Defining wound bed conformability: a new testing methodology to assess the relative swelling rise of foam dressings.

OBJECTIVE: Using a dressing that expands and conforms to the wound bed upon exudate absorption is one of the best ways to promote wound healing. While many products claim wound bed conformability, no externally replicated or verified test methodology had been developed to quantify a wound dressing's ability to conform to the wound bed. The Relative Swelling Rise (RSR) test methodology was developed to measure the relative swelling rise of foam dressings upon fluid absorption, and offers a quantifiable and easily replicated method to measure wound bed conformability. METHOD: The RSR test method was developed, validated and reliability tested by Coloplast A/S, Denmark. External replication was provided by ALS Odense, Denmark (previously DB Lab). Circular fences provide a fixed diameter to apply and contain the fluid and prevent horizontal spreading in the test set-up. The swelling height is quantified relative to the fence's inner diameter, i.e., the ratio alpha (α), and allows evaluation of a material's ability to conform to the wound bed. RESULTS: Biatain Silicone foam products (n=3, Coloplast A/S, Denmark) were tested, all afforded an average α-ratio from 0.30 to 0.60. The relative standard deviations were between 1-3%, demonstrating the strength of the test. Robustness of the methodology was demonstrated through the internal validation study, the reliability study, and both an internal and external replication study, as well as a systematic literature review and expert review of the construct, content, criterion and generalisability of the method. CONCLUSION: Having a validated, effective and easily replicable testing method to quantify wound bed conformability of foam dressings is an important step towards achieving better healing outcomes.

Clinical performance and safety of a debridement pad with abrasive and non-abrasive fibres.

BACKGROUND: Debridement is key to removing devitalised tissue, debris and biofilm as part of wound-bed preparation. Unlike many other methods of debridement, mechanical debridement with a pad is effective enough to be used independently without an adjunctive method of debridement, while being more accessible than other standalone options. OBJECTIVE: To explore the clinical performance and safety of a debridement pad with both abrasive and non-abrasive surfaces in daily clinical practice. METHODS: This was a prospective, non-controlled, non-randomised, single-arm, open-label, multicentred observational evaluation. Inclusion criteria were wounds >4 cm2 covered with at least 30% debris, necrotic tissue or slough in patients aged ≥18 years. The treatment protocol comprised a single application of the debridement pad. The primary outcome measure was the amount of necrotic tissue, slough or debris in the wound bed. Secondary outcomes included the appearance of the wound bed, edges and periwound skin; self-reported pain scores; foreseeable negative impacts; and clinician satisfaction. RESULTS: A total of 62 participants with a variety of wound types were included in the analysis. Most wounds (87%) had been present for over 3 months and had high or moderate exudate levels (90%). A significant reduction was observed in all three parameters: necrotic tissue (p=0.043), slough (p<0.001) and debris (p<0.001). Necrotic tissue, slough and debris showed mean relative reductions of 40%, 72% and 40%, respectively. Of participants, 84% did not experience an increase in pain during the debridement procedure. CONCLUSION: This clinical real-world data shows the debridement pad to be an effective and well-tolerated device for debridement and wound bed preparation.

Microjet wound therapy versus sharp debridement on wound size reduction: a pilot randomised controlled trial.

OBJECTIVE: There are several methods of treating hard-to-heal (chronic) wounds, each differing in terms of efficiency, selectivity, speed, cost and pain. The objective is to activate a wound to initiate the healing cascade. For this pilot study we assessed the feasibility of a new microjet wound therapy technology compared to standard sharp debridement in wound outcomes. METHOD: A randomised, controlled, open-label pilot study was conducted in one outpatient wound clinic in Western Switzerland from March 2022 to May 2023. RESULTS: A total of 13 consecutive patients were randomly assigned to receive either microjet wound therapy (n=5) or standard mechanical debridement with instruments (n=8). As a feasibility study, there was insufficient power to detect significant differences between the groups. However, in the intervention group, our analysis may indicate a modestly faster reduction in wound area. Microjet wound therapy appears to alleviate patient anxiety and offer cost savings due to the potential for reduced time, as well as the number of required treatments. This meant fewer overall consultations. CONCLUSION: This study highlights a trend that may indicate that microjet therapy holds value in promoting faster healing of hard-to-heal wounds, and it provides a feasibility basis for a sufficiently powered multicentre trial.

Effects of concurrent optical and magnetic stimulation in hard-to-heal wounds: a real-world evidence case series.

OBJECTIVE: This work explores concurrent optical and magnetic stimulation (COMS) effects on hard-to-heal wounds in real-world settings. METHOD: In this case series, participants received COMS 1-3 times per week for up to 12 weeks alongside standard wound care. RESULTS: A total of 27 patients (18 female and nine male) were included. Mean age was 72 years. Participants' wounds that were unresponsive to standard wound care included: venous leg ulcers (VLUs, n=13); mixed leg ulcers (MLUs, n=4); diabetic foot ulcers (DFUs, n=1); pressure ulcers (PUs, n=5); and traumatic wounds (TWs, n=4). On average, COMS was applied twice a week, resulting in an overall mean wound area reduction of 69%. In 24 participants, COMS was used primarily to achieve wound closure by the end of the 12-week period, of which: 12 were classified as complete wound closure (50%; VLUs=8, PUs=3 and TW=1); four as likely-to-heal (17%; VLUs=2 and MLUs=2); four as 'improved' (17%; MLU=1, DFU=1 and TWs=2); and four as 'non-responding' (17%; VLUs=3 and MLU=1). The best results were achieved in PUs and VLUs (respectively 100% and 62% categorised as completely healed). When used in participants where its purpose was other than that of achieving wound closure, COMS was successfully used to debride two PUs, and for wound bed preparation in one TW. CONCLUSION: In this case series, COMS showed positive effects and appeared to be beneficial in healing different types of hard-to-heal wounds in community health and homecare settings. Novel COMS therapy aspects emerged: (1) positive outcomes for PU and VLU treatment; (2) COMS as a potential debridement tool when sharp debridement is unfeasible; and (3) COMS as a promising method to prepare wound beds for subsequent skin grafting or skin replacement procedures.

Silver nanoparticle dressing: The knowledge of advantages and limits improves the indications in clinical practice.

Silver nanoparticle dressings have gained popularity recently as a way to treat challenging wounds. Notwithstanding the properties of Ag-NPS (silver nanoparticles) described by several articles, there is a lack of clinical studies that guide healthcare professionals to specific and conscious use. In this case series, Ag-NPS dressing was tested on a randomized group of 10 patients with complex wounds requiring conservative treatment. Each case was analysed, recording the patient's history, the peculiar characteristics and the progressive changes in the wound. The wound bed and the quality of the peri-wound skin improved and a decrease in signs of infection was observed. The application of the dressing was simple and comfortable for the patient and it was appreciated for its sealing ability. A few capacity restrictions showed up: those should be read as elements to improve the indications for this peculiar dressing. The thin tissue matrix of the Ag-NPS dressing does not allow for massive absorption and also performs poorly in reducing little exudate. The reduction in wound width is also limited: reconstructive surgery was required in half of the enrolled patients to achieve wound healing.

Combination therapy of negative pressure wound therapy and antibiotic-loaded bone cement for accelerating diabetic foot ulcer healing: A prospective randomised controlled trial.

Negative pressure wound therapy (NPWT) and antibiotic-loaded bone cement (ALBC) are commonly used treatments for diabetic foot ulcers (DFUs). However, the combined efficacy of these two modalities remains unclear. This clinical study aimed to assess the effectiveness and underlying mechanisms of NPWT&ALBC in the management of DFUs. A total of 28 patients were recruited, 16 of whom served as controls and received only NPWT, whilst 12 received NPWT&ALBC. Both groups underwent wound repair surgery following the treatments. Blood samples were obtained to detect infections and inflammation. Wound tissue samples were also collected before and after the intervention to observe changes in inflammation, vascular structure and collagen through tissue staining. Compared with the NPWT group, the NPWT&ALBC group exhibited a superior wound bed, which was characterised by reduced inflammation infiltration and enhanced collagen expression. Immunostaining revealed a decrease in IL-6 levels and an increase in α-SMA, CD68, CD206 and collagen I expression. Western blot analysis demonstrated that NPWT&ALBC led to a decrease in inflammation levels and an increase in vascularization and collagen content. NPWT&ALBC therapy tends to form a wound bed with increased vascularization and M2 macrophage polarisation, which may contribute to DFUs wound healing.

Blue light photobiomodulation for reactivation of healing in wounds not responding to standard therapy.

OBJECTIVE: Blue light (410-430nm) has been suggested to be effective in the healing process of hard-to-heal wounds. The aim of this study was to test this hypothesis. METHOD: This single-centre observational study assessed the efficacy of photobiomodulation with blue light (120 seconds at a distance of 4cm from the wound bed once a week for four weeks) in activating healing in patients with hard-to-heal skin lesions (mean duration 23.9 months) of the lower limb that had not responded to four weeks of standard treatment. RESULTS: A total of 59 patients were assessed. Wounds were divided into groups according to aetiology: hard-to-heal venous wound (30.5%); hard-to-heal arterial and mixed wounds (16.9%); hard-to-heal inflammatory wound (22.0%); other hard-to-heal wounds (13.6%); and acute wound (16.9%). The mean reduction in wound area at the end of the four-week treatment period with blue light compared with baseline was 51.38% (p<0.001) across all wounds. Among subgroups, the best performance was obtained for hard-to-heal venous wounds, achieving a 63.36% (p<0.001) mean reduction in wound size, and acute wounds, achieving a mean reduction of 82.76% (p<0.001). The greatest mean change in wound bed score was seen at the end of the four-week treatment period with blue light, with an increase in the mean score from 8.6 at baseline to 12.8 at week four (77.2%; p<0.001). There was a clear decrease in pain during blue light treatment, achieving a reduction in the average numeric rating scale (NRS) from 4.3 at baseline to 1.8 at week 4 (53.23%; p <0.001). At week 4, the highest proportion of complete healing was seen in acute (100.0%) and venous wounds (83.3%). CONCLUSION: Based on these results, photobiomodulation with blue light appears to reactivate the healing process in acute and hard-to-heal wounds that do not respond to standard treatment. Photobiomodulation with blue light treatment is easy to perform and safe, with no reported adverse events or side-effects.

Edge trenching: a case study of a novel debridement technique.

Debridement is a vital part of wound bed preparation; however, even a perfectly debrided wound may stall if it has vertical edges or the tissue in the wound base does not merge with the wound edges. A novel debridement technique described in this case study allows wound remodelling to overcome these difficulties.

Cost-Effectiveness of PHMB & betaine wound bed preparation compared with standard care in venous leg ulcers: A cost-utility analysis in the United Kingdom.

BACKGROUND: Wounds cost £8.3 billion per year in the United Kingdom (UK) annually. Venous leg ulcers (VLUs) account for 15% of wounds and can be complicated to heal, increasing nurse visits and resource costs. Recent wound bed preparation consensus recommends wound cleansing and biofilm disrupting agents. However, inert cleansers such as tap water or saline are inexpensive, an evaluation of evidence is required to justify the higher upfront costs of treatment with active cleansers. We undertook a cost-effectiveness analysis of the use of a biofilm disrupting and cleansing solution and gel, Prontosan® Solution and Gel X, (PSGX) (B Braun Medical), as compared to the standard practice of using saline solution, for treating VLUs. METHODS: A Markov model was parameterised to one-year costs and health-related quality of life consequences of treating chronic VLUs with PSGX versus saline solution. Costs are viewed from a UK healthcare payer perspective, include routine care and management of complications. A systematic literature search was performed to inform the clinical parameters of the economic model. Deterministic univariate sensitivity analysis (DSA) and probabilistic sensitivity analysis (PSA) were undertaken. RESULTS: For PSGX an Incremental Net Monetary Benefit (INMB) of £1,129.65 to £1,042.39 per patient (with a Maximum Willingness to Pay of £30k and £20k per QALY respectively), of which cost savings are £867.87 and 0.0087 quality-adjusted life years (QALYs) gain per patient. PSA indicates a 99.3% probability of PSGX being cost-effective over saline. CONCLUSIONS: PSGX for the treatment of VLUs is dominant compared with saline solution in the UK with expected cost-savings within a year and improved patient outcomes.

Implications of endotoxins in wound healing: a narrative review.

Bacterial toxins are thought to play a role in delayed wound healing in critically colonised and infected wounds. Endotoxins are released from Gram-negative bacteria when they are lysed by host phagocytic cells during an immune response, or by antimicrobial agents, potentially leading to a detrimental effect on the host tissues. Endotoxins can affect all aspects of the wound healing process, leading to delayed healing and contributing to wound chronicity. Release of endotoxins by bacteria can also have serious systemic effects (for example, septic shock) that can lead to high levels of patient mortality. This review summarises the role and implications on wound healing of bacterial endotoxins, describing the impact of endotoxins on the various phases of the wound healing response. There is a paucity of in vivo/clinical evidence linking endotoxins attributed to a wound (via antibiotic treatment) or their release from infecting bacteria with parameters of delayed wound healing. Future work should investigate if this link is apparent and determine the mechanism(s) by which such detrimental effects occur, offering an opportunity to identify possible treatment pathways. This paper describes the phenomenon of antimicrobial-induced endotoxin release and summarises the use of wound dressings to reduce wound bioburden without inducing microbial death and subsequent release of endotoxins, thus limiting their detrimental effects.

Wound dressing adherence: a review.

Wound dressing adherence is an important problem that is frequently encountered in wound care, and is associated with both clinical and economic burdens. However, only a few review articles have focused on this issue. The objective of this review was to present a comprehensive discussion of wound dressing adherence, including the mechanism of dressing adherence, adverse consequences (clinical burdens and economic burdens), factors affecting adherence (dressing-, patient- and wound-related factors, and factors related to the wound care procedure), tests to assess dressing adherence (in vitro assay, in vivo assay and clinical trials), and reduction of wound adherence (modification of dressing adherence and special care in particular patients). Accordingly, this review article emphasises an awareness of dressing adherence, and is intended to be an informative source for the development of new dressings and for wound management.

HydroTac-a hydro-responsive wound dressing: a review of the in vitro evidence.

AIM: The aim of this review is to identify and summarise the key in vitro evidence available to support the use of HydroTac (HRWD-2) to address specific aspects associated with the treatment of both acute and hard-to-heal wounds. BACKGROUND: The provision of a moist wound healing environment to support optimal wound healing has been a basic tenet in wound care since the pioneering work on the benefits of occlusion to support wound healing. Modern wound dressings have adopted the benefits of moist healing through their innovative development. HRWD-2 has been shown in clinical studies to enable and support good healing outcomes and the in vitro evidence in support of this dressing is presented in this article. METHOD: An online literature search (supplemented with a manual search of resources not available online) was conducted to identify articles and studies describing in vitro evidence in support of HRWD-2 in aspects important for promoting a healing response in the clinical environment. RESULTS: In vitro studies showed that HRWD-2 contributes to balancing moisture levels and enhances the availability of growth factors known to be important for re-epithelialisation. Pre-clinical studies indicate that HRWD-2 enhances wound re-epithelialisation. Together these results suggest that HRWD-2 promotes a moist healing environment leading to the dressing supporting re-epithelialisation. In vitro data indicating an intrinsic lower in vitro adherence of HRWD-2 likely translate clinically to the benefits of an atraumatic wound dressing, including reduced pain (specifically at dressing change). CONCLUSION: The in vitro evidence presented in this review supports the successful clinical results reported for HRWD-2 in terms of fluid management, wound healing and pain reduction at dressing change.

Wound tissue segmentation by computerised image analysis of clinical pressure injury photographs: a pilot study.

OBJECTIVE: Wound tissues can provide ample information about the wound development and healing process. However, the manual identification and measurement of wound tissue types is time-consuming and challenging due to the complexities of pressure injuries (PI). This study aims to develop an image analysis algorithm to automatically identify and differentiate wound tissue types from PI wound beds. METHOD: This was a cross-sectional algorithm development study. PI photographs were obtained from a western Pennsylvania hospital. We used our previously developed wound bed segmentation tool to identify PI wound beds. We then used the k-means clustering method to classify the subzones on the wound beds. Finally, the support vector machine classifier was used to identify the classified subzones to certain types of wound tissue. RESULTS: An image analysis algorithm was developed, using 64 selected PI photographs, to automatically identify different wound tissues for PIs. CONCLUSION: Validation of the wound tissue identification of the PIs by image analysis algorithm demonstrated that our image analysis algorithm is a reliable and objective approach to monitoring wound healing progress through clinical PI photographs, and offers new insight into PI evaluation and documentation. DECLARATION OF INTEREST: The authors have no conflicts of interest to declare.

The value of administering intravenous antibiotics during haemodialysis in the treatment of diabetic foot infections.

OBJECTIVE: People with diabetes who are on haemodialysis (HD) are at a high risk of diabetic foot infections (DFI) and related complications. We explored the value of treating DFI with intravenous (IV) antibiotics during HD. METHOD: This was an observational study of consecutively treated patients with DFIs with IV antibiotics during HD. Data collected included baseline characteristics, IV antibiotics used, details of multidisciplinary interventions and DFI treatment outcome. RESULTS: A cohort of 11 patients, mean (±standard deviation) age 62.4±12.7 years, had 15 episodes of treatment with IV antibiotics during HD. Of the patients, six (54.5%) were male and nine (81.8%) had type 2 diabetes. The estimated mean glomerular filtration rate (eGFR) was 11.4±3.9ml/minute. All patients had infected foot ulceration, soft tissue infection, six (54.5%) patients had osteomyelitis, and two (18.2%) had wet gangrene. The commonest IV antibiotic used was vancomycin (10/15 episodes, 66.7%). Other IV antibiotics used were daptomycin and meropenem. In three episodes, oral ciprofloxacin was used with IV antibiotics. The mean duration of antibiotic treatment was 9.2±4.9 weeks. Of the episodes, 11 (73.3%) were treated successfully with IV antibiotics alone and two (13.3%) episodes required minor surgical debridement/amputation. Some 10 (90.9%) members of the cohort had peripheral arterial disease and of those, five (50%) underwent angioplasty during IV antibiotic treatment. CONCLUSION: HD provides a good opportunity for treatment with IV antibiotics in DFI. This mode of administration of IV antibiotics, along with multidisciplinary intervention, is associated with ulcer healing and resolution of infection in over three-quarters of patients with DFI. DECLARATION OF INTEREST: The authors have no conflicts of interest to declare.

The importance of periwound skin in wound healing: an overview of the evidence.

DECLARATION OF INTEREST: The authors have no conflicts of interest.

Hydro-responsive wound dressings for treating hard-to-heal wounds: a narrative review of the clinical evidence-part 2.

This narrative clinical review summarises the key evidence in support for the use of a hydro-responsive wound dressing, HydroTac (HRWD-2, PAUL HARTMANN AG, Germany) to address key aspects associated with the treatment of both acute and hard-to-heal wounds. This review demonstrates how HRWD-2 can be used in general to address the challenges presented by a wide range of wound types and skin injuries. It highlights the ability of HRWD-2 to regulate an optimal moist wound environment that promotes wound progression and healing. Key aspects covered in this review include the dressing's ability to: promote certain phases of the wound healing response (for example, re-epithelialisation) address the concepts and needs for wound progression as set out in the TIME wound management framework provide an optimal hydration level reduce tissue trauma and pain at dressing change.

The clinical impact of hydro-responsive dressings in dynamic wound healing: Part II.

OBJECTIVE: Over the course of a wound's healing trajectory, whether the wound is acute or hard-to-heal, management is likely to involve the use of several different dressing types. Minimising the complexity of treatment (in terms of dressing usage) would aid clinicians in providing effective wound care but excellent clinical outcomes must remain the primary goal. METHOD: This study was an open-labelled, non-comparative study assessing the clinical effectiveness of a coordinated wound dressing treatment regimen. After an initial phase of using a hydro-responsive wound dressing (HydroClean, HRWD-1, PAUL HARTMANN AG, Germany) to cleanse and debride hard-to-heal wounds, the wounds were subsequently treated with either HydroTac (HRWD-2, PAUL HARTMANN AG, Germany) (to maintain healing progression and re-epithelialisation) or RespoSorb (a superabsorbent dressing, PAUL HARTMANN AG, Germany) (to manage moderate-to-high levels of exudate). The Pressure Ulcer Scale for Healing (PUSH) assessment tool was used to measure the wound status over the course of the treatment period and to assess several wound status parameters (for example, wound area, exudate levels and wound characteristics such as level of re-epithelialisation). RESULTS: The results from this study demonstrated that wounds treated with HRWD-2 showed a positive healing response when using the PUSH score assessment tool with a significant mean reduction (p<0.0001) in the PUSH score of wounds treated with HRWD-2, with >75% of wounds being closed by the end of the study. This result underlines the effectiveness of HRWD-2 in supporting healing progression. CONCLUSION: The results from this study support the coordinated use of HRWDs for the effective management and treatment of a variety of hard-to-heal wounds.

Topical cannabis-based medicines - A novel adjuvant treatment for venous leg ulcers: An open-label trial.

Venous leg ulcers are highly prevalent lower limb integumentary wounds that remain challenging to heal despite the use of evidence-based compression therapies. A multitude of adjuvant treatments has been studied but none have demonstrated enough efficacy to gain adoption into treatment guidelines. Global attention on Cannabis-Based Therapies is increasing and has been driven by quantum scientific advancements in the understanding of the endocannabinoid signalling system. Topical Cannabis-Based Medicines represent a novel treatment paradigm for venous leg ulcers in terms of promoting wound closure. Fourteen complex patients with sixteen recalcitrant leg ulcers were treated with Topical Cannabis-Based Medicines in conjunction with compression bandaging, every second day, to both wound bed and peri-wound tissues. The cohort had a mean age of 75.8 years and was medically complex as reflected by a mean M3 multimorbidity index score of 2.94 and a mean Palliative Performance Scale score of 67.1%. Complete wound closure, defined as being fully epithelialized, was achieved among 11 patients (79%) and 13 wounds (81%) within a median of 34 days. All three remaining patients demonstrated progressive healing trends but were lost to follow-up. The treatments were well tolerated, and no significant adverse reactions were experienced. The rapid wound closure of previously non-healing venous leg ulcers among elderly and highly complex patients suggests that Topical Cannabis-Based Medicines may become effective adjuvants in conjunction with compression therapy. This may also indicate that they may have an even broader role within integumentary and wound management. Therefore, this treatment paradigm warrants being subjected to controlled trials.

Novel antimicrobial ointment for infected wound healing in an in vitro and in vivo porcine model.

Microbial contamination of wounds is a significant problem that delays healing, particularly when bacterial biofilms are present. A novel combination of pectinic acid (PG) + caprylic acid (CAP) was previously found in vitro to be highly effective in eradicating various pathogens in biofilms with minimal cytotoxicity. In this study, a novel wound ointment was formulated with PG + CAP and first assessed in vitro using a well-established biofilm eradication model. In vitro, the PG + CAP ointment was shown to be efficacious in reducing the microbial biofilms. This ointment was then tested in vivo in two pilot porcine wound healing models, with and without Staphylococcus aureus microbial challenge. Ointments were applied to each wound daily, and healing by wound closure area measurement was assessed weekly over 4 weeks. After 4 weeks, pigs were sacrificed and wounds were scored for reepithelialization, inflammation, granulation tissue, and collagen deposition. We compared PG + CAP to hydroxyethylcellulose + glycerol ointment base (control) and MediHoney (comparator). In the porcine microbial challenge model, the novel antimicrobial PG + CAP wound ointment rapidly eradicated bacterial organisms embedded in wounds, was safe and well-tolerated, and was associated with enhanced healing compared to ointment base and MediHoney. Specifically, the cumulative histopathology, reepithelialization of epidermis, and mature granulation tissue in the wound bed was significantly better with PG + CAP than with control and MediHoney treatments. This ointment warrants further study as a non-antibiotic ointment for use in treating a wide array of infected wounds.

Microcirculatory changes in venous leg ulcers using intermittent electrostimulation of common peroneal nerve.

OBJECTIVE: Activation of the venous muscle pumps of the leg by intermittent transdermal neuromuscular stimulation of the common peroneal nerve has been previously shown to augment venous and arterial flow in patients with leg ulcers. This study aims to establish if microcirculation in the wound bed and periwound area are augmented by the activation of a neuromuscular electrostimulation device (NMES) (Geko, Firstkind Ltd., UK). METHOD: In this self-controlled, observational study, laser speckle contrast imaging was used to map and quantify microcirculatory flow in the wound bed and periwound area of patients with venous leg ulcers (VLU). Values of flow and pulsatility in these locations were compared with the NMES device, both active and inactive. RESULTS: A total of 16 patients took part in the study. Microvascular flux increased by 27% (p=0.014) in the wound bed, and by 34% (p=0.004) in the periwound area, when the NMES device was activated. Pulsatility increased by 170% (p<0.001) in the wound bed and 173% (p<0.001) in the periwound area when the device was activated. CONCLUSION: Intermittent electrostimulation of the common peroneal nerve substantially increased both microcirculatory flux and pulsatility in the wound bed and in the periwound area of the VLUs of patients in this study. This provides a plausible mechanistic explanation for its reported efficacy in healing VLUs.