Lower Limb Ulcers Research Articles

A comparative study of negative pressure dressing and conventional dressing in lower limb ulcers

Background: Lower limb ulcer is a common disease among the Indian population with a prevalence of approximately 1% to 2% which is slightly higher in the older population. There are various modalities of treatment with the main aim being early wound healing. This study is done to compare the results of negative pressure dressing and conventional dressing in lower limb ulcers.Methods: This study, done at the Department of Surgery, G. K. General Hospital and Gujarat Adani Institute of Medical Sciences, Bhuj, from October 2017 to September 2018 is a prospective study. A total of 120 patients were randomly divided in two group comprising of 60 patients each. The patients in Group A were treated with negative pressure dressing while those in Group B were treated with conventional dressing. The patients were assessed, in both test and control groups, with parameters like appearance of granulation tissue, bacterial clearance and wound healing.Results: 80% of the patients belonged to the age group of 41-60 years while others were less than 40 years. We observed that in Group A majority of the patients had wound healing in 11-40 days while in Group B majority patients took 31-60 days for their wounds to be healed.Conclusions: We conclude that negative pressure dressing is more efficient as compared to conventional dressing for healing of lower limb ulcers, enabling a shorter hospital stay and early resumption of daily activities to the patient.

The Impact of COVID-19 Pandemic on Vascular Leg Ulcers.

The aim of this study was to evaluate the impact of 2 lockdown periods during coronavirus disease 2019 (COVID-19) on the course and management of nonhealing vascular ulcers of lower limbs. A total of 41 patients were included in the study. Before the pandemic began they had been seen at our unit at weekly intervals. During lockdown from March 9, 2020, to May 18, 2020 subjects were not allowed to enter the hospital unless they needed urgency or emergency surgery, or oncological management. During the second lockdown, from October 19, 2020, to December 11, 2020 patients could be followed up at distance by direct outreach including telephoning contacts. Data obtained early after each lockdown were compared with those obtained prior to the pandemic. Data for the first lockdown show that pain intensified and there was an increase in the recurrence rate of wounds, of their severity, and of superimposed infections as compared with the prelockdown period. The risk of lower-limb amputation was also considerably greater. During the second and less restrictive lockdown, patients were followed up by telemedicine and data indicate that skin lesions had not worsened any further. The management of vascular wounds was impacted by the pandemic unfavorably with health care failures in the hospital as well as in the primary care settings. In conclusion, the treatment of vascular leg ulcers is challenged by the COVID-19 pandemic as this spreads worldwide. This seems to be in keeping with what happens for other diseases. The data we obtained indicate that the pandemic-related lockdown has a deleterious effect on vascular skin wounds, with an increase of severity and mortality risk. The impact appears to be proportional to the number and the degree of limitations imposed on people.

Pain Control in Dermatologic Conditions.

Pain management in dermatologic conditions can be complicated by the primary disease burden and associated decreased quality of life, disability, and psychosocial issues. This review focuses on pain management strategies in some of the more painful dermatologic conditions. Pain management in painful dermatologic conditions such as pyoderma gangrenosum, postherpetic neuralgia, lower limb ulcers, and hidradenitis suppurativa revolves around treatment of the underlying disease process. Topical agents such as topical steroids and systemic immunosuppressants with over-the-counter analgesics usually suffice in mild to moderate pain. Severe pain may need neuropathic agents and referral to interventional pain physicians for consideration of advanced techniques such as epidural steroid injections and sympathetic nerve blocks. Part of the treatment process is for dermatologists to establish patient expectations and to treat pain within their scope of practice. More research is needed towards pain control in painful dermatologic conditions with elucidation of treatment algorithms unique to each condition.

Management for people living with chronic lower-limb ulcers

Managing chronic lower-limb ulcers involves using both best practice guidelines and strategies for pain management. Developing a patient-centred plan of care, which includes managing the various types of pain and adopting current best practice guidelines such as those published by Wounds Canada, can optimize the care for patients living with lower limb ulcers.

Benefits of sucrose octasulfate (TLC-NOSF) dressings in the treatment of chronic wounds: a systematic review.

Management of chronic wounds remains one of the major challenges for health professionals and patients. An evidence-based decision is important to ensure that patients are receiving the best treatment proven to reduce healing time and improve outcomes, including economic benefits and patients' health-related quality of life (HRQoL). Due to recent restrictions because of the COVID-19 pandemic, including closure of wound care centres within hospitals and a drop in patient volume, chronic wound management needs simple-to-use dressings which are still effective and evidence-based solutions. This systematic review was conducted to identify the clinical evidence available on a sucrose octasulfate dressing (TLC-NOSF, UrgoStart dressing range, Laboratoires Urgo, France) to explore its efficacy in the management of chronic wounds, particularly lower limb ulcers, diabetic foot ulcers and pressure ulcers. A literature search of PubMed, Cochrane Library and Google Scholar was conducted based on the PICO model (patient/population, intervention, comparison and outcomes) to retrieve publications of different levels of evidence in order to evaluate outcomes of the use of TLC-NOSF dressings. A total of 21 publications of different levels, ranging from double-blind randomised control trials to case reports, involving over 12,000 patients, were identified through PubMed, with a further eight publications through Google Scholar and two publications through Cochrane Library. A total of seven results were omitted due to the lack of relevance or repetition. All the evidence provided suggest that these dressings provide clinicians with an evidence-based option for the management of chronic wounds; that the TLC-NOSF dressings are beneficial in promoting the healing process, reducing healing times, enhancing patients' HRQoL, and in allowing a more cost-effective procedure.

STUDY THE CLINICO-DEMOGRAPHIC-ETIOLOGIC PROFILE OF DIAGNOSED CHRONIC LEG ULCER PATIENTS AT SKMCH, MUZAFFARPUR, BIHAR

Aim: to study the clinico-demographic-etiologic prole of the patients diagnosed with chronic leg ulcer. Materials and methods: prospective clinical study was conducted among 50 patients of lower limb ulcers who attended Surgery OPD of Sri Krishna Medical College and Hospital, Muzaffarpur, Bihar. The selected cases were studied with respect to detailed history along with clinical examination and required investigations were done to reach the denitive diagnosis. Result: Most common age group involved in our study is <60 years (42%) followed by <40 years (34%). Male was the predominant sex involved accounting for 41 cases (82%) and females had the disease in 9 cases (18%). Majority of the patients i.e. 21 patients (42%) were farmers by occupation. The most common etiological type was Diabetic ulcers present in 17 cases (34%) followed by trauma 14 (28%). Diabetes Mellitus was the most common systemic disease in our study accounting for 21 patients (48%). The venous ulcers occurred more commonly in the gaiter zone (100%) whereas arterial and diabetic ulcers occurred mainly on the foot i.e., 100% and 52.9% respectively. Conclusion: The present study concluded that the most common etiologies for chronic leg ulcer were diabetes mellitus and trauma. Results of this study may benet development of clinical management policies concerning chronic wounds.

Intralesional Infiltrations of Cell-Free Filtrates Derived from Human Diabetic Tissues Delay the Healing Process and Recreate Diabetes Histopathological Changes in Healthy Rats.

Lower limb ulcers in type-2 diabetic patients are a frequent complication that tributes to amputation and reduces survival. We hypothesized that diabetic healing impairment and other histopathologic hallmarks are mediated by a T2DM-induced tissue priming/metabolic memory that can be transferred from humans to healthy recipient animals and consequently reproduce diabetic donor's phenotypes. We examined the effect of human T2DM tissue homogenates injected into non-diabetic rat excisional wounds. Fresh granulation tissue, popliteal artery, and peroneal nerve of patients with T2DM were obtained following amputation. Post-mammoplasty granulation and post-traumatic amputation-tissue of normal subjects acted as controls. The homogenates were intralesionally injected for 6-7 days into rats' excisional thickness wounds. Infiltration with the different homogenates caused impaired wound closure, inflammation, nerve degeneration, and arterial thickening (all P < 0.01 vs relevant control) resembling histopathology of diabetic donor tissues. Control materials caused marginal inflammation only. Infiltration with glycated bovine albumin provoked inflammation and wound healing delay but did not induce arterial thickening. The reproduction of human diabetic traits in healthy recipient animals through a tissue homogenate support the notion on the existence of tissue metabolic memory-associated and transmissible factors, involved in the pathogenesis of diabetic complications. These may have futuristic clinical implications for medical interventions.

Usage of Mathematical Modeling and Optimization in Development of Hydrogel Medical Dressings Production

In connection with the significant complication of research objects of technological systems and the considerable increase in expenses for carrying out experimental research, improving the mathematical modeling methods of these systems is a current problem. By using the means of mathematical modeling and optimization, the calculation of the main technological parameters of the formation method of film hydrogel products based on silver-filled copolymers of 2-hydroxyethylmethacrylate with polyvinylpyrrolidone was performed. The technological parameters of the polymerization processes, chemical reduction of silver ions, and centrifugal formation of the film cloth were substantiated. These are the components of the technological process, which occurs in one stage in the form of a centrifugal unit. By using the obtained results, silver-filled films were obtained, which are characterized by unique properties and can be used in the treatment of trophic ulcers of lower limbs.

Pyoderma gangrenosum and cobalamin deficiency in systemic lupus erythematosus: a rare but non fortuitous association

BackgroundPyoderma gangrenosum (PG) is an uncommon, idiopathic, ulcerative neutrophilic dermatosis. In many cases, PG is associated with a wide variety of different disorders but SLE in association with PG is relatively uncommon. In this article we present the case of a middle aged patient with PG as the initial clinical presentation of SLE. We also provide a brief review of cobalamin deficiency which occurred in our patient and evidence-based management options.Case presentationA 35 years old man presented with a 5 month history of debilitating painful lower limb and scrotal ulcers. This was associated with polyarthralgia and morning stiffness involving both hands. He also complained of swallowing difficulties. He had unintentional weight loss of 10 kg and fatigue. Physical examination revealed alopecia, multiple cervical lymphadenopathies, bilateral parotid gland enlargement and atrophic glossitis. There was Raynaud’s phenomenon noted over both hands and generalised hyper-pigmented fragile skin. Laboratory results disclosed anaemia, leukopenia, hyponatraemia and hypocortisolism. Detailed anaemic workup revealed low serum ferritin and cobalamin level. The autoimmune screen showed positive ANA, anti SmD1, anti SS-A/Ro 52, anti SSA/Ro 60, anti U1-snRNP with low complement levels. Upper gastrointestinal endoscopy with biopsies confirmed atrophic gastritis and duodenitis. Intrinsic factor antibodies and anti-tissue transglutaminase IgA were all negative. Punch biopsies of the leg ulcer showed neutrophilic dermatosis consistent with pyoderma gangrenosum. Based on the clinical findings and positive immunologic studies, he was diagnosed as systemic lupus erythematosus. His general condition improved substantially with commencement of corticosteroids, immunosuppressants and vitamin supplements.ConclusionsWe report a case of PG as the first manifestation of SLE which was treated successfully with immunosuppressants and vitamin supplements. Our report highlighted the need to consider connective tissue diseases such as SLE in a patient presenting with PG in order for appropriate treatment to be instituted thereby achieving a good outcome.

Hospitalization Costs of Lower Limb Ulcerations and Amputations in Patients with Diabetes in Romania.

In this retrospective case-control study conducted in Cluj-Napoca, Romania, we assessed the effect of ulcerations/amputations on hospitalization costs of patients with diabetes. Patients with (Group 1) or without (Group 2) ulcerations/amputations (case-control ratio 3:1) admitted to a single diabetes center between 2012–2017 were included. The effects of hospitalization days, age, duration of diabetes, body mass index and glycated hemoglobin (HbA1c) on total costs was explored using a multivariate linear regression analysis, enter model. Overall, 876 patients were included (Group 1: 682, 323 [47.4%] with amputations; Group 2: 194). Median (interquartile range) total expenses in Group 1 were 40% higher compared to Group 2 (€724 [504; 1186] vs €517 [362; 645], p < 0.001). Significant differences were observed between hospitalization costs (p < 0.001), cost of food (p < 0.001), medication (p = 0.044), drugs administered at the emergency room/intensive care unit (p < 0.001) and other expenses (p = 0.003). Hospitalization costs represented 80.5% of total expenses in Group 1 and 76.3% in Group 2. In multivariate analysis, hospitalization days influenced significantly the total costs in both groups (p < 0.001); in Group 2, the effect of HbA1c was also significant (p = 0.021). Diabetic foot ulcers and subsequent amputations most likely impose a significant economic burden on the Romanian public healthcare system.

Lower Limb Ulcer Associated with Peritonitis in Patients Undergoing Peritoneal Dialysis.

PurposePeritoneal dialysis (PD)-related peritonitis and lower limb ulcer are the important complications in patients undergoing PD. Although the association between lower limb ulcer and peritonitis in patients undergoing PD is unclear, based on our clinical experience and the clinical importance of the complications in patients undergoing PD, we hypothesized that lower limb ulcer is associated with peritonitis in patients on PD.Patients and MethodsIn this single center, retrospective cohort study, we studied 87 patients who started undergoing PD at our hospital from April 2015 to March 2020. We compared these 8 patients with lower limb ulcer with the other 79 patients without lower limb ulcer. We compared between the patients in the objection period of this study about peritonitis using Log rank test, and used the unpaired t-test and Fisher’s exact test to compare the clinical factors between the two groups. Moreover, we used univariate and multivariate logistic regression analyses to study the association of PD-related peritonitis with the clinical factors.ResultsThe period developed first peritonitis of the patients on PD with lower limb ulcer was significant shorter than those without lower limb ulcer in Log rank test (P = 0.011). The Fisher’s exact test and unpaired t-test showed that the difference in the prevalence of PD-related peritonitis (P = 0.009), peritonitis/patient years (P = 0.036), the BMI (P = 0.007) and icodextrin (P = 0.001) were significant. Lower limb ulcer had significant associations with peritonitis in patients on PD in both univariate [odds ratio (OR) 8.461, 95% confidence interval (CI) 1.854–45.60, P = 0.006] and multivariate [OR 7.169, 95% CI 1.519–39.480, P = 0.013] logistic regression analysis.ConclusionIn conclusion, lower limb ulcer may be associated with peritonitis in patients undergoing PD. Further large-scale, prospective studies are required to confirm these results.

Application of Traditional Chinese Medicine nursing technique pricking blood therapy for the chronic skin ulcer of lower limb

Application of Traditional Chinese Medicine nursing technique pricking blood therapy for the chronic skin ulcer of lower limb

Evaluation Of The Radiofrequency Ablation Of Lumbar Sympathetic Ganglia In Lower Limb Ischemic Ulcers In Indian Population

Antecedentes: la simpatectomía lumbar mediante radioablación es un tratamiento útil de la isquemia periférica. Sin embargo, la eficacia clínica con respecto a las úlceras de las extremidades inferiores no está suficientemente establecida en la población india. El estudio se realizó para evaluar el papel de la ablación por radiofrecuencia (ARF) de los ganglios simpáticos lumbares en la cicatrización de las úlceras isquémicas del miembro inferior. Método: El estudio prospectivo con 63 pacientes registrados en el servicio de Cirugía General con úlceras isquémicas de miembros inferiores entre diciembre de 2017 y julio de 2019 fueron tratados con ARF. Se excluyó del estudio a los pacientes con enfermedad cardiopulmonar, embarazadas, malformaciones congénitas o infección cutánea en el lugar de la intervención, o que padecían trastornos hemorrágicos. Se realizó una investigación clínica de la herida y se recopilaron datos demográficos. La reducción comparativa en el tamaño de la herida se evaluó mediante el ANOVA de Friedman (P &lt;0,001). La diferencia en la puntuación del dolor, la estancia hospitalaria y la distancia recorrida se evaluaron mediante la prueba de pares emparejados de Wilcoxon (P &lt;0,001), la prueba t para datos no emparejados y la prueba t para datos emparejados (P &lt;0,05). Resultado: la mayoría de los pacientes eran hombres (n = 40) con una edad media de 60,93 DE14,34 años. Se observó una reducción significativa en el tamaño de la herida, las puntuaciones de dolor y la estancia hospitalaria después del procedimiento (P &lt;0,001). El número de sesiones de RFA se asoció significativamente con el tamaño de la úlcera y la clasificación de Fontaine 2 y 3 (P &lt;0,0001). Conclusión: La ARF de los ganglios simpáticos lumbares es una posible modalidad de tratamiento para las úlceras isquémicas de las extremidades inferiores.

Surgical treatment of traumatic arteriovenous fistula after failed endovascular treatment

Endovascular interventional therapy is the first choice for the treatment of the traumatic arteriovenous fistula (AVF) because of its small trauma, fast recovery, exact effect, and low incidence of complications. However, surgery is still an important option for patients with contraindications to endovascular treatment or failure of endovascular treatment. We present the case of a 64-year-old male who was carried out with traumatic AVF and given endovascular treatment in other hospital 10 years ago. However, AVF did not disappear after surgery, and symptoms of venous hypertension such as lower limb swelling and ulcers appeared. We removed the stent and repaired the AVF with opening surgery. AVF did not recur after 1-year follow-up.

Patient and clinician experiences and opinions of the use of a novel home use medical device in the treatment of peripheral vascular disease - a qualitative study

BackgroundPeripheral vascular diseases have a significant impact on functional quality of life. Previous research has demonstrated the complex, limiting and costly economic implications of these conditions such as lower limb ulceration chronicity and ischaemic amputation. These complex, limb and life threatening conditions demand the development of novel interventions with objective research as part of that development. Hence, a novel intermittent negative pressure medical device in the form of a wearable boot (FlowOx™) was developed. As part of the development process, this study aimed to explore patient and clinician opinions of the boot.MethodsA qualitative approach was used to collect patient and clinician experiences in Norway. An advisory group informed the semi-structured questions used in seven patient interviews and one clinician focus group (n = 5). The data were recorded digitally and transcribed verbatim. Patient and clinician data were analysed as distinct groups using a thematic process.ResultsData analysis resulted in five themes from the patients which gave insight into; the impact of the disease process; practicalities of using the boot, positive experiences of use; perceived outcomes; reflecting on use. Six themes were created from the clinicians. These gave insight into; ideal outcomes and how to measure them; ways to potentially use the boot; using research in healthcare; positives of the device; observed effects and next steps; potential improvements to the device.ConclusionThis study provides insight into the experiences and opinions of FlowOx™. Patients and clinicians were positive about the device due to its ease of use. Those patients with peripheral arterial disease experienced significantly more benefit, especially for ischaemic ulceration than those with a chronic venous condition. Clinicians placed value on the patient reported outcomes in the treatment decision-making process. This preliminary study into experiences of FlowOx™ use provides valuable feedback that will inform design modification and ongoing research into implementation points and prospective user groups. FlowOx™ demonstrates potential as a conservative therapy offering users a convenient, home use, self-care management solution for improving symptomatic peripheral arterial disease and quality of life.

Leishmaniasis: still a diagnostic challenge?

American cutaneous leishmaniasis (ACL) should be differentiated from traumatic ulcers, venous ulcers, tropical ulcer, lower limb ulcers due to sickle cell anemia, pyodermatitis, paracoccidioidomycosis, syphilis, cutaneous neoplasms, among others.1 Histopathology may be suggestive, but it is rarely specific enough to make the diagnosis without identification of the amastigote forms of the parasite.2 Among the non-specific alterations to the histopathological examination, pseudoepitheliomatous hyperplasia (PEH) presents as a challenge, especially in the differential diagnosis with squamous cell carcinoma (SCC).

Incidence of lower limb amputation in Central Australia.

Objective The aims of this study were to review the demographic details of those who have undergone lower limb amputation (LLA) surgery in Central Australia and determine the region-specific age-adjusted incidence rate of LLA. Methods A retrospective audit of service users who underwent LLA in a Central Australian hospital from 2012 to 2017 was undertaken. Demographic, operative and postoperative outcomes data were collected. The age-adjusted incidence rate of LLA was determined using the direct method. Demographic data were analysed using descriptive parametric analysis. Results In the period 2012-17, 166 service users underwent a total of 291 amputations in 231 episodes of care (hospital admissions). The age-adjusted incidence rate of LLA was 87.4 per 100000 for females and 104.6 per 100000 for males in this region. In total, 84% (n=140) of those requiring amputation surgery identified as Aboriginal Australians (P<0.001), 54% (n=75) of whom were female. Aboriginal Australians who underwent LLA were, on average, 13 years younger and were more likely to have type 2 diabetes (P<0.001) and require renal dialysis (P<0.001) than the non-Aboriginal Australian cohort. Of the Aboriginal Australians who underwent LLA, 82% (n=103) lived very remotely (>100km from the central town's centre), compared with 23% of non-Aboriginal Australians (P<0.001). In addition, 46% (n=64) of Aboriginal Australians who underwent LLA required renal dialysis. Those requiring renal dialysis were more likely to require subsequent amputation (P=0.014) and had a higher mortality rate following amputation (P=0.031). Partial foot amputation was the most common level of amputation in Central Australia (38%). Conclusions Central Australia appears to have the highest incidence rate of LLA for any region in Australia, with Aboriginal Australians, particularly females and those undergoing renal dialysis, being disproportionately represented. Further studies should aim to determine targeted, culturally safe and successful methods of diabetic foot ulcer prevention, early detection and management with a view to reducing the high amputation rates for these cohorts. What is known about the topic? Large health inequalities between Aboriginal and non-Aboriginal Australians exist. Aboriginal Australians are currently fourfold as likely as non-Aboriginal Australians to have type 2 diabetes (T2D), increasing their risk of LLA. There is a geographical variance in the incidence of LLA in Australia; the Northern Territory is overrepresented, with rates two- to threefold higher than that of the national average. Regional incidence rates are not currently known. What does this paper add? This study showed that the age-adjusted incidence rate for LLA in Central Australia is significantly higher than in other regions in Australia. Most LLA surgeries undertaken in Central Australia were performed for Aboriginal Australians who have T2D, with a disproportionate representation of females and those requiring renal dialysis. What are the implications for practitioners? This study shows that there is a need for further research and preventative measures to address the high rates of LLA among Aboriginal Australians, particularly for females and those with renal impairment. These groups could benefit from targeted, culturally safe approaches to early identification, referral and management of lower limb ulceration by relevant service providers.

Clinical efficacy and influencing factors of different modes of continuous negative pressure wound therapy on venous ulcer wounds of lower limbs

Clinical efficacy and influencing factors of different modes of continuous negative pressure wound therapy on venous ulcer wounds of lower limbs

An audience survey of practice relating to pain in the management of chronic venous leg ulcers.

Venous leg ulcers (VLU) respond well to compression, yet many ulcers remain unhealed after 1 year. Practitioners could be reluctant to apply compression to patients with significant ulcer pain. This study aimed to capture the views of practitioners on compression therapy for patients with painful VLU. A survey was conducted at a UK meeting in 2019 using handheld voting pads to capture the anonymous responses to four questions to which a mean of 90 practitioners responded. Nearly 40% of practitioners treat six or more patients a day with painful lower-limb ulcers. Some 80% felt confident in managing patients with painful ulcers; yet, most practitioners suggested they would refer onward for pain management. Some 40% would omit or reduce compression therapy as a pain management strategy. This survey supports the need for technological solutions that reduce VLU pain so that patients receive effective compression therapy.

Epidemiological Study of Ulcers of the Lower Limb in a Tertiary Care Teaching Institute

Lower limb ulcers are common in old age group there are several causes which includes venous valve insufficiency, diabetes mellitus, skin malignancies. We in the present study tried to evaluate the epidemiology of population affected with lower limb ulcers and treatment and outcome of such conditions. Methods: This cross-sectional study was conducted in the Department of General Surgery, Prathima Institute of Medical Sciences, Nagnur, Karimnagar. All cases of leg ulcers reporting to this institute except those which occur due to trauma and in children &lt; 12 years of age were included in the study. Result: In the study n=50 cases of both sexes with leg ulcers were included. The most commonly involved age group was &gt; 70 years. Diabetic ulcers were detected in 44% of cases in males and 18% of cases in females. In the cases right limb was involved in n=24(48%) cases and left limb was involved in n=23(46%) of cases and bilateral involvement was found in n=3(6%) of cases. The predominating organism found was Staphylococcus aureusfollowed by Klebsiellaand streptococcus. Conclusion: The study found that found to be ulcer of the leg associated with diabetes mellitus, ulcer due to venous valve incompetence. The diabetic ulcer was more common in males, more prevalent in patients above the age of 51 years. Venous ulcers are commonly seen are saphenofemoral junction incompetence and perforator incompetence. As far as the treatment of these cases is concerned the use of antibiotics and dressings helps to a great deal in management. Skin grafting may be considered with wide defects where healing is difficult without grafts.