Venous leg ulcers: potential algorithms of care.

Management of VLUs can be challenging, depending on wound complexity, and may require the use of several treatment modalities to achieve complete wound closure or significant wound area reduction. This review presents a systematic approach to management of VLUs based on previous literature and the authors' clinical experience, with consideration given to wound size, etiology, and responses to prior treatment. Techniques described include debridement (autolytic, enzymatic, sharp/surgical), compression therapy, physical therapy, medical adjuncts, and cellular- and tissue-based therapy. The algorithm of care for VLUs is multimodal. Appropriate diagnostic studies must be performed, including venous duplex and appropriate pathophysiology to confirm the diagnosis of VLU. After the correct diagnosis is confirmed, appropriate treatment may commence. All patients should undergo appropriate wound debridement; the exact modality used is dependent on wound characteristics. Patients must also adhere to consistent compression therapy. Any underlying venous disease that is amenable to surgical intervention should be addressed. Treatment with a medical adjunct and physical therapy are recommended. For patients who do not achieve significant wound area reduction, the addition of CTP is recommended. Use of these methods should result in substantial wound area reduction and/or wound closure.

The Evidence for Antimicrobial and Hard to Infect Regenerative Matrices.

Preparation of the wound bed is a key step in the use of cell- and tissue-based therapy (CTP). In particular, good pre-application debridement is an essential component of CTP. However, there are many situations in which the wound bed is not adequately debrided, including trauma, burn, and in cases of chronic wounds with significant biofilm. In the setting of inadequate wound bed preparation, the use of a CTP that has either added or intrinsic antimicrobial properties is attractive. Some CTPs include added antimicrobial agents such as PHMB or silver, while others have intrinsic antimicrobial components, such as Omega 3 fatty acids. In addition, some wound-covering dressings are completely synthetic, and therefore simply do not become infected. A full understanding of the basic science and clinical data supporting the use of these therapies is important for the advanced wound care practitioner.

Hydrosurgical Debridement Use Associated With Decreased Surgical Site-Related Readmissions: A Retrospective Analysis.

INTRODUCTION: Debridement is the cornerstone of wound care management. It allows for the removal of fibrinous and necrotic debris from the wound bed as well as the reduction of bacterial bioburden, thus allowing for proper granulation and wound healing. Hydrosurgical debridement uses a controlled, high-pressure fluid jet to cut and remove necrotic debris, contaminants, and bacteria, thereby facilitating a potentially more aggressive debridement. OBJECTIVE: The efficacy of this system was compared with that of other methods of debridement in reducing readmissions due to surgical site infections (SSIs). MATERIALS AND METHODS: Two Current Procedural Terminology codes were used to identify 289 unique patients treated for lower extremity wounds. All patients were treated at a vascular surgery service in a large tertiary care wound program from January 2016 to June 2018. Chart review on wound management was performed. A total of 190 of the 289 patients underwent wound debridement over the course of treatment. Logistic regression was calculated with subsequent SSI admission as the dependent variable. RESULTS: On assessing readmissions owing to SSI following debridement, use of hydrosurgical debridement was found to be associated with decreased SSI admissions (odds ratio, 0.31; 95% CI, 0.142-0.677; P < .05). This finding was compared with the results of either standard sharp soft tissue excisional debridement or the use of pulse irrigation. CONCLUSIONS: There are multiple options to consider when formulating an approach for wound management, including the method of debridement used. One goal of debridement is to decrease the bacterial bioburden in the wound bed to both encourage better wound healing and decrease the rate of wound infections. The present study found that the use of hydrosurgical debridement was associated with decreased SSI readmissions, which could potentially result in better wound care for the patient and possibly decreased health care costs because of a lower rate of readmissions. Further investigation of these 2 potential outcomes is necessary.

The Role of Intermittent Pneumatic Compression in the Treatment of Lower Extremity Chronic Wounds.

Intermittent pneumatic compression devices (IPC) are often used as noninvasive adjuncts in patients with lymphedema, and more recently with venous stasis disease, to promote flow and reduce the adverse effects of interstitial edema associated with both disorders. We will be focusing on lower extremity wounds associated with venous and/or lymphatic disease, the combination often referred to as "lymphophlebitic" disease, and the treatment effect of IPC on this disease process and its sequelae. The function and purpose of pneumatic compression is closely examined along with a variety of pneumatic compression devices that currently exist in the market. A thorough review of the literature was conducted to evaluate the utility of intermittent pneumatic compression in the treatment of lower extremity venous stasis ulcers. Additionally, the author describes personal experience with the use of pneumatic compression on 10 patients with venous stasis ulcers at a single center. There is significant data supporting the use of IPC in patients with lymphophlebitic disease. Overall, ideal patient selection may be crucial. Previous data has shown that patients with high body mass index (>33 kg/m2) and poor functional status (walking less than 200m a day) are related to poor ulcer healing. Therefore, a study that looks primarily at this group (as our small quality assurance [QA] project did) may show increased benefit in this population. It is clear that IPC is of benefit to some patient cohorts with lymphophlebitic disease. This advanced therapy would help patients who have failure of their calf muscle pump and an inability to improve it through other means. However, it is only part of an algorithm that includes: direct wound bed management, moisture control, possible primary venous disease intervention, physical therapy, weight loss, and improved nutrition.

Cryopreserved Allograft Use in Vascular Surgery.

In vascular surgery, bypass procedures are standard treatments for many arterial and venous diseases. The choice of conduit for the bypass operation is fundamental in planning for the appropriate intervention for each individual patient. Although an autogenous conduit is superior, this option is not available in many patients, and prosthetic grafts have been the preferred conduit in a variety of clinical situations. However, since prosthetic graft infections are seen in all realms of vascular surgery, from arteriovenous access to aortic graft infections and lower-extremity bypass infections, cryopreserved arterial and venous allografts, which are relatively resistant to infection, have become the conduit of choice. This discussion will focus on the clinical applications of cryopreserved allografts in vascular surgery, specifically lower-extremity peripheral bypass, aortic disease, and dialysis access.

Titanium alloy surface oxide modulates the conformation of adsorbed fibronectin to enhance its binding to α(5) ß(1) integrins in osteoblasts.

Our laboratory has previously demonstrated that heat (600°C) or radiofrequency plasma glow discharge (RFGD) pretreatment of a titanium alloy (Ti6Al4V) increased the net negative charge of the alloy's surface oxide and the attachment of osteoblastic cells to adsorbed fibronectin. The purpose of the current study was to investigate the biological mechanism by which these surface pretreatments enhance the capacity of fibronectin to stimulate osteoblastic cell attachment. Each pretreatment was found to increase the binding (measured by ELISA) of a monoclonal anti-fibronectin Ig to the central integrin-binding domain of adsorbed fibronectin, and to increase the antibody's inhibition of osteogenic cell attachment (measured by hexosaminidase assay). Pretreatments also increased the binding (measured by ELISA) of anti-integrin IgG's to the α(5) and ß(1) integrin subunits that became attached to fibronectin during cell incubation. These findings suggest that negatively charged surface oxides of Ti6Al4V cause conformational changes in fibronectin that increase the availability of its integrin-binding domain to α(5) ß(1) integrins.