Management and prevention of venous leg ulcers: a literature-guided approach

Managing venous leg ulcers involves management techniques that are indicated both in the treatment of all chronic leg ulcers and those that are specific to venous leg ulcers. The first step in managing venous leg ulcers is performing a holistic assessment of the patient. Once this is complete, any systemic or local factors that may affect wound healing should be addressed. This approach to managing the whole patient is critically important because if significant general wound healing factors are not treated, other specific attempts at healing the venous ulcer will be fruitless. This paper reviews nutritional supplementation, wound bed preparation, antimicrobial therapy, venous insufficiency, compression therapy, different bandage systems, therapeutic adjuncts to compression therapy, and recent advances in vascular surgery. Recurrence prevention also is discussed.     

Clinical approach to chronic wound management in older adults

Older adults are at high risk of developing chronic wounds due to numerous changes that occur with aging. It is reasonable to consider chronic wounds as a geriatric syndrome—highly prevalent, multifactorial, and associated with substantial morbidity and mortality. Due to the morbidity and cost associated with chronic wounds, prevention, early diagnosis, and treatment are important. The most common chronic wounds presenting in older adults are pressure and vascular wounds, including those associated with diabetes. Atypical wounds are also common and should raise the suspicion for skin malignancy. Diagnosis is primarily clinical and assessment should include documentation of wound characteristics, such as location, size and depth, presence of slough, drainage, odor, and infection. The mainstay of treatment is based on the TIME principle: T issue debridement, I nfection control, M oisture balance, and optimal wound E dges. The use of protein supplements has been shown to improve wound healing in subsets of older adults. In addition to wound care and optimizing nutrition, disease-specific wound therapy forms an integral part of wound management. Pressure reduction for pressure injury, compression therapy for venous wounds, evaluation of arterial circulation with ABI or arterial Doppler and iCC for diabetic ulcers form the mainstays of therapy. Atypical wounds may present as chronic ulcers and should be biopsied. The goals of treatment should be realistic and for some older adults, palliative wound management may be more appropriate.     

Therapie des Dekubitus beim älteren Patienten

The treatment of pressure sores in elderly patients requires careful documentation and a comprehensive treatment plan, which takes into account the patient's overall situation. The treatment has to be evidence based. At the moment only three recommendations can be based on two or more prospective, randomized clinical studies: to use a dressing to maintain a moist environment at the wound/dressing interface, to reduce the risk of infection and enhance wound healing by hand washing, wound cleansing and debridement and to institute a systemic antibiotic treatment for patients with advancing cellulitis, sepsis and osteomyelitis. For other treatment options such as topical negative pressure, maggot therapy, electromagnetic therapy, therapeutic ultrasound or growth factors, the data at present are not sufficient to support general use in pressure sore treatment.     

Venous leg ulcers in the elderly patient: associated stress, social support, and coping

Although psychosocial issues in wound management are critical considerations when formulating diagnostic and treatment algorithms, they frequently are overlooked. Clinician consideration and evaluation of associated stresses, social support, and coping are particularly important when caring for elderly patients with recalcitrant venous ulcers. The Health Belief Model and health locus of control may help explain patient responses to health issues. The psychosocial effects of chronic illness, emotional impact of pain, physiological responses to stress, and issues related to treatment adherence must be considered. Recent research has contributed substantially to understanding of these concerns in the general patient population and in persons with venous ulcers. However, quantitative data are limited and studies examining the effects of educational level, ethnicity, socio-economic status, and clinician-patient relationships on psychosocial health in general, and wound healing in particular, are needed. Despite these limitations, increased awareness of the psychosocial dynamic in elderly patients should be integral to the wound care protocol.     

Bacterial population of chronic crural ulcers: is there a difference between the diabetic, the venous, and the arterial ulcer?

BACKGROUND: At the Surgical Department of Surgery of the University Hospital Würzburg microbiological examinations were performed of the ulcer grounds from patients with diabetic-neuropathic, diabetic-ischemic, venous, and arterial leg ulcers. The aim of the examination was to evaluate possible differences in the healing process of these ulcers based on the knowledge of their bacterial populations. PATIENTS AND METHODS: In a period of four months, 63 patients were consecutively examined by taking a bacteriological swab of their ulcer area. The healing process of their wounds was followed and related to the impact of bacterial colonisation and clinical signs of infection. RESULTS: 95% of the venous and arterial leg ulcers had a positive smear, whereas only 70% of diabetic ulcers were positive for bacterial growth. Bacterial population of the three ulcer entities, however did not differ significantly. 100% of the clinically infected venous and arterial ulcers but only 80% of the diabetic wounds revealed a positive smear. On the other hand, only 22% of the venous ulcers with a positive smear developed a clinical infection in contrast to 70% of the arterial and diabetic. Venous ulcers showed only in a few patients prolonged healing, even in cases of marked bacterial contamination. Despite of clinical signs of infection however, diabetic wounds sometimes did not reveal a positive wound smear (20%). All infected venous, but only 20% of the infected ischemic ulcers healed satisfactorily. Arterial wounds with no bacterial growth healed significantly better than contaminated wounds. This difference was not significant in the other entities. Radical removal of the infection by minor amputation increased the healing rate in diabetic ulcers over 80%, whereas ischemic wounds did not profit from this therapy. CONCLUSIONS: A positive bacterial wound smear is not inevitably correlated with a protracted leg ulcer healing. Nevertheless a fulminant infection often developed in diabetic ulcers despite the initial inability to demonstrate bacterial growth. In order to start antibiotic treatment as early as possible, a wound smear should be obtained routinely from patients with diabetic ulcers. In chronic venous ulcers, a routine swab does not appear to be indicated as it bears no clinical consequences. The same applies to patients with surgically fully treated peripheral arterial occlusive disease. As ischemia presents the limiting factor, antibiotic therapy in case of infection will not prevent imminent amputation.     

Pneumonia induced by nocardia -- a case report

We describe a case of lung manifestation of nocardiosis with upper lobe shrinking of the right lung in a 45 year old patient without evident signs of an immuno-compromising illness. The patient came to the hospital in a reduced general state of health with severe cough, red and brown sputum and exertional dyspnoea. X-ray pictures of the thorax showed inflammatory infiltration and shrinking of the upper left lobe of the right lung. Gram-positive, branching rods were detected in the patient's bronchial secretion with the microscope and in cultures. Nocoardia transvalensis was identified via polymerase chain reaction (PCR). The antibiotic therapy was planned according to the bacterial resistance pattern. Imipenem was administered for 5 weeks and Amikacin was added for 3 weeks in the 3 (rd) week of therapy. The patient left the hospital in a good general state of health. There was no relapse.     

Clinical quality indicators of venous leg ulcers: development, feasibility, and reliability

In the clinical setting, diagnosis and treatment of venous leg ulcers can vary considerably from patient to patient. The first step to reducing this variation is to document venous leg ulcer care through use of quantitative scientific documentation principles. This requires the development of valid and reliable evidence-based quality indicators of venous leg ulcer care. A Scandinavian multidisciplinary, cross-sectional panel of wound healing experts developed clinical quality indicators on the basis of scientific evidence from the literature and subsequent group nominal consensus of the panel; an independent medical doctor tested the feasibility and reliability of these clinical indicators, assessing the quality of medical technical care on 100 consecutive venous leg ulcer patients. Main outcome measures were healing, recurrence, pain, venous disease diagnosis, differential diagnosis and treatment, and inter- and intra-rater reliability. The indicators proved feasible and reliable to measure (inter-rater kappa = 0.79, P < 0.01 and intra-rater kappa = 0.89, P < 0.1). Within 3 months of initial examination, venous etiology was verified by duplex in 61 of the 98 participating patients (62%) and 31 (32%) were assessed for venous surgery. Distal arterial pressure was measured following initial examination in 33 of the patients (34%). All patients (100%) were prescribed compression therapy. Of the 98 patients, 11 (11%) had ulcers recur in 3 months and 72 (73%) healed in 12 months, which is in line with the literature. It is feasible to reliably measure the quality of medical technical venous leg ulcer care in the clinical setting using a few strategic clinically relevant indicators of quality.     

Photographic assessment of the appearance of chronic pressure and leg ulcers

The purpose of this paper was to examine the validity and reliability of using photographs of wounds to accurately assess wound status. The results of assessing wound appearance using wound photographs was compared to results obtained from a bedside assessment using the Pressure Sore Status Tool (PSST). The photographic wound assessment tool (PWAT) used in this comparison represents a modified version of the PSST and includes the six domains that can be determined from wound photographs. The PWAT was used on photographs of both chronic pressure ulcers (n = 56) and leg ulcers due to vascular insufficiency (n = 81). The photographic tool has excellent intrarater (ICC = 0.96) and interrater (ICC = 0.73) reliability and good concurrent validity (r = 0.70) compared with a full bedside assessment PSST. The PWAT has also shown to be sensitive to change in wound appearance of healing ulcers, but not nonhealing ulcers. These results would suggest that in the event that a full bedside assessment is not possible, wound photographs may be used to accurately assess wound appearance of both chronic pressure ulcers located on the trunk and vascular ulcers of the lower extremity. Establishing a valid and reliable assessment of wound healing using photographic images is of great relevance to the advancing fields of computer image analysis and telemedicine.     

An unusual case of ruptured distal anterior cerebral artery aneurysm associated with brucellosis

Reports have noted aneurysmal dilatation of arteries in association with brucellosis, but involvement of intracranial vessels has not been documented to date. Sixty-one year old female patient who had been diagnosed with brucellosis 14 months earlier presented with symptoms of subarachnoid hemorrhage (SAH). Due to deterioration of the patient's clinical condition in spite of a two-drug antibiotic regimen, she was treated surgically and made a full recovery. It is important to identify this association promptly, as there are clinical implications for optimal management. The article also discusses the timing and duration of antibiotic therapy, indications for and considerations regarding surgery, and the use of other treatment modalities.     

Chronic venous insufficiency

Chronic venous insufficiency of the lower extremities is a complicated disorder that affects the productivity and well-being of millions of people worldwide. Management requires careful differential diagnosis and a systematic long-term multidisciplinary care effort directed toward realistic goals within the context of the patient's lifestyle. Optimal therapy requires control of abnormal venous physiology combined with adjunctive treatments to correct secondary skin ulceration, infection, and lymphedema. Fundamental management tools are limb elevation, simple dressings, antibiotics, and elastic compression garments. Patients with large leg ulcers may benefit from split-thickness skin grafting. Other selected patients may benefit from ligation and stripping of superficial veins or subfascial interruption of perforating veins. New endoscopic methods have dramatically reduced morbidity from subfascial perforator surgery. Surgery directed at correcting valvular reflux and venous occlusion is possible in highly selected patients.     

Best practices for the prevention and treatment of venous leg ulcers

Chronic venous insufficiency is the most common cause of leg ulcers. Its incidence increases as the population ages. Managing venous leg ulcers involves treating the cause, optimizing local wound care, and addressing patient-centered concerns. The cornerstone of the diagnosis of chronic venous insufficiency includes demonstrating venous disease. The clinician must rule out significant coexisting arterial disease by performing a thorough clinical assessment and obtaining an ankle brachial pressure index. The most important aspect of treatment is resolving edema through high compression therapy for those individuals with an ankle brachial pressure index greater than or equal to 0.8. Other components of successful chronic venous insufficiency management include increasing mobility and medical management. Selected patients may respond to surgery, biologicals, adjunctive therapies, and lifestyle enhancements. Twelve recommendations are made incorporating current best clinical practices and expert opinion with available research. The approach to venous disease is best accomplished through a multidisciplinary team that revolves around the active participation of patients and their families. The authors' intent is to provide a practical, easy-to-follow guide to allow healthcare professionals to provide best clinical practices.     

Management of parastomal ulcers

Management of surgically placed ostomies is an important aspect of any general surgical or colon and rectal surgery practice. Complications with surgically placed ostomies are common and their causes are multifactorial. Parastomal ulceration, although rare, is a particularly difficult management problem. We conducted a literature search using MD Consult, Science Direct, OVID, Medline, and Cochrane Databases to review the causes and management options of parastomal ulceration. Both the etiology and treatments are varied. Different physicians and ostomy specialists have used a large array of methods to manage parastomal ulcers; these including local wound care; steroid creams; systemic steroids; and, when conservative measures fail, surgery. Most patients with parastomal ulcers who do not have associated IBD or peristomal pyoderma gangrenosum (PPG) often respond quickly to local wound care and conservative management. Patients with PPG, IBD, or other systemic causes of their ulceration need both systemic and local care and are more likely to need long term treatment and possibly surgical revision of the ostomy. The treatment is complicated, but improved with the help of ostomy specialists.     

Leg ulcers in patients with rheumatoid arthritis--a prospective study of aetiology, wound healing and pain reduction after pinch grafting

OBJECTIVE: To study the aetiology of leg ulcers in patients with rheumatoid arthritis (RA) and to study healing and pain relief after pinch grafting. METHODS: Twenty patients with RA and leg ulcers were studied. Diagnosis of the ulcers was founded on the clinical picture and measurements of the ankle-brachial pressure index. To detect vasculitis, skin biopsies were taken for immunohistochemistry and histopathology. Pain severity was assessed pre- and post-operatively using a visual analogue scale. RESULTS: Ten of the 20 patients had ulcers with multifactorial aetiology. Fifteen had signs of venous insufficiency, 11 had histopathological evidence of vasculitis, four had reduced arterial circulation and two patients had diabetes. Healing after pinch grafting was found in eight patients, all of whom had an ulcer area less than 15 cm(2). Eleven out of 18 patients had pain reduction after pinch grafting. CONCLUSION: The causation of leg ulcers in patients with RA was found to be multifactorial, with vasculitis and venous insufficiency as the main determinants. Pinch grafting seems to be a good alternative to conservative treatment for minor leg ulcers for these patients, regarding both wound healing and pain relief.     

Evaluation of two calcium alginate dressings in the management of venous ulcers

Calcium alginate dressings facilitate the management of highly exudating wounds such as venous ulcers. To evaluate and compare the performance of two calcium alginate dressings in the management of venous ulcers, a prospective, randomized, controlled clinical study was conducted among 19 outpatients at two wound clinics in California. Ten patients (53%) were treated with Alginate A and nine patients (47%) with Alginate B. Dressings were changed weekly and patients were followed for a maximum of 6 weeks or until the venous ulcer no longer required the use of an alginate dressing. At each dressing change, the wound was assessed and dressing performance evaluated. Absorbency of exudate, patient comfort during wear, ease of removal, adherence to wound bed, dressing residue following initial irrigation, patient comfort during removal, ease of application, and conformability were assessed. Patients using Alginate A experienced significantly less foul odor (P = 0.02) and less denuded skin (P = 0.04) than Alginate B at follow-up wound assessments. With the exception of conformability, Alginate A was rated significantly better than Alginate B (P less than or equal to 0.05) in all dressing performance assessments. No significant healing differences were observed. As the different performance characteristics of various calcium alginate dressings become more obvious in clinical practice, further study is warranted to determine their optimal effectiveness.     

Assessment of venous leg ulcers: an in-depth discussion of a literature-guided approach

Venous leg ulcers represent a significant public health problem that will increase as the population ages. The elderly, the most likely to be afflicted by this condition, present the clinician with special challenges. The diagnosis of venous leg ulcers involves taking a careful history, paying attention to the existence of factors that predispose individuals to the development of chronic venous insufficiency. Clinical features of venous insufficiency are important because their recognition allows clinicians to distinguish venous from other chronic ulcers. An essential part of the assessment of all patients with chronic wounds is an evaluation of intercurrent diseases, common in the elderly, which may impact on the wound healing process. Thus, in addition to managing venous insufficiency and the wound bed, all other factors, systemic and local, that may impede healing need to be investigated and corrected if necessary. Social and psychological issues common to all chronic illnesses need to be addressed as well. This holistic approach should be standard practice and is applicable to the assessment and management of all chronic leg ulcers. This often requires coordinating a multidisciplinary team of wound healing caregivers. More work needs to be done to clarify a few issues because areas of controversy persist. Although a great deal is known about the effects of vitamin deficiency on acute wounds, less is known about chronic ulcers. Similarly, the role of vitamin supplementation in managing chronic ulcers needs further study. Guidelines are needed to determine indications for wound culturing. In addition, more study is required to establish the most effective means of obtaining quantitative cultures. However, the relationship between bacteria and chronic wound healing goes beyond simple quantitation and other factors such as bacterial virulence and host resistance. These controversial issues will be reviewed. Treatment and prevention of venous leg ulcers will be discussed in a subsequent article.     

Medical management of spinal epidural abscesses: case report and review.

Although the traditional management of spinal epidural abscesses includes antibiotic therapy and surgical drainage, numerous reports have appeared in the literature that describe a nonsurgical approach. We report the successful nonsurgical management of a case of an extensive spinal epidural abscess in which the patient was closely monitored by serial studies with magnetic resonance imaging. Review of the literature from 1970 to 1990 revealed 37 cases that describe conservative management of spinal epidural abscesses. Despite successful conservative management reported for some cases, sudden neurological deterioration of patients receiving appropriate antibiotic therapy has also occurred. A true index of the success of nonsurgical therapy is difficult to discern since cases may have been selectively reported and unsuccessful attempts at conservative management may have never been reported once a laminectomy was performed. A prospective investigation that includes clearly defined indications for conservative management vs. surgical intervention and that can be studied with an intention-to-treat analysis is needed.     

Venous ulcers: pathophysiology and treatment options

Venous ulcers affect approximately 1% of the world's population, increasing healthcare expenditures and decreasing quality of life. Several hypotheses may help explain their origin. Incompetent veins or valves or impaired muscle function may lead to abnormal calf muscle pump function that can elevate ambulatory venous pressure (venous hypertension). This hypertension subsequently results in local venous dilatation and pooling, concomitantly trapping leukocytes that may release proteolytic enzymes that destroy tissues. Venous pooling also induces interendothelial pore widening and deposition of fibrin and other macromolecules that "trap" growth factors within them, rendering them unavailable for wound repair. Compression therapy, the mainstay treatment, reduces edema, reverses venous hypertension, and improves calf muscle pump function. Several treatment options can be employed as adjuvants to compression--eg, systemic therapy with pentoxifylline or aspirin, autologous grafts, tissue-engineered skin, growth factor therapy, and/or vein surgery. The epidemiology, pathophysiology, diagnosis, and management options regarding venous ulcers are reviewed.     

The therapy of peripheral vascular ulcers--surgical management.

Venous ulcers are a common malady of the civilized world. The etiology and its pathogenesis has been presented for a better understanding of its appropriate therapy. A conservative and surgical approach is necessary for effective treatment, of which the final goal is to reduce ambulatory venous hypertension and the prevention of venous ulcer formation. An effective regime of elastic support, periodic leg elevation and surgery for incompetent perforators is highly rewarding. The good results in the use of dextranomer for highly exudative ulcers have also been presented as another adjunct in the local care of venous ulcers.     

A trial of silver sulfadiazine in the local treatment of venous ulcer

Silver sulfadiazine, in cream form, has been mostly used in the treatment of burns. Its trial in the treatment of leg ulcers has been satisfactory. This preparation is well tolerated, and effective on wound cleansing and granulation tissue formation. It is particularly indicated in cases of superinfected ulcers, effective on most Gram + and Gram - bacteria.     

Growth factors in wound healing: the next great innovation?

Wound healing is a complex process that, in the vast majority of cases, normally leads to complete healing. It can be likened to the construction of a building, having many of the same requirements. As long as these requirements are satisfied, the healing of the acute wound proceeds uneventfully. Unfortunately, significant impediments to healing occasionally exist and the acute wound stops healing, becoming chronic. If these impediments can be controlled, most of these chronic wounds will eventually heal, albeit slowly. For example, the venous leg ulcer will heal once one applies proper compression therapy that provides the necessary support counteracting the underlying venous hypertension and provides appropriate wound care. Similarly, diabetic neuropathic foot ulcers will not heal until the disordered glucose metabolism is controlled and causative pressure on the foot is offloaded. Thus, successful healing of chronic wounds involves the treatment of underlying causes. Sometimes, however, proper management of these underlying diseases does not result in healing. Conventional therapy, unfortunately, does not have an answer for this dilemma. Growth factors provide a means by which cells are able to communicate with each other. They have profound effects on cell proliferation, migration, and extracellular matrix synthesis and release. Considering applying topically active growth factors directly to the wound surface in order to stimulate some aspect of the healing process has always been attractive. To date, Platelet-Derived Growth Factor (PDGF) has been the most researched of all the growth factors. Originally studied in the management of pressure ulcers, PDGF was eventually approved in North America for the treatment of diabetic lower extremity ulcers. The clinical data surrounding these indications will be reviewed. The future in growth factor research may require a greater understanding of how these substances interact with each other. Wound dressings of the future may include several growth factors, each with a specific function. In this way, the application of topically active growth factors to chronic ulcers just might be the next great innovation in wound healing.