Venous ulcers of the lower limb: Where do we stand?

Superficial Venous Disease-An Updated Review

BACKGROUND

This review article provides an updated review of a relatively common pathology with various manifestations. Superficial venous diseases (SVDs) are a broad spectrum of venous vascular disease that predominantly affects the body's lower extremities. The most serious manifestation of this disease includes varicose veins, chronic venous insufficiency, stasis dermatitis, venous ulcers, superficial venous thrombosis, reticular veins, and spider telangiectasias.

METHODS

The anatomy, pathophysiology, and risk factors of SVD were discussed during this review. The risk factors for developing SVD were related to race, age, sex, lifestyle, and certain genetic conditions as well as comorbid deep vein thrombosis. Various classification systems were listed, focusing on the most common one-the revised Clinical-Etiology-Anatomy-Pathophysiology classification. The clinical features including history and physical examination findings elicited in SVD were outlined.

RESULTS

Imaging modalities utilized in SVD were highlighted. Duplex ultrasound is the first line in evaluating SVD but magnetic resonance imaging and computed tomography venography, plethysmography, and conventional venography are feasible options in the event of an ambiguous venous duplex ultrasound study. Treatment options highlighted in this review ranged from conservative treatment with compression stockings, which could be primary or adjunctive to pharmacologic topical and systemic agents such as azelaic acid, diuretics, plant extracts, medical foods, nonsteroidal anti-inflammatory drugs, anticoagulants and skin substitutes for different stages of SVD. Interventional treatment modalities include thermal ablative techniques like radiofrequency ablationss, endovenous laser ablation, endovenous steam ablation, and endovenous microwave ablation as well as nonthermal strategies such as the Varithena (polidocanol microfoam) sclerotherapy, VenaSeal (cyanoacrylate) ablation, and Endovenous mechanochemical ablation. Surgical treatments are also available and include debridement, vein ligation, stripping, and skin grafting.

CONCLUSIONS

SVDs are prevalent and have varied manifestations predominantly in the lower extremities. Several studies highlight the growing clinical and financial burden of these diseases. This review provides an update on the pathophysiology, classification, clinical features, and imaging findings as well as the conservative, pharmacological, and interventional treatment options indicated for different SVD pathologies. It aims to expedite the timely deployment of therapies geared toward reducing the significant morbidity associated with SVD especially varicose veins, venous ulcers, and venous insufficiency, to improve the quality of life of these patients and prevent complications.

Nutrients with Antioxidant Properties and Their Effects on Lower-Limb Ulcers: A Systematic Review

Chronic lower-limb ulcers (LLUs) are ulcers that fail to proceed through an orderly and timely process to produce anatomic and functional integrity. LLUs reduce the quality of life of affected individuals and are a public health problem. The treatment options include medications or surgery. Nutrition therapy is an important adjunct to improve the clinical picture and healing of LLUs. Considering that nutrients with antioxidant properties can improve the process of tissue healing, this systematic review aimed to evaluate the efficacy of antioxidant nutrient supplementation in the treatment of LLUs through randomized clinical trials. This systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses and the Cochrane Handbook for Systematic Reviews of Interventions. The guiding question was-can antioxidant nutrients help in the treatment of chronic LLUs? In total, 1184 articles were found when searching for antioxidant nutrients associated with the most common causes of LLUs. Fourteen articles were included in this review after removing duplicates, studies with topical and/or venous use of antioxidants, and articles published in other languages, except English. Omega-3 fatty acids, magnesium, zinc, vitamins A, C, D, and resveratrol along with probiotics positively improved the ulcer healing. These effects were more significant when there was initially a deficiency of the respective supplemented nutrients. Therefore, correcting and maintaining an adequate nutritional status can improve ulcer healing and contribute to the clinical treatment of patients with LLUs.

Exploring causal correlations between inflammatory cytokines and varicose veins: A Mendelian randomization analysis

This study aimed to investigate the causal relationship between inflammatory cytokines and the risk of varicose veins. The data were sourced from genome-wide association studies (GWAS) of European individuals. Multiple Mendelian randomization (MR) methods were used to evaluate the association between inflammatory cytokines and varicose veins. The study found significant associations between elevated levels of certain inflammatory biomarkers (e.g., CASP-8, Vascular endothelial growth factor A levels (VEGF_A)) and an increased risk of varicose veins, while others (e.g., 4EBP1, MMP-10) showed a protective effect. The MR-Egger Intercept and heterogeneity tests indicated no significant pleiotropy or heterogeneity. This comprehensive MR analysis identifies several cytokines as potential contributors to the pathogenesis of varicose veins, offering insights into novel therapeutic targets. Our findings underscore the importance of inflammation in varicose veins and suggest that targeting specific cytokines could be a promising strategy for the treatment and prevention of varicose veins.

Clinical applications of skin traction technique with adjustable tension in treatment of large area skin defects

OBJECTIVE

To explore the clinical applications of the adjustable skin traction technique in the treatment of large area skin defects.

RESEARCH DESIGN

A prospective study.

BACKGROUND

The skin is the largest organ of the human body and skin tissue exposed to external environment which makes it vulnerable to damage. There are many reasons for skin defects such as trauma, infection, burns, scars, tumors resection, inflammation, pigmented nevus, etc. Skin traction is the application of pulling force to the trunk or extremities for immobilization, fracture reduction and deformity correction. This technique accurately controls skin expansion which is safe, convenient and accelerates wound healing.

METHODS

A prospective study was conducted on 80 patients suffered from large area skin defects in the department of orthopedics, the first affiliated hospital of Zhengzhou University from September 2019 to January 2023. There were 40 patients in the experimental group who underwent skin traction. In contrast, 40 people in the control group underwent skin flaps or skin grafts without skin traction. The inclusion criteria include large area skin defects, normal peripheral skin & blood supply, normal vital organs, no severe coagulation dysfunction etc. Male & female with and without skin traction are 22 & 18 and 25 & 15 respectively. The skin traction device used was a hook and single rod type. The skin defect area was approximately 15 cm × 9-43 cm × 10 cm.

RESULTS

Postoperatively, the experimental group with traction showed 2 cases of skin infection, 1 case of skin necrosis and 3 cases of inflammation recurrence. In contrast, the control group without traction showed 8 cases of skin infection, 6 cases of skin necrosis and 10 cases of inflammation recurrence. Skin infection (P = 0.04), skin necrosis (P = 0.02) and inflammatory response (P = 0.03) represented significant differences between two groups. There was also a significant difference in hospitalization costs (P = 0.001).

CONCLUSION

Skin traction has huge clinical applications including a shorter hospital stay, faster wound healing, lower hospitalization cost, high satisfaction rate, and a fair skin appearance after surgery. It is an effective method of treating skin and musculoskeletal defects.

The utility of hyperspectral imaging in patients with chronic venous disorders

OBJECTIVE

The underlying pathophysiology of lower limb changes in chronic venous disorders (CVD) may involve alteration in microcirculation and tissue oxygenation. Hyperspectral imaging (HSI) is a noninvasive tool that is used clinically to measure transcutaneous oxygenation in peripheral artery disease and diabetic foot disease. However, there has been little application in venous disease. The aim of this study was to determine if transcutaneous oxygenation in the lower limb, as measured by HSI, changes depending on the clinical component of the Clinical-Etiological-Anatomical-Pathophysiological (CEAP) classification in CVD.

METHODS

This was an observational study of patients with CVD recruited from a vascular specialist clinic at a tertiary hospital from January 2020 to January 2021. Participants were allocated to eight groups according to the clinical component of CEAP classification of CVD. Baseline demographic and risk factor information were collected. Transcutaneous oxygenation was measured using HSI at seven sites around the foot and gaiter area in the supine and standing position. Participants rested supine for 15 minutes before the supine measurements and then stood for 15 minutes before the standing measurements. Tissue oxygenation was analyzed over a fixed circular surface area of 79 mm² at the target location. Calculations of oxyhemoglobin level (artificial unit [AU]), deoxyhemoglobin level (AU), oxygen saturation (%), and temperature (°C) were obtained. The Northern Ethics Committee (18/NTA/78) approved this conduct of the study and participants signed written consent forms.

RESULTS

There were 94 participants (164 lower limbs) included in the study. The median age was 59 years and 59 participants (63%) were women. At all sites except the heel, deoxyhemoglobin measurements increased in the standing position compared with the supine position (P < .001). In the gaiter region, there was nearly a doubling in deoxyhemoglobin level at 5 cm above the medial malleolus (supine 43.88 AU vs standing 80.46 AU; P < .001) and 5 cm above the lateral malleolus (supine 46.33 AU vs standing 87.72 AU; P < .001). When measurements were stratified by clinical class of the CEAP classification, there was a greater increase in deoxyhemoglobin levels with increasing clinical class in the standing position (P < .001). This finding was not observed in the supine measurements.

CONCLUSIONS

In CVD, HSI shows an increase in deoxyhemoglobin in the standing compared with supine position, particularly in the gaiter region. Furthermore, standing deoxyhemoglobin increases as the CEAP clinical class increases. Thus, this noninvasive tool may respond to venous physiology and may supplement the clinical class of the CEAP classification system.

Catalytic Nanomedicine - A new Approach and Solution for Chronic Ulcers: Case Series

Chronic ulcers are a major public health problem, due to their chronic nature, their poor response to treatment, the high frequency of recurrences, and their affection to the patient's quality of life. Even with the development of new therapies in the field of chronic wound care, chronic ulcers remain a clinical problem. As a novel branch of research, Catalytic Nanomedicine has offered promising results in disinfection and treatment of chronic wounds through the use of bionanocatalysts, organically functionalized mesoporous nanostructured materials with catalytic properties. Particularly, Cu/TiO2-SiO2 mixed oxide bionanocatalysts have shown favorable results for chronic ulcer healing. In this work, we present the treatment of 15 patients (8 females and 7 males, mean age of 69.59 ± 12.07 years old) affected with chronic ulcers (wound age ranging from 4 months to 10 years old, mean size of 12.94 ± 18.20 cm2) by the administration of Cu/TiO2-SiO2 bionanocatalysts embedded in a nanoemulsion matrix. In all cases, complete epithelialization and healing of the lesions was achieved (healing time from 3 to 35 weeks), without the appearance of side effects. Wound healing time was analyzed in the context of initial wound size, wound's age, patient's age, and concomitant conditions, being wound size and patient's age the main factor affecting the duration of the treatment with the bionanocatalysts.

Silk-based phyto-hydrogel formulation expedites key events of wound healing in full-thickness skin defect model

Immense socio-economic burden of chronic wound demands effective, low-cost strategies for wound care. Herein, we have developed a chemical crosslinker-free phyto-hydrogel by encapsulating phytochemicals of Aloe vera mucilage extract (AVM) in the self-assembled polymeric chains of two different silk fibroin (SF) proteins (from Bombyx mori and Antheraea assamensis). Additionally, polyvinylpyrrolidone (PVP) has been used as a stabilizer that also contributed to the mucoadhesive property of the composite (SAP; made of SF, AVM, and PVP) hydrogel. The physicochemical properties of the hydrogel were evaluated and compared with SF hydrogel containing only SF proteins without any additives. The biocompatibility assessment of the hydrogel under in vitro conditions has shown improved cellular proliferative and migratory responses, suggesting faster tissue repairability of the hydrogel. A detailed in vivo comparative study with a commercially available DuoDERM® gel revealed that SAP hydrogel not only promoted wound closure but also showed better deposition and remodeling of the extracellular matrix. Moreover, the hydrogel also demonstrated its ability to downregulate pro-inflammatory markers (IL-1β, TNF-α) and upregulation of anti-inflammatory markers (IL-10, TGF-β) at the early stage of healing. Therefore, the bioactive proteins-carbohydrates composite efficiently accelerates skin regeneration and possesses great translational potential to offer a low-cost alternative wound care therapeutic.

Surgery for deep venous insufficiency

BACKGROUND

Chronic deep venous insufficiency is caused by incompetent vein valves, blockage of large-calibre leg veins, or both; and causes a range of symptoms including recurrent ulcers, pain and swelling. Most surgeons accept that well-fitted graduated compression stockings (GCS) and local care of wounds serve as adequate treatment for most people, but sometimes symptoms are not controlled and ulcers recur frequently, or they do not heal despite compliance with conservative measures. In these situations, in the presence of severe venous dysfunction, surgery has been advocated by some vascular surgeons. This is an update of the review first published in 2000.

OBJECTIVES

To assess the effects of surgical management of deep venous insufficiency on ulcer healing and recurrence, complications of surgery, clinical outcomes, quality of life (QoL) and pain.

SEARCH METHODS

The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase and CINAHL databases, and the WHO ICTRP and ClinicalTrials.gov trials registries to 23 June 2020.

SELECTION CRITERIA

We considered randomised controlled trials (RCTs) of surgical treatment versus another surgical procedure, usual care or no treatment, for people with deep venous insufficiency.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion, extracted data and assessed the risk of bias with the Cochrane risk of bias tool. We evaluated the certainty of the evidence using GRADE. We were unable to pool data due to differences in outcomes reported and how these were measured. Outcomes of interest were ulcer healing and recurrence, complications of surgery, clinical changes, QoL and pain.

MAIN RESULTS

We included four RCTs (273 participants) comparing valvuloplasty plus surgery of the superficial venous system with surgery of the superficial venous system for primary valvular incompetence. Follow-up was two to 10 years. All included studies investigated primary valve incompetence. No studies investigated other surgical procedures for the treatment of people with deep venous insufficiency or surgery for secondary valvular incompetence or venous obstruction. The certainty of the evidence was downgraded for risk of bias concerns and imprecision due to small numbers of included trials, participants and events. None of the studies reported ulcer healing or ulcer recurrence. One study included 27 participants with active venous ulceration at the time of surgery; the other three studies did not include people with ulcers. There were no major complications of surgery, no incidence of deep vein thrombosis and no deaths reported (very low-certainty evidence). All four studies reported clinical changes but the data could not be pooled due to different outcome measures and reporting of the data. Two studies assessed clinical changes using subjective and objective measurements, as specified in the clinical, aetiological, anatomical and pathophysiological (CEAP) classification score (low-certainty evidence). One study reported mean CEAP severity scores and one study reported change in clinical class using CEAP. At baseline, the mean CEAP severity score was 18.1 (standard deviation (SD) 4.4) for limbs undergoing external valvuloplasty with surgery to the superficial venous system and 17.8 (SD 3.4) for limbs undergoing surgery to the superficial venous system only. At three years post-surgery, the mean CEAP severity score was 5.2 (SD 1.6) for limbs that had undergone external valvuloplasty with surgery to the superficial venous system and 9.2 (SD 2.6) for limbs that had undergone surgery to the superficial venous system only (low-certainty evidence). In another study, participants with progressive clinical dynamics over the five years preceding surgery had higher rates of improvement in clinical condition in the treatment group (valvuloplasty plus ligation) compared with the control group (ligation only) (80% versus 51%) after seven years of follow-up. Participants with stable preoperative clinical dynamics demonstrated similar rates of improvement in both groups (95% with valvuloplasty plus ligation versus 90% with ligation only) (low-certainty evidence). One study reported disease-specific QoL using cumulative scores from a 10-item visual analogue scale (VAS) and reported that in the limited anterior plication (LAP) plus superficial venous surgery group the score decreased from 49 to 11 at 10 years, compared to a decrease from 48 to 36 in participants treated with superficial venous surgery only (very low-certainty evidence). Two studies reported pain. Within the QoL VAS scale, one item was 'pain/discomfort' and scores decreased from 4 to 1 at 10 years for participants in the LAP plus superficial venous surgery group and increased from 2 to 3 at 10 years in participants treated with superficial venous surgery only. A second study reported that 'leg heaviness and pain' was resolved completely in 36/40 limbs treated with femoral vein external valvuloplasty plus high ligation and stripping of the great saphenous vein (GSV) and percutaneous continuous circumsuture and 22/40 limbs treated with high ligation and stripping of GSV and percutaneous continuous circumsuture alone, at three years' follow-up (very low-certainty evidence).

AUTHORS' CONCLUSIONS

We only identified evidence from four RCTs for valvuloplasty plus surgery of the superficial venous system for primary valvular incompetence. We found no studies investigating other surgical procedures for the treatment of people with deep venous insufficiency, or that included participants with secondary valvular incompetence or venous obstruction. None of the studies reported ulcer healing or recurrence, and few studies reported complications of surgery, clinical outcomes, QoL and pain (very low- to low-certainty evidence). Conclusions on the effectiveness of valvuloplasty for deep venous insufficiency cannot be made.

Limb salvage procedure in immunocompromised patients with therapy-resistant leg ulcers-The value of ultra-radical debridement and instillation negative-pressure wound therapy

The purpose of this study was to analyse the outcome of our established triple treatment strategy in therapy‐resistant deep‐thickness chronic lower leg ulcers. This limb salvage approach consists of ultra‐radical surgical debridement, negative‐pressure wound therapy (NPWT) with or without instillation, and split‐thickness skin grafting. Between March 2003 and December 2019, a total of 16 patients and 24 severe cases of lower leg ulcers were eligible for inclusion in this highly selective population. A total of seven patients received immunosuppressive medication. Complete wound closure was achieved in 25% and almost 90% of included lower leg ulcer cases after 3 and 24 months of our triple treatment strategy, respectively. The overall limb salvage rate was 100%. Bacterial colonisation of these wounds was significantly reduced after multiple surgical debridements and NPWT. Fasciotomy and radical removal of devitalised tissue such as deep fascia, tendons, and muscles combined with NPWT showed promising results in terms of the overall graft take rate. This treatment strategy was considered as last resort for limb salvage in such a critically ill and immunocompromised patient population. Surgeons should be aware of its efficacy and consider the triple treatment strategy especially if no other limb salvage option remains.

Effectiveness of autologous platelet-rich plasma gel in the treatment of hard-to-heal leg ulcers: a randomised control trial

OBJECTIVE

Regenerative medicine products such as autologous platelet-rich plasma (autologous PRP) gel may speed up the process of healing. Clinical studies show promising results in the treatment of diabetic foot ulcers (DFUs), however there is lack of scientific evidence of autologous PRP effectiveness in treating leg ulcers of other aetiology. This study evaluates the effectiveness of autologous PRP gel in the treatment of hard-to-heal leg ulcers compared with existing conventional treatment.

METHOD

A prospective, randomised controlled, open-labelled clinical trial was carried out between 2014 and 2018. An eight-week study protocol was chosen or until 100% wound re-epithelialisation was observed. Wound size reduction, granulation tissue formation, microbiological wound bed changes and safety were evaluated.

RESULTS

A total of 69 patients (35 in the autologous PRP group and 34 in the control group) were included in the study; 25.71% of the autologous PRP group and 17.64% of control group had ulcers completely re-epithelialised (p>0.05). Wound size reduction in the autologous PRP group was 52.35% and 33.36% in the control group (p=0.003). The autologous PRP group showed superiority over conventional treatment in wound bed coverage with granulation (p=0.001). However, more frequent wound contamination was observed at the end of treatment in the autologous PRP group (p=0.024). No severe adverse events were noted during the study. Both treatment methods were considered equally safe.

CONCLUSION

Topical application of autologous PRP gel in leg ulcers of various aetiology show beneficial results in wound size reduction and induces the granulation tissue formation. However, it is associated with more frequent microbiological wound contamination.

Experience in the Management of Patients with Chronic Vascular Ulcers of the Lower Limbs Using Negatively Charged Polystyrene Microspheres

BACKGROUND

Chronic ulcers of the lower limbs are a socioeconomic health problem, having a high incidence in the adult population. Despite a correct etiological treatment, in addition to the multiple lesion management options available, healing percentage and speed remain low, which makes it a great therapeutic challenge.

OBJECTIVE

To describe the outcome and effectiveness of the use of PolyHeal® Micro in the granulation and epithelialization of chronic ulcers of the lower limbs.

METHODS

Descriptive observational case series of 19 patients with diagnosis of chronic vascular ulcers of the lower limbs, treated at Medical Center Nuestra IPS and Medical Center Juan Pablo II in Bogotá between March 2018 and December 2018, who received PolyHeal® Micro as topical treatment for their lesions. Patients were assessed taking into account age, sex, ulcer size, pain, wound exudate, as well as granulation and epithelialization response.

RESULTS

In this series, the mean age of patients was 67.9 years, they were mostly females (84%), and the most common location of ulcers was the internal malleolus (50%). In terms of wound severity, 47% were found to be severe, 43% moderate, and 10% mild. The median time of lesion onset was 28 weeks, with a maximum of 2080 and a minimum of 8 weeks. In total, 87% of the ulcers were of venous etiology. After 12 weeks of treatment with Polyheal, ulcers showed a significative improvement of Wollina score means: 0.80 ± 0.90-5.90 ± 1.47; (p < 0.000). Wound area mean at the start of treatment was 31.6 cm2, and at the end of treatment was 17.85 cm2, which is equivalent to a wound area surface reduction of 54.2%, with a statistically significant p value. The interquartile range showed a reduction of 64.3% in the central means of wounds. Seventy percent of the patients reached a granulation percentage greater than 70%, 17% of the lesions exhibited an improvement of 30-70%, and there was an overall granulation improvement in 87% of the patients. Concerning epithelialization, 40% of patients reached a percentage higher than 70%, and 17% of patients between 30% and 70%. Treatment time was 12 weeks in 68% of cases, with an average response time of 8.1 weeks. Based on the visual analogue scale (VAS), a reduction in patients' perception of pain was achieved, dropping from an average of 6 (moderate to severe pain) to 2 (little pain), demonstrating an improvement in this regard. Fifty percent of the ulcers showed decreased exudate, resulting in a dry state. The patient satisfaction rate at the end of treatment was 89%.

CONCLUSION

The use of PolyHeal® Micro for an average of 8.1 weeks of treatment showed a high rate of granulation and epithelialization in chronic ulcers of the lower limbs, improving pain perception in these patients and generating a high degree of treatment satisfaction.

Contemporary occurrence and aetiology of chronic leg ulcers in Africa: a systematic review and meta-analysis protocol

INTRODUCTION

Chronic leg ulcers are known as a major and snowballing threat to public health and the global economy. In Africa, there is controversy on the dearth of studies reporting the epidemiology of chronic leg ulcers. The present systematic review and meta-analysis aim at synthesising the prevalence, incidence and aetiologies of this ailment in this continent from contemporary data.

METHODS AND DESIGN

We will include cohort studies, case-control, cross-sectional studies and case series with more than 30 participants. Electronical databases including African Journals Online, MEDLINE, Excerpta Medica Database and Web of knowledge, and grey literature will be searched for relevant abstracts of studies published and unpublished between 1 January, 2000, and 28 February, 2019, without language restriction. The review will be reported according to the Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines. Each study included in this review will be assessed for methodological quality. Clinically homogenous studies will be pooled using random-effects meta-analysis. Visual inspection of funnel-plots and the Egger's test will be used to investigate publication bias. Meta-regression and subgroup analyses will be performed to investigate the possible sources of heterogeneity.

ETHICS AND DISSEMINATION

The present study will be based on published data; therefore, ethical approval is not required. Result of the review will be presented at conferences, to relevant health authorities and will be published in a biomedical peer-reviewed journal.

PROTOCOL REGISTRATION NUMBER

CRD42018108250.

Ultrasonic debridement management of lower extremity wounds: retrospective analysis of clinical outcomes and cost

Objective:

The aim of this study was to assess wound healing outcomes following direct, low-frequency, high-intensity, ultrasonic debridement as a surgical adjunct for non-healing lower extremity wounds.

Methods:

A retrospective review was conducted for patients undergoing lower extremity wound treatment with direct, low-frequency (22.5 kHz), high-intensity (~60 W/cm2) ultrasonic debridement between January 2010 and January 2016. Clinical outcomes were assessed up to 180-days post-ultrasonic debridement. Descriptive statistics, cost and univariate analysis were performed.

Results:

Overall, 82 wounds in 51 patients were included. Mean age was 57.0 years (range: 32–69), and average body mass index (BMI) was 30.8 kg/m². Patient comorbidities consisted of smoking (47%; n=24), hypertension (75%; n=38), diabetes (45%; n=23), and peripheral vascular disease (51%, n=26). Average wound age at initial presentation was 1013 days (range: 2–5475 days) with an average wound size of 9.0cm x 7.4cm. At 180-days post-debridement, 60% (n=49) of wounds had completely healed. Readmission (47%; n=24) and reoperation (45%; n=23) rates were characterised by the reason for readmission and reoperation respectively. Readmission for wound healing (70%, n=39) was primarily for further debridements (41%; n=16). Wound infection (30%; n=7) was the most common readmission for wound complications (30%; n=17). Reoperations primarily consisted of treatments for further wound healing 96% (n=51). Cost analysis showed a lower total treatment cost for patients with improved healing ($78,698), compared with non-improved wounds ($137,707).

Conclusion:

In a complex, heterogeneous cohort of chronic extremity wounds, the use of direct, low-frequency, high-intensity, ultrasonic debridement is a safe and reliable adjunctive therapy for the management of these wounds.

Prospective study of cryopreserved placental tissue wound matrix in the management of chronic venous leg ulcers

OBJECTIVE

Chronic venous leg ulcers (VLUs) affect up to 2% of the general population, resulting in a significant socioeconomic burden. Placental tissue that contains mesenchymal stem cells and active growth factors has been shown to be beneficial in healing of chronic wounds. We compared the efficacy of a human viable wound matrix (hVWM) of cryopreserved placental tissue for the treatment of refractory VLUs with standard therapy.

METHODS

This prospective single-center open-label single-arm study enrolled patients with Clinical, Etiology, Anatomy, and Pathophysiology clinical class C6 VLUs. The ulcers of all enrolled patients had failed to heal after a trial of standard therapy of at least 12 weeks, which included weekly multilayer compression therapy along with local wound care. The same patients subsequently received application of hVWM (Grafix; Osiris Therapeutics, Columbia, Md) every 1 to 2 weeks in addition to standard therapy. Healing with hVWM therapy was then compared with standard therapy, with each patient serving as his own control.

RESULTS

There were 30 VLUs in 21 consecutive eligible patients who were enrolled in the study. All patients were men with an average age of 67 years (standard deviation [SD], ±10.8 years), and the average area of venous ulcers before hVWM initiation was 12.2 cm² (SD, ±14.6 cm²; range, 3.3-12.3 cm²). Duplex ultrasound confirmed superficial or deep system venous reflux in all patients. Complete ulcer healing was achieved in 53% (16/30) of VLUs refractory to standard therapy after application of hVWM. There was a mean reduction in wound surface area by 79% (SD, ±27.3%; P < .001 compared with standard therapy) after a mean treatment time of 10.9 weeks. Eighty percent of VLUs were reduced in size by half compared with 25% with standard therapy (P < .001). The mean rate of reduction in ulcer area after hVWM applications was 1.69% per day vs 0.73% per day with standard therapy (P = .01).

CONCLUSIONS

Cryopreserved placental tissue (hVWM) improves healing processes to achieve complete wound closure in a significant proportion of chronic VLUs refractory to standard therapy. Adjunctive therapy with hVWM provides superior healing rates in refractory VLUs.

Adjuvant Lymphatic Osteopathic Manipulative Treatment in Patients With Lower-Extremity Ulcers: Effects on Wound Healing and Edema

Context

In 2012, the US wound registry estimated that the cost of managing chronic wounds in the United States exceeded $50 billion. A large percentage of these wounds are venous stasis ulcers of the lower extremity. Evidence suggests that adjuvant osteopathic manipulative treatment (OMT) may provide a benefit by reducing edema and subsequent healing times in venous stasis ulcers of the lower extremity.

Objective

To determine whether a lymphatic OMT protocol improves wound healing rates among patients with lower-extremity edema.

Methods

This pilot study was a nonrandomized before-after community trial of lymphatic OMT in patients with lower-extremity wounds and edema. Wound surface area measurements for the preliminary phase were obtained retrospectively. During the intervention period, patients received 10 minutes of OMT twice per week. The OMT protocol, which aimed to improve lymphatic flow, included myofascial thoracic outlet release, doming of the diaphragm, pelvic diaphragm release, popliteal release, and pedal pump (2-3 minutes of continuous pump) performed in sequence. Rates of wound healing were compared between the preliminary (standard therapy), intervention (standard therapy plus OMT), and follow-up (standard therapy) phases. Rates of change in edema (measured using leg volume) were evaluated during the intervention phase. A custom-designed questionnaire was used to assess patients’ satisfaction with their treatment and confidence that its effects on their health were good.

Results

Eight patients were included in the study. The wound surface area increased during the preliminary phase by a mean of 10 cm2/wk and decreased during the intervention phase by a mean of 4.9 cm2/wk. Patients’ mean leg volume decreased during the intervention phase. Six patients were “very satisfied” with their treatment.

Conclusion

The adjunctive OMT protocol may have reduced edema and reversed the trend of wound growth in patients with venous stasis ulcers. Edema reduction is a mainstay of current wound therapy, and any modality that decreases edema may subsequently decrease healing times.

Epidemiology of venous leg ulcers in primary health care: Incidence and prevalence in a health centre-A time series study (2010-2014)

The aims of the study were to describe and analyse the temporal trend of the prevalence and incidence of venous leg ulcers (VLU) over the years 2010 to 2014, to determine healing times and temporal trends in the study period, and to evaluate related aspects such as the use of the Ankle-Brachial Pressure Index (ABPI) in a primary care health centre. This was a retrospective study based on a time series (years 2010-2014) of the prevalence and incidence of VLUs in people aged over 40 years in a primary care centre in Barcelona City. We reviewed 3920 electronic health records selecting patients, per year (2010-2014), with VLUs based on the ICD-10 diagnoses. For prevalence, we took into account any patient with an active VLU in the year of study. For incidence, we took into account patients with a new VLU in the year of study. A descriptive analysis was carried out based on each of the collected variables. The variables were examined according to the years of study (time series) by one-factor analysis of variance (anova) or Kruskal-Wallis non-parametric test, as appropriate. A survival analysis by Kaplan-Meier curves and log-rank test was also performed. A total of 139 patients met the VLU criteria. Among them, only 79.2% were classified as having a VLU and had a correct ICD diagnosis. The prevalence and incidence increased over the years, doubling in patients aged over 65 years. Incidence increased from 0.5 new cases per 1000 people/year in 2010 to 1 new case for every 1000 people/year in 2014. Moreover, the prevalence ranged between 0.8 and 2.2 patients with VLU for every 1000 people/year. During the study period, a total of 84.2% of the VLUs healed (117/139 VLU). Regarding average annual time to healing, the trend indicates that lesions took less time to heal (Kruskal-Wallis test, P = 0.004), ranging between 453,9 weeks in 2005 to 19 weeks in 2014. The use of ABPI also evolved and was found to be increasingly performed prior to the appearance of the lesion. The epidemiological profile of people affected by VLUs continues to be, mainly, that of women of an advanced age, over 70 years. The frequency of VLU occurrence rose continually over the years, but healing took less time, and use of ABPI improved. Assigning a reference nurse in the wounds unit and the organisational structure around this problem may have an influence on improving care and the approach to these types of lesions.

Optimal Compression Therapy and Wound Care for Venous Ulcers

Venous leg ulcers remain a major public health issue with significant economic impact. Two main components of the management of patients with venous leg ulcers are compression therapy and wound care. This article addresses principles and specific aspects of compression therapy and focal wound care for patients with venous leg ulcers.

Escleroterapia de safena associada a enxerto de pele no tratamento de úlceras venosas

Contexto

Úlceras são a resultante final de varizes associadas a refluxo de veias safenas.

Objetivo

Demonstrar a possibilidade de associar dois procedimentos, a escleroterapia com espuma de veias safenas e o enxerto de pele parcial, para o tratamento de pacientes com úlceras venosas relacionadas a refluxo de veias safenas.

Métodos

Foram tratados 20 membros em 20 pacientes, todos com ulcerações relacionadas a refluxo de veias safenas. Realizamos o enxerto de pele expandida, seguido da escleroterapia ecoguiada com espuma de polidocanol nas veias associadas às úlceras, através de punção ou dissecção da veia.

Resultados

Em todos os casos, houve melhora dos sintomas relacionados à úlcera e cicatrização da lesão. Em 11 casos, obtivemos a viabilidade do enxerto de pele por completo; em quatro casos, houve cicatrização de cerca de 50% da lesão; e nos cinco casos restantes, houve cicatrização de aproximadamente 75% da lesão. A primeira ultrassonografia de controle revelou esclerose completa dos vasos tratados em 19 dos 20 casos e esclerose parcial sem refluxo detectável em um caso. Na segunda ultrassonografia, realizada após 45 dias, observamos esclerose completa de 15 casos; em cinco casos, houve esclerose parcial, dos quais três sem refluxo detectável e dois com refluxo em segmentos isolados associados a varizes. A complicação mais frequente foi a pigmentação nos trajetos venosos, observada em 13 pacientes. Um caso apresentou trombose assintomática de veias musculares da perna.

Conclusão

Essa associação de procedimentos consiste em uma opção válida com potencial para promover um tratamento mais breve e de menor custo.

In vitro significance of SOCS-3 and SOCS-4 and potential mechanistic links to wound healing

Wound healing and the management of chronic wounds represent a significant burden on the NHS. Members of the suppressor of cytokine signalling (SOCS) family have been implicated in the regulation of a range of cellular processes. The current study aims to explore the importance of SOCS-3 and SOCS-4 in regulating cellular traits associated with wound healing. SOCS-3 over-expression and SOCS-4 knockdown mutant lines were generated and verified using q-PCR and western blotting in human keratinocytes (HaCaT) and endothelial cells (HECV). Over-expression of SOCS-3 resulted in a significantly reduced proliferative rate in HaCaT keratinocytes and also enhanced the tubule formation capacity of HECV cells. SOCS-4 knockdown significantly reduced HaCaT migration and HECV cell tubule formation. Suppression of SOCS-4 influenced the responsiveness of HaCaT and HECV cells to EGF and TGFβ and resulted in a dysregulation of phospho-protein expression in HaCaT cells. SOCS-3 and SOCS-4 appear to play regulatory roles in a number of keratinocyte and endothelial cellular traits associated with the wound healing process and may also be able to regulate the responsiveness of these cells to EGF and TGFβ. This implies a potential regulatory role in the wound healing process and, thus highlights their potential as novel therapies.

Bacterial Contribution in Chronicity of Wounds

A wound is damage of a tissue usually caused by laceration of a membrane, generally the skin. Wound healing is accomplished in three stages in healthy individuals, including inflammatory, proliferative, and remodeling stages. Healing of wounds normally starts from the inflammatory phase and ends up in the remodeling phase, but chronic wounds remain in an inflammatory stage and do not show progression due to some specific reasons. Chronic wounds are classified in different categories, such as diabetic foot ulcer (DFU), venous leg ulcers (VLU) and pressure ulcer (PU), surgical site infection (SSI), abscess, or trauma ulcers. Globally, the incidence rate of DFU is 1-4 % and prevalence rate is 5.3-10.5 %. However, colonization of pathogenic bacteria at the wound site is associated with wound chronicity. Most chronic wounds contain more than one bacterial species and produce a synergetic effect that results in previously non-virulent bacterial species becoming virulent and causing damage to the host. While investigating bacterial diversity in chronic wounds, Staphylococcus, Pseudomonas, Peptoniphilus, Enterobacter, Stenotrophomonas, Finegoldia, and Serratia were found most frequently in chronic wounds. Recently, it has been observed that bacteria in chronic wounds develop biofilms that contribute to a delay in healing. In a mature biofilm, bacteria grow slowly due to deficiency of nutrients that results in the resistance of bacteria to antibiotics. The present review reflects the reasons why acute wounds become chronic. Interesting findings include the bacterial load, which forms biofilms and shows high-level resistance toward antibiotics, which is a threat to human health in general and particularly to some patients who have acute wounds.

Identifying the trends in wound-healing patents for successful investment strategies

Background

Recently, the need for rapid wound-healing has significantly increased because of the increasing number of patients who are diagnosed with diabetes and obesity. These conditions have contributed to a surge in the number of patients with chronic wounds worldwide. Furthermore, many cost-effective wound-healing technologies have been developed in order to keep up with the increased demand. In this paper, we performed a quantitative study of the trends associated with wound-healing technologies using patent data.

Methodology

We analyzed the trends considering four different groups of patent applicants: firms, universities, research institutes, and individuals using a structural topic model. In addition, we analyzed the knowledge flow between patent applicants using citation analysis, and confirmed the role of applicants in the knowledge-flow network using k-means clustering. As a result, the primary wound-healing technology patents applied for by the four groups varied considerably, and we classified the roles of patent applicants were found in the knowledge-flow network.

Conclusions

Our results showed the organizations that are leading each area of wound-healing technology. Furthermore, from the results, we identified specific institutions that are efficient for spreading knowledge related to wound-healing technology based on the patents. This information can contribute to the planning of investment strategies and technology policies related to wound-healing.

The difficulty and the solution of compression therapy in a healed venous leg ulcer

Continuing preventative treatment once a venous ulcer is healed is fraught with dangers, with the most common problem being the inability of the wearer or their carer to apply compression therapy. A new novel compression modality has been introduced to solve the dilemma of applying compression once an injury has healed. This compression is also time-saving for practitioners who wish to heal leg ulcers. This will have an impact on the time restrictions of practice and district nurses-who have a 10-15 minute slot to dress and bandage their patients' venous ulcers.

Management of perforator vein aneurysms in the lower extremities

OBJECTIVE

Perforator vein aneurysms (PVAs) of the lower extremity have not been defined or reported. This study reports the clinical presentation of patients, the PVA characteristics, and the clinical outcome of their management.

METHODS

Patients with signs and symptoms of chronic venous disease who had a PVA were included. Diagnosis of a PVA was made with duplex ultrasound. Normal perforator veins have a diameter of <3 mm. A PVA was defined as a diameter dilation of >9 mm, and it was always found below the deep fascia. The topography and morphology of the aneurysms were described in detail. All PVAs were treated with subfascial ligation with or without aneurysm excision. All patients were followed up for a minimum of 3 months with clinical examination and duplex ultrasound, and complications were noted.

RESULTS

There were 21 aneurysms identified in 19 patients. Fourteen (73.7%) patients were female. The mean age at diagnosis was 49 years with a standard deviation of 9. Aneurysm size ranged from 9.8 to 22.2 mm, with a mean diameter of 15.7 mm and a standard deviation of 3.8. Seventeen aneurysms were fusiform, one was saccular, and one was multilobar. The perforators of the great saphenous vein distribution were most frequently involved, whereas only one involved deep vein disease. Few patients had symptoms, such as pressure and pain directly over the affected perforator. There was no association between the location and size of the PVA and the severity of chronic venous disease. Fourteen patients were treated surgically; five patients preferred conservative treatment with elastic compression stockings. Fourteen patients (73.7%) had ligation with (n = 9) or without (n = 5) excision of the aneurysm. All underwent concomitant phlebectomies, and eight of them also had ultrasound-guided foam sclerotherapy. Endovenous thermal ablation of saphenous veins was performed in seven patients, whereas two had ligation and stripping. There were four minor postoperative complications in four patients, all of which resolved within 6 weeks. The median follow-up was 21 months, ranging from 3 to 52 months. There were no recurrences of a PVA. Five patients preferred conservative treatment. The diameter changed from 0 to 13 mm during the follow-up, and the patients' symptoms remained the same or had mild worsening.

CONCLUSIONS

PVAs are rare without causing significant symptoms locally. Diagnosis is made with duplex ultrasound because the affected vein is located below the deep fascia. As only one case in our series of 19 involved the deep veins, we believe that PVAs originate from superficial veins. The condition is relatively benign, and the treatment outcomes are very good with limited complications experienced. However, selective treatment of PVAs may not be needed for most of them as treatment of the superficial veins connecting with the PVA may be sufficient.

Pentoxifylline and its applications in dermatology

Pentoxifylline is a methyl-xanthine derivative with many anti inflammatory effects. Pentoxifylline has been found to be effective for many dermatological as well as non-dermatological conditions. It has been used both as primary drug as well as adjuvant and is a safe and relatively cost-effective alternative drug. In this article, we review the literature and highlight various important aspects of pentoxifylline.

Chronic Leg Ulcers: Epidemiology, Aetiopathogenesis, and Management

Chronic leg ulcer is defined as a defect in the skin below the level of knee persisting for more than six weeks and shows no tendency to heal after three or more months. Chronic ulceration of the lower legs is a relatively common condition amongst adults, one that causes pain and social distress. The condition affects 1% of the adult population and 3.6% of people older than 65 years. Leg ulcers are debilitating and greatly reduce patients' quality of life. The common causes are venous disease, arterial disease, and neuropathy. Less common causes are metabolic disorders, hematological disorders, and infective diseases. As many factors lead to chronic lower leg ulceration, an interdisciplinary approach to the systematic assessment of the patient is required, in order to ascertain the pathogenesis, definitive diagnosis, and optimal treatment. A correct diagnosis is essential to avoid inappropriate treatment that may cause deterioration of the wound, delay wound healing, or harm the patient. The researchers are inventing newer modalities of treatments for patients with chronic leg ulceration, so that they can have better quality life and reduction in personal financial burden.