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Non-surgical treatment of venous leg ulcers “Edemas slow down the healing of wounds”

Issue 02/2020

Treating venous leg ulcers caused by impaired perfusion in the lower leg is one of the major challenges in medical practice. In addition to wound dressing management that considers the individual stages of the condition, efficient decongestion forms the basis for treatment success.

A lower leg ulcer is usually characterized by a reduced healing tendency based on a lack of perfusion. As the most severe form of chronic venous insufficiency (stage-III CVI according to Widmer), venous leg ulcers are the most frequent manifestation at about 49%, followed by arterial ulcerations at 15% and mixed arterial and venous ulcers (16%) where CVI occurs together with peripheral arterial disease (PAD). This means ulcers caused by perfusion problems account for 80% of lower leg ulcers. “Venous leg ulcers can develop over very long periods until the affected person realizes that external help is needed. When the lower leg ulcer continues to progress with open, weeping wounds that smell, the feeling of shame also increases. This may result in even more time passing before the patient confides in a physician,” reports the surgeon John Hakman, specializing in lymphology and project manager of the “Lymphology and Wound Healing Colloquium” (see box). Professional, interdisciplinary treatment management is then vital to prevent losing even more time. According to John Hakman: “A patient with a venous leg ulcer often experiences a lot of pain as well as restrictions in joint and general mobility as well as shortcomings in self-care expertise. Eventually, this will have adverse psychosocial effects, with all these factors creating a lot of suffering for the patient.”

Patient 1, 56 years old, condition after injury to the left lower leg and chronification of the wound, CVI on both sides (r. C3/4, l. C6), edemas on both sides, significant exudate production. Treatment: surgical debridement, local wound treatment, adapted complex decongestive therapy (CDT); later: skin graft and flat-knit stockings.

Differential diagnostics required

The foundation of any ulcer treatment is to obtain a comprehensive medical history as well as a clinical examination that includes precise documentation of the wounds. Furthermore, it is important to differentiate the relevant underlying and secondary conditions as exactly as possible. In addition to the obligatory pulse status and the assessment of peripheral arterial perfusion, the ankle-brachial pressure index is used, sometimes duplex sonography of veins and arteries, and in cases of PAD, MR angiography or CT angiography with subsequent interventional or open arterial revascularization surgery, depending on the duplex sonography findings. After eliminating the causes of the ulcer (arterial revascularization, treatment of varicose veins, etc.), venous leg ulcer treatment is then based on the perfusion conditions. The chronic open wound should always be treated according to individual requirements and the relevant stage. During local treatment, it is first cleaned, deposits or dead tissue removed, if applicable, and then an appropriate wound dressing is applied. To accompany this treatment, the skin should be cared for and the edges of the wound should be protected.

 

Left lower leg after about 18 months.

Decongestion to combat
chronification

But there is a decisive factor in wound healing which, according to Dr. med. Hans-Walter Fiedler, vascular surgeon and lymphologist from Soest as well as co-founder of the Lymphology and Wound Healing Colloquium, is given too little consideration: perfusion. He starts with a definition: “In our Colloquium’s view, perfusion plays a vital role in wound management. It not only includes hemoperfusion but also, in addition to arterial and venous perfusion, most of all local exudate and transudate drainage, aided by a sufficient lymphatic system.” After all, a chronic wound is characterized by pathophysiological damage to all vessels – arterial, venous and lymphatic – as well as impaired function on a cellular level: “Consequences of the significantly increased volume in exudate are impaired perfusion and drainage in the wound and on its edges as well as cellular dysfunction,” Dr. Fiedler explains.
And he continues: “In addition to mechanical insufficiencies based on local damage – for example, caused by blocked or destroyed lymph vessels – dynamic insufficiencies also develop – sometimes as a consequence of the capillary permeability being disrupted. According to Földi, these result in a safety valve insufficiency with fibrotic edema development when all lymphatic compensatory mechanisms have been exhausted. And edemas slow down wound healing, for example, by extending the diffusion distances. If the edema is not treated appropriately in time, the consequence will always be the wound becoming chronic!”

From practitioners for practitioners

Identifying the significant role of the lymphatic system for the treatment of wounds was one of the founding causes of the “Lymphology and Wound Healing Colloquium” in April 2016. Members include (from right to left) John Hakman, Specialist in Surgery from Iserlohn, Peter Nolte, Specialist in General Medicine from Meinerzhagen-Valbert, Dr. med. Hans-Walter Fiedler, Specialist in Surgery/Vascular Surgery from Soest as well as Expert Orthotist Falk Peters, Managing Director of Sanitätshaus Enneper at Südwestfalen Medical-Center in Iserlohn. The Colloquium supports expert knowledge and interdisciplinary cooperation between the different professions involved in the treatment of wounds. For this, the group’s activities include the organization of regular further education events. Contact: John Hakman, Colloquium Project Manager, e-mail: j-hakman@t-online.de

Patient 2, 67 years old, has been suffering from venous leg ulcers on both ankles for six years. The picture shows the left edematous ankle. The wound produces exudate, it smells and hurts a lot. The area surrounding the wound shows severe fibrosis, and local lymph drainage is impaired. The treatment includes debridement of the wound and protection of its edges, adapted CDT and mobilization of the patient.

Adapted complex decongestive therapy

Together with his colleagues from the Colloquium, Peter Nolte, Specialist in General Medicine from Meinerzhagen-Valbert, also advocates the early treatment of existing edemas and their professional removal. For the majority of patients with chronic wounds and lymphedema, the method of choice is adapted complex decongestive therapy (CDT). “Its first pillar is manual lymph drainage (MLD) – this includes the edges of the wound and its immediate surroundings. It helps with edema reduction and loosening of local fibrosis as well as improvement of lymphangiomotor function. If required, intermittent pneumatic compression can also help,” Peter Nolte explains. The second pillar is compression therapy. During the initial decongestive phase, multi-layer compression bandages – ideally lymphological compression bandages – are applied, and the compressive effect can be increased using pressure pads, for example. During the consequent maintenance phase, compression stockings or a compression stocking system is generally used. “Luckily, there are only very few disorders or conditions in which MLD or compression therapy are not possible,” John Hakman adds. Other components of adapted CDT include decongestive physiotherapy, skin care and the application of suitable wound dressings, good patient education as well as the treatment of co-morbidities. “If appropriately adapted CDT is started in time in cases of chronic wounds, there will be fewer edemas, reduced fibrosis and less exudate. This also means a reduced use of wound dressings and less frequent bandage replacement with quicker healing – leading to lower costs,” Dr. Fiedler summarizes.

Venous leg ulcers

A venous leg ulcer (VLU) is a substance defect in the tissue. This defect extends from the dermis to the subcutis and usually occurs in the lower third of the lower leg, in the area of the medial malleolus. Particularly high blood pressure in the veins and skin capillaries caused by vein problems in this area is responsible for its development. This increased pressure is often the result of a defect in the venous valves, for example, following deep vein thrombosis (post-thrombotic syndrome), but it can also develop in cases of obesity, restricted joint mobility or heart valve disease. Because of the high hydrostatic pressure in the large leg veins, pressure in the venous (post-)capillary vessels also rises, from which – owing to congestion-induced damage to the capillary membranes – proteins and inflammatory cells increasingly permeate the tissue, resulting in fibrosing edema, i.e. lymphedema with typical inflammation. At the same time, more capillary vessels and initial lymph vessels are damaged and, over the long term, their structure changes due to fibrotic microangiopathic processes; as a result, the tissue no longer receives the required nutrients because of excessively long, impassable diffusion paths, and the skin cells die over time.

The VenoTrain ulcertec stocking system is used during the maintenance phase.

Monitoring the wound

Patients with venous leg ulcers still need stamina for professional decongestion. “After decongestion of the wound edges has been completed, i.e. the surroundings of the wound in the broadest sense, to aid exudate management, and having established low-germ, damp wound conditions, granulation can be expected to start around the edges of the wound five to seven days later,” John Hakman reports from his own experience. If healing doesn’t progress as desired, several parameters need to be checked: “Are there any signs of an infection? Is another debridement needed? Are the decongestive measures sufficient? Sometimes, surgery is required to relieve pressure on the venous system,” the surgeon explains.

Preventing recurrences

After twelve months, the venous leg ulcer has healed completely. The patient is no longer in pain and demonstrates good mobility. .

One aspect is very important to Falk Peters, who is also a Colloquium member and managing director of Sanitätshaus Enneper medical supply retailer at Südwestfalen Medical-Center: “Treating venous leg ulcers is a long-term project that patients must be educated about and motivated for again and again.” Plus, those affected should also consistently continue their compression therapy once the venous leg ulcer has healed. At about 50 per cent, the rate of recurrence for venous leg ulcers during the first year after healing is still quite high at the moment.1 Long-term compression therapy significantly contributes to maintaining a state without venous leg ulcers as well as achieving more quality of life in general.
The expert orthotist attaches a lot of importance to the right medical product being prescribed. In order to avoid mistakes when prescribing a product – with the agreement of the patients – his team contacts the physicians, if required, to coordinate the process in good time. “If there are delays during treatment, everyone involved can quickly become frustrated, thus jeopardizing successful healing,” Falk Peters explains.
The members of the Colloquium believe that networking during the treatment of venous leg ulcers also makes a considerable difference. Interdisciplinary collaboration between physicians, medical supply retailers, physiotherapists and nursing care services ensures a high level of patient independence and constant updating and adjusting of treatment needs. “Good treatment of venous leg ulcers always means teamwork as well,” John Hakman summarizes

The VenoTrain ulcertec with patented rhomboid knit ensures continuous therapeutic pressure. Slight transverse extension makes the overstocking easy and painless to put on.

Stocking selection based on the
treatment phase

The type of compression garment is always based on the treatment phase and the individual patient’s needs. If the patient has an active venous leg ulcer (VLU), phlebological or lymphological compression bandages are used during the initial decongestive phase, i.e. for severely congested extremities with a high degree of wound exudation. A suitable compression stocking should be chosen for the maintenance phase. Depending on the edema situation and individual anatomy, a flat-knit, custom-made compression stocking, such as the VenoTrain curaflow, can be used.

Systematic compression

In most cases, an ulcer compression stocking system is used for VLU. The VenoTrain ulcertec consists of an overstocking and a liner. The liner, which also secures the wound dressing, provides continuous, low-level compression during periods of rest, thus assisting the wound healing process by applying basic compression, even at night. The overstocking, with its patented special knit, ensures a high level of working pressure during movement and is easy to put on and take off. To ensure targeted treatment, the system is available in two sets with different compression strengths around the ankle:
VenoTrain ulcertec 39 (moderate) and VenoTrain ulcertec 46 (strong).
When the VLU has healed, long-term, consistent compression therapy is recommended to prevent recurrence.

Klare WR., Eder S.: Erfolgreiches Therapiekonzept des Ulcus cruris. Deutsches Institut für Wundheilung (2008). In the guidelines “Medizinische Kompressionstherapie der Extremitäten mit Medizinischem Kompressionsstrumpf (MKS), Phlebologischem Kompressionsverband (PKV) und Medizinischen adaptiven Kompressionssystemen (MAK)” – AWMF registration number: 037/005 – Chapter 3 states that compression therapy is indicated to prevent the recurrence of venous leg ulcers.

 

Images: Bauerfeind, Colloquium Lymphologie & Wundheilung, John Hakman


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