Management Of Chronic Leg Ulcers Research Articles

Fat grafting: an adjunct in management of chronic leg ulcers

Chronic leg ulcers (CLU’s) are one of the most challenging medical conditions, mostly resistant to conventional therapy. Several treatment modalities are present but none have become standard of care. Autologous fat contains adipose derived stem cells (ADSC’s) which is believed to have abundant growth factors (GF’s) required for its regenerative and reparative properties. Our observational study was conducted to see the feasibility and efficacy of fat grafting in management of CLUs with complete wound healing as final outcome. 14 patients with CLUs (any etiology, >3 months and multiple ulcers were counted as individual cases if >3 cm apart) were included with coagulopathies, uncontrolled diabetes mellitus (Hba1c>9 mmol/mol) being the exclusions. Fat was harvested using standard Coleman’s technique. Study was conducted from December 2015 to December 2017 in tertiary care hospital and patients were followed up for next 24 months. All cases were evaluated clinically. Average age of wounds before intervention was 33.34 months, average wound size 16.46 cm2 and 4.9 cc of average fat was transferred underneath the ulcer. 11 out of 14 wounds healed completely within average 27.4 days and final outcome was not achieved in 3. Pain assessed using visual analogue scale (VAS) in immediate post operative period till 48 hours (telephonically). Patients were evaluated at 1 week, 1 month, 3 months and 6 months after procedure for pattern of wound healing and related complications. Fat grafting is easy, safe, effective and a minimally invasive OPD procedure with short recovery time for managing CLUs.

Objective assessment of Platelet-Rich Plasma (PRP) potentiality in the treatment of Chronic leg Ulcer: RCT on 80 patients with Venous ulcer.

Chronic venous leg ulcer reduces the patients' activities and their overall quality of life. Platelet-rich plasma (PRP) was previously investigated as promising less invasive management for leg ulcers. To re-assess the efficacy and safety of PRP in the management of chronic leg ulcers due to venous factors. RCT enrolled 80 patients who clinically presented with chronic venous leg ulcers. Forty patients were allocated randomly for the treatment with autologous platelet-rich plasma (PRP). Intradermal and subdermal injection of PRP by 27guage syringe weekly, in all edges and in the granular floor of the ulcer for 4-6 sessions. Another 40 patients managed by conventional treatment by compression and dressing for the same period were allocated as Group B. Objective assessment achieved by the percentage of reduction of the size of the ulcer area, rate of healing, incidence of recurrence, and if side effects have been reported. PRP therapy showed better results and high p value significance when compared to conventional therapy. This study shows that PRP is effective and significant in promoting the wound healing process in chronic leg venous ulcers. PRP is simple, safe, and has a short learning curve technique.

A review of the effectiveness of homoeopathy in the management of chronic leg ulcers

Background and Objectives: Any ongoing injury which shows no inclination to heal following 3 months of suitable therapy or in a time of a year the injury is not completely healed comprise chronic leg ulcers. Venous, Arterial and Neuropathic ulcers are the major types of chronic leg ulcers and factors like smoking, obesity, Diabetes mellitus & increased age boost up the incidence of ulceration. Expanded rate of leg ulcers, monetary weight, and recurrence of the ulcer which increases the degree of Homeopathy. The present review comprises the literature on the Homoeopathic approach in managing the various chronic leg ulcers. Materials and Methods: A literature search was conducted in databases like PubMed, Google Scholar, Wiley online library, Springer, Scopus, AYUSH portal, to collect all relevant research studies, review article, case series & case reports, published from 1990 until July 2020. This research was categorised by study type and assessed according to study design with their clinical outcomes.Results: Out of these 5 studies, 3 are case studies & one is a prospective observational study and one is a randomized clinical trial and it shows that chronic leg ulcers have marked improvement by the use of Homoeopathic medicine both internally and externally.Conclusion: Homoeopathy is effective in the management of chronic leg ulcers mainly diabetic foot ulcers and varicose ulcers. A combination of both internal and external medicines also showed excellent results in treating this illness. There is only limited evidence available to show the effectiveness of Homoeopathy and more studies needed for the same.

Efficacy of platelet rich plasma in chronic leg ulcers: a prospective randomized controlled study

<p class="abstract"><strong>Background:</strong> Chronic wounds affect approximately 1-2% of the population in Europe and the United States. Platelet rich plasma (PRP) has emerged as an effective, inexpensive, minimally invasive treatment modality for chronic leg ulcers. Objective of the study was to evaluate the efficacy of PRP, and to compare the effectiveness of PRP to regular antiseptic dressing in the management of chronic leg ulcers.</p><p class="abstract"><strong>Methods:</strong> A hundred patients with chronic leg ulcers of more than 6 weeks duration were randomized into two groups (PRP and conventional dressing group). Patients in the PRP group received weekly intradermal injections of PRP to the wound in addition to conventional daily dressings till complete healing of the ulcers or up to a maximum of 6 weekly PRP sessions. Percentage of improvement in the area and volume of the ulcers were recorded. Patients were followed up at 1 month post PRP treatment.</p><p class="abstract"><strong>Results:</strong> The mean reduction in the area of the ulcers at the end of 6 weeks was 66.39% in the PRP group and 28.6% in the control group. The mean reduction in volume of the ulcers at the end of 6 weeks was 71.80% and 37.88% in the case and control group respectively. At the end of 1 month post treatment follow-up, 74% and 10% of the ulcers treated with PRP and with conventional dressing respectively showed complete healing.</p><p class="abstract"><strong>Conclusions:</strong> Leg ulcers treated with PRP showed a significantly higher reduction in the area and volume of the ulcers compared to ulcers treated with conventional moist dressing.</p>

Consensus on the diagnosis and management of chronic leg ulcers - Brazilian Society of Dermatology

BackgroundChronic leg ulcers affect a large portion of the adult population and cause a significant social and economic impact, related to outpatient and hospital care, absence from work, social security expenses, and reduced quality of life. The correct diagnosis and therapeutic approach are essential for a favorable evolution. ObjectiveTo gather the experience of Brazilian dermatologists, reviewing the specialized literature to prepare recommendations for the diagnosis and treatment of the main types of chronic leg ulcers. MethodsSeven specialists from six university centers with experience in chronic leg ulcers were appointed by the Brazilian Society of Dermatology to reach a consensus on the diagnosis and therapeutic management of these ulcers. Based on the adapted DELPHI methodology, relevant elements were considered in the diagnosis and treatment of chronic leg ulcers of the most common causes; then, the recent literature was analyzed using the best scientific evidence. ResultsThe following themes were defined as relevant for this consensus - the most prevalent differential etiological diagnoses of chronic leg ulcers (venous, arterial, neuropathic, and hypertensive ulcers), as well as the management of each one. It also included the topic of general principles for local management, common to chronic ulcers, regardless of the etiology. ConclusionThis consensus addressed the main etiologies of chronic leg ulcers and their management based on scientific evidence to assist dermatologists and other health professionals and benefit the greatest number of patients with this condition.

Efficacy of topical silver preparations for treating non- healing ulcers versus conventional dressing

During the past three decades considerable knowledge has been gained regarding the patho-physiology and management of chronic leg ulcers. Despite all these, the management of chronic leg ulcers is still a fertile field for experimentation. Various studies have been conducted and a number of procedures and techniques have evolved with varying degrees of success. The study was estimated to include 50 patients who present with non-healing ulcers at hospital with purposive sampling technique. In group 1, 56% of patients were having slough on Day 0 and on Day 10 it was decreased to 24 %. That is, 32% decrease in slough. In Group1, 52% of patients were having serous discharge and it has been increased to 88 % on day 10. In group 2, 68% of people having slough on Day 0 and it was decreased to 52 % on day 10, that is 16% decrease in slough noted on day 10. In group 2, 44% of people were having serous discharge on Day 0 and it has been increased to 56% on day 10. That is 12 % increase in serous discharge over 10 days.

Effectiveness of Various Modalities of and Protocol for Optimal Management of Chronic Leg Ulcers

Effectiveness of Various Modalities of and Protocol for Optimal Management of Chronic Leg Ulcers

Adjuvant Biological Therapies in Chronic Leg Ulcers

Current biological treatments for non-healing wounds aim to address the common deviations in healing mechanisms, mainly inflammation, inadequate angiogenesis and reduced synthesis of extracellular matrix. In this context, regenerative medicine strategies, i.e., platelet rich plasmas and mesenchymal stromal cell products, may form part of adjuvant interventions in an integral patient management. We synthesized the clinical experience on ulcer management using these two categories of biological adjuvants. The results of ten controlled trials that are included in this systematic review favor the use of mesenchymal stromal cell based-adjuvants for impaired wound healing, but the number and quality of studies is moderate-low and are complicated by the diversity of biological products. Regarding platelet-derived products, 18 controlled studies investigated their efficacy in chronic wounds in the lower limb, but the heterogeneity of products and protocols hinders clinically meaningful quantitative synthesis. Most patients were diabetic, emphasizing an unmet medical need in this condition. Overall, there is not sufficient evidence to inform routine care, and further clinical research is necessary to realize the full potential of adjuvant regenerative medicine strategies in the management of chronic leg ulcers.

Chronic leg ulcers in adult patients with rheumatological diseases – a 7‐year retrospective review

Chronic leg ulcers in patients with rheumatological diseases can cause significant morbidity. We performed a retrospective case review to describe the epidemiology, clinical features and outcome of chronic leg ulcers in this group of patients. Twenty-nine patients with underlying rheumatological conditions, such as, rheumatoid arthritis (15 patients), systemic lupus erythematosus (8 patients), overlap syndromes (3 patients), systemic sclerosis (1 patient) and ankylosing spondylitis (1 patient) were included. The ulcers were mostly located around the ankle (55·2%) and calves (37·9%). The predominant aetiology of the ulcers, in decreasing order of frequency, was venous disease, multifactorial, vasculitis or vasculopathy, infective, pyoderma gangrenosum, ischaemic microangiopathy and iatrogenic. Treatment modalities included aggressive wound bed preparation, compression therapy (17 patients), changes in immunosuppressive therapy (15 patients), hyperbaric oxygen therapy (4 patients) and cellular skin grafting (2 patients). Management of chronic leg ulcers in rheumatological patients is challenging and the importance of careful clinicopathological correlation and treatment of the underlying cause cannot be overemphasised.

Evidence-based treatment of chronic leg ulcers.

Chronic leg ulcers are defined as those that show no tendency to heal after 3 months of appropriate treatment or are still not fully healed at 12 months. In this article, we present an approach to the challenging problem of chronic leg ulcers that is based on the principles of evidence-based medicine, i.e., the explicit use of the best available scientific evidence as a guide to treatment. Selective review of the relevant literature, including current guidelines and meta-analyses, concerning diagnostic and therapeutic strategies for chronic leg ulcers. The main types of causally directed treatment are: vein surgery to eliminate pathological reflux, interventions to improve the circulation in arterial occlusive disease, and treatment of underlying diseases, such as diabetes mellitus. Physicians providing modern evidence-based management of chronic leg ulcers should make use of their own clinical experience in combination with the best current scientific evidence. It seems clear that the many available treatment options should be evaluated critically in an interdisciplinary setting. In particular, causally directed treatment must be provided in addition to symptomatic, stage-based local wound treatment.

The use of honey-derived dressings to promote effective wound management

Clinical observations suggest that honey holds significant promise as an effective treatment for a number of medical conditions and particularly in the management of non-healing wounds. This article explores the healing properties of honey and illustrates the effectiveness of using honey in the management of chronic leg ulcers.

A New Approach in the Management of Chronic Nonhealing Leg Ulcers

Chronic leg ulcers are a major cause of mortality and morbidity. The efficacy of hyperbaric oxygen treatment is being evaluated in the management of nonhealing leg ulcers to improve skin graft survival. Twenty-seven patients with 36 chronic leg ulcers were examined. Each wound received 12 preoperative hyperbaric oxygen treatments, split-thickness skin grafting, followed by 12 postoperative hyperbaric oxygen treatments. Wound transcutaneous oxygen tension measurements (TCOM) were taken. The graft take was evaluated. At 18 months follow-up, 18 skin grafts (50%) showed complete take, 15 (41.7%) demonstrated partial take, and 3 (8.3%) failed. Hyperbaric oxygen treatment is an effective adjunct in the management of chronic leg ulcers, and its use resulted in increased graft take and survival.

Cost-Effectiveness: Seeking Value for Money in Lower Extremity Wound Management

This article discusses the different methods of evaluating cost in relation to the outcomes of treatment, and reviews the evidence of cost-effectiveness (CE) in the management of chronic leg ulceration. In essence, the CE argument revolves around the need to demonstrate outcomes of treatment in relation to particular levels of financial input by the health providers. High CE allows for either the same number of patients to be treated more efficiently (at a lower cost) or more patients to be treated for the same financial input. A review of medical and nursing databases (Medline, Embase, and Cinahl) identified studies of CE of dressing materials (n = 8), use of compression therapy (n = 4), and other treatments (n = 2). In addition, 5 research groups have undertaken studies to evaluate the relative CE of different systems of care. Overall conclusions are that modern wound dressings provide a more cost-effective alternative to saline gauze, whereas the evidence relating to the use of tissue-engineered skin is less clear. The use of compression bandaging is substantially more cost-effective when compared with a system of care where compression is not systematically offered. The systems that offer compression are not only cost-effective but also lead to reductions in absolute cost. The evaluation of CE is likely to become an ever-increasing part of wound care evaluation as we strive to achieve greater efficiency in the use of scarce health resources.

Strategies and approaches towards evidence-based practice in the management of chronic leg ulcers by nurses working in the community in Kronoberg County, Sweden and the East Riding & Hull, UK

Aim: This paper reports one aspect of a study concerning management of chronic leg ulcers by nurses working in the community in Kronoberg County, Sweden (KC) and the East Riding & Hull, UK (ER). Our study focus was to describe reported evidence-based practice in leg ulcer care in two samples of nurses from two countries. The paper describes the overall utilisation of clinical guidelines and their use in clinical assessment, documentation and resource utilisation. Method: A semi-structured self-administered questionnaire was used. The questionnaire was sent to practising community nurses, nurses working in primary health care and nurses working in nursing homes. A total of 222 nurses working in KC, Sweden and 124 nurses in ER, UK (response rate 55% vs 50%) returned the questionnaire. Results: The results provide a rather mixed picture in relation to evidence-based practice. Whilst 60.3% of nurses in KC and 87.1% in ER use guidelines, the reported use of guidance on diagnostic investigations is much more variable both in terms of frequency and indication ( P=0.000). The widest difference was found in the use of cleansing agents: in KC 83.7% of nurses used tap water against 92.8% of nurses in ER who used a sodium chloride preparation ( P=0.000). Conclusion: This study provides information on the reported use of guidelines by the nurses in two different countries. It raises questions about the relationship between evidence and practice. Comparison between the two countries helps to expose the taken for granted expectations of practice.

Management of chronic leg ulcers by nurses working in the community in Sweden and the UK.

This study compared the management of chronic leg ulcers by nurses in community, primary health care and nursing home settings in Kronoberg, Sweden, and East Riding, UK. A questionnaire was sent to all nurses in the two areas enquiring about their occupational background, leg ulcer management, resource utilisation and education and training. It also asked about their preferred treatment choices for four types of chronic leg ulcers described in case studies. Response rates of 50% (UK) and 54% (Sweden) were achieved. Nurses in the UK undertook diagnostic investigations of non-healing leg ulcers as part of the initial assessment, whereas in Sweden these were undertaken by physicians. In Sweden daily dressing changes were more frequent and often involved nurse auxiliaries. Patients and relatives almost never participated in dressing changes in the two countries. Sodium chloride was the most commonly used cleansing agent in the UK, as opposed to warm water in Sweden. The use of antibacterial/antiseptic dressings and antibiotics was more frequent in the UK. Nurses there also used scientific and professional literature more frequently. Swedish nurses experienced more problems in obtaining new information. Differences exist between the two countries in leg ulcer management. These may be related to differences in the health-care systems, staff training and attitudes to evidence-based practice.

Diagnosis Of Leg Ulcers

In the United States, leg ulcers present a significant clinical problem, occurring at a rate of approximately 600,000 new cases per year. (1) The most common types are venous, arterial, and neuropathic ulcers. Venous hypertension is the primary culprit in venous ulcerations. Peripheral vascular disease due to atherosclerosis with microvascular or macrovascular changes leads to ischemic ulcers. Sensory impairment with loss of protective sensation in the foot and repetitive trauma lead to neuropathic ulcers. Unusual causes of leg ulcers must be considered in the differential diagnosis. To arrive at the diagnosis, the clinician must perform a thorough history and physical examination, and order relevant investigative studies. Good management of chronic leg ulcers depends on correction of identified underlying conditions, long-term multidisciplinary care effort, and integrating traditional and new wound-healing technologies. Most patients with chronic leg ulcers benefit from the use of compression bandaging at a level appropriate to their vascular status. Venous ulcers must be managed with an arsenal of strategies to control venous insufficiency, heal the wound, and prevent recurrence. Surgery with revascularization remains the treatment of choice for chronic ischemic leg ulcers. In the absence of vascular compromise, up to 90 percent of neuropathic ulcers will heal with proper ulcer debridement, treatment of infection, saline wet-to-dry dressings, and relief of weight from the ulcerated area. The available armamentarium for wound care includes over 2000 wound dressing products and elastic compression wraps. Chronic leg ulcer treatment options have been expanded by alternatives available to treating these wounds. These alternatives include hyperbaric oxygen therapy, bioengineered skin substitutes, recombinant platelet-derived growth factors and vacuum assisted wound closure. Patients with large leg ulcers may benefit from skin grafting. Other patients may benefit from ligation and stripping of superficial veins or subfascial interruption of perforating veins.

Management Of Leg Ulcers

In the United States, leg ulcers present a significant clinical problem, occurring at a rate of approximately 600,000 new cases per year. (1) The most common types are venous, arterial, and neuropathic ulcers. Venous hypertension is the primary culprit in venous ulcerations. Peripheral vascular disease due to atherosclerosis with microvascular or macrovascular changes leads to ischemic ulcers. Sensory impairment with loss of protective sensation in the foot and repetitive trauma lead to neuropathic ulcers. Unusual causes of leg ulcers must be considered in the differential diagnosis. To arrive at the diagnosis, the clinician must perform a thorough history and physical examination, and order relevant investigative studies. Good management of chronic leg ulcers depends on correction of identified underlying conditions, long-term multidisciplinary care effort, and integrating traditional and new wound-healing technologies. Most patients with chronic leg ulcers benefit from the use of compression bandaging at a level appropriate to their vascular status. Venous ulcers must be managed with an arsenal of strategies to control venous insufficiency, heal the wound, and prevent recurrence. Surgery with revascularization remains the treatment of choice for chronic ischemic leg ulcers. In the absence of vascular compromise, up to 90 percent of neuropathic ulcers will heal with proper ulcer debridement, treatment of infection, saline wet-to-dry dressings, and relief of weight from the ulcerated area. The available armamentarium for wound care includes over 2000 wound dressing products and elastic compression wraps. Chronic leg ulcer treatment options have been expanded by alternatives available to treating these wounds. These alternatives include hyperbaric oxygen therapy, bioengineered skin substitutes, recombinant platelet-derived growth factors and vacuum assisted wound closure. Patients with large leg ulcers may benefit from skin grafting. Other patients may benefit from ligation and stripping of superficial veins or subfascial interruption of perforating veins.

Leg Ulcers: Economic Aspects

Objective: To review what is known about the cost of leg ulcers, and venous leg ulcers in particular. Method: Searches of the Medline and Cochrane Library databases. Reviewing reference lists of personally gathered articles in the field of chronic leg ulcers. Synthesis: Most publications dealing with the economics of leg ulcers are cost studies assessing the cost of different dressings or bandages, and only a few have given estimates of the total costs of leg ulcer management. The latter, in conjunction with accurate epidemio-logical data, are essential to estimate the nationwide costs of leg ulcer management. The costs consist of direct and indirect costs for society. Direct costs are mainly staff costs for managing dressing-changes. Based on the few estimates made, approximately 1% of the total health care costs in the western world are likely to be used for management of chronic leg ulcers. To reduce the costs of leg ulcer management a reduction in the frequency of dressing-change is recommended. Improved use of high technology, such as duplex Doppler diagnostics and varicose vein surgery, is also likely to be cost-effective. On the basis of two health economic analyses leg ulcer clinics alone do not appear to reduce the costs of leg ulcer management, mainly because of an inability to prevent recurrent ulceration. Conclusion: The cost implications of chronic leg ulcers are insufficiently studied but there is no doubt that managing patients with leg ulcers takes a substantial proportion of the health care budget. More health economic analyses are needed to define the best treatment in order to reduce total costs.

Randomised Trial Comparing Two Four-Layer Bandage Systems in the Management of Chronic Leg Ulceration

Objective: To compare a new four-layer bandage system (Profore) with the original 4LB in the closure of chronic leg ulceration. Design: Prospective randomised stratified parallel-groups open trial. Methods: Patients newly presenting to community leg ulcer services with chronic leg ulceration were screened for inclusion in this trial. Patients with arterial disease (ankle brachial pressure index <0.8) and causes of ulceration other than venous disease were excluded. In patients with bilateral ulceration, the limb with the larger area of ulceration was studied. The ulcer was dressed with a simple low-adherent dressing and all bandages were changed weekly unless required more frequently. Patients were randomised to receive either the original four-layer bandage or the newer system (Profore). Results: In all 233 patients were randomised, of whom 232 attended at least one follow-up visit (115 original, 117 Profore). At 12 weeks complete healing of the ulcerated limb, analysed by ‘intention-to-treat’ was 60% using the original 4LB compared with 72% using Profore. The difference of 11.8% (95% confidence interval (CI) −0.3% to 23.9%) had largely disappeared after 24 weeks, with 73% healed using the original 4LB and 76% using Profore, a difference of 3.0% (95% CI −8.2% to 14.2%). After 24 weeks of treatment the Kaplan-Meier estimate of complete healing was 82% using the original system and 84% using the Profore system. Overall, there was a higher healing rate for patients on Profore (hazard ratio = 1.18, 95% CI 0.87 to 1.59), but this did not achieve statistical significance ( p = 0.28). Conclusion: Ulcer healing using the newer Profore system is as good as with the original four-layer system.

Randomised Trial Comparing Two Four-Layer Bandage Systems in the Management of Chronic Leg Ulceration

Randomised Trial Comparing Two Four-Layer Bandage Systems in the Management of Chronic Leg Ulceration