2 Over view Definition Problem – How big is it ? Types Pathophysiology of venous , arterial , diabetic ulcersAssessment / EvaluationsTreatment options – Dressing agents , surgical options
3 UlcersAn ulcer is defined as an area of discontinuation of the surface epithelium.A leg ulcer is a discontinuity of the squamous epithelium of the skin usually around the ankle or on the foot
4 Chronic UlcerA chronic leg ulcer is more difficult to define but many people consider ulceration of more than 4-6 weeks duration as being chronic.Chronic ulcers results when sequel of repair is disturbed at one or more stages of inflammation , proliferation , re epithelialization ,remodellingStaph aureus , Strep pyogens , Strep fecalis , E coli are common organisms colonizing the ulcers
5 Incidence 12/10000 - Irish data 2-4% of the population at any given time will have ulcers due to venous disease% of the total populationAverage age of patients 70 years – increased as more people are living longerWomen are twice likely to be affected than men .
6 Diabetes – Facts 16 million diabetics 15% develop foot related problems30% all hospitalizations due to foot related problems50000 amputations50% develop contra lateral foot problems and 50% again will have amputations3 year mortality is approximately 50% .
8 Venous ulcersAnkle pressure at ankle when standing is 125 cms H2O but on walking the action of calf muscles surrounding the vein pushes the blood out of the leg and reduces the pressures to about 40 cms of H2O
9 Venous ulcers venous hypertension Reflux Obstructive Superficial or deep veinsCombinationObstructivePrimary varicose veinsSecondary veinsvenous hypertension
10 Venous hypertension Increased pressure at ankle Swelling of the tissueswidening endothelial gap junctionsSequestration of the RBCs, WBCs , Proteins
11 Post thrombotic events ObstructionValves get damaged during healing processChronic venous insufficiencyPoor venous return
12 Venous hypertension Fibrin cuff theory Increased venous pressure Loss of plasma proteinsFibrinogen forms a cuff around the capillariesFibrin cuff interferes with the exchange of oxygenTissue breaks down
13 Venous hypertension Leukocyte migration theory White cells migrate into the interstitial tissuebreak down of the WBCs lead to the cytokines and proteases release .Loss of tissue integrity
14 Arterial occlussionIndicate the presence of severe occlusive disease . Atherosclerosis , vasospasm , inflammatory vascular disease /loss of nutrients and oxygen lead to tissue break downarterial ulcers are common in the feet , head of the 1st and 5th metatarsals .
17 DiabetesHyper glycemia leads to increase in glucose content in the tissues which binds to proteins leading to cellular damageIncrease sorbitol and fructose in cells leads to accumulation of water in the cellsIncreased sorbitol leads to decreased myoinositol in cells also postulated for the cellular damgeNeutrophil dysfunction and phagocytosis
18 Diabetic ulcers Vision loss Shoe trauma / Thermal injury Charcots foot ( neuro osteoarthropathy)Six times more incidence of PAOD than the rest of the population
26 Why assessment Pre requisite for the effective leg ulcer management Minimizes improper use of treatmentReduces the risk of long term ulcerationsFacilitates early detection of life or limb threatening problemsFor developing strategies to limit the recurrences
27 Assessment Allows Etiology of ulcers Local or general factors that may cause a delay in healingSocial circumstances and optimum setting for care
28 Assessment Falls into Medical history Physical examination non invasive evaluationsInvasive evaluations
29 Ulcer examination Site Size Shape number floor edge / margin Base surrounding skinExamination of the arterial . Venous , lymphatics , neurological systemevaluation of the nutritional status and underlying medical conditions that prolong wound healing
30 Ulcer evaluations highest ankle pressure ABI =Highest brachial pressureFor screening of the arterial diseaseFor compression therapyFor monitoring purposes
32 Ulcer evaluations FBC,ESR,Renal & Liver functions Wound swab and qualitative culturesDuplex studies of the venous systemConnective disease profileX-ray of the long bonesAngiographyBiopsy of the ulcers ( Marjolins ulcers)
37 Dressing agents No role for Hydrogen peroxide Boric acid EUSOL Dakin solution (hypochlorite )IodineAs they are toxic to the tissues
38 Dressing agents Poly urethane films Foams and Hydrocolloids transmit water vapour , oxygen , carbon di oxidenon absorbentuseful for healing wounds with minimal drainageFoams and HydrocolloidsPermeable , easy to apply , minimum re injury when removing the dressings60-95% water content maintains the moist atmosphere
39 Dressing agents Alginates Cultured keratinocytes Sea weed preparation absorb exudatesuseful for exudative woundsCultured keratinocytesCells are cultured and transferred to petroleum gauzelabour intense and expensive
40 Growth factors and wound healing They are poly peptides , stimulate wound healing , promote chemotaxis , miotgenesis of fibroblasts and smooth muscle cellsPlate let derived growth factor , Insulin like growth factor , epidermal growth factor , fibroblast growth factor , transforming growth factor 1
41 Compression therapy Developed by the Charing cross group Different sizes for various ankle diametersMain stay of the venous diseasePrevention and treatment<0.8 ABI will need further assessmentimproves healing rate compared to no compression therapyMulti layer better than single layerhigher the pressure better the healing rate
42 Profore Multiple layer bandage for the venous hypertension Padding , crepe , light compression ,high compression layers0.6 – 0.7 ABI – use Profore liteABI <0.5 contraindication for the compression therapy
43 Management issues Nutrition-proteins , zinc , vitamin c Pain managementChange of dressingsRemoval of slough- hydrogels , varidasedecrease the bacterial load – iodoflexReduction of exudates- alginatesOdour – iodoflex, silver , metronidazoleEczema- steroids
44 Role of antibioticsBacteria can secondarily colonize the wound and general tendency is to over treat .Not necessarily indicate infectionwound bacteria may be transient and may not be detected on random swabsFever /erythema /swelling / increased pain / leucocytosis
45 Management issuesLong term use of compression therapy is useful in preventing the recurrencesBelow knee stockings are as good as above knee stockingsReplace every 6 monthsTo be used for the day time and foot care at nightkeep foot end elevated.
46 Management issues Education – 20% chances of recurrences avoid standing for long durationWalkingto keep physically activecare of foot20% chances of recurrences
47 Surgery for lower limb ulcers Venous .Varicose vein – SFJ / SPJ ligation , GSV stripping , Avulsion of varicosities .Sub fascial perforator surgeryDeep vein reconstructionArterialAngioplastyBypass procedures