Measurement of the healing of venous ulcers

Prescribed exercise regimen versus usual care and hypochlorous acid wound solution versus placebo for treating venous leg ulcers: study protocol for a randomised controlled trial (Factorial4VLU)

INTRODUCTION

Compression is the mainstay of treatment for venous leg ulcers (VLUs) and there are few effective adjuvant treatments. There is only observational evidence supporting the use of hypochlorous acid (HOCl) as a topical wound solution on VLU and some limited randomised evidence for the effect of a prescribed regimen of exercise.

METHODS AND ANALYSIS

The Factorial4VLU trial is a pragmatic, blinded, factorial randomised controlled trial, with 380 participants receiving either a prescribed exercise regimen compared with usual care and either active HOCl wound solution or placebo wound solution at each dressing change for up to 24 weeks. All participants will receive compression therapy. The primary outcome is the proportion of participants with healed VLU at 12 weeks after randomisation as adjudicated by blinded review of ulcer photographs. Secondary outcomes are proportion healed at 24 weeks, time to healing, estimated change in ulcer area, change in 2-Minute Walk Test, change in health-related quality of life, incidence of infection and incidence of all-cause adverse events. If either of the interventions shows a statistically significant positive difference on healing outcomes, cost-effectiveness will be modelled using a health service perspective.

ETHICS AND DISSEMINATION

The Factorial4VLU trial received ethical approval from the Northern B Health and Disability Ethics Committee. We plan to publish the results within 1 year of trial completion and will include the results on the trial registration page.

TRIAL REGISTRATION NUMBERS

Australia and New Zealand Clinical Trials Register (http://www.anzctr.org.au) (ACTRN12620000116921); Universal Trial Number (WHO) (U1111-1236-2997).

Wool-derived keratin dressings versus usual care dressings for treatment of slow healing venous leg ulceration: a randomised controlled trial (Keratin4VLU)

OBJECTIVE

To determine the effect of a keratin dressing for treating slow-to-heal venous leg ulcers (VLU) on VLU healing.

DESIGN

Pragmatic parallel group randomised controlled trial.

SETTING

Community-dwelling participants.

PARTICIPANTS

People aged 18 or more years with VLU (either present for more than 26 weeks or ulcer area larger than 5 cm² or both).

INTERVENTION

Wool-derived keratin dressing or usual care formulary of non-medicated dressings, on a background treatment with compression.

PRIMARY AND SECONDARY OUTCOME MEASURES

Healing at 24 weeks based on blinded assessment of ulcer photographs. Other outcomes included time to complete healing, change in ulcer area to 24 weeks, change in health-related quality of life and incidence of adverse events.

RESULTS

We screened 1068 patients with VLU and randomised 143 participants (51.1% of target recruitment), 71 to the keratin dressing group and 72 to the usual care group.The mean age was 66.1 years (SD 15.9) and 53 participants (37.1%) were women. There were no significant differences between the groups on the primary outcome (risk difference -6.4%, 95% CI -22.5% to 9.7%), change in ulcer area (-1.9 cm², 95% CI -16.5 to 12.8 cm²), time to complete healing (HR 0.80, 95% CI 0.52 to 1.23) or the incidence of adverse events (incidence rate ratio 1.19, 95% CI 0.89 to 1.59) in the intention-to-treat analyses. However, the direction of effect on the primary outcome was reversed in a per protocol analysis specified a priori (risk difference 6.2%, 95% CI -12.4% to 24.9%).

CONCLUSION

The effect of adding a keratin dressing to the treatment regimen for prognostically slow-to-heal VLU remains unclear.

TRIAL REGISTRATION NUMBER

NCT02896725.

Wool-derived keratin dressings versus usual care dressings for treatment of slow-healing venous leg ulceration: study protocol for a randomised controlled trial (Keratin4VLU)

INTRODUCTION

Keratins, filament-forming proteins found in vertebrate epithelium, are downregulated in slow-healing venous leg ulcers (VLU) compared with normal-healing VLU. Laboratory and animal model research has suggested exogenous keratins increase expression of endogenous keratins. A non-randomised controlled trial of an exogenous keratin dressing reported increased healing in slow-healing VLU. To date, no randomised controlled trial has been done to verify these promising findings.

METHODS AND ANALYSIS

The Keratin4VLU trial is a single-blind, pragmatic, parallel group, randomised controlled trial of keratin dressings compared with usual care non-medicated dressings in patients with VLU where either (1) the ulcer area is greater than 5 cm², (2) the ulcer has been present for more than 26 weeks or (3) both. All patients will receive compression therapy. The primary outcome is the proportion of patients with healed VLU at 24 weeks after randomisation as adjudicated by blinded review of an ulcer photograph. Secondary outcomes are time to healing, estimated change in ulcer area, change in health-related quality of life, agreement between blinded and unblinded assessors and adverse events. The analysis will be intention-to-treat on the primary and secondary outcomes (excepting health-related quality of life).

ETHICS AND DISSEMINATION

The Keratin4VLU trial received ethical approval from the Northern A Health and Disability Ethics Committee. We plan to publish the results within 1 year of trial completion and will include the results on the trial registration page.

TRIAL REGISTRATION NUMBER

NCT02896725; Pre-results.

Self-Care-Based Treatment Using Ordinary Elastic Bandages for Venous Leg Ulcers

Objective: We aimed to study venous leg ulcer (VLU) healing and recurrence rates of VLU using a self-care-based treatment strategy. Methods: The study included 36 patients (43 legs) who visited our clinic between April 2009 and June 2015 because of non-healing VLUs and who had been treated by us for more than a year (until June 2016). Patients or their caregivers were first provided instructions for performing the "no-intentional-stretch" bandaging technique using ordinary elastic bandages. Wounds were cleansed with tepid water daily, and bandages were re-applied by patients or their caregivers; this was continued until VLUs were healed. Compression was discontinued after healing, but was restarted if persistent swelling and/or dermatitis was noticed on their legs. Results: The median ulcer size was 6.5 cm² (range, 1-105 cm²). The median number of clinic visits until healing was six (range, 3-35). The 6- and 12-month healing rates were 67% and 86%, respectively. Twenty (44%) legs required compression therapy after VLU healing. The cumulative recurrence-free rate at 60 months was 86%. Conclusion: Reasonable healing and recurrence rates were achieved by applying a self-care-based VLU treatment strategy.

Effects of Topic Simvastatin for the Treatment of Chronic Vascular Cutaneous Ulcers: A Pilot Study

Recent research suggests that statins might be useful in the process of wound healing, playing a positive immune-modulatory role, improving microvascular function and reducing oxidative stress. The aim of this pilot study was to evaluate the efficacy of topic application of Simvastatin-based cream in the treatment of chronic vascular cutaneous ulcers, comparing this type of treatment to a collagen-based dressing, proven to be effective for ulcer treatment. A total of 20 ulcers were studied in 2 Groups of randomly-chosen patients for a period of one month. In the first Group a 0.5% Simvastatin-based cream was topically administered, while the second Group (control) was treated with an absorbable type I bovine collagen-based medication. Each week, wound healing progress was observed in both Groups, and the ulcers photographed. Wound healing rate was calculated by considering the absolute change in area and by the formula "healing ratio (%) = [(Area₀ - Area_t4)/Area₀] × 100," both sets of data being related to the days comprised in the study in order to calculate healing rate per day. Statistical analysis was performed by Student t test. Study endpoint equaling the time-course changes of ulcer areas. At the end of the study, when considering absolute change in area, the experimental Group appeared to heal better and faster than the control Group although differences between the Groups were not statistically significant. Conversely, rates of wound healing in the experimental and control Groups were 46.88% and 64% respectively, revealing statistically significant differences. (P < 0.05). In conclusion, topic application of a simvastatin-based cream proved to be well- tolerated but not effective in the management of vascular leg ulcers in a 4 week-period.

Amniotic membrane can be a valid source for wound healing

Amniotic membrane (AM) can promote proper epithelialization with suppression of excessive fibrosis by creating a supportive milieu for regeneration of chronic ulcer bed.

Low-dose aspirin as an adjuvant treatment for venous leg ulceration: study protocol for a randomized controlled trial (Aspirin4VLU)

AIM

The aim of this study was to determine the effect of low-dose aspirin on venous leg ulcer healing when used in addition to compression.

BACKGROUND

The mainstay of treatment for venous leg ulcers is compression therapy and there are few adjuvant treatments to accelerate healing.

DESIGN

Pragmatic, community-based, double-blind, randomized trial.

METHODS

Participants with venous leg ulcers will receive either 150 mg aspirin or placebo daily for up to 24 weeks. Participants will receive background treatment with compression therapy (system of choice guided by participant and/or clinical preference) delivered through district nursing services. The primary outcome will be time-to-healing. Secondary outcomes will include proportion healed at 24 weeks, change in ulcer area, change in health-related quality of life, adherence, efficacy of blinding and adverse events. The trial was funded in June 2014.

DISCUSSION

The trial commenced in March 2015 and is successfully recruiting. The trial is one of three trials that will contribute to an individual participant data meta-analysis to be undertaken at the York Trials Centre.

TRIAL REGISTRATION

Registered 5 June 2014 ClinicalTrials.gov NCT02158806. Protocol version 1·1, 14 April 2015.

A Painless Method of Ultrasonically Assisted Debridement of Chronic Leg Ulcers: A Pilot Study

OBJECTIVES

Devitalized tissue in a recalcitrant leg ulcer is common and may impede healing. The aim of this study was to evaluate the use of a non-invasive low frequency ultrasound device to debride chronic leg ulcers as an adjunct to compression bandages therapy.

METHODS

19 patients with leg ulceration of at least 6 months were recruited. Low frequency ultrasound at 25kHz was delivered by a portable Sonaca--180 via a handheld probe, using normal saline as the irrigation/coupling medium. The ultrasound was applied for 10-20 seconds per probe head area onto the ulcer. Each leg underwent treatment at an interval of 2-3 weeks with compression bandages reapplied at the end of the treatment. Serial colour photographs were taken to evaluate the response at each visit.

RESULTS

Each patient received on average 5.7 treatments each ranged from 5-20 minutes depending on the ulcer size. Symptomatic relief (pain and odour reduction) was achieved in 6 patients. 7 patients achieved complete ulcer healing (mean ulcer size=4.72+/-SD 1.872cm(2)) but no response was observed in 8 patients. There were no major complications of the treatment which was relatively painless.

CONCLUSIONS

The application of low frequency ultrasound debridement may heal some recalcitrant ulcers when standard compression regimens have failed. It is cheap and does not require admission. The role of simple wound cleansing requires further investigation.

Excision and meshed skin grafting for leg ulcers resistant to compression therapy

Background

The aim of this study was to determine the success of excision and meshed skin grafting for chronic leg ulcers. The effects of different ulcer aetiology and ulcer size on outcome were also assessed.

Methods

All patients who had excision and mesh grafting for chronic leg ulceration between January 1996 and December 2004 at St Thomas' Hospital were reviewed. Recurrence was classified as any breakdown of the ulcer during follow-up.

Results

Sixty-two patients with 100 chronic leg ulcers underwent operation. Seventy-two of the ulcers were venous and the median ulcer size was 36 (range 1·5–192) cm2. Only three patients left the hospital with their ulcers unhealed, but ulcers had recurred in 28 (28 per cent) by 2 months. A further 17 ulcers recurred later, with just over half (55 per cent) remaining healed by 5 years. There was no difference between the recurrence rates of venous ulcers and ulcers of other aetiologies (P = 0·980), or large (more than 10 cm2) and small ulcers (P = 0·686).

Conclusion

Wide local excision and meshed skin grafting benefitted over half of these patients with refractory leg ulcers. Recurrence was most likely to occur in the first 2 months and, provided that ulcers were healed at this time, there was a low rate of further breakdown.

Wound measurement by curvature maps: a feasibility study

A non-contact wound measurement method by laser scanner and curvature maps is presented. A patient's foot ulcer is scanned by FastSCAN ten times over a three-week period. With the surface's 3D coordinates, curvature maps of the ulcerous area are calculated. Utilizing a specified rim curvature value, the wound edge is detected and processed via cubic spline smoothing, which is qualitatively verified by a photograph. Subsequently, the depth, area and volume of the wound can be calculated. The results indicate that laser scanning followed by curvature analysis might be a potential clinical tool for non-contact measurement of wounds.

MICROBIOLOGICAL PROFILE OF CHRONIC ULCERS OF THE LOWER LIMB: A PROSPECTIVE OBSERVATIONAL COHORT STUDY

BACKGROUND

The aim of the study was to determine the microbiological profile of chronic lower-limb ulcers in a tertiary outpatient setting.

METHODS

A prospective observational cohort study of 39 patients with lower-limb ulcers of more than 1 month duration, presenting to the leg ulcer clinic. Superficial swab and punch biopsy samples were taken from each ulcer.

RESULTS

Mean age was 68.7 years. Venous ulcers were most common (51%) followed by arterial ulcers (13%), ulcers in people with diabetes having arterial disease (13%), unspecified ulcers (13%) and ulcers in people with diabetes (10%). The most common organisms were Staphylococcus aureus (38-44%) followed by Pseudomonas aeruginosa (26-28%). Biopsy and swab results were concordant in 18 (46%), had at least one organism in common in 10 (26%) and had no concordance in 11 (28%). Histological analysis did not show any cases of malignancy. Ulcer area was significantly lower after 2 months of treatment (P = 0.047). Venous ulcers had the best outcome at 2 months, whereas people with diabetes with arterial disease fared poorly.

CONCLUSION

The microbiological profile of chronic leg ulcers has application to general treatment principles as well in guiding the necessity and choice of antibiotic therapy. Concordance between swab and biopsy results was poor; we recommend biopsy in the tertiary setting.

Upregulation of inducible nitric oxide synthase (iNOS) expression in faster-healing leg ulcers

OBJECTIVE

Chronic leg ulcers represent a growing clinical problem in the light of today's ageing population. Nitric oxide (NO), which is mostly produced by inducible nitric oxide synthase (iNOS) in healing wounds, exerts beneficial effects on many processes of healing, including bactericidal effects, angiogenesis, epithelialisation and ECM formation. This study sought to investigate whether iNOS expression in chronic leg ulcers can be correlated with the healing process.

METHOD

Sixteen patients with chronic leg ulcers were recruited and attempts were made to take punch biopsies at two separate time points (however, a second biopsy could not be obtained on seven patients). A linear healing rate was derived using the obtained ulcer area and perimeter. The iNOS levels in the biopsy samples were assessed using immunoblotting.

RESULTS

The mean linear healing rate of patients with high iNOS levels was significantly higher (p < 0.01) than that of patients with low iNOS levels. An incidental finding was that the linear healing rate was significantly higher (p < 0.05) post-biopsy than before biopsy in the same patients.

CONCLUSION

This study therefore shows for the first time that high iNOS levels are associated with higher healing rates and have the potential to be used in prognostication. This also opens the possibility of augmentation of ulcer healing through the manipulation of wound NO levels.

Using wound area measurement to predict and monitor response to treatment of chronic wounds

A wound measurement system has been launched that incorporates wound tracing and digital planimetry. It is hoped its speed and accuracy will enable more clinicians to use wound area measurements to predict treatment outcomes.

Treatment of venous leg ulcers with Dermagraft

BACKGROUND

A number of different treatment approaches have been recommended for the treatment of venous ulceration, including local ulcer treatment, compression and drug therapy. Recent advances in tissue engineering have resulted in living tissues being developed for cutaneous wound repair and skin replacement. The aim of this pilot study was to compare the rate of healing of venous ulcers in patients treated with Dermagraft (a human fibroblast-derived dermal replacement) and compression therapy or compression therapy alone.

METHODS

A total of 18 patients with venous ulceration of the leg were recruited into the pilot study. Ten patients were treated with Dermagraft and compression therapy, and eight patients were treated with compression therapy alone. Healing was assessed by ulcer tracing and computerised planimetry. Skin perfusion was measured by laser Doppler.

RESULTS

Five (50%) of the patients treated with Dermagraft and one (12.5%) control patient had healed by the end of the 12-week study period (NS). The total ulcer area rate of healing and linear rate of healing was significantly improved in patients treated with Dermagraft (P=0.001 and P=0.006, respectively, Mann-Whitney U-test). The number of capillaries increased in both the treatment and control group. Peri-ulcer skin perfusion increased by 20% in patients treated with Dermagraft, compared with 4.9% in the control group.

CONCLUSION

The data from this small pilot study suggests that Dermagraft is associated with improved healing of venous ulceration. Following this pilot study, further clinical studies are needed to confirm the validity of these results in 'hard to heal' venous leg ulcers.

Increased but ineffectual angiogenic drive in nonhealing venous leg ulcers

OBJECTIVE

Our previous work demonstrated that angiogenesis is inhibited in nonhealing venous ulcers. The object of this study was to determine whether local expression of vascular endothelial growth factor (VEGF) and other major regulators of vessel growth are related to healing of venous ulcers.

SUBJECTS AND METHODS

The study included 35 patients with venous ulcers (CEAP 6) and 9 patients whose ulcers had healed (CEAP 5). Control subjects were 18 patients undergoing routine operations (8 with closed suction drains, 10 standard skin biopsies). Healing ulcers were defined as having healed in less than a year from entry to the study; nonhealing ulcers failed to heal in this period. A 1-cm square biopsy specimen was taken from the edge of the ulcer or from a site of lipodermatosclerosis around a healed ulcer. Wound fluids were aspirated from beneath transparent occlusive dressings. Concentrations of VEGF(165) and VEGF-R1 were measured in tissue homogenates with enzyme-linked immunosorbent assay, and results are expressed as mean +/- SEM per milligram of soluble protein (SP). Expression of mRNA transcripts for the VEGF splice variants VEGF(121), VEGF(189), and VEGF(165); the receptors VEGF-R1 and VEGF-R2; the angiopoietins Ang-1 and Ang-2; and their receptor, Tie-2, were measured in biopsy samples with multiplex polymerase chain reaction. Expression of each transcript was normalized to that of the housekeeping gene, GAPDH. Results were analyzed with analysis of variance, t test, and chi(2) test.

RESULTS

There was no difference in VEGF(165) protein concentration between biopsy specimens from healing ulcers (2.12 +/- 0.34 ng/mg SP; n = 18) and nonhealing ulcers (2.36 +/- 0.39 ng/mg SP; n = 12), but concentration was higher in all ulcer samples compared with healthy skin (0.57 +/- 0.20 ng/mg SP; n = 10; P <.01)) and healed ulcers (0.33 +/- 0.06 ng/mg SP; n = 9; P <.01). Concentration of VEGF(165) protein in wound fluid was significantly higher in nonhealing venous ulcers (67.17 +/- 13.87 ng/mg SP; n = 13) compared with healing venous ulcers (32.19 +/- 7.90 ng/mg SP; n = 19; P <.05) or acute wounds (12.26 +/- 4.50; n = 8; P <.01). Concentration of VEGF-R1 was similar in wound fluid obtained from healing ulcers (7.18 +/- 1.34 ng/mg SP; n = 13) and nonhealing ulcers (7.02 +/- 1.21 ng/mg SP; n = 19), and acute wounds (7.12 +/- 2.35 ng/mg SP; n = 8). There was a weak but significant correlation between VEGF(165) protein concentration in the ulcer biopsy specimen and wound fluid from the same ulcer (R(2) = 0.2; P =.019; n = 27). Expression of mRNA for VEGF receptors and Tie-2 was poor. VEGF(121) was expressed in all samples, and VEGF(165) in 43 of 48 samples. mRNA expression of VEGF(189) (P =.001), Ang-1 (P =.002), and Ang-2 (P =.026) was found in more samples from unhealed ulcers than from other sites. Healed ulcers had reduced mRNA expression of VEGF(165) (0.181 +/- 0.003) than did healing ulcers (0.307 +/- 0.016; P =.007) or nonhealing ulcers (0.375 +/- 0.033; P =.001). Relative expression of VEGF(165) to Ang-2 was much lower in healed ulcers (0.4236 +/- 0.060) than in healing ulcers (1.382 +/- 0.235; P =.010) and nonhealing ulcers (1.887 +/- 0.280; P =.003).

CONCLUSION

In nonhealing venous ulcers there is a consistently high level of expression of VEGF, at both the gene transcript and protein level. As our previous data demonstrated that angiogenesis is depressed in these poorly healing ulcers, an increase in VEGF production may indicate an increased but ineffectual angiogenic drive. It is also possible that undiscovered inhibitors are released in the ulcer environment.

Randomized clinical trial of three-layer paste and four-layer bandages for venous leg ulcers

BACKGROUND

Both four-layer and three-layer paste bandages are widely used in the treatment of venous leg ulcers. The aim of this study was to compare the efficacy of these two bandaging regimens.

METHODS

The study was a prospective, randomized, open comparison of a consecutive cohort of 133 patients with venous ulcers. Participants were stratified by ulcer size into one of three groups and were randomized within each group to receive either three-layer paste or four-layer bandages. All patients were followed for 1 year. The time taken to complete ulcer healing was the primary endpoint. The time taken to apply the bandages, comfort, tolerability and cost were also assessed. Analysis was performed on the basis of intention to treat.

RESULTS

Ulcers healed completely in 51 (80 per cent) of 64 patients treated with three-layer paste bandages compared with 45 (65 per cent) of 69 patients treated with the four-layer regimen (P = 0.031). This difference developed only after 20 weeks of treatment. The median times to complete healing were 12 weeks for three-layer and 16 weeks for four-layer treatment (P = 0.040). Results of venous function tests, including half-refilling times, were similar in the two groups.

CONCLUSION

Three-layer paste bandages were significantly more effective at healing venous ulcers than the four-layer regimen in this study.

Measuring the size of ulcers by planimetry: a useful method in the clinical setting

OBJECTIVE

The aim of this study was to compare four measurement methods. Digital planimetry was compared with mechanical planimetry, placing the film over graph paper and counting the squares (grid tracing), and multiplying the two maximal perpendicular diameters of the ulcer (diameter product).

METHOD

Twenty patients with 50 chronic leg ulcers of various aetiology and sizes (20 ulcers were < or = 3 cm2, 15 ulcers were > 3 cm2 and < or = 10 cm2, and 15 ulcers were > 10 cm2) were enrolled consecutively into this study. Ulcer area was calculated from film transparency tracings using a digital planimeter, a mechanical planimeter, grid tracing and diameter product.

RESULTS

The mean difference of digital planimetry versus mechanical planimetry, grid tracing and diameter product was 0.51 cm2, 0.72 cm2 and -5.38 cm2, respectively. For all methods difference tended to increase with ulcer size.

CONCLUSION

Digital and mechanical planimetry, together with grid tracing, appear to be appropriate means of obtaining accurate surface area measurements. Digital planimetry is a quick and practical method and could therefore be recommended in the clinical setting.

Randomized clinical trial comparing the efficacy of two bandaging regimens in the treatment of venous leg ulcers

BACKGROUND

Many venous ulcers are healed by the application of external compression. It has been suggested that bandages capable of producing greater compression enhance healing. The aim of this study was to compare the time to total healing of venous ulcers in two groups of patients treated with different compression regimens in a randomized prospective trial.

METHODS

A total of 112 patients was studied and all were treated with a zinc-impregnated paste bandage applied directly to the ulcer. Fifty-seven patients had the paste covered by Tensopress and 55 by Elastocrepe bandages. Both groups had a tubular bandage applied over the top to retain the bandage in place. All ulcers were stratified and randomized within one of three size groups. The 'venous' aetiology of the ulcer was confirmed on completion by calf pump function tests.

RESULTS

By 26 weeks, 58 per cent of the patients treated with Tensopress and 62 per cent of those treated with Elastocrepe bandages were healed. The median healing times were 9 and 9.5 weeks respectively. Similar numbers of patients were excluded or withdrawn from both groups. Large ulcers healed significantly more slowly than small ulcers.

CONCLUSION

There was no significant improvement in venous ulcer healing using higher compression elastic bandages.

Reliability of digital videometry and acetate tracing in measuring the surface area of cutaneous wounds

PURPOSE

The purpose of this study was to evaluate the reliability of digital videometry and acetate tracing in the measurement of cutaneous wound area.

METHODS

Four clinicians used both digital videometry and acetate tracing to measure five wounds that were artificially created on a cadaver specimen. In addition, the clinicians used an analog centimeter ruler to determine a rough estimate of the area of each wound. The wounds were measured a total of five times with each measurement instrument using a non-sequential repeat measures design. Associations between the three wound measurement techniques were examined with Pearson correlation coefficients. In addition, intraclass correlation coefficients (ICC) were calculated for each pair of the three measurement techniques.

RESULTS

Correlation between the measurement systems for all raters combined yielded Pearson r-values of 0.93 for ruler and acetate, 0.95 for ruler and digital and 0.97 for acetate and digital. Furthermore, the average measure ICC between acetate and digital was 0.94, between acetate and ruler was 0.76 and between digital and ruler was 0.57.

CONCLUSION

These results suggest that wound area measurements obtained using digital videometry and acetate tracing are very similar and both techniques can be used interchangeably in either clinical or research settings.

Digital imaging: an accurate and easy method of measuring foot ulcers

AIMS

A progressive reduction in the area of foot ulcer on serial measurement is traditionally done by tracing the margin of the ulcer on a transparent film and counting the number of squares on a graph paper underneath. We set out to use and validate the measurement of foot ulcers using a digital imaging technique and compare this with the traditional method.

METHODS

Thirty diabetic foot ulcers (18 patients) were studied over 10 weeks. Each ulcer was traced by three independent observers with a pen over a flexigrid Opsite film and digital photographs were taken. Each observer calculated the area of an ulcer first using a 1-mm2 graph paper and then with the computer software. For each ulcer we calculated the mean area using measurements from all the observers. We then calculated the deviation from this mean for each observer.

RESULTS

There was significantly less interobserver variation using the digital image than the traditional method with mean coefficient of variation (CV) 16% vs. 27%; P = 0.05.

CONCLUSIONS

The digital imaging method was faster and easier to use and the patients preferred it, as it was a noncontact method. In addition it also provides a photographic record for comparison.

The influence of dressings on venous ulcer healing--a randomised trial

OBJECTIVE

To assess the effect of different dressings on venous ulcer healing.

DESIGN

A randomised clinical trial.

MATERIALS

Patients were randomised to treatment with one of three dressings: a zinc oxide impregnated bandage, a zinc oxide impregnated stockingette, or an alginate dressing. All patients were treated as outpatients and had compression bandaging with two minimal stretch bandages (Elastocrepe) and a stockingette (Tubigrip) to keep the bandages in place.

METHODS

One hundred and thirteen patients (133 ulcerated limbs) with chronic ulceration of the leg due to venous disease alone, and attending Fremantle Hospital Leg Ulcer Clinic, Western Australia were entered into the study. Healing was measured as complete healing of the ulcerated limb or failure of the limb to heal within 9 months.

RESULTS

There was no significant difference between the three groups in ulcer size, duration, and other parameters compared. Healing was affected significantly by ulcer size and which leg was ulcerated. There was significantly faster healing with the paste bandage.

CONCLUSION

The use of a paste bandage significantly improved the healing of chronic venous ulcers when used in combination with compression bandaging, and compared to an alginate dressing and a zinc oxide impregnated stockingette.

Measuring healing in leg ulcers: practice considerations

Clinical nursing practice requires reliable and valid methods of measuring healing in patients with leg ulcers. By comparing the reliability and validity of four methods of measuring leg ulcer healing, digital planimetry (computerized area measurement), the Kundin Wound Gauge (volume and area measurement), the Healing Scale (measuring perceptions of healing), and the Johnson Scale (measuring wound characteristics), with the standard technique of stereophotogrammetry, implications for nursing practice and research were identified. Stereophotogrammetry, defined as topographical mapping measuring volume and area, was found to be reliable and suitable for clinical trial evaluations and for monitoring healing in hospitals or clinics. In a sample of hospital and community patients with leg ulcers (n = 82), weekly clinical comparisons using digital planimetry and the Kundin Wound Gauge, both reliable methods, supported the suitability of these measures, for monitoring healing in any setting (r = .99; r = .98, respectively). The Healing and Johnson Scales did not show concurrent validity when compared with stereophotogrammetric methods and had limited reliability. This study provided three reliable and valid methods of measuring healing suitable for practice. Time intervals and endpoints for clinical trials and evaluating practice need to be considered in terms of instrument error rates and delayed healing in older people.

The influence of wound geometry on the measurement of wound healing rates in clinical trials

PURPOSE

The comparison of wound healing rates in clinical trials presents a challenging problem. Wound healing typically has been expressed as a change in area over time or a percent change in area over time. These methods are inaccurate, however, when applied to wounds of varying size and shape. A relatively small amount of healing in a large wound will produce a greater change in area than in a smaller wound. Conversely, measurement of the percent change in area of a wound will tend to exaggerate the healing rates of smaller wounds. A method of calculating average linear healing of the wound edge toward the center of the wound has been proposed that should not be influenced by wound size: D = delatA divided by P, where D = linear healing, deltaA = change in area, and P = mean perimeter. The purpose of this study was to examine linear healing of the wound edge as a method of measuring wound healing in clinical trials.

METHODS

We observed 39 patients with venous stasis ulcers. The area, perimeter, length, and width of each wound were calculated with computerized planimetry. Change in area per day and linear healing rate of the wound edge per day were calculated. Multiple linear regression analysis was used to explore factors that influence wound healing as measured by these methods.

RESULTS

The change in area per day was significantly and independently influenced by initial area (p < .0001), perimeter (p < .0001), length (p < .00055), and width (p < .0175). Linear healing per day was not influenced by any geometric variable, including area, perimeter, length, width, and ratio of width to length.

CONCLUSION

Linear healing per day is a valid means of comparing wound healing rates in wounds of different dimensions. Linear healing per unit of time should be preferred to measurements of change in wound area to quantify wound healing rates in clinical trials.

The use of video image analysis for the measurement of venous ulcers

The accurate measurement of the size of skin wounds and ulceration is important for comparing the efficiency of treatment modalities and for monitoring progress in the individual patient. Although various methods of differing sophistication are in use, many of the common simpler techniques lack accuracy and reliability. We describe a new technique of ulcer measurement which uses video image recording, capture and computer analysis. A method of correcting for limb convexity in a two-dimensional image is presented. The method has an overall accuracy of 1.82% and a clinical precision of 3.41%, both of which are significantly better than acetate tracings or photographic methods. The technique is simple and rapid, and once established it incurs minimal ongoing costs.

Guidelines for the management of chronic venous leg ulceration. Report of a multidisciplinary workshop. British Association of Dermatologists and the Research Unit of the Royal College of Physicians

This document is the product of a multidisciplinary workshop held in November 1991 between the audit subcommittee of the British Association of Dermatologists and the Research Unit of the Royal College of Physicians. Participants included dermatologists, vascular surgeons, general practitioners, community nurses and physicians involved in care of the elderly. The text is based on papers submitted to, and presented and discussed at, the workshop, and on comments received in response to subsequent wide dissemination of the proceedings to speciality associations. Participants in the workshop, and contributors to the guidelines are: Dr B. R. Allen (Nottingham), Sister S. Bainsborough (Exeter), Professor K. Burnand (London), Professor D. Burrows (Belfast), Mr M. J. Callam (Bedford), Dr G. W. Cherry (Oxford), Dr R. P. R. Dawber (Oxford), Dr W. S. Douglas (Airdrie), Dr A. Y. Finlay (Cardiff), Dr D. Gawkrodger (Sheffield), Dr D. J. Gould (Truro), Dr A. Hopkins (Royal College of Physicians, London), Dr D. McGibbon (London), Dr A. M. Middleton (London), Dr L. Millard (Nottingham), Dr L. Rhodes (Liverpool), Professor T. J. Ryan (Oxford), Dr N. B. Simpson (Newcastle), Dr F. D. Skerrett (Fowey), Dr J. M. Sowden (Nottingham), Miss L. A. Stone (London), Dr R. Williams (Rhyl). Papers presented to the workshop (copies available from the Royal College of Physicians of London): 1. Callam M. J. Epidemiology, natural history and rate of recurrence of leg ulcers. 2. Ryan T. J. Pathology of venous leg ulcers. 3. Gould D. J. Assessment of severity; process and outcomes of care. 4. Millard L. The role of infection. 5. Cherry G. Treatment of known effectiveness. 6. Burnand K. Indications for surgical treatment.

Venous ulcers

Successful therapy of venous ulcers combines local wound treatment modalities and ambulatory hemodynamic support to control the underlying disease. Compression bandaging reduces or eliminates edema, and a moist wound environment not only debrides necrotic tissue but also aids development of granulation tissue, a prerequisite for epidermal repair. We have occluded chronic wounds, known to be heavily colonized, with a hydrocolloid dressing for up to 7 days and found that soft-tissue infections occurred in only 1% of all dressing changes in our clinic, compared with 6.5% generally reported in the literature. In venous ulcers, resident bacteria may be beneficial in that their proteolytic activity assists with autolysis of fibrinopurulent wound exudate. The importance of lysing fibrin and reducing the number of existing fibrin "cuffs," thereby improving local tissue oxygenation and nutrient/waste exchange, is not completely understood; however, this phenomenon, in part, may explain the excellent clinical results obtained with one type of hydrocolloid dressing (DuoDERM), which has been shown to lyse fibrin more effectively than other types of moisture-retentive and hydrocolloid dressings.

Venous leg ulcers: an analysis of underlying venous disease

Patients with venous leg ulcers have a readily recognized clinical syndrome of shallow ulcers, oedema, leg pain, venous ankle blush, lipodermatosclerosis, varicose veins, hyperpigmentation, and atrophie blanche, and they are assumed to have venous abnormalities. We examined 43 patients with venous leg ulcers, and compared those with obvious venous abnormalities (defined as historical or clinical evidence of deep venous thrombosis or varicose veins) with those with presumed venous abnormalities (defined as lacking any such evidence), to see if they presented with different clinical features. We found that both groups had similar clinical features, with the exception that lipodermatosclerosis was present more frequently in those patients with obvious venous abnormalities (94 vs. 36%, P < 0.001). Most patients with presumed venous abnormalities had musculoskeletal conditions which might cause calf pump dysfunction (91%). Using air plethysmography, we were unable to confirm that all patients with presumed venous abnormalities did have intrinsic venous abnormalities. We propose that ulcers occurring in this clinical syndrome be designated as calf pump dysfunction ulcers (CPD ulcers), rather than venous ulcers.

Outpatient treatment of chronic venous ulcers in a specialized clinic

Chronic leg ulcers have many different causes and therefore need an accurate diagnosis in order to give the most effective treatment. A specialized clinic was set up in Fremantle Hospital in July 1988 with the aims of performing a thorough clinical and laboratory assessment to establish the cause of ulceration in every patient, and treating patients according to the cause of ulceration. Patients with arterial, neoplastic or dermatological conditions were treated as appropriate for their diagnosis and patients with other chronic ulcers were managed as outpatients where possible. Patients were seen between July 1988 and July 1989. Only 43% had purely venous ulcers, 32.6% had a venous component plus some other abnormality, and 5.2% were purely arterial. Using an outpatient treatment regimen, 67% of all ulcerated limbs and 73.7% of limbs with purely venous ulcers were healed within 6 months. Only 11 patients with venous ulceration (15 limbs) failed on this therapy and required admission during the observation period. The initial ulcer size was shown to influence the time to total healing of the limb. The healing rates achieved compare favourably with studies from other specialized centres and suggest that the majority of patients with chronic leg ulcers can be treated successfully using ambulatory outpatient dressing techniques.