Transcatheter Arterialization of Deep Veins in Chronic Limb-Threatening Ischemia.

BACKGROUND: Approximately 20% of patients with chronic limb-threatening ischemia have no revascularization options, leading to above-ankle amputation. Transcatheter arterialization of the deep veins is a percutaneous approach that creates an artery-to-vein connection for delivery of oxygenated blood by means of the venous system to the ischemic foot to prevent amputation. METHODS: We conducted a prospective, single-group, multicenter study to evaluate the effect of transcatheter arterialization of the deep veins in patients with nonhealing ulcers and no surgical or endovascular revascularization treatment options. The composite primary end point was amputation-free survival (defined as freedom from above-ankle amputation or death from any cause) at 6 months, as compared with a performance goal of 54%. Secondary end points included limb salvage, wound healing, and technical success of the procedure. RESULTS: We enrolled 105 patients who had chronic limb-threatening ischemia and were of a median age of 70 years (interquartile range, 38 to 89). Of the patients enrolled, 33 (31.4%) were women and 45 (42.8%) were Black, Hispanic, or Latino. Transcatheter arterialization of the deep veins was performed successfully in 104 patients (99.0%). At 6 months, 66.1% of the patients had amputation-free survival. According to Bayesian analysis, the posterior probability that amputation-free survival at 6 months exceeded a performance goal of 54% was 0.993, which exceeded the prespecified threshold of 0.977. Limb salvage (avoidance of above-ankle amputation) was attained in 67 patients (76.0% by Kaplan-Meier analysis). Wounds were completely healed in 16 of 63 patients (25%) and were in the process of healing in 32 of 63 patients (51%). No unanticipated device-related adverse events were reported. CONCLUSIONS: We found that transcatheter arterialization of the deep veins was safe and could be performed successfully in patients with chronic limb-threatening ischemia and no conventional surgical or endovascular revascularization treatment options. (Funded by LimFlow; PROMISE II study ClinicalTrials.gov number, NCT03970538.).

To Mesh or Not to Mesh: What Is the Ideal Meshing Ratio for Split Thickness Skin Grafting of the Lower Extremity?

Split-thickness skin grafts can provide effective autologous wound closure in patients with dysvascular comorbidities. Meshing the graft allows for reduced donor site morbidity and expanded coverage. This study directly compares outcomes across varying meshing ratios used to treat chronic lower extremity wounds. Patients who received split-thickness skin grafts to their lower extremity for chronic ulcers from December 2014 to December 2019 at a single center were retrospectively reviewed. Patients were stratified by meshing ratios: nonmeshed (including pie crusting), 1.5:1, and 3:1. The primary outcome was clinical "healing" as determined by surgeon discretion at 30 days, 60 days, and the latest follow-up. Secondary outcomes included postoperative complications, graft loss, ulcer recurrence, progression to amputation, and mortality. A total of 321 patients were identified. Wound sizes and location differed significantly, with 3:1 meshing applied to the largest wounds (187.8 ± 157.6 cm2; 1.5:1 meshed, 110.4 ± 103.9 cm2; nonmeshed 38.7 ± 55.5 cm2; p < .0001) mostly of the lower leg (n = 18, 75%; 1.5:1 meshed, n = 23, 43.4%; nonmeshed n = 62, 25.7%; p < .0001). Meshed grafts displayed a significantly higher proportion of healing at 30 and 60 days, but no differences persisted by the final follow-up (16.5 ± 20.5 months). Longitudinally, nonmeshed STSG was associated with most graft loss (46, 19.1%; p = .011) and ulcer recurrence (44, 18.3%; p = .011). Of the 3 meshing ratios, 3:1 exhibited the lowest rates of complications. Our results suggest that 3:1 meshing is a safe option for coverage of large lower extremity wounds to minimize donor site morbidity.

Sublesional fat grafting leads to a temporary improvement of wound healing in chronic leg ulcers: A prospective, randomised clinical trial.

Chronic wounds remain a therapeutic and financial challenge for physicians and the health care systems. Innovative, inexpensive and effective treatment methods would be of immense value. The sublesional fat grafting could be such treatment, although effectiveness and safety have only been assessed in a few randomised clinical trials. The fat graft was obtained by liposuction, washed with the Coleman method and then injected sublesional and into the wound margins after surgical debridement. For the control group, saline solution was used instead of fat. The primary endpoint was to determine the wound size reduction in both groups. The wounds were measured preoperatively, intraoperatively and 3, 7, 21 and 60 days after the intervention. A p-value of <0.05 was considered significant. Furthermore, histology and microbiology of the wounds and pain were assessed. A temporary effect of the treatment was observed after 14 and 21 days. The wound size reduction was significantly larger in the intervention group, whereas after 60 days, no significant difference was detected between both groups. No adverse events could be reported and the pain level was almost equal in the control and intervention group. Sublesional fat grafting temporarily enhanced healing of chronic wounds. The procedure was safe and the pain level was low. Repeated interventions could lead to complete wound closure, which should be determined in future studies.

Unique Usages of Dehydrated Human Amnion Chorion Membrane Allografts in Dermatology.

Dehydrated human amnion chorion membrane (dHACM) allografts are synthetic skin substitutes derived from placental tissue. dHACM allografts are used for replacing lost or damaged dermal tissue, as they contain many of the components found within the extracellular matrix that are beneficial in wound healing. Common uses of dHACM allografts include the healing of diabetic and non-diabetic foot and leg ulcers, decubitus ulcers, and wounds following debridement. While these grafts have been proven to be beneficial in other disciplines of medicine, their potential for use in the field of dermatology is emerging. Current clinical cases and research have shown dHACM allografts to be beneficial in repairing damaged tissue due to dermatologic conditions. They could play a role in the treatment of conditions causing chronic wounds, including dermal scarring or loss, and the repair of fragile skin. Examples of dHACM allograft use in dermatology include cases of pyoderma gangrenosum, Netherton syndrome, and wound healing with Mohs micrographic surgery. This literature review explores the efficacy of using dHACM allografts for the treatment of healing wounds within the field of dermatology. J Drugs Dermatol. 2023;22(12):1228-1231. doi:10.36849/JDD.7115.

Biomarkers of Skin Graft Healing in Venous Leg Ulcers.

There is a need for biomarkers that predict the success of transplantation of venous leg ulcers (with autologous split-thickness skin grafts). The primary objective of this exploratory study was to investigate the association between split-thickness skin graft healing in venous leg ulcers and candidate wound fluid biomarkers representing inflammatory cell and endogenous proteinase activities, and bioactivity. A secondary objective was to compare biomarker levels of the 17 venous leg ulcers with sterile split-thickness skin graft donor-site wounds in another 10 patients with venous leg ulcers. Wound fluids were collected for 24 h using a validated method. The concentration of preoperative matrix metalloproteinase-9 in wound fluid was higher in venous leg ulcers showing good healing (n = 10) than in venous leg ulcers showing poor healing (n = 7) 12 weeks after transplantation with meshed split-thickness skin grafts. The diagnostic value of matrix metalloproteinase-9 was good according to receiver-operating characteristic curve analysis. Matrix metalloproteinase activity in wound fluids from split-thickness skin graft donor-site wounds increased as a function of time and healing, but was still lower than matrix metalloproteinase activity in venous leg ulcer wound fluids, which showed increased levels of most biomarkers except for matrix metalloproteinase-9 and matrix metalloproteinase-2. In conclusion, wound fluid matrix metalloproteinase-9 concentration is a potential predictive biomarker of split-thickness skin graft healing in venous leg ulcers.

Early ABI Testing May Decrease Risk of Amputation for Patients With Lower Extremity Ulcers.

BACKGROUND: Patients with lower extremity wounds from diabetes mellitus or peripheral artery disease (PAD) have a risk of amputation as high as 25%. In patients with arterial disease, revascularization decreases the risk of amputation. We aimed to determine if the early assessment of arterial perfusion correlates with the risk of amputation. METHODS: We retrospectively reviewed patients referred to the vascular clinic over 18 months with Rutherford Grade 5 and 6 chronic limb-threatening ischemia to determine if patients had a pulse exam done at the time the wound was identified and when ankle brachial index (ABI) testing to evaluate perfusion was performed. Kaplan Meier analysis was used to determine if the timing of ABI testing affected the time to revascularization, wound healing, and risk of amputation. RESULTS: Ninety-three patients with lower extremity wounds were identified. Of these, 59 patients (63%) did not have a pulse exam performed by their primary care provider when the wound was identified. Patients were classified by when they underwent ankle brachial index testing to assess arterial perfusion. Twenty-four had early ABI (<30 days) testing, with the remaining 69 patients having late ABI testing. Patients in the early ABI group were more likely to have a pulse exam done by their PCP than those in the late group, 12 (50%) vs. 22 (32%), P = 0.03. Early ABI patients had a quicker time to vascular referral (13 days vs. 91 days, P < 0.001). Early ABI patients also had quicker times to wound healing than those in the late group (117 days vs. 287 days, P < 0.001). Finally, patients that underwent early ABI were less likely to require amputation (Fig. 1), although this did not reach statistical significance (P = 0.07). CONCLUSIONS: Early ABI testing expedites specialty referral and time to revascularization. It can decrease the time to wound healing. Larger cohort studies are needed to determine the overall effect of early ABI testing to decrease amputation rates.

Pain control with punch grafting in ulcers with underlying arteriolosclerosis.

OBJECTIVE: Martorell hypertensive ischaemic ulcers are often misdiagnosed and can be a clinical and therapeutic challenge. Controversy exists regarding both their underlying triggers and the type of treatment that should be carried out. This study was designed to compare the effectiveness of punch grafting and conventional therapy in pain reduction. METHOD: A single-centre retrospective study was performed, including 40 patients with a clinical diagnosis of a Martorell ulcer or post-traumatic ulcer secondary to arteriolopathy in the elderly, who were treated with punch grafting (n= 24) or conventional medical treatment (n=16). RESULTS: There was a statistically and clinically significant reduction in pain after punch grafting. The minimal overall reduction was of three points in visual analogue pain scores. Of the patients who received punch grafting, 80% reported a VAS pain score of 0 at the third follow-up, in contrast with the 44% (n=4) patients who were treated without punch grafting. The mean time to epithelialisation was 82.1 days in patients who received conventional treatment and 43.5 days in those who received punch grafts. CONCLUSION: Punch grafting is a simple, validated and cost-effective technique that can be performed on an outpatient basis, promotes wound healing and reduces pain. It may control pain and stimulate epithelialisation even if the wound does not present with optimum wound bed characteristics for graft taking. Pain reduction and faster epithelialisation are associated with improvements in patients' quality of life.

Curing Necrotic Angiodermatitis with an Intact Fish Skin Graft in a Patient Living with Diabetes.

Background and Objectives: We describe a case of necrotic angiodermatitis. Materials and Methods: We used an intact fish skin graft to treat a patient living with diabetes, which was complicated by end-stage renal failure and arterial hypertension. The entire therapeutic procedure was carried out in ambulatory care without requiring the hospitalization of the patient. Results: The patient experienced a marked reduction in pain and complete epithelization of the lesion after 10 weeks of treatment. Conclusion: Our experience presents a new therapeutic approach to necrotic angiodermatitis.

[Management of chronic ulcers: punch grafting]. / Prise en charge des ulcères chroniques : la greffe en pastilles.

Chronic ulcers are a common but important dermatological problem and a major source of expense in the western countries. Skin graft is a surgical procedure in which skin or skin substitute is transplanted in order to close a wound. This article aims to review the different categories of grafts, their indications for the healing of chronic ulcers of the lower limbs, emphasizing the position of punch grafts in the treatment arsenal.

Les ulcères chroniques représentent un problème dermatologique courant et donc une source majeure de dépenses dans les pays occidentaux. La greffe de peau est une intervention chirurgicale au cours de laquelle la peau ou un substitut de peau est transplanté afin de favoriser la cicatrisation d'une plaie. Cet article a pour but de faire le point sur les différentes catégories de greffe, leurs indications dans la prise en charge des ulcères chroniques des membres inférieurs en soulignant la place des greffes en pastilles dans l'arsenal thérapeutique à disposition.

Malignant Transformation of Nonhealing Ulcer-Basal Cell Carcinoma.

We discuss the rare case of a 72-year-old female with a history of a nonhealing lower extremity ulcer that was biopsied, revealing malignant transformation to basal cell carcinoma (BCC). Although BCC is the most common malignancy worldwide, malignant transformation of nonhealing wounds is more often associated with squamous cell carcinoma. Current literature estimates the rate of BCC arising from venous stasis ulcer to occur between 1.5 and 15%. When diagnosed early, BCC can have cure rates of up to 95%. However, metastatic BCC has a median survival of roughly 8 months. We believe it is important to raise awareness of this rare, but often curable, clinical diagnosis to improve long-term outcomes.

Efficacy of maggot debridement therapy on refractory leg ulcers of Behçet disease: an open-label study.

BACKGROUND: Cutaneous ulcers of Behçet disease (BD) are rare but have high morbidity and resistance to conventional therapies. An important and essential aspect of ulcer management is debridement. Regarding maggot therapy (MT), excretions of the green bottle fly, Lucilia sericata, have been shown to have the ability to remove necrotic debris and promote healing. AIM: To evaluate the efficacy of MT for cutaneous ulcers of BD. METHODS: In this open-label trial, patients with BD with refractory leg ulcers suitable for MT were enrolled. Maggot application was performed until complete debridement was achieved, and all patients were followed up for 12 months afterwards to assess the total healing of ulcers. RESULTS: In total, 24 patients with 32 ulcers were enrolled. Using MT, 91.6% of all ulcers were completely debrided. Mean time to debridement was 14.9 days and mean number of cycles required was 5.3. Mean ulcer size was decreased by 23% with treatment. Time to debridement was positively correlated with pretreatment ulcer size and ulcer duration (P = 0.01 and P < 0.01) but not with ulcer depth, comorbidities, smoking, age or sex (P > 0.05 for all). During follow-up, 79.1% of all ulcers healed completely. Mean time required for total healing was positively correlated with ulcer duration, pretreatment and post-treatment ulcer area, ulcer depth and mean time to total debridement (P < 0.03, P = 0.00, P = 0.04 and P < 0.01, respectively). CONCLUSIONS: To our knowledge, the findings presented in this first and unique study may provide key answers about factors affecting success rate of MT in BD cutaneous ulcers.

[Long-term healing of a therapy-refractory venous leg ulcer after crural fasciectomy and split skin graft transplantation]. / Langfristige Abheilung eines therapierefraktären Ulcus cruris venosum nach kruraler Fasziektomie und Spalthauttransplantation.

A 59-year-old obese woman had been suffering from a painful, chronic leg ulcer since 1986. We diagnosed a venous leg ulcer due to functional chronic venous insufficiency in the context of obesity per magna (dependency syndrome) and arthrogenic congestion syndrome due to immobility. Although a high ligation and stripping of the great saphenous vein and several so-called shave therapies with split skin transplantation after appropriate wound bed preparation had been previously performed, the wound persisted. In 2012, the patient wanted to amputate her leg because the course of wound healing was so refractory to therapy and she suffered from severe pain. As an alternative to amputation, we performed a crural fascietomy and, after a wound bed preparation with two cycles of negative pressure wound therapy, we covered the defect with a split skin graft using the mesh graft technique. The surgery could be performed without complications and the skin healed completely. At the current presentation 7 years after the intervention, complete healing of the previously therapy-refractory venous leg ulcer was shown despite the persistent obesity per magna and immobility. This case report shows that a crural fasciectomy should be considered, especially in the case of otherwise therapy-refractory courses of venous leg ulcers.

Rates and timing of subsequent amputation after initial minor amputation.

OBJECTIVE: Studies evaluating major amputation after initial minor amputation are few with rates of subsequent major amputation ranging from 14% to 35% with limited understanding of associated comorbidities and time to limb loss. The aim of this study is to determine the major amputation rates for patients who had already undergone an initial minor amputation and determine which factors are associated with the need for subsequent major amputation. METHODS: Using statewide data between 2005 and 2013, patients with peripheral artery disease (PAD), diabetes mellitus (DM), and combined PAD/DM who had a lower extremity ulcer and who had also undergone a minor amputation were identified. These patients were evaluated for the rate of subsequent major amputation and competing risk Cox proportional hazards modeling was used to study which factors were associated with the risk of subsequent limb loss. RESULTS: The cohort consisted of 11,597 patients (DM, n = 4254; PAD, n = 2142; PAD/DM, n = 5201) with lower extremity ulcers who underwent an initial minor amputation. The rate of any subsequent amputation was highest in patients with PAD/DM (23% vs DM = 17%, PAD = 17%; P = not statistically significant). The rate of subsequent minor amputation was 16% in the PAD/DM versus 15.2% in PAD and 12.2% in patients with DM (P < .001). Patients with PAD/DM had the highest rate of subsequent major amputation (6.3% vs DM = 5.2%, PAD = 2.1%; P < .001). There was no statistically significant difference in the median time to major amputation among the three groups (PAD/DM, 13 months; DM, 14 months; PAD, 8.6 months; P = NS). Patients who were revascularized before a repeat minor amputation had a decreased risk of a major amputation compared with those who were intervened on after a repeat minor amputation (hazard ratio, 0.002; 95% confidence interval, 0-0.22). Patients treated completely in the outpatient setting were also less likely to undergo subsequent major amputation (hazard ratio, 0.7; 95% confidence interval, 0.5-0.98) compared with those who required hospitalization or presented to the emergency room. CONCLUSIONS: Patients with ulcers and combined PAD and DM have a higher risk for secondary major and minor amputation than patients with either disease alone with half of the limb loss occurring at approximately 1 year after the initial minor amputation. Additionally, early diagnosis and appropriate referral may result in decreased limb loss for these patients.

Free gastroepiploic lymph nodes and omentum flap for treatment of lower limb ulcers in severe lymphedema: Killing two birds with one stone.

BACKGROUND AND OBJECTIVES: In patients with lymphedema, the disruption of the lymphatic network increases skin turgor and fibrosis of subcutaneous tissue, delays wound healing, causing recurrent ulcerations and infections. In these cases, management of ulcers can be challenging. METHODS: Between January 2016 and June 2018, patients presenting with lymphedema were enrolled at our Institution. We selected patients with severe lymphedema and ulcers of lower limbs and we performed a surgical approach, involving free gastroepiploic lymph nodes and omentum flap, harvested through laparoscopy. RESULTS: We enrolled 135 patients presenting for lymphedema. Among them, 10 eligible cases underwent excision of the ulcer and reconstruction with omentum flap. Mean age was 57.8 years and average follow-up 24.1 months. Circumferences and skin tonicity significantly decreased from the preoperative period. Lymphoscintigraphy showed improvement of the lymphatic drainage and restoration of lymphatic network. No episodes of infection were recorded in the postoperative period. CONCLUSIONS: Our combined procedure merges free flap techniques and lymphedema surgery: omentum covers the defect while providing a new source of lymph nodes, improving the lymphatic networks of the affected limb. This technique can highly increase the quality of life of the patient in a single-stage operation with fast recovery and low donor site morbidity.

The Controlling Nutritional Status Score is Significantly Associated with Complete Ulcer Healing in Patients with Critical Limb Ischemia.

BACKGROUND: It has been reported that the Controlling Nutritional Status (CONUT) score, calculated using the serum albumin concentration, total peripheral lymphocyte count, and total cholesterol concentration, is a valuable nutritional status index. In the present study, we assessed whether the CONUT score was a significant predictor of complete ulcer healing in patients with critical limb ischemia (CLI). METHODS: In this retrospective, single center, cohort study, conducted from January 2013 to June 2018, we treated 112 limbs of 89 patients with Fontaine 4 CLI at the Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Japan. The primary endpoint of the study was complete ulcer healing after revascularization, and the secondary endpoint was amputation-free survival (AFS). RESULTS: The mean follow-up time was 17.8 months. Complete ulcer healing was achieved during the follow-up period in 91 (81.2%) limbs. The median ulcer healing time was 104 days (range, 16-574 days). In multivariate analysis, improvement of lower skin perfusion pressure ratio of <1, end-stage renal disease, and high CONUT score (>4) were predictive of incomplete ulcer healing in patients with Fontaine 4 CLI. In addition, the AFS rate was significantly better in patients with a CONUT score ≤4 than in those with a CONUT score >4. CONCLUSIONS: The CONUT score was associated with postprocedure ulcer healing and long-term limb retention in patients who underwent revascularization. The management of CLI involving ischemic foot ulcers may require ongoing consideration of nutritional status.

Perioperative Outcomes of Lower Extremity Revascularization for Rest Pain and Tissue Loss.

BACKGROUND: Critical limb ischemia (CLI) is the clinical manifestation of severe peripheral artery disease presenting as rest pain (RP) and tissue loss (TL). Most studies compare CLI as a homogenous group with claudication with limited database studies specifically studying these differences. We hypothesize that CLI should be stratified into RP and TL because of significant differences in disease severity, comorbidities, and outcomes. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database from 2012 to 2016 was reviewed. All patients with a postoperative diagnosis of CLI undergoing femoral to popliteal bypass (FPB) with vein or graft were identified. Patients were stratified into cohorts based on International Classification of Disease (ICD)-9 or ICD-10 codes for RP or TL (gangrene or ulcer). Univariate and multivariate analyses were performed to examine 30-day mortality, morbidity, major amputation, and readmission adjusting for demographics, comorbidities, and procedural details. RESULTS: There were 5,304 patients. Compared to RP, patients with TL were older (P < 0.0001) and more likely to be dependent (P < 0.0001). TL patients were also more likely to have diabetes (P < 0.0001), congestive heart failure (P < 0.0001), renal failure (P = 0.004), dialysis (P < 0.0001), history of wound infection (P < 0.0001), and sepsis (P < 0.0001). TL patients had higher American Society of Anesthesiologists class (P < 0.0001), were less likely to be transferred from home (P < 0.0001), and more likely to receive an FPB with vein (P = 0.03). Patients with TL had worse perioperative outcomes compared with RP in terms of pneumonia (P = 0.004), unplanned intubation (P = 0.009), cardiac arrest requiring cardiopulmonary resuscitation (P = 0.003), bleeding requiring transfusions (P < 0.0001), sepsis (P < 0.0001), septic shock (P = 0.02), and reoperation (P < 0.0001). TL was associated with significantly higher 30-day morbidity (P < 0.0001), 30-day mortality (P < 0.0001), major amputation (P = 0.0004), and readmission rates (P = 0.005). Patients with TL compared with those with RP also had longer hospital stays (P < 0.0001) and days between operation to discharge (P < 0.0001). TL was independently associated with increased 30-day morbidity (OR: 1.16 [1.00-1.35]) and major amputation (OR: 2.48 [1.29-4.76]) compared with RP. CONCLUSIONS: Patients with RP and TL have drastic differences that impact perioperative mortality and readmissions. TL is an independent predictor of 30-day morbidity and major amputation. The stratification of CLI into RP and TL can provide insight into variations in outcomes and provide a means to quantify the risks associated with the 2 manifestations of the disease.

Cadaveric Skin Grafts May Greatly Increase the Healing Rate of Recalcitrant Ulcers When Used Both Alone and in Combination With Split-Thickness Skin Grafts.

BACKGROUND: Leg ulcers that do not heal despite appropriate treatment are defined as recalcitrant ulcers. Large surface area, depth, and long duration represent some of most important factors impeding ulcer healing. After sharp debridement, dermal substitutes including skin from cadaver donors may increase the healing rate of recalcitrant ulcers reducing the risk of scar formation and recurrence. OBJECTIVE: Assessing if, after sharp debridement, dermal substitutes including skin from cadaver donors may increase the healing rate of recalcitrant ulcers reducing the risk of scar formation and recurrence. PATIENTS AND METHODS: Among patients admitted to our hospital for all types of chronic leg ulcers, we retrospectively reviewed the records of patients affected by recalcitrant ulcers (surface greater than 100 cm, tissue loss involving epidermis, dermis, and subcutaneous tissue, duration longer than 1 year, and showing no healing tendency). After sharp debridement, the ulcers were covered by allografts with strict follow-up after discharge. Multiple allografts were performed when necessary, and a final autograft was applied in case of incomplete healing. RESULTS: The records of 414 patients were analyzed. Forty-three patients were lost at follow-up, and the remaining 371 healed after 765 grafting procedures. In 163 patients, the ulcers healed by means of a final autograft. In all the remaining cases, allograft led to ulcer healing. CONCLUSION: Allografts represent an effective treatment option in case of recalcitrant, large, deep and long-lasting leg ulcers.

Use of a bacterial fluorescence imaging system to target wound debridement and accelerate healing: a pilot study.

OBJECTIVE: Optimal wound-bed preparation consists of regular debridement to remove devitalised tissues, reduce bacterial load, and to establish an environment that promotes healing. However, lack of diagnostic information at point-of-care limits effectiveness of debridement. METHOD: This observational case series investigated use of point-of-care fluorescence imaging to detect bacteria (loads >104CFU/g) and guide wound bed preparation. Lower extremity hard-to-heal wounds were imaged over a 12-week period for bacterial fluorescence and wound area. RESULTS: A total of 11 wounds were included in the study. Bacterial fluorescence was present in 10 wounds and persisted, on average, for 3.7 weeks over the course of the study. The presence of red or cyan fluorescent signatures from bacteria correlated with an average increase in wound area of 6.5% per week, indicating stalled or delayed wound healing. Fluorescence imaging information assisted in determining the location and extent of wound debridement, and the selection of dressings and/or antimicrobials. Elimination of bacterial fluorescence signature with targeted debridement and other treatments correlated with an average reduction in wound area of 27.7% per week (p<0.05), indicative of a healing trajectory. CONCLUSION: These results demonstrate that use of fluorescence imaging as part of routine wound care enhances assessment and treatment selection, thus facilitating improved wound healing.

Limb salvage procedure in immunocompromised patients with therapy-resistant leg ulcers-The value of ultra-radical debridement and instillation negative-pressure wound therapy.

The purpose of this study was to analyse the outcome of our established triple treatment strategy in therapy-resistant deep-thickness chronic lower leg ulcers. This limb salvage approach consists of ultra-radical surgical debridement, negative-pressure wound therapy (NPWT) with or without instillation, and split-thickness skin grafting. Between March 2003 and December 2019, a total of 16 patients and 24 severe cases of lower leg ulcers were eligible for inclusion in this highly selective population. A total of seven patients received immunosuppressive medication. Complete wound closure was achieved in 25% and almost 90% of included lower leg ulcer cases after 3 and 24 months of our triple treatment strategy, respectively. The overall limb salvage rate was 100%. Bacterial colonisation of these wounds was significantly reduced after multiple surgical debridements and NPWT. Fasciotomy and radical removal of devitalised tissue such as deep fascia, tendons, and muscles combined with NPWT showed promising results in terms of the overall graft take rate. This treatment strategy was considered as last resort for limb salvage in such a critically ill and immunocompromised patient population. Surgeons should be aware of its efficacy and consider the triple treatment strategy especially if no other limb salvage option remains.

[Martorell hypertensive ischemic ulcer: an atypical wound to know]. / Angiodermite nécrotique†: un ulcère à connaître.

Martorell hypertensive ischemic ulcer is often an unrecognized cause of chronic leg ulcer and may result in a delayed management. We describe a typical case report with clinical key features for diagnosis and therapeutic management. Pathophysiology and main differential diagnosis are discussed. Skin biopsy can be used to rule out differential diagnosis. Management should be focused on pain control, evaluation and treatment of cardiovascular risks before performing a skin graft.

L'angiodermite nécrotique ou ulcère de Martorell est une cause souvent méconnue d'ulcère chronique des membres inférieurs, pouvant conduire à un retard de prise en charge. Au travers d'un cas clinique typique, nous discutons des hypothèses physiopathologiques et de la prise en charge diagnostique et thérapeutique. La biopsie cutanée permet d'éliminer les diagnostics différentiels. Le traitement est spécifique et repose sur un contrôle de la douleur, la recherche et le traitement des facteurs de risque cardiovasculaire avant d'entreprendre une greffe cutanée de peau mince.