Management Of Lower Extremity Wounds Research Articles

The Twizzler: a modified primary closure for distal lower extremity wound reconstruction utilizing a dynamic winch stitch.

Management of lower extremity wounds following successful tumor excision presents multiple challenges. Distal lower extremity integument is highly prone to edema often lacks adequate skin laxity for standard primary closures. The closure must be resilient enough to withstand mobility. As a result, optimal reconstruction may include skin grafting, rotational flaps, free tissue transfers, healing by second intention, or some combination. These methods may involve multiple steps in reconstruction, a prolonged recovery period, increased cost, and higher infection risk. We propose a modified primary closure that takes advantage of the visco-elastic properties of the skin without introducing additional components or steps. This technique is initiated with percutaneous suture in order to intermittently stretch the skin with constant tension. This load cycling allows for lower extremity skin to stretch over time and ultimately reduce wound edge tension, allowing for ease of absorbable suture placement. The Twizzler technique is cost-effective, uses readily available supplies, and effectively closes relatively large defects on the lower extremities.

Surgical Management of Lower Extremity Wounds in the Solid Organ Transplant Patient Population: Surgeon Beware.

Objective: To evaluate our institutional outcomes of surgical management of lower extremity (LE) wounds in the solid organ transplant recipient population. Approach: An 8-year retrospective review was conducted for all solid organ transplantation (SOT) recipients with LE wounds necessitating surgical management at our tertiary limb salvage center. Outcomes of interest included wound healing, surgical treatment, progression to amputation, and amputation level. Factors contributing to amputation progression were analyzed. The article adheres to the Strengthening the Reporting of Observational Studies in Epidemiology statement. Results: Sixty-four SOT recipients underwent surgical management for their LE wounds between 2010 and 2018. Median number of surgeries per patient was 5 (interquartile range = 2-8); 47 of 64 patients (73.4%) underwent amputation, and 17 of 64 patients (26.6%) underwent nonamputation surgical management. In the amputation group, the majority of primary amputations were minor (42/47, 89.4%); 24 of 42 (57.1%) patients progressed to a higher amputation level, 16 of 42 (38.1%) healed after their index procedure, and 2 of 42 (4.8%) were lost to follow-up (LTFU) after their primary minor amputation. Five of 47 (10.6%) patients undergoing amputations required primary below-knee amputations. In the nonamputation group, 15 of 17 (88.2%) healed, 1 of 17 (5.9%) expired, and 1 of 17 (5.9%) was LTFU. Innovation: To identify the outcomes of patients undergoing surgical management for LE wounds after SOT and elucidate clinical factors that impact the rate of limb salvage. Conclusions: This is the first comprehensive analysis of LE wounds in the transplant population. Our analysis indicates high rates of failed minor amputation, and frequent progression to major amputation in SOT patients. Preexisting comorbidities and immunosuppressive regimens complicate limb salvage; therefore, further research is warranted to optimize surgical LE wound management in this population.

The Application of Ultra-High-Frequency Ultrasound in Dermatology and Wound Management.

The management of lower extremity wounds is frequently performed by means of clinical examination, representing a challenge for the clinician due to the various conditions that can potentially enter differential diagnosis. Several diagnostic techniques are available in the dermatologist's arsenal as a support to diagnosis confirmation, including dermoscopy and ultrasonography. Recently, a novel ultrasonographic technique involving the use of ultra-high ultrasound frequencies has entered the scene, and appears a promising tool in the diagnostic workup of skin ulcerative lesions. The focus of this review is to discuss the potential role of ultra-high-frequency ultrasonography in the diagnostic workup of wounds in the light of the current applications of the technique.

The use of negative pressure therapy for the treatment Of lower-extremity wounds.

Abstract Background: lower extremity wounds with exposed bone, tendon or orthopedic hardware present a difficult treatment challenge. Objective: The purpose of this study is to assess the role of the vacuum assisted closure (VAC) therapy in the management of lower extremity wounds. Material and methods: A prospective analytic cohort study was conducted among 15 patient referred for reconstruction of lower extremity wounds. The study was conducted between January 2019 to June 2019. The wounds were inspected, surgical debridement was done if needed, and the VAC dressings were changed every 72 hours. Primary outcome was wound healing and granulation tissue formation. Secondary outcome was wound infection and wound size. Results: Vacuum- assisted closure therapy greatly decrease the surface area of the wound. Profuse granulation tissue formed rapidly, covering the bone and hardware. There was no statistically significant difference between the included patients regarding the pattern of wound infection pre and after negative pressure therapy (p=0.655). Results were both functionally and aesthetically satisfactory. Conclusion: VAC therapy appears to be a simple and more effective than conventional dressings for the management of difficult wound in terms of reduction in wound volume, depth, treatment duration and cost minimize the number of local and free-flap transfers.

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

The aim of this study was to assess wound healing outcomes following direct, low-frequency, high-intensity, ultrasonic debridement as a surgical adjunct for non-healing lower extremity wounds. A retrospective review was conducted for patients undergoing lower extremity wound treatment with direct, low-frequency (22.5 kHz), high-intensity (~60 W/cm2) ultrasonic debridement between January 2010 and January 2016. Clinical outcomes were assessed up to 180-days post-ultrasonic debridement. Descriptive statistics, cost and univariate analysis were performed. Overall, 82 wounds in 51 patients were included. Mean age was 57.0 years (range: 32-69), and average body mass index (BMI) was 30.8 kg/m². Patient comorbidities consisted of smoking (47%; n=24), hypertension (75%; n=38), diabetes (45%; n=23), and peripheral vascular disease (51%, n=26). Average wound age at initial presentation was 1013 days (range: 2-5475 days) with an average wound size of 9.0cm x 7.4cm. At 180-days post-debridement, 60% (n=49) of wounds had completely healed. Readmission (47%; n=24) and reoperation (45%; n=23) rates were characterised by the reason for readmission and reoperation respectively. Readmission for wound healing (70%, n=39) was primarily for further debridements (41%; n=16). Wound infection (30%; n=7) was the most common readmission for wound complications (30%; n=17). Reoperations primarily consisted of treatments for further wound healing 96% (n=51). Cost analysis showed a lower total treatment cost for patients with improved healing ($78,698), compared with non-improved wounds ($137,707). In a complex, heterogeneous cohort of chronic extremity wounds, the use of direct, low-frequency, high-intensity, ultrasonic debridement is a safe and reliable adjunctive therapy for the management of these wounds.

Incidence of heparin-induced thrombocytopenia in lower-extremity free flap reconstruction correlates with the overall surgical population

Lower-extremity free flap reconstruction is a growing trend in the management of lower extremity wounds. Heparin-induced thrombocytopenia (HIT) is a significant risk to free flap reconstruction. The purpose of this study was to investigate the incidence of HIT in patients receiving lower-extremity free flap surgery. We conducted a retrospective, single center, IRB approved cohort study in which we reviewed all patients who received lower-extremity free flap surgeries between 2011 and 2016. The 4T and HIT Expert Probability (HEP) scores were calculated to assess the likelihood of HIT. One hundred patient charts revealed three patients with HIT. One patient was excluded due to a prior diagnosis of HIT. HIT incidence in patients receiving lower-extremity free flaps was between 1% and 3%, which is consistent with the national average. 4T scores indicated that two of three HIT-positive patients had a high probability of HIT (approximately 64%), and one of three HIT-positive patients had an intermediate probability (approximately 14%). HEP scoring indicated that all the three (100%) patients had HIT. These data suggest that the incidence of HIT in patients receiving lower-extremity free flaps correlates with the incidence of HIT nationally. The use of available scoring methods and other algorithms, combined with patient history helps to assess the immediate perioperative risks of HIT in the absence of rapid immunologic confirmatory tests. This knowledge can allow for successful free flap salvage or for performance of free flaps in patients with a history of HIT.

Case series of 18 patients with lower extremity wounds treated with a concentrated surfactant–based gel dressing

The purpose of this case series was to assess the performance of a concentrated surfactant-based gel (CSG) dressing on 18 patients in the outpatient setting over 4weeks. Wounds selected were full thickness, had been presented for greater than 4weeks, and were located on the lower extremities. Patients were given the CSG dressing and instructed on its use. On follow-up clinic visits, the wound was assessed, measurements were obtained, Pressure Ulcer Scale for Healing (PUSH) Tool scores completed, and satisfaction with the dressing was solicited. Individual analysis of each subject's wound was conducted to determine if there was a healing trend over time with a decrease in total PUSH score. Descriptive statistics were used to analyze the results. Eighteen patients participated in this case series involving 9 women and 9 men with a mean age of 66 years (range from 52 to 91). All 18 of the patients had a primary diagnosis of peripheral vascular disease with 7 patients having venous leg ulcers and 11 patients with lower extremity arterial ulcers. The mean Total PUSH score before the CSG dressing was applied was 10.7 (range from 5 to 15) (standard deviation [SD] 3.09) and posttreatment was 8.3 (range from 0 to 14) (SD 4). All 18 patients had a decrease in their pretreatment score from the first clinic visit compared with the posttreatment PUSH Tool score, indicating that the CSG dressing may be an effective dressing in the management of lower extremity wounds.

The efficacy of electrical stimulation in lower extremity cutaneous wound healing: A systematic review.

Current gold standard lower extremity cutaneous wound management is not always effective. Cutaneous wounds generate a "current of injury" which is directly involved in wound healing processes. Application of exogenous electrical stimulation has been hypothesised to imitate the natural electric current that occurs in cutaneous wounds. The aim of this extensive review was to provide a detailed update on the variety of electrical stimulation modalities used in the management of lower extremity wounds. Several different waveforms and delivery methods of electrical stimulation have been used. Pulsed current appears superior to other electrical modalities available. The majority of studies support the beneficial effects of pulsed current over conservative management of lower extremity cutaneous wounds. Although it appears to have no benefit over causal surgical intervention, it is a treatment option which could be utilised in those patients unsuitable for surgery. Other waveforms and modalities appear promising; however, they still lack large trial data to recommend a firm conclusion with regards to their use. Current studies also vary in quantity, quality and protocol across the different modalities. The ideal electrical stimulation device needs to be non-invasive, portable and cost-effective and provides minimal interference with patients' daily life. Further studies are necessary to establish the ideal electrical stimulation modality, parameters, method of delivery and duration of treatment. The development and implementation of newer devices in the management of acute and chronic wounds provides an exciting direction in the field of electrotherapy.

Systemic and Local Effects of Warm Oxygen Exposure to the Lower Extremities in Healthy Volunteers.

Warmth to the extremity is known to improve the cutaneous blood flow and tissue perfusion. Oxygen is essential for healing of chronic wounds. Topical oxygen therapy has become standard therapy in management of lower extremity wounds. A combination of local heat and oxygen is likely to be beneficial in many clinical scenarios of non-healing wounds without any systemic effects. To evaluate the local and systemic effects of the exposure of extremity to warm oxygen in healthy volunteers. Thirty one volunteers were included in the study. The index foot was exposed to oxygen 7l/min, 93%-95% concentration at temperature of 43oC for 90 minutes with the device. The following parameters such as basal and periprocedural blood pressure, body temperature, heart rate, 24 lead ECG, temperatures at foot and plethysmographic waveforms from the index foot were measured. A NRS-11 questionnaire was asked to the patient to rate his or her pain from 0 to 10 and documented by health care worker at the end of the session. The skin temperature of index foot reached to 34oC from 32.9oC, (p=0.011). The average pulse amplitude changed from 39.8 mV to 79.8 mV over the duration of the experiment (p< 0.001). Overall heart rate and core body temperature decreased and not much change in blood pressure. The result of the study can be extrapolated to the healing of chronic non healing wounds using warm oxygen therapy. Further studies are required on patient population to prove benefits in clinical settings.

Changing paradigms in lower extremity reconstruction in war-related injuries.

BackgroundBallistic high-energy trauma has substantially increased the severity of non-fatal extremity injuries incurred in modern warfare. Expedient medical care, refinement in surgical techniques, and soft tissue coverage have brought about a paradigm shift in the management of lower extremity wounds during the last decade with an increased emphasis on limb salvage.MethodsA literature-based study was conducted to analyze reconstructive modalities based on the location, depth, and severity of wounds, as well as mechanism of injury, concomitant vascular injuries and open fractures, choice of flap, timing of definitive reconstruction, and complications.ResultsExtremity injuries account for over 60 % of injuries in the recent conflicts in Iraq and Afghanistan, with the majority secondary to explosive devices. The severity of these injuries is profound compared with civilian registries, and conventional injury scoring systems have failed to accurately predict outcomes in combat trauma. The mainstay of treatment is serial debridement, negative pressure therapy, fracture stabilization, and treatment of concomitant injuries by the forward medical teams with subsequent definitive reconstruction after transport to an advanced military treatment facility. Autologous reconstruction with free tissue transfer and pedicled flaps remains the primary modality for soft tissue coverage in limb salvage. Adjunct innovative modalities, such as external tissue expansion, dermal substitutes, and regenerative matrices, have also been successfully utilized for limb salvage.ConclusionLower extremity injuries account for the vast majority of injuries in modern warzones. Explosive devices represent the most common mechanism of injury, with blast impact leading to extensive soft tissue injuries necessitating complex reconstructive strategies. Serial debridement, negative pressure therapy, and autologous reconstruction with free tissue transfer and pedicled flaps remain the mainstay of treatment in recent conflicts.

Efficacy and Complication Rates of Full-Thickness Skin Graft Repair of Lower Extremity Wounds After Mohs Micrographic Surgery

Repair of below-the-knee lower extremity defects after Mohs micrographic surgery (MMS) that are not amenable to primary closure can be challenging given the high propensity for complications. No criterion standard exists for management of these wounds, but secondary-intention healing, partial- and full-thickness skin grafts (FTSGs), and various flaps are possible options to manage these wounds. Few data exist on the efficacy of FTSG repairs for lower extremity wounds. Assess the efficacy and complications rates of FTSG repairs for lower extremity wounds after MMS. This was a retrospective review of 80 FTSG repairs performed after MMS. Data were derived from 45 cases at Beth Israel Deaconess Medical Center and 35 cases at University of California, San Diego (UCSD) Medical Center. Seventy-two of 80 cases (90%) had full graft survival, six (7.5%) had partial failure, and two (2.5%) had complete failure. In the cases where grafts had failed, wounds healed by secondary intention without further complications. Other complications included infections in nine (11%) cases and hematoma formation in two (2.5%). FTSG is a consistent and safe reconstructive option for the management of lower extremity wounds after MMS.

Enhanced Healing of Surgical Wounds of the Lower Leg Using Weekly Zinc Oxide Compression Dressings

Management of lower extremity wounds after Mohs micrographic surgery can pose a challenge to the surgeon. Postoperative reactive edema and inflammation can lead to a painful and protracted healing course. Unna boots deliver zinc oxide to the wound bed and surrounding skin while providing compression and occlusion of the wound. To evaluate the utility of weekly Unna boot therapy in decreasing postoperative edema, inflammation, and morbidity; minimizing postoperative wound care; and improving the rate of wound healing in patients with lower leg surgical defects. Ten patients (6 men, 4 women) aged 72 to 91 with postoperative defects on the distal lower extremity were treated with weekly Unna boots until wounds had sufficiently granulated or re-epithelialized. In all 10 patients, weekly Unna boot therapy was well tolerated, with high satisfaction levels relating to minimal postoperative wound care, rapid granulation, minimal pain, and excellent esthetic outcome of postoperative wounds. No infections or other complications were noted during the healing process. LIMITATIONS This was not a randomized, controlled trial. In patients with postoperative wounds of the lower leg, weekly Unna boots significantly improve the healing process, decrease postoperative pain, and minimize wound care.

Management of Lower Extremity Wounds in Patients With Peripheral Arterial Disease: A Stratified Conservative Approach

Traditional wound care algorithms include aggressive detection of peripheral arterial disease (PAD) and treatment with revascularization for all patients with PAD and lower extremity wounds. Not every patient with PAD and a wound meets Transatlantic Inter-Society Consensus (TASCII) criteria for critical limb ischemia. We hypothesize that a conservative approach to selected patients with PAD and lower extremity wounds may be safe, provide acceptable limb salvage, and that failure of this approach does not translate into increased limb loss. Veterans referred with PAD and nonhealing ulcers/wounds were prospectively enrolled into our Prevention of Amputation Care Team program. Patients were stratified according to management strategies which included revascularization, primary amputation, palliative limb care, and aggressive local care without revascularization (conservative group). Patients were assigned to conservative management group on the basis of transcutaneous oxygen measurement (TcpO2) and ankle-brachial index (ABI). Healing rates, need for "late" revascularization, major amputation rates, and survival of this conservative group were analyzed in terms of ABI and ankle pressures. Between January 2006 and March 2009, a total of 190 lower extremity wounds in 178 patients with PAD were analyzed. Forty-nine patients with 52 wounds (27.9%) were deemed candidates for conservative treatment. During mean follow-up of 14.5 months, complete wound healing was documented in 33 patients (35 wounds: 67%). Mean time to complete wound healing was 4.5 months. Predictors of healing included mean ABI (0.62 vs. 0.42 [p < 0.001]) and ankle pressures >70 mm Hg (p = 0.025). Sixteen patients (17 wounds: 33%) were not healed at the time of analysis. Of these, three patients (four wounds: 8%) showed active healing and 13 (13 wounds: 25%) failed conservative management. Nine patients (9 wounds: 17%) underwent late revascularization. There was one case of amputation (2%) and six cases of mortalities (12.2%). There was no increase in the rates of limb loss and mortality in patients who failed conservative management and underwent "late" revascularization. Conservative management of lower extremity nonhealing wounds in selected patients with PAD is successful in over two-thirds of the patients. The failure of conservative management does not increase mortality or amputation rates. When the TcPO2 is >30 mm Hg, the ABI and the TASC II definition of critical limb ischemia predict wound healing and should be key factors in considering conservative therapy.

Salvage Reconstruction of Lower Extremity Defects With Muscle Flaps

Summary: The management of lower extremity wounds has changed as reconstructive options have broadened. Free tissue transfer has enabled salvage of limbs that would have previously been amputated. At the same time, development of new local flaps has allowed successful reconstruction of wounds without the need for microsurgery. Additionally, vacuum-assisted closure therapy has dramatically impacted wound care and facilitated complex wound closure without the need for flaps (DeFranzo et al. Plast Reconstr Surg 2001;108:1184–1191). As surgical techniques have improved, the need for surgical salvage of lower extremities has concomitantly increased. The lives of multi-trauma patients, whether after a motor vehicle accident or wartime injury, are preserved at higher rates, producing more medically stable individuals with salvageable extremities. As cancer treatment improves, quality of life becomes a more important consideration, and limb-preserving surgery is more frequently expected. This article discusses methods of reconstructing complex lower extremity wounds. Surgical techniques, and anatomically based descriptions of commonly used flaps, are outlined. Perioperative management of these reconstructed extremities is also detailed.

Role of Hyperbaric Oxygen Therapy in the Management of Lower Extremity Wounds

Role of Hyperbaric Oxygen Therapy in the Management of Lower Extremity Wounds

The Role of Nutrition in the Management of Lower Extremity Wounds

From 3000 BC, healers have understood the importance of nutrition in wound care and used nutritional supplements to aid healing. Many of the teachings from Hippocrates, the father of modern-day medicine, clearly state his firm belief that good health can be achieved through nutrition. In the early 1900s when advances in biochemistry were frequent, many of the essential constituents of nutrition were characterized, which formed the basis for many animal and human wound-healing experiments. This led to the discovery of vitamin C, zinc, and many other components essential for the orderly progression of healing. Modern-day research has concentrated on finding nutritional components that can enhance healing through supra-physiological doses, such as in the use of the amino acids arginine and carnitine. However, clinicians need to be aware that approximately 50% of patients admitted to the hospital are malnourished, requiring dietary supplementation; appropriate nutritional assessment and advice therefore should be an integral part of all wound management. This review provides an up-to-date commentary on the role of nutrition in wound care, with specific emphasis on lower limb wounds, from a historical perspective, and within it both the biomedical approach and current herbalist practices are considered.

The Multidisciplinary Approach to Limb Salvage

There is considerable morbidity and mortality associated with ulcerations of the lower limbs in patients with diabetes as well as non-diabetic patients. The role of the primary care physician and podiatrist in the evaluation, diagnosis, and management of lower extremity wounds is critical. Careful assessment and management of vascular disease by vascular surgeons and interventionalists, biomechanical foot abnormalities by the podiatrist, wound coverage by the plastic surgeons and aggressive treatment of infections and metabolic derangements by the physicians are required. The multidisciplinary approach provides a comprehensive treatment protocol and significantly increases the chances of successfully healing the ulcer and prevents recurrence. It also provides for increased academic output through publications, participation in clinical trials and educational venues.

The Management of Lower Extremity Wounds Using Topical Negative Pressure

The delivery of topical pressures at subatmospheric levels to heal acute and chronic wounds has been widely reported. This article reviews the role of this therapeutic modality to treat wounds of the lower extremity. Recent literature is re-viewed, and mechanisms of action of this process are also discussed.

Assessment and management of patients with venous, arterial, and diabetic/neuropathic lower extremity wounds.

Most healthcare providers recognize that management of lower extremity wounds presents a difficult challenge. These chronic wounds significantly impact the quality of life for individuals and have implications for costs and utilization of healthcare resources. Lower extremity wounds can be due to a myriad of different diseases, but the primary causes are chronic venous insufficiency, lower extremity arterial disease, and diabetes/neuropathy. Differential assessment is necessary prior to implementation of management strategies in order to address the etiology and pathogenesis factors that are related to each type of leg wound. This article presents an overview of the risk and predisposing factors for venous, arterial, and diabetic/neuropathic wounds. Additionally, it addresses issues of differential assessment including typical locations, common clinical characteristics, typical wound appearance, key management issues, considerations for alternative treatments, collaborative care, and patient/family education.

Mathematical Methods Relevant to the Study of Wound Healing

Over recent years there has been a growing interest in the application of mathematical techniques and methods to improve understanding of clinical problems. Mathematical methods permit accurate description and quantification of observations and processes. Wound healing is a clinical problem that needs support in order to improve management and understanding of the mechanisms that may disarrange healing processes. This article attempts to provide an overview of currently available methods that have a direct relevance to the management of lower extremity wounds. Mathematics can provide valuable assistance and insight to clinical understanding, but only if applied correctly. It is hoped that examples of good practice will promote the utilization of this versatile tool.