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Optimal Care of Chronic, Non-Healing, Lower Extremity Wounds: A Review of Clinical Evidence and Guidelines

Published on: December 17, 2013
Project Number: RC0507-000
Product Line: Rapid Response
Research Type: Devices and Systems
Report Type: Summary with Critical Appraisal
Result type: Report

Report in Brief

Context
Chronic leg and foot ulcers occur in many adults with vascular disease or diabetes. These ulcers may last 12 to 13 months and recur in 60% to 70% of patients. Care for chronic wounds has been reported to cost 2% to 3% of health care budgets in developed countries.

Technology
Multidisciplinary care teams may include wound care nurses, physical therapists, chiropodiatrists, vascular surgeons, and others.When specialists such as vascular surgeons are involved, they may perform complex procedures such as venous ablation or revascularization.

Issue
It is unclear when patients should be referred to specialists or when care should be specialist-led. A review of clinical evidence and current guidelines will help inform decisions about the care of patients with chronic lower extremity wounds.

Methods
A limited literature search was conducted of key resources, and titles and abstracts of the retrieved publications were reviewed.Full-text publications were evaluated for final article selection according to predetermined selection criteria (population, intervention, comparator, outcomes, and study designs).

Results
The literature search identified 239 citations, with 3 additional articles identified from other sources. After screening the abstracts, 11 were deemed potentially relevant and 5 reports met the criteria for inclusion in this review: 1 non-randomized study and 4 guidelines.

Key Messages

  • Among patients who receive specialist-led care, those who undergo venous ablation may have improved healing of ulcers. This is based on one study, and the result was not statistically significant.
  • Evidence-based guidelines highlight the need for multidisciplinary care. The team should include health professionals as well as at-home caregivers, patients, and families.
  • Reasons to use specialist-led care may include: unclear cause for the wound, wounds caused by ischemia (lack of blood supply), patients unable to manage the wound-care regimen, suspected cancer, wounds with unusual distribution, or patients with peripheral artery disease.

Question

  1. What is the clinical evidence regarding the need for specialist-led advanced care for chronic, non-healing, non-pressure related lower extremity wounds?
  2. What are the evidence-based guidelines regarding the multidisciplinary management of chronic, non-healing, non-pressure related lower extremity wounds?

Key Message

Evidence from one uncontrolled non-randomized study suggests that specialist-lead advanced care for chronic, non-healing, non-pressure related wounds may result in positive outcomes such as healing and that mixed arterial and venous ulcerations are a complex wound presentation for which there is little consensus regarding optimal management. Evidence regarding specialist care compared to healing in the absence of specialist-led advanced care is lacking. Evidence-based guidelines highlight the need for multidisciplinary care that includes participation from at-home caregivers and the patient. Indications for specialist-lead advanced care include evidence of ischemia, inability to comply with wound-care regimens, suspected malignancy, and peripheral arterial disease.

Tags

ulcer, diabetic foot, leg ulcer, lower extremity, wound healing, wounds and injuries, Ulcers