by 8.7 (OR 95% CI 2.1-60.8; P = .009) times. In conclusion, venous ulcers recurrence incidence was 48.5%, with obesity as a risk factor. This study demonstrates that the clinical approach of people with venous ulcers should not finish when the wound is healed. For ulcer recurrence prevention interventions addressing systemic factors, besides topical management of the wound, are essential.