Skin grafting in the treatment of hard-to-heal leg ulcers

Some risk factors or comorbidities may make Chronic Leg Ulcers (CLU) very difficult to heal. These ulcers are usually defined refractory ulcers and may require an in-hospital intensive care to increase the healing rate. Aim of this retrospective study was to assess if our clinical routine in hospitalized patients, made up with surgical debridement followed by donor skin grafting (allografts), may favor the ulcer healing. The records of 120 patients (55 males and 65 females; mean age 73.9±11.3 years) with ulcers greater than 100 cm2 and lasting for more than 1 year were analyzed. The median ulcer size was 165 cm2 (IQR 130-250 cm2; range 100-1000 cm2). The median ulcer duration was 24 months (IQR 16-32 months; range 12-300 months). The ulcer pathophysiology was venous in 74 patients, arterial in 21, mixed in 12, vasculitis in 5 and post-traumatic in 8 patients. After debridement the patients were submitted to allograft procedures (single or multiple) up to the ulcer healing. When allograft was able to create an effective granulation tissue and reduce the ulcer size an autograft was performed to get the ulcer closure. 109 patients healed and 11 were lost at follow-up. 65 patients healed just with one allograft in 16 weeks (IQR 13-21 weeks). 42 patients healed with 2 procedures in 20 weeks (IQR 18-23 weeks). 31 of them received a final autograft while 11 healed with two allografts. 2 patients with an ulcer surface of 200 cm2, both affected by CLI, healed with 3 allografts procedures in 40 and 33 weeks, respectively. Pain and exudate amount were significantly decreased and even disappeared after the first allograft. Allografts alone or followed by an autograft are able to get the ulcer healing also in case of extensive and long lasting ulcers refractory to all previous treatments.

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Healing rates following venous surgery for chronic venous leg ulcers in an independent specialist vein unit

Phlebology The Journal of Venous Disease ◽

10.1258/phleb.2012.011097 ◽

2013 ◽

Vol 28 (3) ◽

pp. 132-139 ◽

Cited By ~ 9

Author(s):

C A Thomas ◽

J M Holdstock ◽

C C Harrison ◽

B A Price ◽

M S Whiteley

Keyword(s):

Retrospective Study ◽

Clinical Improvement ◽

Ulcer Healing ◽

Surgical Intervention ◽

Response Rate ◽

Significant Proportion ◽

Leg Ulcers ◽

Venous Leg Ulcers ◽

Venous Surgery

Objectives This is a retrospective study over 12 years reporting the healing rates of leg ulcers at a specialist vein unit. All patients presented with active chronic venous leg ulcers (clinical, aetiological, anatomical and pathological elements [CEAP]: C6) and had previously been advised elsewhere that their ulcers were amenable to conservative measures only. Method Seventy-two patients (84 limbs) were treated between March 1999 and June 2011. Patients were contacted in August 2011 by questionnaire and telephone. Of 72 patients, two were deceased and two had moved location at follow-up, so were not contactable. Fifty patients replied and 18 did not (response rate 74%), representing a mean follow-up time of 3.1 years. Results Ulcer healing occurred in 85% (44 of 52 limbs) of which 52% (27) limbs were no longer confined to compression. Clinical improvement was achieved in 98% of limbs. Conclusions This study shows that a significant proportion of ulcers currently managed conservatively can be healed by surgical intervention.

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Clinical Efficacy of Combination of Rifampin and Streptomycin for Treatment of Mycobacterium ulcerans Disease

Antimicrobial Agents and Chemotherapy ◽

10.1128/aac.00299-10 ◽

2010 ◽

Vol 54 (9) ◽

pp. 3678-3685 ◽

Cited By ~ 86

Author(s):

Fred Stephen Sarfo ◽

Richard Phillips ◽

Kingsley Asiedu ◽

Edwin Ampadu ◽

Nana Bobi ◽

...

Keyword(s):

Body Weight ◽

Clinical Efficacy ◽

Healing Rate ◽

Average Rate ◽

Community Setting ◽

Skin Grafting ◽

Complete Healing ◽

Mycobacterium Ulcerans ◽

The Times

ABSTRACT We have evaluated the clinical efficacy of the combination of oral rifampin at 10 mg/kg of body weight and intramuscular streptomycin at 15 mg/kg for 8 weeks (RS8), as recommended by the WHO, in 160 PCR-confirmed cases of Mycobacterium ulcerans disease. In 152 patients (95%) with all forms of disease from early nodules to large ulcers, with or without edema, the lesions healed without recourse to surgery. Eight patients whose ulcers were healing poorly had skin grafting after completion of antibiotics. There were no recurrences among 158 patients reviewed at the 1-year follow-up. The times to complete healing ranged from 2 to 48 weeks, according to the type and size of the lesion, but the average rate of healing (rate of reduction in ulcer diameter) varied widely. Thirteen subjects had positive cultures for M. ulcerans during or after treatment, but all the lesions healed without further antibiotic treatment. Adverse events were rare. These results confirm the efficacy of RS8 delivered in a community setting.

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A randomized trial of surgery alone versus surgery plus compression in the treatment of venous leg ulcers in patients with primary venous insufficiency

Vojnosanitetski pregled ◽

10.2298/vsp180710147m ◽

2020 ◽

Vol 77 (8) ◽

pp. 811-815

Author(s):

Dragan Milic ◽

Sasa Zivic ◽

Mladjan Golubovic ◽

Dragan Bogdanovic ◽

Milan Lazarevic ◽

...

Keyword(s):

Ulcer Healing ◽

Venous Insufficiency ◽

Healing Rate ◽

Surgical Intervention ◽

Compression Therapy ◽

Healing Time ◽

Leg Ulcers ◽

Compression Device ◽

Group A ◽

Group B

Background/Aim.Venous leg ulcers (VLU) are a significant health problem worldwide. It is well known that VLU are difficult to treat and that they have high tendency for recurrence. Compression therapy is the preferred treatment modality but there is growing evidence that correction of underlying venous disorder in early stages of the disease in addition to compression treatment may improve ulcer healing and reduce recurrence rate. Methods. An open, prospective, randomized, single-center study, with a 6-months follow-up was performed to determine the efficacy of two different treatment modalities (surgery alone versus surgery plus compression) in the treatment of VLU in patients with primary venous insufficiency. Patients with secondary venous insufficiency and/or thrombosis were excluded from the study. Overall, 71 patients were randomized (37 men, 34 women; mean age 60 years) into two groups: the group A ? 34 patients who underwent surgical intervention (stripping) and postoperatively were treated with simple wound dressing only, and the group B ? 37 patients who underwent surgical intervention (stripping) and wore a heelless open-toed elastic class III compression device knitted in tubular form ?Tubulcus? (Laboratoires Innothera, Arcueil, France). All patients in group B were instructed to wear compression device continuously during the day and night. The study was performed at the Clinic for Cardiovascular and Transplant Surgery, Clinical Centre Nis (Serbia) with primary endpoint of the study being complete ulcer healing at 180 days. Results. The healing rate was 29.41% (10/34) in the group A, and 56.76% (21/37) in the group B (p < 0.01). Mean healing time in the group A was 141 ?15 days, and in the group B it was 98 ?12 days (Log-rank life table analysis: p < 0.001). Conclusion. This study suggests that for VLU in patients with primary venous insufficiency, surgery plus compression therapy provides higher healing rate and faster healing time compared to surgery only.

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Non diabetic chronic leg ulcers: etiology and management

International Surgery Journal ◽

10.18203/2349-2902.isj20192368 ◽

2019 ◽

Vol 6 (6) ◽

pp. 2070

Author(s):

Pankaj Narwade ◽

Divish Saxena ◽

Nitin Wasnik ◽

Murtaza Akhtar

Keyword(s):

Healing Rate ◽

Skin Grafting ◽

Complete Healing ◽

Leg Ulcer ◽

Female Ratio ◽

Thickness Skin ◽

The Mean ◽

Male To Female ◽

Sixth Decade ◽

Chronic Leg Ulcers

Background: Chronic leg ulceration has varied etiologies and a systemic approach towards its pathogenesis, definitive diagnosis and optimal treatment is the need of the hour. Paucity of research data on non-diabetic chronic leg ulcer becomes the rational of present study.Methods: Total number of 60 patients with non-healing ulcer below knee and above ankle for more than 6 weeks duration were included in this observational study. A detailed clinical presentation, relevant biochemical, microbiological and imaging investigations were recorded. The management of these ulcers was based on its etiology with an approach to conservative management (antibiotics, daily dressings, improvement in nutritional status) to surgical debridement, wide local excision followed by split thickness/full thickness skin grafting. Outcome of present study was in terms complete or partial healing of ulcer, persistence or recurrence of ulcer.Results: Majority of patients (28.33%) with chronic leg ulcer presented during sixth decade with a male to female ratio of 5:1. The mean duration of chronicity of ulcer was 17.75 months with standard deviation of 7.83 months. Trauma was the commonest etiological factor (45%) followed by venous insufficiency (31.66%). About 31.66% of ulcers were managed conservatively and 68.32% by surgical procedure. Complete healing rate was found in 66.67% patients, persistence of ulcer in 18.32%, partial healing in 11.67% patients and 1.67% patient showed recurrence.Conclusions: Trauma and venous etiology were commonest cause of chronic leg ulcer. A comprehensive etiological assessment and judicious use of conservative or surgical therapy are pivotal in management of these ulcers.

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Measurement and Prediction of Progress in Delayed Wound Healing

Journal of the Royal Society of Medicine ◽

10.1177/014107688708000406 ◽

1987 ◽

Vol 80 (4) ◽

pp. 210-212 ◽

Cited By ~ 24

Author(s):

C J K Bulstrode ◽

A W Goode ◽

P J Scott

Keyword(s):

Healing Rate ◽

Close Correlation ◽

Complete Healing ◽

Size Change ◽

Delayed Wound Healing ◽

Ulcer Size ◽

Epithelial Migration ◽

Significant Difference ◽

The Difference ◽

Chronic Leg Ulcers

Thirty chronic leg ulcers have been studied under controlled conditions until complete healing occurred. Measurement was performed weekly using a computer-linked stereocamera which is capable of measuring skin defects noninvasively with errors of less than 2%. There was a significant difference in healing rate for the first two weeks between clean ulcers entering the trial directly and ulcers admitted first for cleansing before joining the trial. The difference suggests that the weekly healing rate of an ulcer may take up to 2 weeks to respond to a new form of treatment. Absolute ulcer size, change in ulcer size and rate of epithelial migration did not correlate well with time to complete healing, but percentage change in area in the third week was found to be the parameter which gave the earliest close correlation with time to complete healing. Using this parameter, on the data available it was found that time to complete healing could be predicted to within one week for 50% of the ulcers, making this a simple and useful early predictor of treatment efficiency.

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Novel Surgical Treatment for Refractory Heel Ulcers in Werner’s Syndrome

Case Reports in Orthopedics ◽

10.1155/2013/287025 ◽

2013 ◽

Vol 2013 ◽

pp. 1-4

Author(s):

Keisuke Oe ◽

Masahiko Miwa ◽

Yoshitada Sakai ◽

Masahiro Kurosaka

Keyword(s):

Surgical Treatment ◽

Skin Graft ◽

Donor Site ◽

Skin Grafting ◽

Split Thickness Skin Graft ◽

Leg Ulcers ◽

Werner’S Syndrome ◽

Werner's Syndrome ◽

Thickness Skin ◽

Chronic Leg Ulcers

Patients with Werner’s syndrome frequently develop chronic leg ulcers that heal poorly. We present a patient who suffered from this rare syndrome and developed typical heel ulcers. Treatment of the ulcer is challenging, as flap options are limited over the lower third of the leg and skin grafting is not easy as there is a lack of healthy granulations. We successfully treated the ulcer with osteomyelitis by drilling the bone and applying an ultrathin split thickness skin graft with the thigh skin as the donor site.

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Effect of foam sclerotherapy on healing and long-term recurrence in chronic venous leg ulcers

Phlebology The Journal of Venous Disease ◽

10.1258/phleb.2011.011118 ◽

2013 ◽

Vol 28 (3) ◽

pp. 140-146 ◽

Cited By ~ 42

Author(s):

S R Kulkarni ◽

F J A Slim ◽

L G Emerson ◽

C Davies ◽

R A Bulbulia ◽

...

Keyword(s):

Ulcer Healing ◽

Healing Rate ◽

Leg Ulcers ◽

Venous Reflux ◽

Foam Sclerotherapy ◽

Recurrence Rates ◽

Venous Ulceration ◽

Venous Leg Ulcers ◽

Venous Surgery

Introduction The ESCHAR trial showed that superficial venous surgery and compression in chronic venous ulceration achieved a 24-week healing rate of 65% and 12-month recurrence rate of 12%. Foam sclerotherapy treatment is an alternative to surgery. The aim of this study is to assess the effect of foam sclerotherapy on ulcer healing and recurrence in chronic venous leg ulcers. Methods Chronic venous leg ulcers (CEAP [clinical, aetiological, anatomical and pathological elements] 5 and CEAP 6) with superficial venous reflux were treated between March 2006 and June 2011 with ultrasound-guided foam sclerotherapy and compression. Venous duplex was performed on all legs before and after treatment. Twenty-four-week ulcer healing and one- and four-year ulcer recurrence rates were calculated using Kaplan–Meier survival analysis. Results Two hundred legs (186 patients) with chronic venous ulcers (CEAP 5: n = 163 and CEAP 6: n = 37) were treated with foam sclerotherapy. Complete occlusion was achieved in 185/200 (92.5%) limbs, short segment occlusion in 14/200 (7%) limbs and one leg segment failed to occlude. One patient suffered an asymptomatic non-occlusive deep vein thrombosis (DVT) diagnosed on duplex scan at one week and one presented with an occlusive DVT three weeks following a normal scan at one week. One patient developed an asymptomatic occlusive DVT at two weeks following a non-occlusive DVT diagnosed on initial one-week scan. Eighteen patients were lost to follow-up (3 moved away and 15 died of unrelated causes). The 24-week healing rate was 71.1% and one- and four-year recurrence rates were 4.7% and 28.1%, respectively. Conclusion Foam sclerotherapy is effective in abolition of superficial venous reflux and may contribute to similar ulcer healing and long-term recurrence rates to superficial venous surgery. Foam sclerotherapy is an attractive alternative to surgery in this group of patients.

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Treatment of Chronic Leg Ulcers in the Community: A Comparative Trial of Scherisorb and Iodosorb

Phlebology The Journal of Venous Disease ◽

10.1177/026835558700200209 ◽

1987 ◽

Vol 2 (2) ◽

pp. 115-121 ◽

Cited By ~ 29

Author(s):

A.J. Stewart ◽

D.J. Leaper

Keyword(s):

Healing Rate ◽

Comparative Trial ◽

Leg Ulcers ◽

The Cost ◽

Community Trials ◽

Chronic Leg Ulcers

Ninety-five patients with chronic leg ulcers have been recruited from the community and randomized to have Scherisorb or Iodosorb dressings for the care of their ulcers. The overall healing rate at 10 weeks was 29% with no difference being found in the two dressing groups. The ulcers which healed had statistically significant higher basal temperature at entry to the trial (P< 0.05), were significantly smaller (P< 0.01), and had been present for the shorter time (P<0.01) compared with those which did not heal. Similar frequencies of dressing changes and time taken were found in both groups but the cost of treating a patient with Scherisorb was £3.33 compared with £4.68 for Iodosorb. We conclude that an acceptable healing rate was found with both dressings which is comparable with other community trials but that the addition of iodine as an antiseptic does not increase the chances of healing.

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Maggots as a wound debridement agent for chronic venous leg ulcers under graduated compression bandages: A randomised controlled trial

Phlebology The Journal of Venous Disease ◽

10.1177/0268355514555386 ◽

2014 ◽

Vol 30 (10) ◽

pp. 693-699 ◽

Cited By ~ 9

Author(s):

CE Davies ◽

G Woolfrey ◽

N Hogg ◽

J Dyer ◽

A Cooper ◽

...

Keyword(s):

Controlled Trial ◽

Leg Ulcers ◽

Median Percentage ◽

Ulcer Size ◽

Wound Debridement ◽

Venous Leg Ulcers ◽

Area Reduction ◽

Compression Bandaging ◽

Compression Bandages ◽

Chronic Leg Ulcers

Objectives Slough in chronic venous leg ulcers may be associated with delayed healing. The purpose of this study was to assess larval debridement in chronic venous leg ulcers and to assess subsequent effect on healing. Methods All patients with chronic leg ulcers presenting to the leg ulcer service were evaluated for the study. Exclusion criteria were: ankle brachial pressure indices <0.85 or >1.25, no venous reflux on duplex and <20% of ulcer surface covered with slough. Participants were randomly allocated to either 4-layer compression bandaging alone or 4-layer compression bandaging + larvae. Surface areas of ulcer and slough were assessed on day 4; 4-layer compression bandaging was then continued and ulcer size was measured every 2 weeks for up to 12 weeks. Results A total of 601 patients with chronic leg ulcers were screened between November 2008 and July 2012. Of these, 20 were randomised to 4-layer compression bandaging and 20 to 4-layer compression bandaging + larvae. Median (range) ulcer size was 10.8 (3–21.3) cm2 and 8.1 (4.3–13.5) cm2 in the 4-layer compression bandaging and 4-layer compression bandaging + larvae groups, respectively (Mann–Whitney U test, P = 0.184). On day 4, median reduction in slough area was 3.7 cm2 in the 4-layer compression bandaging group ( P < 0.05) and 4.2 cm2 ( P < 0.001) in the 4-layer compression bandaging + larvae group. Median percentage area reduction of slough was 50% in the 4-layer compression bandaging group and 84% in the 4-layer compression bandaging + larvae group (Mann–Whitney U test, P < 0.05). The 12-week healing rate was 73% and 68% in the 4-layer compression bandaging and 4-layer compression bandaging + larvae groups, respectively (Kaplan–Meier analysis, P = 0.664). Conclusions Larval debridement therapy improves wound debridement in chronic venous leg ulcers treated with multilayer compression bandages. However, no subsequent improvement in ulcer healing was demonstrated.

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