Comparison of the healing rates and complications of three four-layer bandage regimens

This randomised controlled study compares the healing rates, complications and patient and staff acceptability of three four-layer bandage regimens for leg ulcers. A total of 149 patients were recruited into the study, of whom 50 received the original Charing Cross system (CX4L), 50 a modified Charing Cross system (Parema) and 49 a commercially available kit, Robinson Ultra Four (Robinson). No significant difference was found in the healing rates of the three systems. Overall 12 weeks' healing was 65%, while the 20-week healing rates for the individual systems were 87% (CX4L), 84% (Parema) and 83% (Robinson). Analysis of known risk factors for delayed healing showed that no bandaging system had an advantage over the others. Staff familiarity resulted in an initial preference for the CX4L but there was no bandage preference by the end of the study. The data suggest that none of the systems has an advantage over the others and that cost savings can be made by pursuing a competitive pricing policy.     

The K-Four bandage system: evaluating its effectiveness on recalcitrant venous leg ulcers

This evaluation examined the effectiveness of the K-Four (Parema) high compression bandage system on 50 patients with recalcitrant 'hard-to-heal' venous leg ulcers and relates the outcome to an earlier randomised study which compared three other four-layer bandage systems. Twelve-week healing rates were 53.2% in the current series, which included patients with poor mobility, large ulcers and long pretreatment ulcer duration, rising to 69.5% at 20 weeks. When account was taken of known risk factors for delayed ulcer healing, no significant difference could be identified between between either K-Four or the earlier evaluated bandages, which included the original Charing Cross system, where the overall healing rates were 64.5% and 80%, respectively, at 12 and 20 weeks. It would seem more likely that treatment outcome is related to patient risk factors for delayed healing and bandaging expertise than to the bandage system employed.     

Compression strapping: the development of a novel compression technique to enhance compression therapy and healing for 'hard-to-heal' leg ulcers

Non healing wounds of the lower limb continue to be a significant issue for both practitioners and patients. Failure of gold-standard management demands a creative response. This article describes the development of a novel and intuitive strapping technique overlying the compression bandage that appears to have an influence in healing complex lower limb ulcers. A retrospective audit of 17 patients with 25 ulcers allows further analysis and discussion. The strapping technique uses cohesive inelastic compression bandaging; narrow strips of bandages are layered in a fan distribution over the ulcer and oedema. This approach seems to offer an intuitive response to these complex wounds, allowing management to be tailored to the site of the ulcer and oedema. Tolerance for this less bulky compression therapy regime is excellent, thereby aiding healing and reducing all costs associated with non healing leg ulcers.     

Randomized clinical trial and economic analysis of four-layer compression bandaging for venous ulcers

BACKGROUND: The aim of this study was to compare the cost-effectiveness of four-layer compression bandaging for venous leg ulcers with that of other available treatments. METHODS: In this pragmatic trial, 200 patients with a venous leg ulcer were randomized either to four-layer bandaging (intervention group; n = 100) or to continue their usual system of care (control group; n = 100). The follow-up for each patient was 12 weeks. Analysis was by intention to treat; the main outcome measures were time to healing and cost to the health board per leg healed. RESULTS: Baseline characteristics were well matched in the two groups. The Kaplan-Meier estimate of the healing rate at 3 months was 54 per cent with four-layer bandaging and 34 per cent in the control group. Throughout the 3 months, four-layer bandaging healed leg ulcers significantly earlier (P = 0.006). There was a significant reduction in the median cost per leg healed with four-layer bandaging (euro 210 versus euro 234; P = 0.040). CONCLUSION: Four-layer bandaging is currently the most effective method of treating venous leg ulcers in a community setting.     

Nurses' evaluation of a new four-layer bandage system

This small study was undertaken to evaluate a new four-layer bandage (4LB) system (Ultra Four, Robinson). The aim was to provide initial user information about the product and compare it with the previously used original Charing Cross 4LB system. Subjective evaluations of the comparative performance of the Ultra Four system were assessed using a weekly treatment questionnaire in 30 patients. Both patients and nurses commented on the usability of each individual layer and the overall performance of the new system over a period of up to 12 weeks or until healing. After 12 weeks 15/30 ulcers (50%) had healed. Using life table analysis, allowing for patients who failed to reach 12 weeks, the expected healing rate was 65%. The performance of each individual layer was considered similar to those of the Charing Cross 4LB in terms of wear and tear, slippage and ease of removal. However, there was an indication that the fourth layer provided superior wear and tear at the heel and better ease of application and ease of removal than the original. After one week of treatment the Ultra Four system was rated better than the original 4LB for wear and tear at the heel in 15/28 patients (54%), for overall wear and tear in 12/25 (48%), for ease of application in 9/27 (33%) and for ease of removal in 11/26 (42%). This study relied on the nurses' experience rather than a direct comparison between bandages. However, it does indicate that the relative performance of products may help nurses to make decisions when objective comparative data are not available.     

Multiplexed analysis of matrix metalloproteinases in leg ulcer tissue of patients with chronic venous insufficiency before and after compression therapy

Elevated matrix metalloproteinases (MMP) levels have been implicated in the pathogenesis of chronic venous insufficiency ulcers. Quantitative measurements of a broad range of MMP proteins in human tissue treated with compression bandaging have not been reported. The goal of this study was to determine the expression of a wide range of proteases in untreated venous leg ulcer tissue and the changes in these levels after 4 weeks of high‐strength compression therapy. Twenty‐nine limbs with new or untreated chronic venous insufficiency and leg ulceration received therapy for 4 weeks with sustained high compression bandaging. Biopsies were obtained from healthy tissue and from ulcerated tissue before and after therapy. A novel multiplexed protein assay was used to measure multiple MMPs in a single sample. MMP protein activity, TIMP protein levels, and gene expression levels were also addressed. MMP1, 2, 3, 8, 9, 12, and 13 protein levels were elevated in ulcer tissue compared with healthy tissue. MMP8 and 9 were highly expressed in ulcer tissue. MMP3, 8, and 9 significantly decreased following treatment. Reduction in the levels of MMP1, 2, and 3 was associated with significantly higher rates of ulcer healing at 4 weeks. We conclude that compression therapy results in a reduction of the pro‐inflammatory environment characterizing chronic venous ulcers, and ulcer healing is associated with resolution of specific elevated levels of protease expression.     

Haemodynamic study examining the response of venous blood flow to electrical stimulation of the gastrocnemius muscle in patients with chronic venous disease.

OBJECTIVES: The aim of this study was to explore the option of stimulating calf muscle contraction through externally applied neuromuscular electrical stimulation (NMES) and to measure venous blood flow response to this stimulation. METHODS: Ten patients with class 6 chronic venous disease (CEAP clinical classification) were recruited. Measurements of peak venous velocities in the popliteal vein were recorded by Duplex scanning in response to six test conditions; 1. Standing, 2. Voluntary calf muscle contraction, 3. Standing with NMES applied, 4. Standing with compression bandaging applied to the leg, 5. Voluntary calf muscle contraction with compression bandaging applied to the leg, 6. Stationary with compression bandaging applied to the leg and NMES applied. Comfort assessment was completed using visual analogue scales at each test stage and on study completion each patient completed a short structured interview to determine comfort and acceptability of NMES. Statistical analyses were carried out using SPSS, Version 9. Non-parametric testing was used in all analyses using the Wilcoxon Signed Ranks Test for paired samples. RESULTS: There was a significant increase in venous velocities on voluntary contraction of the calf muscle (median resting vel 7.3 cm/s; voluntary contraction median 70 cm/s) and with the introduction of NMES, both with compression (median velocity 15 cm/s, p = 0.005 Wilcoxon) and without compression (median velocity 13 cm/s, p = 0.005 Wilcoxon). The greatest increase with NMES was when combined with compression bandaging. All patients reported the stimulus as an acceptable treatment option with 90% reporting NMES as comfortable. CONCLUSIONS: Healing rates in venous ulceration with the application of compression bandaging remain between 50 and 70%. This study shows a positive haemodynamic response to NMES. Further research is needed to quantitatively measure the effect of NMES on ulcer healing.     

A factorial, randomized trial of pentoxifylline or placebo, four-layer or single-layer compression, and knitted viscose or hydrocolloid dressings for venous ulcers

OBJECTIVES: We evaluated the effectiveness of pentoxifylline, knitted viscose or hydrocolloid dressings, and single-layer or four-layer bandaging for venous ulceration. METHOD: A factorial randomized controlled trial with 24-week follow-up was conducted in leg ulcer clinics in Scotland with blinded allocation to pentoxifylline (1200 mg) or placebo, knitted viscose or hydrocolloid dressings, and single-layer or four-layer bandages. The study enrolled 245 adults with venous ulcers. The main outcome measure was time to complete healing. Secondary outcomes included proportions healed, withdrawals, and adverse events. Analysis was by intention to treat. RESULTS: There was no evidence of interaction between the drug, bandages, and dressings. Pentoxifylline was associated with nonsignificant increased ulcer healing (62% vs 53%; P = .21). Four-layer bandages were associated with significantly higher healing rates (67% vs 49%; P = .009). There was no difference in healing between knitted viscose and hydrocolloid dressings (58% and 57%; P = .88). Cox regression models increased the significance of the pentoxifylline effect (relative risk of healing, 1.4; 95% confidence interval, 1.0 to 2.0). CONCLUSIONS: Pentoxifylline increased the proportion healing compared with placebo to the same extent as shown in recent systematic reviews, although this finding was only statistically significant when a secondary adjusted analysis was conducted. Four-layer bandaging produced higher healing rates than single-layer bandaging. There was no difference in time to healing between knitted viscose and hydrocolloid dressings.     

生肌长皮膏联合加压包扎治疗下肢慢性溃疡的机制研究

目的:研究并探讨生肌长皮膏联合加压治疗促进下肢慢性溃疡愈合的临床疗效和作用机制。方法:2010年3月至2013年9月我院外科门诊96例下肢慢性溃疡病人,分为长皮膏组、长皮膏加压组和对照组,每组32例。治疗后3、7、14和21 d观察3组病人创面肉芽生长和溃疡愈合情况,记录愈合时间,取创面肉芽组织标本测定组织中羟脯氨酸含量和缺氧诱导因子1(HIF-1)基因的表达。结果:生肌长皮膏联合加压治疗可促进下肢慢性溃疡创面愈合,缩短创面愈合时间,增加羟脯氨酸含量并促进HIF-1基因表达,与对照组和长皮膏组相比,差异有统计学意义(P<0.05)。结论:生肌长皮膏联合加压治疗能通过促进胶原合成和HIF-1的分泌从而显著加快创面愈合,缩短创面愈合时间,为其临床应用提供了依据。     

Management of mixed arterial and venous leg ulcers

BACKGROUND: The aim was to assess healing in patients with mixed arterial and venous leg ulcers after protocol-driven treatment in a specialist leg ulcer clinic. METHODS: The study included consecutive patients referred with leg ulceration and venous reflux over 6 years. Legs without arterial disease (ankle : brachial pressure index (ABPI) above 0.85) were treated with multilayer compression bandaging and patients with severe disease (ABPI 0.5 or less) were considered for immediate revascularization. Those with moderate arterial compromise (ABPI above 0.5 up to 0.85) were initially managed with supervised modified compression and considered for revascularization if their ulcer did not heal. Healing rates were determined using life-table analysis. RESULTS: Of 2011 ulcerated legs, 1416 (70.4 per cent) had venous reflux. Of these 1416, 193 (13.6 per cent) had moderate and 31 (2.2 per cent) had severe arterial disease. Healing rates by 36 weeks were 87, 68 and 53 per cent for legs with insignificant, moderate and severe arterial disease respectively (P < 0.001). Seventeen legs with moderate and 15 with severe arterial disease were revascularized. Of these, ulcers healed in four legs with moderate and seven with severe disease within 36 weeks of revascularization (P = 0.270). Combined 30-day mortality for revascularization was 6.5 per cent. CONCLUSION: A protocol including supervised modified compression and selective revascularization achieved good healing rates for mixed arterial and venous leg ulceration.     

When is reduced-compression bandaging safe and effective?

During a one-year period 44 patients were treated with reduced-compression bandaging in the vascular unit at a district general hospital. Twenty patients with venous ulcers were referred from community leg ulcer clinics because they could not tolerate standard compression bandaging (group 1). A further 24 patients had mixed aetiology leg ulcers (group 2), and high-compression bandaging was not attempted because of significant peripheral vascular disease (ankle brachial pressure index < 0.8). Forty-two patients tolerated reduced-compression bandaging without discomfort or skin pressure changes. Healing was achieved in 32 patients (13 in group 1 and 19 in group 2). All non-healed ulcers were considered smaller at the time of final follow-up, and had less exudate. Reduced-compression bandaging has been shown to be effective and well tolerated by patients with venous ulcers who cannot comply with high-compression bandaging. With close supervision, it is safe to use in patients with significant peripheral vascular disease.     

Mobility in patients with venous leg ulceration.

OBJECTIVES: To compare mobility in patients with venous leg ulcers to matched controls and determine the influence of mobility, age and ulcer size on ulcer healing. METHODS: 25 leg ulcer patients, and 25 matched controls wore a mobility monitor (ActivPAL, PAL Technologies Ltd, Glasgow, Scotland)) which recorded the number of steps and amount of time spent walking, standing, sitting or lying for a one-week period. A walking index was calculated. The ulcer group were treated with compression bandaging and ulcer healing recorded over 12 weeks. RESULTS: There were 13 female subjects in each group. The median age was 70.5 (range 30-89) years. There was no difference in the amount of time either group spent standing, walking and resting. There was a significant reduction in the number of steps taken and in the walking index in the ulcer group compared to controls (ulcer group, median 6,685 steps/day, range 2074-17,999; control group median 8750, range 4917-16,043, p<0.05, Mann Whitney u test). Smaller ulcers and ulcers of recent onset were most likely to heal within 12 weeks (p=0.005 and p=0.011 respectively, Chi squared test). The percentage of time spent mobilising and resting did not influence ulcer healing (r(s)=-0.125; p=0.55). CONCLUSIONS: Mobility patterns among patients with leg ulcers are not significantly different to age matched controls. Ulcer patients take fewer steps per week compared to controls indicating they have reduced calf muscle pump function. Further studies are required to determine whether therapies which increase calf muscle activity have a role in ulcer treatment.     

Non-elastic compression: an alternative in management of chronic venous insufficiency.

Non-elastic compression has been used to treat venous insufficiency of the lower extremities for more than 150 years. The best and most recognized example is the Unna boot. When compared with other dressings, the Unna boot has performed as well as or better than other forms of compression. While the Unna boot is used worldwide, a 3- or 4-layer dressing has emerged as the dressing of choice in treating severe chronic venous insufficiency in the United States and English-speaking European countries. In the United States, non-elastic compression can also be applied as a CircAid legging. This semirigid support has been compared with heavyweight class 3 below-knee medical stockings. At 2 and 6 hours after application, inelastic compression maintained limb size and reduced venous volume better than did stockings. At 6 hours, the ejection fraction of the calf muscle pump was increased and venous filling index significantly improved with inelastic compression compared with stockings. Comparison of elastic stockings with short-stretch bandages has also been completed. The short-stretch bandage was found to be similar but not identical to the semirigid inelastic support device. The studies have shown that venous filling index improved by short-stretch bandaging and that venous reflux time was prolonged more by the short-stretch bandages than by stockings. The findings of these studies demonstrate that the inelastic support dressing mimics the action of the Unna boot in providing counter-pressure to perforating vein outflow. This may improve cutaneous and subcutaneous microcirculation in a manner similar to perforating vein surgery, which has been shown to accelerate leg ulcer healing.     

Treatment of Venous Leg Ulcers with Dermagraft

BACKGROUND: A number of different treatment approaches have been recommended for the treatment of venous ulceration, including local ulcer treatment, compression and drug therapy. Recent advances in tissue engineering have resulted in living tissues being developed for cutaneous wound repair and skin replacement. The aim of this pilot study was to compare the rate of healing of venous ulcers in patients treated with Dermagraft (a human fibroblast-derived dermal replacement) and compression therapy or compression therapy alone. METHODS: A total of 18 patients with venous ulceration of the leg were recruited into the pilot study. Ten patients were treated with Dermagraft and compression therapy, and eight patients were treated with compression therapy alone. Healing was assessed by ulcer tracing and computerised planimetry. Skin perfusion was measured by laser Doppler. RESULTS: Five (50%) of the patients treated with Dermagraft and one (12.5%) control patient had healed by the end of the 12-week study period (NS). The total ulcer area rate of healing and linear rate of healing was significantly improved in patients treated with Dermagraft (P=0.001 and P=0.006, respectively, Mann-Whitney U-test). The number of capillaries increased in both the treatment and control group. Peri-ulcer skin perfusion increased by 20% in patients treated with Dermagraft, compared with 4.9% in the control group. CONCLUSION: The data from this small pilot study suggests that Dermagraft is associated with improved healing of venous ulceration. Following this pilot study, further clinical studies are needed to confirm the validity of these results in 'hard to heal' venous leg ulcers.     

Prospective clinical study of a new adhesive gelling foam dressing in pressure ulcers

This prospective, non comparative study evaluated the safety and effectiveness of an adhesive gelling foam dressing in pressure ulcer management. Twenty-three subjects with exuding pressure ulcers were recruited from seven centres in the USA and Canada. Study treatment included an adhesive gelling foam dressing, optional tape/roll bandaging and mandatory pressure-reducing/relieving devices. Subjects were followed until ulcer healing, for up to 28 days, or on patient withdrawal from the study, whichever came first. Dressings were changed at least once every 7 days. Mean percentage change in ulcer area from baseline to final measurement was -13%. Investigators reported healing or subjective improvement of ulcer condition in 61% of patients. Mean dressing wear time was 4.2 days. Subjects found the dressing was comfortable, soothing and cushioning in situ at 80%, 64% and 70% of dressing changes, respectively. Subjects reported pain severity of none or mild for every dressing change. Fourteen subjects experienced adverse events, including seven subjects with study-related maceration, erythema, wound enlargement, blister or infection. A regimen including an adhesive gelling foam dressing proved to be safe and effective for managing exudate, protecting the surrounding skin, minimising pain and supporting healing of pressure ulcers with exudate.     

The impact of providing product funding for compression bandaging and medical footwear on compression use, wound healing and quality of life

A study conducted in an Australian home nursing service sought to ascertain whether the provision of funding for compression bandaging and medical footwear would impact on compression therapy use, wound healing and quality of life (QoL) among people with venous leg ulcers. Clients (n = 120) were randomly allocated to evaluation funded or not evaluation funded groups, the former provided funding for compression bandaging and medical footwear. Outcome measures included the number of wounds healed, healing rate, compression use and QoL. Analysis included ttests and Kaplan-Meier Survival Analysis. An alpha level of 0·05 classified findings as significant. There were no significant differences between groups for rate or time to healing, wounds healed or compression use. The evaluation funded group were significantly more likely to receive medical footwear. Those with confirmed diagnosis and who received multilayer bandaging, irrespective of group, achieved healing rates significantly higher than those who wore other compression therapy. Factors other than cost intervened with the capacity to evaluate the impact of wound product subsidisation. Further exploration of how to best promote evidence-based practice and future research to evaluate clinically and cost-effective wound treatments in a range of health care settings is required.     

Venous leg ulcer care: how evidence-based is nursing practice?

OBJECTIVES: The objectives of this study were to (1) determine how congruent community-provided leg ulcer care was with best practice for venous leg ulcers and (2) identify organizational and clinical factors associated with the provision of best practice for venous leg ulcers. DESIGN: The practice variation study group was an audit of nursing agency client records to determine the provision of care. SETTING AND SUBJECTS: The study population was a home care cohort of persons with venous leg ulcers (n = 66) who received care from one Ontario home care nursing agency between March 1999 and November 1999. INSTRUMENT: The audit tool was developed with a checklist reflecting the common recommendations from 3 international practice guidelines, as well as organizational and clinical factors that may influence or reflect best practice. RESULTS: Half of client records (35/66) included an identified etiology of the leg ulcer. An Ankle Brachial Pressure Index score was documented prior to the initiation of compression on fewer than half of the records (21/44). Regular ulcer measurement was done for 11% of the clients (7/64). Two thirds of the clients (44/66) were treated with compression. More than 60% of the clients (40/66) had been seen by either a dermatologist or a vascular surgeon. Topical antibiotics were prescribed for two thirds of clients (44/64). Fifteen percent of clients (10/66) were assessed for pain, and 17% (11/66) received some form of pain management. Documentation of client education specific to the leg ulcer was present on 3% of records (2/66). The mean number of different nurses providing leg ulcer care to each client was 19. A registered practical nurse was the classification of nurse assigned to 43.8% (29/66) of the clients. CONCLUSION: Several gaps were identified in the care provided. A standardized approach to care is needed that includes a comprehensive leg ulcer assessment to determine the ulcer etiology, determination of an Ankle Brachial Pressure Index score to screen for the presence of arterial disease, and compression for all clients who meet the criteria for venous disease. A reorganization of services is required, which includes an increased role for community nurses in leg ulcer assessment and management. Organizational and clinical factors influencing the delivery of best practice need to be identified and addressed.     

A prospective,open, multicentre study to evaluate a new gelling fibre dressing containing silver in the management of venous leg ulcers

This study investigated the performance of a new gelling fibre dressing containing silver (DURAFIBER? Ag; Smith & Nephew, Hull, UK) in moderate to highly exuding venous leg ulcers with one or more clinical signs of infection. Fourteen patients with venous leg ulceration of median ulcer duration 12·5 weeks, recruited from three centres in South Africa, received treatment with the new dressing for a maximum of 8 weeks. Multilayer compression bandaging was used for all patients, at the majority of assessments. The objectives of this study were to assess the clinical acceptability of the dressing in terms of the following characteristics: antimicrobial properties, the progress of the wound towards healing, wear time, exudate management, conformability, patient comfort, pain on application, pain on removal and dressing integrity. The new dressing was rated as clinically acceptable for all characteristics, for all 14 patients (100%). It was easy to apply and remove; in 96·8% of removals, the dressing stayed intact on removal and could be removed in one piece. Fifty per cent of the wounds healed within the 8‐week study duration; between baseline and final assessment, the median percentage reduction in wound area was 98·2% and the median percentage reduction in devitalised tissue was 78%. Exudate levels and wound pain were significantly improved at final assessment compared to baseline assessment, and an increase in the number of patients with healthy peri‐wound skin between baseline and final assessment was observed. A reduction in bioburden and signs of clinical infection and an improvement in quality of life were observed over the 8‐week period. The average wear time was 6·4 days. This study supports the use of new dressing in the management of moderately to highly exuding venous leg ulcers with clinical signs of infection.     

A randomised controlled 8-week crossover clinical evaluation of the 3M Coban 2 Layer Compression System versus Profore to evaluate the product performance in patients with venous leg ulcers

This study compared a two-layer (Coban 2 Layer) and a four-layer (Profore) compression bandage system in venous leg ulcer patients. Participants (n = 81) were enrolled into an 8-week, randomised, open-label, ten-centre, crossover clinical trial. The primary endpoint was bandage slippage measured at each dressing change. Secondary endpoints included wound healing, health-related quality of life (HRQoL) and patient preference. Mean slippage estimated from a mixed analysis of variance model (697 visits) was 2.48 cm for the two-layer system and 4.17 cm for the four-layer system (P < 0.001). There were no significant differences in percent of wounds that healed (Fisher's exact test, P = 0.30), in wound area reduction (Wilcoxon rank-sum test, P = 0.88) or in linear healing rate (Wilcoxon rank-sum test, P = 0.94). The HRQoL Physical Symptoms and Daily Living scores were significantly higher with the two-layer system (pooled two-sample t-test, P < 0.05). Patients had a strong preference for the two-layer system (72%) than the four-layer system (22%), with 6% having no preference. In conclusion, the two-layer system exhibited significantly less bandage slippage than the four-layer system. While less bandage slippage did not appear to impact wound healing, there was indication that it may have influenced patient preference in favour of the two-layer system and potentially impacted patients' HRQoL.     

Healing rates and cost efficacy of outpatient compression treatment for leg ulcers associated with venous insufficiency.

OBJECTIVE: Although newer techniques to promote the healing of leg ulcers associated with chronic venous insufficiency are promising, improved healing rates and cost effectiveness are unproven. We prospectively followed a series of patients who underwent treatment with outpatient compression for venous stasis ulcers without adjuvant techniques to determine healing rates and costs of treatment. METHODS: Two hundred fifty-two patients with clinical or duplex scan evidence of chronic venous insufficiency and active leg ulcers underwent treatment with ambulatory compression techniques. The patients were prospectively followed with wound measurements at 1-week to 2-week intervals, and the factors that were associated with delayed healing were determined. RESULTS: Of all the ulcers, 57% were healed at 10 weeks of treatment and 75% were healed at 16 weeks. Ultimately, 96% of the ulcers healed, and only 1 major amputation was necessitated (0.4%). Initial ulcer size and moderate arterial insufficiency (ankle brachial index, 0.5 to 0.8; n = 34) were factors that were independently associated with delayed healing (P <.01). Patient age, ulcer duration before treatment, and morbid obesity did not significantly affect healing times. The cost of 10 weeks of outpatient treatment with compression techniques ranged from $1444 to $2711. CONCLUSION: The treatment of venous stasis ulcers with compression techniques results in reliable, cost-effective healing in most patients. Current adjuvant techniques may prove to be useful but are likely to be cost effective only in a minority of cases, particularly in patients with large initial ulcer size or arterial insufficiency.