EWMA Journal January 2009 by EWMA European Wound Management Association

Volume 9 Number 1 January 2009

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Published by European Wound Management Association

EMENT ORGANIS G A ATI AN M ON D N

EWMA Council

The EWMA Journal ISSN number: 1609-2759 Volume 9, No 1, January, 2009 Electronic Supplement January 2009: www.ewma.org The Journal of the European Wound Management Association Published three times a year

Marco Romanelli

Editorial Board Carol Dealey, Editor Deborah Hofman, Editor Electronic Supplement

President

Michelle Briggs Finn Gottrup E. Andrea Nelson Marco Romanelli Zbigniew Rybak José Verdú Soriano Rita Gaspar Videira Peter Vowden

Sue Bale Recorder

Luc Gryson

Zena Moore

Treasurer

Secretary & President Elect

Carol Dealey

Finn Gottrup

Marcus Gürgen

Sylvie Meaume

E. Andrea Nelson

Patricia Price

EWMA web site www.ewma.org Editorial Office please contact: EWMA Business Office Congress Consultants Martensens Allé 8 1828 Frederiksberg C, Denmark. Tel: (+45) 7020 0305 Fax: (+45) 7020 0315 ewma@ewma.org Layout: Birgitte Clematide

Paulo Alves

Jan Apelqvist

Severin Läuchli

Maarten J. Lubbers

EWMA Journal Editor

Printed by: Kailow Graphic A/S, Denmark Copies printed: 13,000 Prices: Distributed free of charge to members of the European Wound Management Association and members of co-operating associations. Individual subscription per issue: 7.50€ Libraries and institutions per issue: 25€ The next issue will be published May 2009. Prospective material for publication must be with the editors as soon as possible and no later than 1 February 2009 The contents of articles and letters in EWMA Journal do not necessarily reflect the opinions of the Editors or the European Wound Management Association. Copyright of all published material and illustrations is the property of the European Wound Management Association. However, provided prior written consent for their reproduction obtained from both the Author and EWMA via the Editorial Board of the Journal, and proper acknowledgement and printed, such permission will normally be readily granted. Requests to reproduce material should state where material is to be published, and, if it is abstracted, summarised, or abbreviated, then the proposed new text should be sent to the EWMA Journal Editor for final approval.

Salla Seppänen

José Verdú Soriano

Rita Videira

Peter Vowden

CO-OPERATING ORGANISATIONS’ BOARD Andrea Bellingeri, Italy Saša Borović, Serbia Rosine van den Bulck, Belgium Mike Clark, UK Mark Collier, UK Rodica Crutescu, Romania Louk van Doorn, the Netherlands Bülent Erdogăn, Turkey Milada Francu, Czech Republicl Kiro Georgievski, Macedonia Georgina Gethin, Ireland Finn Gottrup, Denmark João Gouveia, Portugal Luc Gryson, Belgium

Marcus Gürgen, Norway Mária Hok, Hungary Gabriela Hösl, Austria Dubravko Huljev, Croatia Hunyadi János, Hungary Arkadiusz Jawień, Poland Els Jonckheere, Belgium Aníbal Justiniano, Portugal Susan Knight, UK Martin Koschnik, Germany Jozefa Koskova, Slovak Republic Aleksandra Kuspelo, Latvia Goran Lazovic, Serbia Christina Lindholm, Sweden

Editorial Board Members Carol Dealey, UK (Editor) Michelle Briggs, UK Finn Gottrup, Denmark Deborah Hofman, UK E. Andrea Nelson, UK Marco Romanelli, Italy Zbigniew Rybak, Poland José Verdú Soriano, Spain Rita Gaspar Videira, Portugal Peter Vowden, UK

EWMA Journal Scientific Review Panel Paulo Jorge Pereira Alves, Portugal Gabriela Hösl, Austria Caroline Amery, UK Zoltán Kökény, Hungary Sue Bale, UK Zena Moore, Ireland Mark Collier, UK Karl-Christian Münter, Germany Bulent Erdogan, Turkey Pedro L. Pancorbo-Hidalgo, Spain Madeleine Flanagan, UK Hugo Partsch, Austria Milada Franců, Czech Republic Patricia Price, UK Peter Franks, UK Rytis Rimdeika, Lithuania Francisco P. García-Fernández, Spain Salla Seppänen, Finland Luc Gryson, Belgium Carolyn Wyndham-White, Switzerland Gerald Zöch, Austria

For contact information, see www.ewma.org

Magnus Löndahl, Sweden Sandi Luft, Slovenia Kestutis Maslauskas, Lithuania Sylvie Meaume, France Karl-Christian Münter, Germany Guðbjörg Pálsdóttir, Iceland Alessandro Scalise, Italy Salla Seppänen, Finland José Verdú Soriano, Spain Carinne Ward, Malta Anne Wilson, UK Carolyn Wyndham-White, Switzerland Skender Zatriqi, Kosova

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Journal 2009 vol 9 no 1

Dear Readers

M 3 Editorial

Carol Dealey

Science, Practice and Education 5 Wound related pain: evaluating the impact of education on nursing practice Helen Hollinworth

11 Safety and efficacy of a dermal substitute in the coverage of cancellous bone after surgical debridement for severe diabetic foot ulceration Carlo Caravaggi, Adriana Barbara, Sganzaroli, Ileana Pogliaghi, Paola Cavaiani, Matteo Fabbi Ferraresi Roberto

17 Does surgery heal venous ulcers? Giorgio Guarnera

19 The CEAP classification and its evolution Pier Luigi Antignani, Claudio Allegra

26 The role of incompetent perforators Olle Nelzén

33 Hemodynamic patterns of venous reflux in patients with leg ulcers Hugo Partsch

40 Combined superficial and deep vein reflux in venous ulcers: operative strategy Giorgio Guarnera

43 National Wound Prevalence Studies Peter Franks

EBWM 44 Abstracts of recent Cochrane reviews Sally Bell-Syer

EWMA 46 Finnish Wound Care Society (FWCS) Salla Seppänen

48 The first decade of HAAVA Journal Ansa Iivanainen

50 EWMA Patient Outcome Group Finn Gottrup

51 The Implementation Challenge Marco Romanelli

56 EWMA Journal Previous Issues 56 International Journals 58 EWMA Corporate Sponsor Contact Data 60 EWMA Travel Grants

Conferences 61 Conference Calendar

Organisations 62 Cooperating and Associated Organisations

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Journal 2009 vol 9 no 1

ay I start this first Editorial of 2009 by wishing you all a peaceful and successful 2009. It will no doubt be eventful in one way or another, despite the financial problems that are causing difficulties for many. But before considering the prospects for the New Year, I would like to reflect on the year just past. In particular, I would like to correct something that was omitted from my editorial in the last issue of the Journal. I would like to pay tribute to several people who have retired from EWMA Council in 2008 after serving in a variety of ways for a considerable number of years. They are: Judit Daróczy, Peter Franks, Deborah Hofman, Christina Lindholm, Christine Moffatt and Zbigniew Rybak. More can be found about this on page 52-54. As well as their contribution to EWMA, I have valued their friendship over the years and especially their support in hard times as well as the fun we have all had together. They will be missed.

It seems to me that 2008 was a busy year for conferences, especially with our conference in Lisbon fairly closely followed by the World Union conference in Toronto and then numerous others through the rest of the year. One conference that I particularly wish to mention was the annual conference of the Italian society Associazione Italiana Ulcere Cutanee (AIUC). The conference had an international session with several prestigious speakers from across Europe. We are greatly honoured to have the opportunity to publish some of these papers in a special section of this issue of the Journal (pages 17- 43). The section is introduced by Dr Guarnera who was the conference president and focuses on the prevention and management of venous ulceration. It gives us an opportunity to learn more about some of the surgical advances in this field that are generally only discussed in specialist journals. Each year there are mutterings of ‘there are too many conferences for them all to be viable’, but it does not seem to make much difference. However, I believe that in the current economic downturn, things will change. So I would urge you to consider supporting the 19th EWMA Conference to be held in Helsinki, May 20-22 in cooperation with the Finnish Wound Care Society (FWCS). The theme of the conference is: “Healing, Educating, Learning and Preventing in Wound Care”. The sessions will deal with advancement of education and research in relation to epidemiology, pathology, diagnosis, prevention and management of wounds. Key sessions include: n Plenary opening session: HELP – Healing, Educating, Learning, and Preventing in Wound Care n Biofilms n Influence of pharmacological drugs to improve orimpair wound healing n Patient Education and Self Care n The Potentials for Technology in Wound Management – Documentation, Wound Monitoring & Telemedicine n What is new in: Vascular ulcers, Diabetic Foot, Pressure ulcers and Dressing? n Principles of Prevention n Guidelines/Position Documents on Compression, Diabetic Foot, Infectuous Diseases n Wounds caused by Microorganisms The conference will be held at Helsinki Fair Centre, which is located in Itä-Pasila, a modern urban complex within easy reach of the city centre. Participants will therefore not only benefit from the scientific aspect of the conference but also from the beautiful location of the conference. It sounds like a great opportunity to learn more about the latest developments in wound care and also see something of Helsinki. It just remains for me to thank the Editorial Board and the Scientific Review Panel for their hard work in 2008 and hope that they will continue their work for 2009. Carol Dealey, Editor

Science, Practice and Education

Wound related pain: evaluating the impact of education on nursing practice Abstract Background: Nurses’ knowledge and attitudes to patient care are central to sensitively addressing wound related pain. Aim: To compare the effect of an educational initiative at one hospital, with the knowledge and practice of nurses from across the region. Methods: One section of an audit questionnaire was used to determine nurses’ management of wound related pain at one hospital before and after an educational workshop. The same two questions were used on both occasions. A different group of nurses from across the region attending a wound care study day which contained no education on wound pain answered the same two audit questions. This group represented varied areas of practice including nurses from other acute hospitals and community nurses. The study day nurses had no known regional or in-house education on wound related pain in the last 12 months, but it is likely that some had received previous education on this topic. Results: Following the workshop, 18 out of 64 nurses from the hospital studied would review the product if the last dressing change was painful and similarly, 16 out of 64 if a dressing had adhered to the wound bed. In comparison, a much higher number (58 and 60 respectively) of 96 nurses attending the study day would review the dressing in these circumstances. Discussion: One of the essential requirements for learning to occur is motivation. Knowledge is not infectious, but enthusiasm is1. Sensitive management of wound related pain appears to have become embedded in the practice of those nurses who have attended study days and courses with a specific focus on wound related pain led by the author. A single workshop, a section of which was led by the author, and where pain issues are only one component, is probably insufficient to evoke or sustain change. Conclusion: Commitment to addressing issues of wound related pain through an on-going pro-

gramme appears to result in sustained change across a region. Short interventions have limited effect.

Background Nurses are the main professional group caring for people with wounds. Their knowledge and attitudes to patient care are central to wound management that sensitively addresses issues of pain2. Nurses at one general hospital had become deskilled in wound care because virtually all wound care for the Trust concerned is undertaken by a centralised unit with its own staff. This limited knowledge of contemporary wound care was based on observation and incidents reported by the Tissue Viability Nurse Specialist and her staff trained in wound management. As the hospital wished to move much of the wound care back to the clinical areas, a hospital wide educational initiative was preceded and followed by an audit questionnaire to evaluate changes in nurses’ knowledge and practice. This focused organisational approach, aiming to raise the knowledge and practice of nurses at the hospital concerned, provided an opportunity to compare their resultant knowledge specific to wound related pain with that of nurses from across the region. It is this post educational comparison which is presented here. Purely the hospital based audit is published elsewhere3.

Helen Hollinworth MA, RN, RNT Senior Teaching Practitioner Faculty of Health Wellbeing and Science University Campus Suffolk Ipswich Suffolk UK Correspondance to: h.hollinworth@ucs.ac.uk

Methods Two open scenario based questions, within an audit questionnaire to evaluate nurses’ wound care knowledge, were used to determine nurses’ management of wound related pain issues prior to, and four months after a hospital wide educational workshop. The same two questions were used on both occasions. The two hour workshop, part of which focused on wound pain, was repeated over a period of three weeks to enable registered nurses from across the Trust to attend. The workshop 

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focused on the Trust’s wound care policy, wound classification, assessment of wound related pain, and dressing selection based on case studies – including product adherence. The latter section led by the author. A different group of nurses attending a regional wound care study day were invited to respond to the same two scenario based open questions. This regional study day did not include any education specific to pain issues in wound care, and there had been no inclusion of issues around wound related pain in any known regional or in-house education during the previous 12 months. However, the study day group of nurses may have received previous education on this topic by the author as assessment and management of wound related pain has been included in previous regional study days and educational programmes. All data collection occurred in the United Kingdom between June and October 2007. Approval for the audit was gained from the Trust concerned and the author’s university.

Results From the hospital studied, 72 nurses responded to the initial audit questionnaire including the two questions focused on wound related pain, and 64 nurses completed the same audit questionnaire to evaluate the knowledge underpinning their practice four months after the educational initiative3. A further 96 nurses from mixed clinical backgrounds attending a regional study day, not related to pain issues, completed the same two questions focused on wound related pain. These nurses represented acute hospitals other than that used for the educational initiative, community practitioners, together with nurses working in nursing homes and for general practitioners from across the region.

The first question posed the scenario: You are preparing to undertake a patient/client’s wound care when they complain that the last dressing change was rather uncomfortable or painful. What actions would you take?

Four months after attending the hospital-based workshop, 26 of the 64 nurses who responded would review the dressing if a patient complained the last dressing change was painful or uncomfortable; this compared with 25 out of 72 at the initial audit3. In contrast, the frequency with which study day nurses would review the dressing in a similar situation was higher at 58 out of 96 who responded (figure 1). The second question asked of respondents: n While you are changing a patient/client’s wound dressing you find that the product has adhered or stuck to the wound/ulcer bed. What actions, would you take? Similarly, the frequency with which study day nurses would review the dressing if a product had adhered to the wound bed, 60 out of 96 who responded, is higher (figure 2). Four months after the hospital-based workshop only 21 out of 64 nurses were selecting an alternative dressing; this compared to 16 out of 72 at the initial audit3.

Discussion Although a greater number of study day nurses would review the dressing if a patient complained the last dressing change was painful or uncomfortable, there are many other causes of wound related pain which are not linked to

Figure 1: Previous dressing change was rather uncomfortable or painful

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Science, Practice and Education

the product used4. These include the method of cleansing/ cleansing solution used (photograph available if required), prolonged exposure to the air and rough handling, but these were not included in any responses. Providing analgesia prior to the next dressing change can have a profound impact on the patient experience and this was identified by respondents. Pre-emptive analgesia is useful to reduce the neurological barrage of impulses associated with having a wound5. However, the critical issue of pain assessment did not form a category for any of the groups audited. Engaging with the individual to assess their pain experience and gain indicators of pain intensity is a principle of best practice6, and needs to be emphasised in future regional education. Adhered dressings are a common cause of trauma and wound related pain7, 8. Gauze and paraffin tulle are still frequently implicated in adhering to the wound bed, but where there is insufficient exudate, alginates or cellulose dressings will adhere and be difficult to remove9. In addition, viscous drying exudate can cause low-adherent dressings to adhere, as can products applied incorrectly (photo available if required). It is professionally unacceptable for the same product to be reapplied in these circumstances. Once a dressing has adhered to the wound bed, soaking to aid removal may be the only humane option. This approach was stated by nearly all respondents in all groups. But, as many practitioners will confirm from their own experience, the efficacy of this strategy is very limited10. The importance of reviewing product choice in these circumstances is therefore essential; a higher number of study day nurses indicated they would take this approach.

Compared to the Trust nurses, for whom part of a two hour workshop focused on pain issues, the nurses surveyed at the study day had no known regional or in-house education focused on wound related pain during the last 12 months. On the other hand, high attendance wound care study days have been organised in the region, at least annually, and studying a post-graduate tissue viability module is also popular. It is likely that a proportion of nurses at the regional study day had previously attended at least one of these educational opportunities which included detailed exploration of pain issues in wound care. The majority of education related to wound pain for all groups was undertaken by the author. It may also be relevant that the educationalist concerned is passionate about this topic and its significance in practice. The results appear to indicate that sensitive management of wound related pain has become embedded in the practice of the study day nurses, but this is much less evident for the nurses attending the single workshop. The differences in practice exposed between the two groups of nurses post education justify further consideration. One of the essential requirements for learning to occur is motivation11, and important to this discussion is understanding that motivation triggers human behaviour12. In addition, Barnett13 confirms that inspirational teaching requires the teacher to be inspired, and suggests the teacher’s enthusiasm finds an echo with the learner who gives life to this ‘spirit’, or new learning, in their own way. Race1 also makes a point that is pertinent here: knowledge is not infectious, but enthusiasm is. It is possible that sustained commitment by the author to raising the profile of patients’ experiences related to wound care has 

Figure 2: Dressing had adhered to wound or ulcer bed

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Science, Practice and Education

motivated others to share this desire to influence care14. Many nurses from across the region would have engaged in reviewing their practice at educational events over recent years, thus fostering the ‘mind-set’ that sensitive management during wound care procedures is the right of every individual15. On the other hand, the way students approach their learning is fundamental – if they do not seek to understand, then they do not understand16. Some nurses from the hospital workshop group may have been ‘sent’ by their managers because the education was a Trust wide initiative, rather than choosing to attend out of genuine interest which is more likely for those studying post-graduate wound care courses and/or attending study days. However, key to this discussion is recognising that isolated education has minimal impact on practice17. Motivational teaching is important, but frequently new learning needs to be reinforced. Those nurses attending the Trust workshop only received limited input on one occasion relative to pain issues in wound care. The results clearly demonstrate that this short intervention was insufficient to sustain the ‘mind-set’ critical to sensitively addressing wound related pain.

Conclusion The aim of this study was to compare the effect of an educational workshop at one hospital where staff had become deskilled in wound care, with the knowledge and practice of hospital and community nurses from across the region. The focus was on pain issues in wound care. The results demonstrate that commitment to addressing issues of wound related pain through an on-going educational programme appears to result in sustained change across a region. In contrast, short interventions have limited effect. Motivational teaching has a key role in enhancing patient outcomes, but this study demonstrates that one-off learning events do not sufficiently enable sensitive management of wound related pain to become embedded in practice. The challenge therefore is to sustain commitment to on-going education when there are multiple political and clinical demands impacting on nursing practice. Other significant challenges are to engage service users in education, and to inspire professionals other than nurses to recognise and address pain issues related to wound care. m

Implications for clinical practice n Nurses’ attitudes and practice related to wound pain is reflected in the quality of care received by patients n Sustained commitment to addressing pain issues in wound care through on-going educational programmes can result in change across a region n Pain assessment needs to be emphasised in all future regional education n Education which is isolated and entwined with other management outcomes may not sustain change Further research n Education to enhance the knowledge and attitudes of healthcare professionals other than nurses should be a focus for future research

References 1. Race, P., The lecturer’s toolkit. A practice guide to assessment, learning and teaching (third edition). Abingdon, Oxon: Routledge, (2007) 2. White, R., and Harding, K. (eds) Trauma and pain in wound care, Aberdeen: Wounds UK Limited (2006) 3. Hollinworth, H., Taylor, D., and Dyble, T., An educational partnership to enhance wound care, British Journal of Nursing (in press) (2008) (due to be published in Nov) 4. Hollinworth, H., The management of patients’ pain in wound care, Nursing – Standard Supplement, (2007) November 7, 13-20 5. Pediani, R., What has pain relief to do with acute surgical wound healing? World Wide Wounds (2001). Available from: www.worldwidewounds.com 6. World Union of Wound Healing Societies, Principles of Best Practice: Minimising pain at wound dressing-related procedures. A consensus document. (2004) Available on line at: www.wuwhs.org/pdf/consensus_eng.pdf 7. Hollinworth, H. and White, R. The clinical significance of wound pain in White, R., and Harding, K. (eds) (2006) Trauma and pain in wound care, Aberdeen: Wounds UK Limited (2006), 3-16 8. Mudge, E., Meaume, S., Woo, K., Sibbald, R., and Price, P., Patients’ experiences of wound-related pain: an international perspective, European Wound Management Association Journal, (2008), 8 (2), 19-28 9. Hofman, D. Wound pain and dressings, in White, R., and Harding, K. (eds), Trauma and pain in wound care, Aberdeen: Wounds UK Limited, (2006), 79-91 10. Hollinworth, H. and Collier, M., Nurses’ views about pain and trauma at dressings changes: results of a national survey, Journal of Wound Care, (2000), 9 (8), 369-373 11. Murphy, F., Motivation in nurse education practice; a case study approach, British Journal of Nursing, (2006), 15 (20), 1132-1135 12. Cole, G., Management theory and practice, 5th Edition. London, (1993) Letts Educational 13. Barnett, R., A will to learn. Being a student in an age of uncertainty, Maidenhead: Open University Press, (2007) 14. Scott, S. D., ‘New professionalism’ – shifting relationships between nursing education and nursing practice, Nurse Education Today, (2008), 28, 240-245 15. Human Rights Act, Office of Public Sector Information (1998). Available from: www.opsi.gov.uk 16. Prosser, M. and Trigwell, K., Understanding learning and teaching. The experience in higher education, Buckingham: Open University Press, (1999) 17. Randen, M., and Bernhardson, B. M., Pain education and conduction of local guidelines improved the attention to pain, Nursing Science and Research in the Nordic Countries, (2006) 26 (3) 57-59

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Journal 2009 vol 9 no 1

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Science, Practice and Education

Safety and efficacy of a dermal substitute in the coverage of cancellous bone after surgical debridement for severe diabetic foot ulceration Abstract Introduction: Deep Infection of the foot represents a severe complication. After aggressive debridement with residual bone exposition a very proximal mid-foot or rear foot amputation is often the only definitive surgical procedure that permits the foot to be salvaged. Aim: to perform a less severe amputation of the foot by employing a dermal substitute to cover exposed bones. Methods: From September 2006 to February 2008, 23 patients were submitted to aggressive debridement with residual bone exposition (3 TMA, 5 CHOPART amputations, 8 partial calcanectomy, 7 rays amputations). This was followed, after daily dressing to obtain a clean wound, by application of a new dermal substitute constituted by 100% Hyaluronic Acid Benzil Esther (Hyalomatrix PA). Results: We obtained a complete coverage of the exposed cancellous bone in 21 out of 23 patients in a period of 28 ± 17 days of treatment. After a period of 176 ±141 days we observed complete healing of the surgical wounds in 10 out of 23 patients (4 patients treated by skin graft and 6 patients healed by secondary intention). The remaining 11 patients presented reduction of wound area. One patient was submitted to above-the knee amputation due to recurrence of severe foot ischemia while one patient was lost at follow up. Conclusion: Our data demonstrates the safety and efficacy of HyalomatrixPA in coverage of cancellous bone exposition.

Carlo Caravaggi, MD University Vita Salute San Raffaele Milano (Italy) Director Diabetic Foot Departement Abbiategrasso Hospital Abbiategrasso Italy

Figure 1

INTRODUCTION Diabetic foot infection represents a serious complication of the evolution of both neuropathic and neuroischemic foot ulcers. In the international literature, the treatment of choice is considered to be aggressive surgical debridement applied with the aim to obtain control of local and systemic infection. Both in neuropathic and neuroischemic diseases, surgical debridement must be performed as soon as possible in order to save a major part of the foot and to reduce the risk of more proximal foot amputation and major amputation(1-3). Since it is well demonstrated that ischemia is strictly correlated with the risk of failure of any surgical procedures applied on diabetic foot lesions, in cases of severe PVD(4)

Adriana Barbara Sganzaroli, MD Ileana Pogliaghi Paola Cavaiani Matteo Fabbi Diabetic Foot Departement Abbiategrasso Hospital Abbiategrasso Italy Roberto Ferraresi Division of Cardiology, Fondazione IRCCS, Ospedale Maggiore Policlinico, Mangiagalli e Regina Elena, Milan Italy Correspondence to: Carlo Caravaggi carlo.caravaggi@ fastwebnet.it

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Figure 2 EWMA

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Figure 4

it is mandatory to perform a revascularisation procedure after the surgical debridement, with surgical or endoluminal approach, so as to restore a sufficient tissue blood perfusion in the area of the lesion. Deep infection of both the forefoot and mid-foot or deep infection with the involvement of the rear foot with exposition of the calcaneus bone should most often be treated by performing open mid-foot amputation (fig. 1-2) or aggressive heel debridement with subtotal calcanectomy in order to remove all infected tissue (fig. 3-4-5). Once local and systemic infection is under control, the definitive surgical step in cases of forefoot and mid-foot amputation is represented by a very proximal foot amputation at the Lisfranc or Chopart joint level, or below-knee amputation in cases of severe involvement of the os calcis.

AIM OF THE STUDY The objective of diabetic foot surgery is to salvage that part of the foot that allows patients to walk properly with both protective shoes and moulded insole to prevent recurrence of the ulcer. From a biomechanical point of view, the risk of ulcer recurrence is obviously correlated with the length and the stability of the residual foot. In order to minimize the need of very proximal mid-foot amputation or below-knee amputation, we have decided to employ a new bio-inductive dermal substitute (Hyalomatrix® PA, Fidia Advanced Biopolymers, Italy) as a definitive surgical procedure with the aim to obtain the coverage of bone exposition and consequently a less proximal foot amputation or savage of the limb in case of osteomyelitis of the calcaneous bone. MATERIAL AND METHODS Bio-inductive dermal substitute (Hyalomatrix® PA) Description HyalomatrixPA is a dermal substitute that derives from hyaluronic acid (HA) and is composed of a bi-layered, 12

Figure 5

sterile and flexible dressing(5). The wound contact layer consists of an absorbent, biodegradable, non-woven pad made by fibres entirely composed of the benzyl ester of HA (HYAFF). The outer layer is made of a flexible and transparent elastomer film (silicone membrane) that acts as a semi-permeable barrier against external agents and as a fluid-retentive mechanism(6). The HYAFF fibres integrate themselves into the wound bed and provide a three-dimensional scaffold particularly useful for the ordered colonization of fibroblasts, endothelial cells and the deposition of extracellular matrix components, favouring the reconstruction of the dermal tissue(7). Following spontaneous degradation through the de-esterification process, the HYAFF fibres release HA in a prolonged manner(8). The HA contributes to the maintenance of a moist environment which is useful for the wound healing process, but also stimulates angiogenesis, fibroblasts proliferation and controls the inflammation process(9). Protocol of use of Hyalomatrix® PA Preparation of the wound bed The application of the Hyalomatrix PA should follow a very strict protocol. The wound bed should be carefully prepared by performing a surgical debridement that permits the removal of all infected and non-vital tissue. Infected bone must be removed exposing vital bleeding cancellous bone. Daily dressing or negative wound pressure therapy can be applied to obtain a fairly clean wound. Haemostasis has to be carefully obtained Application of Hyalomatrix® PA Once a clean wound bed is obtained, a superficial debridement must be performed before applying the Hyalomatrix PA. All vital tissue and exposed cancellous bone must be slightly bleeding (fig. 6-7). Hyalomatrix PA is then applied on the entire area of the wound in contact with the debrided surface. The Hyalomatrix PA sheet is held in position with sterile staples placed on the border of the wound and in the centre of the wound in order to obtain EWMA

Journal 2009 vol 9 no 1

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a close contact between the inner layer and the wound bed. (fig. 8-9) Non-adherent gauzes and a compressive secondary dressing are then applied and fixed with sterile upper dressing.

Figure 6

Figure 7

Figure 8

Control of the wound bed is made weekly simply removing the secondary dressing. After a gentle cleansing of the graft, new non-adherent gauze is applied. After a few days, beneath the silicone film, it can be observed the appearance of a yellow slough, which does not imply an infection, but represents the progressive degradation and integration of the HYAFF® 11 pad into the wound bed. At the removal of the silicone film, generally after 21 days, a vital and compact new dermis appears on the wound bed.

Description of the study From September 2006 to February 2008, 23 diabetic patients were treated for severe deep infections of the foot. In eight patients we performed an open mid-foot amputation (three transmetatarsal amputations, five Chopart amputations), eight patients were submitted to open partial calcanectomy for heel ulcer with osteomyelitis of the os calcis, and seven patients were subjected to open forefoot amputation (single or multiple rays amputations). Of the 23 patients who presented critical limb ischemia with TcPO2 < 30 mmHg, 18 were submitted to endoluminal revascularisation procedures with angiographic and haemodynamic success (direct blood flow to the foot in at least one leg vessel and TcPO2 > 40 mmHg). Half of the patients received daily dressing with iodoform gauze after rinsing with hydrogen peroxide solution and water sterile solution. In the remaining 50% of patients, negative wound pressure therapy (VISTA S&N) was applied to control the exudates. A clean wound was obtained after a period of 10 ± 3 days (fig. 6-10). All the patients were then submitted to a second surgical look that consisted of debridement of soft tissue and exposed cancellous bone. Hyalomatrix PA was then applied following the protocol previously described. After Hyalomatrix PA treatment, wounds were either grafted with autologous split-skin grafts or left to heal by secondary intention, in this case wounds were dressed weekly with a HA-based dressing (Hyalofill, Fidia Advanced Biopolymers, Italy). Results A complete coverage of the exposed cancellous bone was obtained in 21 out of 23 patients in a period of 28 ± 17 days of treatment. The patients were followed for a period of 176 ±141 days – a complete healing of the sur

Figure 9 EWMA

Journal 2009 vol 9 no 1

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Figure 10

Figure 11

Figure 12

Figure 13

gical wound was observed in 10 patients. Four patients were submitted to skin graft (fig. 10-11-12-13), while six patients healed by secondary intention with re-epithelialisation from wound edges, the remaining 11 patients presented total coverage of the exposed bone with a compact and well organized new dermal tissue. One patient was submitted to above-the-knee amputation due to recurrence of foot infection and severe ischemia. One patient was lost at follow up. Two patients died during the follow up period from myocardial infarction.

procedures (healing by secondary intention or skin graft), permits the realisation of the goal to save a longer stump suitable for foot prosthesis with good residual walking ability. m References 1. Van Baal JG. Surgical treatment of the infected diabetic foot. Clinical Infectious Diseases. 39:S123-S128,2004. 2. Campbell WB, Ponette D, Sugiono M. Long-term results following operation for diabetic foot problems: arterial disease confers a poor prognosis. Eur J Vasc Endovasc Surg. 19:174-177,2000 3. Faglia E, Clerici G et al. The role of early surgical debridement and revascularization in patients with diabetes and deep foot space abscess: retrospective review of 106 patients with diabetes.J Foot Ankle Surg. 2006 Jul-Aug;45(4):220 4. Moulik PK, Mtonga R, Gill GV. Amputation and mortality in new-onset diabetic foot ulcers stratified by etiology. Diabetes Care. 26:491-494,2003

Conclusion The preliminary data resulting from our study demonstrates that Hyalomatryxď&#x203A;&#x161; PA is a novel, safe and effective dermal substitute for the coverage of cancellous bone exposition and for the reconstruction of a compact and stabile new dermis after aggressive debridement in diabetic foot infection, with the coverage of exposed vital and healthy cancellous bone. This new reconstructive surgical approach, when applied with different definitive surgical

5. Price RD, Das-Gupta V, Leigh IM, Navsaria HA. A comparison of tissue-engineered hyaluronic acid dermal matrices in a human wound model. Tissue Eng. 2006; 12(10): 2985-95. 6. Gravante G, Delogu D, Giordan N, Morano G, Montone A, Esposito G. The use of Hyalomatrix PA in the treatment of deep partial-thickness burns. J Burn Care Res. 2007; 28(2): 269-74. 7. Stark HJ, Willhauck MJ, Mirancea N, et al. Authentic fibroblast matrix in dermal equivalents normalises epidermal histogenesis and dermoepidermal junction in organotypic co-culture. Eur J Cell Biol. 2004; 83(11-12): 631-45. 8. Campoccia D, Hunt JA, Doherty PJ, et al. Quantitative assessment of the tissue response to films of hyaluronan derivatives. Biomaterials. 1996; 17(10): 963-75. 9. Chen WYJ, Abatangelo G. Functions of hyaluronan in wound repair. Wound Rep Regen 1999; 7: 79-89.

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Does surgery heal venous ulcers? Introduction

VII National AIUC Meeting Rome 24-27 September 2008

Venous ulcers have a complicated natural history and a complex pathophysiology. Their principal cause is the venous hypertension due to a pathology that involves in various ways and in different combination the three venous systems. Duplex Scanning is the method of choice to assess the haemodynamic patterns of reflux. Partsch underlines the importance to characterize the pathophysiology underlying the clinical picture, and the consequences of venous reflux on the muscle pump and on the microcirculation. Any detected pathology should be classified through the use of the CEAP classification, which helps to guide further therapy. Antignani points out the consensus statement and the process of revision of the classification to make it more adherent to the clinical needs. Compression therapy has a fundamental role in the treatment of chronic venous insufficiency and is sufficient to heal the majority of venous ulcers. Surgical treatment of superficial venous reflux is a common method employed to correct reflux and it achieves ulcer healing in a high percentage of cases. Recent randomised controlled trials demonstrated that superficial venous surgery is associated with similar rates of ulcer healing to compression alone, but with less recurrence. The role of surgery to correct perforating vein incompetence remains controversial. Promising results have been obtained, especially in cases of competent deep veins. NelzĂŠn reports his experience on perforator surgery and suggests a combined approach with superficial venous surgery. Patients with venous ulcers often present combined superficial and deep venous incompetence and this finding is the basis of my paper. If the deep reflux is segmental it may be abolished by superficial venous surgery, but in case of an axial reflux the rate of resolution is low and, in selected cases, a deep venous reconstructive procedure should be considered. However, the effect of deep venous incompetence on the ulcer healing is unclear. Haemodynamic pictures with a combination of partial obstruction and reflux request a complex operative strategy. The aim of the papers presented in this section is to focus on the different aspects of the question topic. I am confident that the information provided, apart from increasing ulcer healing rates, could relieve pain and improve quality of life of our patients. Giorgio Guarnera

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The CEAP classification and its evolution Summary The CEAP classification constitutes the most important progress in the classification of Chronic Venous Diseases (CVD). It was proposed in 1994 and adopted worldwide to facilitate meaningful communication about CVD and serve as a basis for more scientific analysis of management alternatives. This classification, based on correct diagnosis, was also expected to serve as a systematic guide in clinical investigation of patients, as an orderly documentation system and as a basis for decisions regarding appropriate treatment. It is complete and well structured, provides a large number of advantages and it is superior to previous classifications. Some of problems of CEAP classification have been solved during the last 10 years. An international consensus meeting in Rome in 2001 suggested definitions and refinements of the clinical classification, the C in CEAP, which were published in 2003. Finally in 2004, the International Working Group published the first complete revision of the CEAP classification. The changes include additions to, or refinements of, several definitions used in describing CVD, refinement of the C classification of CEAP, addition of the descriptor n (no venous abnormality identified), incorporation of the date of classification and level of clinical investigation. In addition the description of “basic CEAP,” was introduced as a simpler alternative to the full “advanced” CEAP classification. Many questions about CEAP classification have been resolved but other questions are still open; further work is necessary.

INTRODUCTION The development of the CEAP (Clinical-Etiology-Anatomy-Pathophysiology) classification in 1994 by an international ad hoc committee of the American Venous Forum, published in 1995, constituted the most important progress in the classification of chronic venous disorders (CVD) (1,2). Rather than have it stand as a static classification system, an ad hoc committee of the American Venous Forum, working with an international liaison committee, has recommended a number of practical changes. It is important to stress that CEAP is a descriptive classification, whereas venous severity scoring and quality of life scores are instruments for longitudinal research to assess outcomes. This classification, based on correct diagnosis, was also expected to serve as a systematic guide in the daily clinical investigation of patients, as an orderly documentation system and as a basis for decisions regarding appropriate treatment. It contained two parts: a classification of CVD and a scoring system of the severity of CVD. The classification was based on clinical manifestations (C), etiologic factors (E), anatomic distribution of disease (A), and underlying pathophysiologic findings (P), or CEAP. The severity scoring system was based on three elements: number of anatomic segments affected, grading of symptoms and signs, and disability (3,4). Table I

Pier Luigi Antignani, MD Claudio Allegra, MD Department of Angiology S. Giovanni Hospital Rome Italy Correspondence to: Pier Luigi Antignani antignani@mclink.it

OTHER DEVELOPMENTS RELATED TO CEAP In 1998, at an international consensus meeting in Paris, Perrin et al established a classification for recurrent varicose veins (5), the evaluation of which is ongoing. In 2000 Rutherford and the ad hoc Outcomes Committee of AVF (3) published an upgraded version of the original venous severity scoring system. The validity of the new severity score has been evaluated by Meissner and Kakkos 

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Table I: CEAP classification Clinical classification C0: no visible or palpable signs of venous disease C1: telangiectasies or reticular veins C2: varicose veins C3: oedema C4a: pigmentation or eczema C4b: lipodermatosclerosis or atrophie blanche C5: healed venous ulcer C6: active venous ulcer S: symptomatic, including ache, pain, tightness, skin irritation, heaviness, and muscle cramps, and other complaints attributable to venous dysfunction A: asymptomatic Etiologic classification Ec: congenital Ep: primary Es: secondary (post-thrombotic) En: no venous cause identified Anatomic classification As: superficial veins Ap: perforator veins Ad: deep veins An: no venous location identified Anatomical class of CEAP classification Superficial veins: 1 telangiectasia or reticular veins 2 long saphenous vein above knee 3 long saphenous vein below knee 4 short saphenous vein 5 non-saphenous system Deep veins: 6 inferior vena cava 7 common iliac vein 8 internal iliac vein 9 external iliac vein 10 pelvic, gonadal, broad ligament, other veins 11 common femoral vein 12 deep femoral vein 13 superficial femoral vein 14 popliteal vein 15 crural, anterior tibial, posterior tibial, peroneal veins 16 muscular, gastrocnemial, soleal veins Perforating veins: 17 thigh 18 calf Pathophysiologic classification Basic CEAP Pr: reflux Po: obstruction Pr,o: reflux and obstruction Pn: no venous pathophysiology identifiable Advanced CEAP Same as basic CEAP, with the addition that any of 18 named venous segments can be used as locators for venous pathology The CEAP consensus statement has been published in 26 journals and books and in several languages making it a truly universal document for CVD

(4,6). An evaluation of the system by 398 French angiologists was reported by Perrin (7). Uhl et al established a European Venous Registry based on CEAP, and reported studies on intra-observer and inter-observer variability that showed significant discrepancies in the clinical classification of CEAP, which prompted improved definitions of clinical classes C0 to C6 (8,9,10). An international consensus meeting in Rome in 2001 suggested definitions and refinements of the clinical classification, the C in CEAP (11). These not only contributed to CEAP, but formed the basis for its ultimate modification, as recommended below.

REVISION OF CEAP Diagnosis and treatment of CVD is developing rapidly and the need for an update of the classification logically follows (12-15). Venous severity scoring was developed to enable longitudinal outcomes assessment, but it became apparent that CEAP itself required updating and modification. In April 2002 an ad hoc committee on CEAP was appointed by AVF to review the classification and make recommendations for change by 2004, 10 years after its introduction. An international ad hoc committee was also established to ensure continued universal use. The two committees held four joint meetings, with key members contributing in the interim to the revised document. The recommended changes include additions to, or refinements of, several definitions used in describing CVD; refinement of the C classification of CEAP; addition of the descriptor n (no venous abnormality identified); incorporation of the date of classification and level of clinical investigation; and the description of “basic CEAP,” introduced as a simpler alternative to the full (advanced) CEAP classification.

TERMINOLOGY AND NEW DEFINITIONS The CEAP classification deals with all forms of CVDs. The term “chronic venous disorder” includes the full spectrum of morphologic and functional abnormalities of the venous system, from telangiectasias to venous ulcers. Some of these, such as telangiectasias, are highly prevalent in the healthy adult population, and in many cases use of the term “disease” is not appropriate. The term “chronic venous insufficiency” implies a functional abnormality of the venous system, and is usually reserved for more advanced disease, including oedema (C3), skin changes (C4), or venous ulcers (C5-6). It was agreed to maintain the present overall structure of the CEAP classification (16, 17), but to add  more precise definitions.

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References: 1. Vanscheidt W, Münter K-C, Klövekorn W, Vin F, Gauthier J-P, Ukat A. A prospective study on the use of a non-adhesive gelling foam dressing on exuding leg ulcers. J Wound Care 2007; 16: 261-265. 2. Bishop S. Versiva® XC™ Gelling Foam Dressing cushioning and protection claims R&D justification. WHRI2749 MS002 June 2005. Data on file, ConvaTec. ®/TM The following are trade marks of E.R. Squibb & Sons, L.L.C.: Versiva, Versiva XC and Hydrofiber. ConvaTec is an authorised user. ©2008 E.R. Squibb & Sons, L.L.C. 2008. EU-08-780

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The following recommended definitions apply to the clinical (C) classes of CEAP (11,17): – Atrophie blanche (white atrophy): Localized, often circular whitish and atrophic skin areas surrounded by dilated capillaries and sometimes hyperpigmentation. Sign of severe CVD, and not to be confused with healed ulcer scars. Scars of healed ulceration may also exhibit atrophic skin with pigmentary changes, but are distinguishable by history of ulceration and appearance from atrophie blanche, and are excluded from this definition. – Corona phlebectatica: Fan-shaped pattern of numerous small intradermal veins on medial or lateral aspects of ankle and foot. Commonly thought to be an early sign of advanced venous disease. Synonyms include malleolar flare and ankle flare.

– Varicose vein: Subcutaneous dilated vein 3mm in diameter or larger, measured in upright position. May involve saphenous veins, saphenous tributaries, or non-saphenous superficial leg veins. Varicose veins are usually tortuous, but tubular saphenous veins with demonstrated reflux may be classified as varicose veins. Synonyms include varix, varices, and varicosities. - Venous ulcer: Full-thickness defect of skin, most frequently in ankle region, that fails to heal spontaneously and is sustained by CVD.

– Oedema: Perceptible increase in volume of fluid in skin and subcutaneous tissue, characteristically indented with pressure. Venous oedema usually occurs in ankle region, but may extend to leg and foot.

REFINEMENT OF C CLASSES IN CEAP The essential change (18) is the division of class C4 into two subgroups that reflect severity of disease and carry a different prognosis in terms of risk for ulceration: C4 Changes in skin and subcutaneous tissue secondary to CVD, now divided into two subclasses to better define the differing severity of venous disease: C4a Pigmentation or eczema. C4b Lipodermatosclerosis or white atrophy. Each clinical class is further characterised by a subscript for the presence of symptoms (s, symptomatic) or absence of symptoms (a, asymptomatic), for example, C2a or C5s. Symptoms include aching, pain, tightness, skin irritation, heaviness, muscle cramps, and other complaints attributable to venous dysfunction.

– Lipodermatosclerosis (LDS): Localised chronic inflammation and fibrosis of skin and subcutaneous tissues of lower leg, sometimes associated with scarring or contracture of Achilles tendon. LDS is sometimes preceded by diffuse inflammatory oedema of the skin, which may be painful and which often is referred to as hypodermatitis. LDS must be differentiated from lymphangitis, erysipelas, or cellulitis by their characteristically different local signs and systemic features. LDS is a sign of severe CVD.

REFINEMENT OF E, A, AND P CLASSES IN CEAP To improve the assignment of designations under E, A, and P a new descriptor, n, is now recommended for use where no venous abnormality is identified (18). This n could be added to E (En, no venous cause identified), A (An, no venous location identified), and P (Pn, no venous pathophysiology identified).

– Eczema: Erythematous dermatitis, which may progress to blistering, weeping, or scaling eruption of skin of leg. Most often located near varicose veins, but may be located anywhere in the leg. Usually seen in uncontrolled CVD, but may reflect sensitisation to local therapy.

– Pigmentation: Brownish darkening of skin, resulting from extravasated blood. Usually occurs in ankle region, but may extend to leg and foot. – Reticular vein: Dilated bluish subdermal vein, usually 1mm to less than 3mm in diameter. Usually tortuous. Excludes normal visible veins in persons with thin, transparent skin. Synonyms include blue veins, subdermal varices, and venulectasies.

DATE OF CLASSIFICATION CEAP is not a static classification; disease can be reclassified at any time. Classification starts with the patient’s initial visit, but can be better defined after further investigations (18). A final classification may not be complete until after surgery and histopathological assessment. It is therefore recommended that any CEAP classification be followed by the date, for example, C4bS, EPAs,p Pr  (2003-08-21).

– Telangiectasia: Confluence of dilated intradermal venules less than 1mm in calibre. Synonyms include spider veins, hyphen webs, and thread veins.

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LEVEL OF INVESTIGATION A precise diagnosis is the basis for correct classification of a venous problem (13,18). The diagnostic evaluation of CVD can be logically organized into one or more of three levels of testing, depending on the severity of the disease: Level I: office visit, with history and clinical examination, which may include use of a hand-held Doppler scanner. Level II: non-invasive vascular laboratory testing, which now routinely includes duplex colour scanning, with some plethysmographic method added as desired. Level III: invasive investigations or more complex imaging studies, including ascending and descending venography, venous pressure measurements, computed tomography (CT), venous helical scanning, or magnetic resonance imaging (MRI). It is recommend that the level of investigation (L) should also be added to the classification, for example, C2,4b,S, EP,As,p Pr (2003-08-21, L II).

BASIC CEAP A new basic CEAP is offered here. Use of all components of CEAP is still encouraged. However, many use the C classification only, which is a modest advance beyond the previous classifications based solely on clinical appearance. Venous disease is complex, but can be described with use of well-defined categorical descriptions. For the practicing physician CEAP can be a valuable instrument for correct diagnosis to guide treatment and assess prognosis. In

modern phlebological practice most patients will undergo duplex scanning of the venous system of the leg, which will largely define the E, A, and P categories. Nevertheless, it is recognized that the merits of using the full (advanced) CEAP classification system hold primarily for the researcher and for standardized reporting in scientific journals. It enables grouping of patients so that those with the same types of disease can be analyzed together, and such subgroup analysis enables their treatments to be more accurately assessed. Furthermore, reports that use CEAP can be compared with each another with much greater certainty. This more complex classification, for example, also allows any of the 18 named venous segments to be identified as the location of venous disease. For example, in a patient with pain, varicose veins, and lipodermatosclerosis in whom duplex scans confirm primary reflux of the greater saphenous vein and incompetent perforators in the calf, the classification would be C2,4b,S, Ep,As,p, Pr2,3,18. While the detailed elaboration of venous disease in this form may seem unnecessarily complex to some clinicians, it provides universally understandable descriptions, which may be essential to investigators in the field. In essence, basic CEAP applies two simplifications – The first being that, in basic CEAP, the single highest descriptor can be used for clinical classification. For example, in a patient with varicose veins, swelling, and lipodermatosclerosis the classification would be C4b. The more comprehensive clinical description, in advanced CEAP, would be C2,3,4b. The second is that, in basic CEAP, when duplex scanning is performed, E, A, and P should also be classified with the multiple descriptors recommended, but the complexity

References 1. Beebe HG, Bergan JJ, Bergqvist D, Eklöf, B, Eriksson, I, Goldman MP, et al. Classification and grading of chronic venous disease in the lower limbs: a consensus statement. Vasc Surg 1996;30:5-11.

7. Perrin M, Dedieu F, Jessent V, Blanc MP. Evaluation of the new severity scoring in chronic venous disease of the lower limbs: an observational survey conducted by French angiologists. Phlebologie 2003;56:127-36.

14. Antignani PL, Cornu-Thenard A, Carpentier PH, Uhl JF, Partsch H: CEAP classification: past, present and future: results of the questionnaire and of the clinical cases. Int. Angiol. 2001; 20(1): 34

2. Porter JM, Moneta GL, International Consensus Committee on Chronic Venous Disease. Reporting standards in venous disease: an update. J Vasc Surg 1995;21:635-45.

8. Cornu-Thénard A., Uhl J.F., Carpentier P.H., Antignani P.L., Staelens Y., Partsch H. The CEAP classification and the European Phlebological File. Minerva Cardioangiol. 2000; 48 (suppl. 1):232.

15. Antignani PL. CEAP classification. Acta Phlebol. 2002:3;85-94.

3. Rutherford RB, Padberg FT, Comerota AJ, Kistner RL, Meissner MH, Moneta GL. Venous severity scoring: an adjunct to venous outcome assessment. J Vasc Surg 2000;31:1307-12.

9. Carpentier PH, Cornu-Thénard A, Uhl JF, Partsch H, Antignani PL: Appraisal of the information content of the C classes of CEAP clinical classification of chronic venous disorders: A multicenter evaluation of 872patients. J Vasc Surg 2003; 37: 827-33

17. Antignani PL, Cornu-Thènard A, Allegra C, Carpentier PH, Partsch H, Uhl JF. Results of a questionnaire regarding improvement of “C” in the CEAP classification. Eur. J Vasc Endovasc Surg 2004;28:177-81

4. Meissner MH, Natiello C, Nicholls SC. Performance characteristics of the venous clinical severity score. J Vasc Surg 2002;36:89-95. 5. Perrin MR, Guex JJ, Ruckley CV, DePalma RG, Royle JP, Eklof B, et al. Recurrent varices after surgery (REVAS): a consensus document. Cardiovasc Surg 2000;8:233-45. 6. Kakkos SK, Rivera MA, Matsagas MI, Lazarides MK, et al. Validation of the new venous severity scoring system in varicose vein surgery. J Vasc Surg 2003;38:224-8.

10. Uhl JF, Cornu-Thenard A, Carpentier P, Schadek M, Parpex P, Chleir F. Reproducibility of the “C” classes of the CEAP classification. J Phlebol 2001;1:39-48. 11. Allegra C, Antignani PL, Bergan JJ, Carpentier PH, Coleridge Smith P, Cornu-Thenard A, et al. The “C” of CEAP: suggested definitions and refinements. An International Union of Phlebology conference of experts. J Vasc Surg 2003;37:129-31.

16. Moneta GL. A commentary of reference 11. J Vasc Surg 2003;37:224-5.

18. Eklöf B, Rutherford RB, Bergan JJ, Carpentier PH Gloviczki P, et al. for the American Venous Forum International Ad Hoc Committee for Revision of the CEAP Classification, Revision of the CEAP classification for chronic venous disorders: Consensus statement. J Vasc Surg 2004;40:1248-52.

12. Antignani PL, Di Fortunato T: Chronic venous pathology: presentation of a new international classification. Clin. Terap 1997; 148:521-6. 13. Antignani PL: Classification of chronic venous insufficiency: a review. Angiology 2001; 52 (1): 17-26

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of applying these to the possible anatomic segments is avoided in favour of applying the simple s, p, and d descriptors to denote the superficial, perforator and deep systems. Thus, in basic CEAP the previous example, with painful varicosities, lipodermatosclerosis, and duplex scan– determined reflux involving the superficial and perforator systems would be classified as C4b,S, Ep,As,p, Pr, rather than C2,4b,S, Ep,As,p, Pr2,3,18.

popliteal veins. There are no signs of post-thrombotic obstruction. Classification according to basic CEAP: C6,S, Ep,As,p,d, Pr. Classification according to advanced CEAP: C2,3,4b,6,S, Ep,As,p,d, Pr2,3,18,13,14 (2004-05-17, L II). m

REVISION OF CEAP: AN ONGOING PROCESS With improvement in diagnostics and treatment there will be continued demand to adapt the CEAP classification to better serve future developments. There is a need to incorporate appropriate new features without too frequent disturbance of the stability of the classification. Example: A patient has painful swelling of the leg, and varicose veins, lipodermatosclerosis, and active ulceration. Duplex scanning on May 17, 2004, showed axial reflux of the great saphenous vein above and below the knee, incompetent calf perforator veins, and axial reflux in the femoral and DMS 1205-6 Intern.PressMap.EWMAad

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The role of incompetent perforators

Olle Nelzén Ass. Professor of Vascular Surgery at Uppsala University Head of the department of Vascular Surgery & Skaraborg leg Ulcer Centre Skaraborg Hospital /KSS 541 33 Skövde Sweden olle.nelzen@vgregion.se

Abstract Aim: To report what we know and what we still do not know about the role of incompetent perforators in relation to venous leg ulcers. Methods: This report is based on knowledge gathered throughout several years by the author and is not based on a complete new worldwide literature search. The opinion presented is that of the author and is supported by a selection of appropriate references. Results: The role of incompetent perforators (IP) is still very much unclear and there are no results from randomized studies that can guide us. However based on results from uncontrolled patient series there seems to be an advantage for perforator interruption combined with superficial venous surgery, since several series on superficial endoscopic perforator surgery (SEPS) have recorded the lowest reported recurrence rates for venous ulcers. We know that superficial venous surgery alone will only cure about one third of incompetent perforators and seems to result in higher reported rates of leg ulcer recurrence. SEPS is the most thoroughly documented technique to deal with IP and superior to traditional open surgical techniques. Conclusion: The role of IP is still uncertain in relation to venous ulcers. At present available data indicates that perforator interruption in combination with superficial venous surgery is beneficial in order to minimize the recurrence rate of venous leg ulcers. The exact role of IP can only be decided through proper randomized studies.

Introduction The role of incompetent perforators (IP) has been the subject of much debate for several years and so far the matter is still unsettled. Incompetent perforators used to be considered a prerequisite for venous ulcers to develop and that was secondary to post-thrombotic syndrome (PTS). We know

now that this is not true since venous ulcers may develop in legs without perforator incompetence or deep venous incompetence. In fact more than half of all venous ulcers are caused by superficial venous incompetence without any deep vein incompetence and are usually accompanied by perforator incompetence as well. There are two main issues regarding perforators. First, does perforator incompetence normalize as a result of superficial venous surgery alone? Second, some claim perforator surgery is obsolete whilst others recommend treatment, but by which method? This article will try to sort things out and show what we know and what we do not know today about incompetent perforators.

Historical background In 1938 Robert Linton focused attention on the perforating veins and, in fact, he also realised that many venous ulcer were caused by varicose veins, which he named “varicose ulcers”1. The latter was not noticed by the surgical community that instead focused on the IP and ways of dealing surgically with these perforators. Apart from Linton, surgical techniques were proposed by Dodd, Cockett, Felder and others. When Gunnar Bauer from Sweden published his remarkable series of phlebography in leg ulcer patients showing IP and PTS in some 80% of venous ulcer patients the idea of varicose ulcers was more or less forgotten and everything was blamed a previous deep vein thrombosis. However, the heroic wide incisions that many of the proposed surgical techniques used caused substantial problems with wound healing problems, infections, and considerable pain and also required a long hospitalisation. These side effects led to the concept that venous leg ulcers were best treated conservatively by compression bandaging and thus surgeons lost interest. As a result, venous ulcers were left to the care of district nurses, with limited or no help

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from surgeons or physicians. The popularity of performing perforator surgery has thus varied considerably over time. The introduction of Doppler and finally colour Doppler ultrasound (CDU) changed it all. Suddenly we could verify that Linton was right, many patients had â&#x20AC;&#x153;varicose ulcersâ&#x20AC;? only 30-40% were post thrombotic and the majority had incompetent perforators. New techniques always fascinate surgeons and subfascial endoscopic perforator surgery (SEPS) served as fuel in the 1990s. In recent years we have seen a decline in the interest for perforator surgery due to reports that some perforators normalize as a result of superficial venous surgery alone, a point which I will come back to. New endovenous techniques, such as foam sclerotherapy, laser and radio frequency (RF), have however recently emerged providing potentially easier ways of accomplishing perforator interruption. That may very well halt the decline in interest for perforator interruption.

Anatomical considerations/ Pathophysiology Since the invention of CDU we have improved our knowledge of venous pathology and anatomy. There are probably about 60 to100 perforators in the human leg, but only a minority is detectable with traditional imaging techniques. Based on CDU studies we know that IP are usually located on the medial aspect of the leg and preferably on the lower leg. The perforator site most commonly seen incompetent is medial location about 18-20 cm above the sole of the foot (corresponding to the Cockett III perforator). Incompetent perforators on the medial thigh (Hunter, Dodd) are also quite common as well as dorsal (gastrocnemic and soleal perforators) and lateral located perforators. Normal perforators are rarely larger than 1-2 mm and a perforator of >3 mm has a high likelihood of being incompetent. The previous concept that IP are connected to or the result of an incompetent deep venous system seems to be only partly true. That perforators are most often associated with incompetent superficial veins has been documented by several studies using CDU2-4. Re-entry perforators are perforators directly connected to an incompetent stem vein, which as a result may become overloaded, widened and incompetent due to refluxing blood in the stem vein. Single perforators of this sort are likely to have the best chance of becoming normalized by removal of the incompetent stem vein (usually the great saphenous vein) without any perforator interruption. In legs with combined deep and perforator incompetence the overload comes from the deep vein instead and eventually, with time, is likely to also involve the superficial veins related to the

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perforator. A leg ulcer seldom develops without engagement of the superficial veins as well. The reason for this is that ulceration does not occur until the elevated venous pressure reaches the skin and, to achieve this, superficial veins generally have to be involved. The numbers and size of IP are closely correlated to the severity of chronic venous disease and follow the CEAP classification.4-7 Most IP are consequently seen in legs with venous ulceration (CEAP class C6). Furthermore IP aggravate the haemodynamics in a leg with chronic venous disease (CVD).4 The worst situation is seen in legs with combined reflux in all three systems, deep, superficial and perforators, which indirectly indicates that an incompetent perforator is not just an innocent bystander, but adds to the severity. In addition it has been shown that incompetent perforators increase in numbers if the CVD is left untreated, even within a narrow time frame of just a few years.8 Missed IP are strongly correlated to non-healing or recurrent leg ulcers.9All of these findings indicate treatment of IP to prevent further ulceration.

Imaging and haemodynamics Colour Doppler ultrasound (CDU) is today the gold standard for imaging of perforators. This technique can also, to some extent, assess the haemodynamics and thus give some functional data. Phlebography, that used to be the way to diagnose perforators before CDU, is not used for this purpose anymore. That method gave very little dynamic information and induced a risk of overestimating IP. Traditional plethysmographic methods to assess venous haemodynamics are unfortunately not accurate enough to assess IP. Ambulatory venous pressure measurement (AVP) is probably the best method, provided the pressure is measured in a cannulated superficial vein in direct connection with the IP. This is a difficult technique to perform and very few laboratories can actually provide this, so at present we are lacking a reliable and easily performed quantitative method to assess IP and their contribution to global venous function. To find such a method that is accurate enough is not easy since current methods to assess global haemodynamics are also lacking in precision and are, therefore, not really usable for decision-making at patient level. Their main value is within studies to compare and î&#x201A;Š separate groups of patients.

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Treatment options For severe CVD, like patients with venous leg ulceration, there are in reality only two options, compression with bandaging or stockings or surgical intervention. The results from the ESCHAR trial10, 11 has shown strong evidence that superficial surgery combined with compression stockings have significantly less recurrences after one and four years than conservative compression alone. The same study showed, however, no benefit for surgery with compression when healing of open ulcers was concerned; healing after compression treatment alone was equally good. A similar conclusion regarding healing was also reached in a smaller randomised study from the UK.12 Notably perforator incompetence, which was present in 51% of the legs in the ESCHAR study, was left untreated. The reason for not using perforator surgery was based on reports claiming that perforators may often normalize as a result of superficial surgery. The study by Stuart et al.13 found that in only 20% of limbs, where there were no residual superficial or deep venous reflux after surgery, IP remained. That is not however equal to the statement used by the author that “80% of IP regained competence”, since only 65% of a total of 62 legs showed IP. A likely guess, based on given data, is that 40-45% may have normalized. Furthermore their study dealt mostly with patients with varicose veins (C2-C3) and only a few with healed ulcers were included. Their data can therefore not be extrapolated to venous ulcer patients, which we know have much more severe venous dysfunction. Results from a recently published randomized controlled trial of varicose vein patients showed much lower figures, 36% normalized from superficial venous surgery and the control arm in that study encompassed SEPS, which reduced the number of IP significantly.14 From the ESCHAR trial on venous ulcer patients, where no perforator surgery was performed, it was shown that 33% of IP normalized following saphenous surgery alone, based on a CDU follow-up.15 Based on these data it is unlikely that more than one third of incompetent perforators will normalize as a result of saphenous surgery alone in legs with venous leg ulceration. Thus two out of three perforators will remain incompetent and is it then advisable to refrain from performing primary perforator surgery? Surgical alternatives There are many alternative invasive treatments (Table 1) but the surgical techniques have so far been most widely used. The old way of dealing with IP was open surgery usually using long and wide incisions. As a result of fre-

Table 1. Methods to interrupt perforators • Traditional open techniques – Subfascial ligation – Extrafascial ligation • Minimal-invasive open techniques – Ultrasound guided mini incisions – SEPS • New endovenous techniques – Ultrasound guided foam sclerotherapy – Laser ablation – Radiofrequency ablation • Other – Liquid sclerotherapy – Blind shearing – Stab incisions and hooking or grabbing

quent complications and the need for a long hospital stay, that type of surgery was given up a long time ago, as earlier mentioned. Today the open surgery is done through small incisions at each perforator after CDU mapping. Even with this technique wound complications are frequently encountered and one RCT was actually stopped prematurely because of wound complications in half of all patients receiving open surgery compared with no wound complications for the arm with SEPS. 16 Based on that study SEPS seemed to be a safer alternative for the patients although ulcer healing was equal in both groups. In comparison with open surgery, SEPS has several advantages. Firstly – patients with perforators beneath an open ulcer can be treated with SEPS. Secondly – only one incision is needed regardless of how many IP there are, in contrast to surgery that needs long or multiple incisions inducing a risk of wound healing problems. Thirdly – SEPS may detect wide perforators missed by CDU scanning. Fourthly – SEPS easily detects perforators with branches that penetrate the fascia at multiple sites. The latter can be a cause for recurrent perforators following open surgery through small incisions where multiple cannels may easily be overlooked. Van Rij et al.17 found revascularization to be common after open perforator ligation; after three years 30% of the perforators had reconnected but only 18% were incompetent, whether that is also true for SEPS is not known, although recurrence at the same sites have been reported.18 A higher recurrence can be anticipated if clip ligation is used to interrupt flow without dividing the perforator. It has been shown that clips may slip due to movements and muscular activity. From what has been reported the risk of IP recurrence seems lower for SEPS than for open surgical ligation, although there are  no comparative studies.

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Journal 2009 vol 9 no 1

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CDU scanning in the Âoperating theatre before performing SEPS.

New endovenous alternatives The new endovenous alternatives are foam sclerotherapy, laser and radiofrequency obliteration. There are no published data regarding the efficacy of these techniques to treat IP in leg ulcer patients other than anecdotal case reports. Sclerotherapy is not really an entirely new technique since liquid sclerotherapy has been used against IP for the past fifty years, but without proper studies to evaluate the result. What is new in sclerotherapy is the introduction of ultrasound guided foam sclerotherapy to improve the results. There is only one study of some quality assessing the effect of treating IP with foam. Masuda et al. reported from Honolulu the results from treatment of residual IP in limbs that had previously had superficial venous surgery and only one third was leg ulcer patients.19 The result was somewhat disappointing since 30% experienced recurrent IP within the first year. This poor durability of foam has also been reported by others17. When it comes to the other two endovenous techniques, laser and RF, the development has just started and there are no data to guide us. The common problem with the endovenous techniques is that they are difficult, or not possible, to use for perforators beneath an open ulcer, in contrast to SEPS, but may be more attractive for single IP outside the area of the ulcer.

Table 2. Three and five years ulcer recurrence based on all surviving patients within the Skaraborg SEPS study20 and for the subgroups primary versus repeat surgery. Follow-up 3 years 5 years

Overall n=87 8% 18%

Primary surg. n=58 3% 13%

Repeat surg. N=36 13% 37%

Results from perforator interruption At present there are no data from randomised studies assessing the role of perforator interruption. The knowledge of healing and recurrence rates for venous ulcers largely emanates from uncontrolled patient series. The majority of these are retrospective studies with relatively short followup. There are however also some prospective data with longer follow up. In a review of SEPS the combined estimate short term was 88% healing and 13% recurrence.9 The combination of SEPS and superficial vein surgery has in most studies resulted in the lowest recurrence figures based on data from uncontrolled patent series. 9,18,20,21 Our own experience from SEPS We have used SEPS since 1993 and registered consecutively all SEPS procedures and followed them prospectively.21, 22 If the patients had additional superficial venous incompetence then saphenous surgery was performed in addition to SEPS. All patients received additional treat-

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ment with compression until the ulcers healed. Following healing only patients with remaining incompetence, not treatable with surgery, received compression stockings class two. We found that 87% of all patients with open ulcer at the time of surgery (C6) eventually healed. The three and five years recurrence rates were 8% and 18% respectively. In a multivariate analysis previous venous surgery was the only significant risk factor, and the outcomes for these subgroups are shown in table 2. The ESCHAR study in the UK10, 11 showed substantial evidence for superficial surgery combined with compression stockings being significantly better in preventing venous ulcer recurrence than compression alone, leading to a grade A recommendation at evidence level 1b. No perforator surgery was routinely performed within that study. In contrast was the low recurrence rate within our study on SEPS that was achieved without providing all patients with compression hosiery. Even so our long term recurrence rate remained low. In the ESCHAR study the one year recurrence rate was 12% for surgically treated which rose to 31% after four years, compared with our 2% within the first year and 18% after five years. Both studies had similar distributions of C5 and C6 patients and similar proportions with DVI. Approximately 50% of the patients in the ESCHAR had IP in contrast to our patients who obviously all had IP, which meant that our patients had more severe venous References 1. Linton RR. The communicating veins of the lower leg and the operative technique for their ligation. Ann Surg 1938;107:582-93. 2. Stuart WP, Lee AJ, Allan PL, Ruckley V, Bradbury AW. Most incompetent calf perforating veins are found in association with superficial venous reflux. J Vasc Surg 2001;34:774-8. 3. Magnusson MB, Nelzén O, Risberg B, Sivertsson R. A colour Doppler study of venous reflux in patients with chronic leg ulcers. Eur J Vasc Endovasc Surg 2001;21:353-60. 4. Ibegbuna V, Delis KT, Nicolaides AN. Haemodynamic and clinical impact of superficial, deep and perforator vein incompetence. Eur J Vasc Endovasc Surg 2006;31:535-41. 5. Delis KT. Perforator vein incompetence in chronic venous disease: a multivariate regression analysis model. J Vasc Surg 2004;40:626-33. 6. Stuart WP, Adam DJ, Allan PL, Ruckley V, Bradbury AW. The relationship between the number, competence, and diameter of medial calf perforating veins and the clinical status in healthy subjects and patients with lower-limb venous disease. J Vasc Surg 2000;32:138-43. 7. Labropoulos N, Mansour MA, Kang SS, Gloviczki P, Baker WH. New insights into perforator vein incompetence. Eur J Vasc Endovasc Surg 1999;18:228-34. 8. Labropoulos N, Tassiopoulos AK, Bhatti AF, Leon L. Development of reflux in the perforator veins in limbs with primary venous disease. J Vasc Surg 2006;43:558-62.

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disease. Despite this our recurrence rates were much better and one explanation for this might be that the perforators were left untouched in the UK study and their follow-up with CDU also showed that two out of three still remained incompetent after superficial venous surgery.

Summary Incompetent perforators are present in most legs with venous leg ulcers and this adds to the severity of venous dysfunction. Maybe one third of IP can be expected to normalize as a result of superficial venous surgery alone. There is no RCT that has yet been able to define the role of the perforator, but results from uncontrolled studies show the lowest rates regarding ulcer recurrence for the combination SEPS with superficial vein surgery. There is today a grade A recommendation at evidence level Ib (ESCHAR study) that superficial venous surgery is better than conservative compression in preventing venous ulcer recurrence. Therefore surgical intervention should always be considered for patients with venous ulcers regardless if they heal readily on compression or not. There seems to be a potential for further reducing ulcer recurrence by adding perforator interruption, preferably with SEPS. The final role of IP remains to be decided through randomized studies. m

9. Tenbrook Jr JA, Iafrati MD, O´Donnel Jr TF, Wolf MP, Hoffman SN, Pauker SG et al. Systematic review of outcomes after surgical management of venous disease incorporating subfascial endoscopic perforator surgery. J Vasc Surg 2004;39(3):583-9. 10. Barwell JR, Davies CE, Deacon J, Harvey K, Minor J, Sassano A et al. Comparison of surgery and compression with compression alone in chronic venous ulceration (ESCHAR study): randomised controlled trial. Lancet 2004;363(9424):1854-9. 11. Gohel MS, Barwell JR, Taylor M, Chant T, Foy C, Earnshaw JJ, Heather BP, Mitchell DC, Whyman MR, Poskitt KR. Long term results of compression therapy alone versus compression plus surgery in chronic venous ulceration (ESCHAR): randomised controlled trial. BMJ 2007;335:83-8. 12. Stuart WP, Adam DJ, Allan PL, Ruckley CV, Bradbury AW. Saphenous surgery does not correct perforator incompetence in the presence of deep venous reflux. J Vasc Surg 1998;28(5):834-8. 13. Kianifard B, Holdstock J, Allen C, Smith C, Price B, Whiteley MS. Randomized clinical trial of the effect of adding subfascial endoscopic perforator surgery to standard great saphenous vein stripping. Br J Surg 2005;94:1075-80. 14. Gohel MS, Barwell JR, Wakely C, Minor J, Harvey K, Earnshaw JJ, Heather BP, Whymman MR, Poskitt KR. The influence of superficial venous surgery and compression on incompetent calf perforators in chronic venous leg ulceration. Eur J Vasc Endovasc Surg 2005;29:78-82.

16. van Rij AM, Hill G, Gray C, Christie R, MacFarlane J, Thomson I. A prospective study of the fate of venous leg perforators after varicose vein surgery. J Vasc Surg 2005;42:1156-62. 17. Roka F, Binder M, Bohler-Sommeregger K. Mid-term recurrence rate of incompetent perforating veins after combined superficial vein surgery and subfascial endoscopic perforating vein surgery. J Vasc Surg 2006;44:359-63. 18. Masuda EM, Kessler DM, Lurie F, Puggioni A, Kistner RL, Eklof B. The effect of ultrasound-guided sclerotherapy of incompetent perforator veins on venous clinical severity and disability scores. J Vasc Surg 2006;43:551-7. 19. Obermayer A, Göstl K Walli G, Benesch T. Chronic venous leg ulcers benefit from surgery: long-term results from 173 legs. J Vasc Surg 2006;44:572-9. 20. Nelzén O, Fransson I. True long term healing and recurrence of venous leg ulcers following SEPS combined with superficial venous surgery: a prospective study. Eur J Vasc Endovasc Surg 2007;34:605-12. 21. Nelzén O. Prospective study of safety, patient satisfaction and leg ulcer healing following saphenous and subfascial endoscopic perforator surgery. Br J Surg 2000;87:86-91.

15. Sybrandy JE, van Gent WB, Pierik EG, Wittens CH. Endoscopic versus open subfascial division of incompetent perforating veins in the treatment of venous leg ulceration: long-term follow-up. J Vasc Surg 2001;33(5):1028-32.

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Hemodynamic patterns of venous reflux in patients with leg ulcers Abstract Aim of this overview is to underline the practically important potential of correcting venous reflux in order to achieve faster ulcer healing and to reduce ulcerrecurrence. In the majority of cases venous reflux is the deciding triggering factor for the development of venous leg ulcers. More than 80% of patients with venous leg ulcers show refluxes detected by duplex ultrasound in superficial veins, to one half associated with deep vein incompetence. Isolated deep vein incompetence is rare. Taking out refluxing vein segments from the circulation by surgery or endovenous procedures including foam sclerotherapy may speed up ulcer healing and should be considered in every single patient with venous leg ulcers. Faster ulcer-healing after these procedures has been reported in several observational studies, even in the presence of deep vein incompetence. However, up to now one large randomized controlled trial has shown no significant benefit concerning faster ulcer healing compared with good compression therapy alone, but a reduction of ulcerrecurrence after surgery. Conclusion: In addition to the principles of modern ulcer-care especially concerning adequate compression the abolishment of venous reflux is a very promising treatment tool which has been underused in the past. More randomized controlled trials are needed in order to endorse the promising trend of eliminating venous reflux in venous ulcer patients.

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Introduction Following the CEAP classification (1) venous ulcers are characterized by the clinical picture of active (C6) or healed ulceration (C5) of primary, secondary or (rarely) congenital etiology (Ep,s,c), by anatomical damage in the deep, superficial or perforating veins (Ad,s,p) and by a pathophysiology due to reflux, obstruction or both (Pr,o). Venous reflux penetrating down into the ulcer region is the deciding pathophysiologic factor causing ambulatory venous hypertension leading to changes in the microcirculation of the skin and to venous leg ulcers. Venous obstructions specifically in the proximal out-flow segments of the deep veins may play an additional, “permissive” role (2), so that the combination of both, reflux and obstruction is associated with the highest risk of developing ulceration. However, isolated proximal obstructions with competent venous segments in the lower leg will mainly lead to oedema, which may indurate and may also exacerbate, especially after trauma. In principle two major forms of venous ulcers may be differentiated. Most cases present with venous reflux, sometimes in combination with venous obstruction. Intravenous pressure during walking is not reduced as this is the case with normally functioning valves. The resulting “ambulatory venous hypertension” leads to venular and capillary hypertension triggering extravasation and a chronic inflammatory process in the skin which ultimately causes ulceration. Underlying disorders are the post thrombotic syndrome or massive valve incompetence of the saphenous and/or perforating veins, frequently associated with large varicose veins. In obese or immobile individuals increased venous pressure may occur without pathological changes in the large veins and leg ulcers may develop. The common denominator is the problem of gravity in the upright position (“hydrostasis”) which explains the clinical similarity and the beneficial effect of compression therapy in both forms of “venous ulcers”. Table I summarizes the main points of these two major categories of venous leg ulcers. Following the given title of this overview only leg ulcers associated with venous reflux will further be discussed.

Hugo Partsch, M.D Professor of Dermatology Medical University Vienna Baumeistergasse 85 A 1160 Vienna/Austria Chair of the International Compression Club www.icc-compressionclub. com Correspondance to: Hugo Partsch Baumeistergasse 85 A 1160 Vienna/Austria Hugo.Partsch@ meduniwien.ac.at



Table I: Main categories of venous leg ulcers “Reflux ulcer” (~80%) Pathophysiology Ambulatory venous hypertension CEAP C6 Ep,s Ad,s,p, Pr,o Examples Venous valve incompetence (varicose veins, post thrombotic syndrome)

“Hydrostatic ulcer” (~20%) “Integrated” venous hypertension C6 Es An Pn Immobility, Obesity

Venous reflux may be defined as a retrograde flow of abnormal duration in any venous segment. It may be primary, caused by idiopathic dysfunction of venous valves, secondary, caused by thrombosis, trauma, or mechanical, thermal or chemical etiologies or congenital, due to absence or abnormal development of venous valves. Venous ulcers are mainly associated with axial reflux that can be defined as uninterrupted retrograde venous flow from the groin to the calf (3). Such axial reflux may be confined to the superficial or deep venous system or may have a combined pattern involving any combination of the three venous systems (superficial, deep, perforating veins).

Demonstration of venous reflux In the presence of massive varicose veins connected with an incompetent great saphenous vein reflux can be demonstrated by a simple, historic manoeuvre which has been described by Trendelenburg (4). After emptying the veins by leg elevation the great saphenous vein (GSV) is compressed below the groin by a tourniquet or manually and the patient stands up. By blocking the retrograde flow the varicose veins in the leg will fill only when the tourniquet is released, from proximal to distal. This impressive manoeuvre became one of the central arguments for the surgical dogma that varicose veins develop due to valvular incompetence from proximal to distal and therefore can be cured only by ligation and division of GSV at its confluence with the common femoral vein including all tributaries. In recent years this dogma has been questioned, mainly based on ultrasound investigations which were able to demonstrate highly variable distributions of valves and reflux patterns (5). In addition it became clear that massive reflux may be present in the absence of large visible varicosities very frequently. In many patients with typical venous ulcers no large varicose veins may be seen clinically but nearly all of them show massive reflux when examined by ultrasound.

Ultrasound investigations Doppler ultrasound is able to detect retrograde flow in vein segments of interest. Experienced investigators may use simple, hand-held Doppler instruments for screening purposes but should take into account the difficulty to assign venous signals to anatomically clearly defined veins. For the exact location and for measuring quantitative flow parameters a duplex instrument is advisable. This instrumentation combines an ultrasound picture (B-scan) with a dynamic assessment of the blood flow within the vessel concerning flow direction and velocity (Doppler) (Fig 1) (6) To detect retrograde venous flow a transvalvular pressure gradient has to be created either by Valsalva manoeuvre (forced abdominal pressure) or by manual or muscular compression/decompression of distal parts of the extremity in the upright position. The latter test reflects the ability of venous valves to cope with gravity by shifting blood into the proximal direction after passive or active squeezing out the veins. Gravitational tests are able to assess valvular incompetence only for a zone distal but not proximal to the Doppler sample. Most authors define a reflux time longer than 0,5 seconds as pathological. However, reflux time may vary during the day and may be longer than 1 second in proximal venous segments even in normal individuals. Several publications using duplex have reported massive reflux in patients with venous leg ulcers. Fig. 2 shows a summarizing scheme on the location of venous reflux found in a total of 390 legs with venous ulcers (7). All patients presented with major venous reflux, 43% in the superficial veins only and 43% in the superficial and deep veins. These findings have considerable therapeutic implications discussed below. Plethysmographic measurements Global reflux can also be assessed by measuring the time needed to refill an empty vein by retrograde flow. Volume changes of the calf segment are measured using a plethysmographic device (e.g. an air plethysmograph, APG). After emptying the veins by elevating the leg the patient is asked to stand up. Under normal conditions competent venous valves will prevent reflux and a slow volume increase of the calf will be observed, effected by the arterial inflow. In patients with incompetent venous valves the volume increase will occur very fast due to the retrograde filling of the veins. The volume increase per time unit (venous filling index, VFI) gives a quantitative parameter for the

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Fig. 2.

Reflux in venous ulcers Duplex in 390 legs

Sup 44%

Deep

Sup+deep

Sup+ Deep 43%

Superficial

Hanrahan n=95 Labropoulos n= 34 Labropoulos n=112 Labropoulos n=54 Scriven n=95

Perf

Perf+deep

Perrin M. Phlebolymphology 2004;45:276-280

Fig 1: Duplex investigation of the popliteal vein in a patient with postthrombotic leg ulcers. The marker is positioned in the vein and the flow pattern is registered during walking on the spot. As a sign of deep vein incompetence the flow curve (bottom of the picture) shows a prevailing retrograde flow pattern characterized by the tracings down from the zero-line).

severity of total reflux. Tourniquet tests excluding superficial reflux are helpful to differentiate the hemodynamic importance of superficial and deep venous incompetence. Plethysmographic tests may be useful to quantify reflux before and after different therapeutic procedures and also to measure venous pumping function (8). In contrast to duplex which is able to measure reflux in single veins only, plethysmography and also peripheral venous pressure measurements give global information on venous reflux in the whole lower extremity. Different photoplethysmographic instruments have been proposed for screening purposes. After a standardized exercise refilling time is mostly used as the deciding parameter to characterize venous reflux. One of several problems with this technique is the fact that the skin area where the transducers are attached is typically hyperaemic in ulcer patients. This may cause a shortened refilling time even in he absence of any venous reflux. Photoplethysmography is therefore not a valid instrument to differentiate “venous” from “non-venous” ulcers. Retrograde phlebography This technique is still used for the assessment of pelvic reflux and as a golden back-up when deep venous reconstructive surgery is considered. However, in the routine assessment of chronic venous disorders including leg ulcers it has been widely replaced by duplex ultrasound.

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Fig. 2. Patterns of reflux in 390 patients with venous leg ulcers (7).

Location of venous reflux The typical venous leg ulcer is regularly associated with incompetent veins in the vicinity of the ulcer region that can be detected by careful duplex investigation. Most of these refluxes are connected with incompetent branches of the great saphenous vein; ulcers on the lateral aspect of the lower leg are frequently associated with an incompetent small saphenous vein. Deep vein refluxes can additionally be found in about half of the patients, while an isolated deep venous incompetence is relatively rare (Fig 2). If the deep veins are involved refluxes in the popliteal vein and in the deep lower leg veins are of critical importance for the development of leg ulcers. Perforator incompetence The role of perforator incompetence is still under dispute. It is commonly believed that the localisation of venous ulcers on the leg has something to do with incompetent perforators in that region of the extremity. Isolated perforator incompetence is rare and can only rarely be blamed to be the cause for a leg ulcer (Fig 2). In patients with superficial venous reflux (-87% in venous leg ulcers) most perforators are acting as re-entry points of the superficial retrograde blood into the deep system. It may be assumed that the increased amount of blood refluxing down in the superficial veins will dilate the perforators which ultimately may become incompetent. Some authors have described a correlation between the diameter of perforating veins, the incidence of incompetence and the clinical severity  assessed by the CEAP stages (9).

Fig. 3: Venous pressure in a dorsal foot vein measured on both sides in a patient with unilateral post thrombotic syndrome (upper curve). The curves should be read from the right to the left side. Walking on a treadmill reduces the pressure on the contralateral leg (curve at the bottom) , but not on the side with massive venous refluxes in the deep and superficial veins of the post- thrombotic leg (upper curve).

Fig 4a: Pressure measured in a dorsal foot vein in a patient with venous ulcers due to massive reflux in the great saphenous vein (GSV). The curves should be read from the right to the left side. Right: Standing still the intravenous resting pressure is 84 mm Hg. By walking on a treadmill the pressure fluctuates between 50 and 100 mmHg (= ambulatory venous hypertension). Left: After application of a tourniquet at thigh level venous reflux in the GSV is abolished and ambulatory venous hypertension is reduced to values around 30 mm Hg.

Consequences of venous reflux For venous hemodynamics the lower leg of the human is a weak point due to the difficulty that blood has to be transported in the upright position towards the heart against gravity. This is also the reason for the reduced healing of all sorts of wounds on the lower leg compared with other body-regions. Under normal conditions competent venous valves ensure blood flow towards the heart emptying the deep and superficial veins of the distal parts of the lower extremity during walking. This venous emptying is effected by squeezing out the veins with every muscle contraction. Competent venous valves prevent that the blood falls back due to gravity. This complex mechanism is called “venous pump”. Even small leg movement provide a significant pumping action. Ambulatory venous hypertension A very meaningful parameter of a normal venous pump is the venous pressure in a dorsal foot vein which is reduced during walking with every step. In the standing position the intravenous resting pressure reflects the weight of the blood column between the measuring point and the right heart. In a patient with one normal and one post thrombotic leg this resting pressure is the same on both sides which is about 90 mm Hg reflecting the body height (Fig 3). When the patient starts to walk blood will be pumped up from the foot towards the heart on the normal side and the peripheral venous pressure will fall with every step. In the absence of competent valves due to post thrombotic damage in the deep veins blood will oscillate up and down in the distal parts of the lower extremity. Venous pressure

fails to fall with leg movements and the pressure generated by muscle contraction is transmitted to the microcirculation of the skin. This constellation, called ambulatory venous hypertension characterizes the severity of venous pumping deficiency. It could be demonstrated that the amount of ambulatory venous hypertension in patients with chronic venous insufficiency is closely correlated with the risk of developing leg ulcers (8). Sustained venous hypertension may occur in patients with venous outflow obstruction, obesity or severe immobility with a failure of the muscle pump. Microcirculatory damage and skin changes Venous pressure in the leg that is elevated for abnormally prolonged periods of time will lead to an infiltration of the venous and venular wall and of valve leaflets with inflammatory cells, to an increased extravasation of fluid into the tissue (oedema) and to a passage of large protein molecules and of blood cells from the venules into the tissue. An inflammatory chain reaction is initiated causing a degradation of matrix proteins by proteolytic enzymes including metalloproteinases. This chronic inflammation plays a key-role for the development of skin changes including dermal tissue fibrosis and ulceration (10).

Therapeutic consequences Concerning a rational therapy of venous leg ulcers the elimination of venous reflux leading to a reduction of venous hypertension is a promising target to be considered in every single case. EWMA

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Fig 4b: After surgical correction of the venous reflux ambulatory venous hypertension was normalized as predicted by the Âpreoperative tourniquet-test. The long-standing ulcer healed.

Fig 5: Schematic drawing of incompetent perforators on the leg from R. Bjordal (15). An isolated therapeutic occlusion ot perforating veins (middle) is a theoretical concept that will only rarely be achieved. Any kind of surgery or sclerotherapy will practically always involve also the superficial veins (right) thereby preventing not only outward reflux in the perforating veins but also downward retrograde flow in the superficial veins. Beneficial hemodynamic effects after perforator occlusion may therefore be explained by abolishment of superficial reflux as well.

Fig. 6: Pressure measured in a dorsal foot vein of a patient with post- thrombotic leg ulcers walking on a treadmill. Left: without compression, centre: with elastic bandage, right with inelastic bandage. Both bandages were applied with a resting pressure of 50 mm Hg. The pressure peaks during walking reflecting venous reflux with every step are reduced by inelastic (right), but not by the elastic bandage (centre).

Several therapeutic procedures may achieve this goal: 1. Bed rest with leg elevation has been recommended as a treatment modality for managing venous leg ulcers. This approach may have more risks than benefits, especially in elderly persons. In mobile ulcer-patients this kind of management should only be recommended for the resting periods between phases walking exercise. Overweight and long sitting and standing should be avoided. 2. Abolishment of superficial venous reflux by surgery, endovenous procedures or sclerotherapy is gaining increasing interest (Fig. 4). Excellent results concerning faster and more durable ulcer healing have been published in several observational trials using such procedures to eliminate superficial and perforator reflux (11, 12). Especially the combination with ulcer excision and skin grafting is a very promising procedure, at the same time eliminating reflux and transforming a badly healing ulcer into a fresh

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wound that may be successfully grafted (13,14). These positive reports are in disagreement with results from one large randomized clinical trial comparing superficial vein surgery plus compression with good compression therapy alone. While additional surgery achieved a reduction of ulcer recurrence, no benefit was found concerning faster ulcer-healing (15). However, the abolishment of superficial venous refluxes by foam- sclerotherapy (12) is a very pragmatic approach and has become a routine procedure in venous ulcer patients, even in the presence of additional deep incompetence. 3. Abolishment of perforator reflux reveals beneficial effects concerning ulcer-healing in patients with an intact deep venous system, but not in cases with deep incompetence. The outcome of procedures eradicating perforators by various techniques is obscured by the fact that perforator surgery will always interrupt î&#x201A;Š superficial reflux as well (16) (Fig. 5).

Science, Practice and Education

4. Deep venous valve repair is performed only in a few centres up to now, some of them using promising new techniques. A careful preselection of the patients and extreme surgical skill and experience are prerequisites for the impressive results that have been reported (17). 5. Compression bandages using stiff materials applied with high pressure are able to reduce venous reflux and ambulatory venous hypertension (18). It could be shown that the intravenous pressure peaks during walking reflecting venous reflux can be reduced by stiff, inelastic bandages but not with elastic material being applied with the same resting pressure (Fig 6). This is in agreement with plethysmographic results measuring expelled volume and ejection fraction in patients with severe superficial reflux without and with different kinds of bandage materials. Implications for Clinical Practice Leg ulcers should undergo a careful instrumental diagnosis not only concerning the exclusion of arterial occlusions but also to prove or to exclude venous refluxes in each case. The majority of venous ulcers show reflux in superficial, deep and/or perforating veins. Experienced staff may use a hand-held Doppler for screening. For the exact localisation of reflux duplex is the preferred examination. Superficial venous reflux which is found in about 80% of venous ulcers can be successfully abolished by venous surgery or endovenous procedures including foam sclerotherapy. These procedures should be considered especially in patients presenting with recalcitrant ulcers not responding to usual conservative treatment modalities. Even in the presence of concomitant deep vein reflux such interventions are frequently able to promote ulcer healing and to reduce the recurrence rate.

References 1. Porter JM, Moneta GL, An International Consensus Committee on Chronic Venous Disease. Reporting standards in venous disease: An update. J Vasc Surg 1995; 21: 635-45. 2. Raju S, Neglen P. High prevalence of nonthrombotic iliac vein lesions in chronic venous disease: a permissive role in pathogenicity. J Vasc Surg. 2006 Jul;44(1): 136-43 3. Eklof B, Perrin M, Delis K, Rutherford RB , Gloviczki P, and the VEIN-TERM Transatlantic Interdisciplinary Faculty. An update on terminology of chronic venous disorders: the veinterm transatlantic interdisciplinary consensus document. J Vasc Surg  in print 4. Trendelenburg F. Über die Unterbindung der Vena saphena magna bei Unter schenkelvarizen. Beitr klin Chir 1890: 185-210 5. Cavezzi A, Labropoulos N, Partsch H, Ricci S, Caggiati A, Myers K, Nicolaides A, Smith PC. Duplex ultrasound investigation of the veins in chronic venous disease of the lower limbs--UIP consensus document. Part II. Anatomy.Eur J Vasc Endovasc Surg. 2006 Mar;31(3):288-99. 6. Coleridge-Smith P, Labropoulos N, Partsch H, Myers K, Nicolaides A, Cavezzi A. Duplex ultrasound investigation of the veins in chronic venous disease of the lower limbs--UIP consensus document. Part I. Basic principles. Eur J Vasc Endovasc Surg. 2006 Jan;31(1):83-92 7. Perrin M. Rationale for surgery in the treatment of venous ulcer of the leg. Phlebolymphology 2004, 45: 276-280. www.phlebolymphology.org/pdf/ pastIssues/45-2004.pdf 8. Nicolaides AN. Investigation of chronic venous insufficiency. A consensus statement. Circulation 2000; 102:e126-e163 . Stuart WP, Adam DJ, Allan PL, Ruckley CV, Bradbury AW. The relationship between the number, competence, and diameter of medial calf perforating veins and the clinical status in healthy subjects and patients with lower-limb venous disease. J Vasc Surg. 2000 Jul;32(1):138-43. 10. Bergan JJ, Schmid-Schönbein GW, Smith PD, Nicolaides AN, Boisseau MR, Eklof B. Chronic venous disease. N Engl J Med. 2006 Aug 3;355(5):488-98. 11. Guarnera G. The venous ulcer and the superficial venous reflux. Int J Low Extrem Wounds. 2004 Dec;3(4):198-200. 12. Cabrera J, Redondo P, Becerra A, Garrido C, Cabrera J Jr, García-Olmedo MA, Sierra A, Lloret P, Martínez-González MA. Ultrasound-guided injection of polidocanol microfoam in the management of venous leg ulcers. Arch Dermatol. 2004 Jun;140(6):667-73. 13. Obermayer A, Göstl K, Walli G, Benesch T. Chronic venous leg ulcers benefit from surgery: long-term results from 173 legs. J Vasc Surg. 2006 Sep;44(3):572-9. 14. Kjaer ML, Jorgensen B, Karlsmark T, Holstein P, Simonsen L, Gottrup F. Does the pattern of venous insufficiency influence healing of venous leg ulcers after skin transplantation? Eur J Vasc Endovasc Surg 2003; 25: 562-7 15. Gohel MS, Barwell JR, Taylor M, Chant T, Foy C, Earnshaw JJ, Heather BP, Mitchell DC,Whyman MR, Poskitt KR. Long term results of compression therapy alone versus compression plus surgery in chronic venous ulceration (ESCHAR): randomised controlled trial. Br med J 2007; 335: 83. 16. May R, Partsch H, Staubesand J. Perforating Veins. Urban & Schwarzenberg, München, Wien, Baltimore 1981 17. Maleti O, Lugli M. Neovalve construction in postthrombotic syndrome. J Vasc Surg. 2006 Apr;43(4):794-9. 18. Partsch H, Flour M, Coleridge Smith P, Benigni JP, Cornu-Thénard A, Delis K, Gniadecka M, Mariani F, Mosti G, Neumann HAM, Rabe E, Uhl JF. Indications for compression therapy in venous and lymphatic disease. Consensus based on experimental data and scientific evidence. Int Angiology 2008;27: 193-219

Future Research Randomized controlled trials with sufficient sample size are required in order to justify the new enthusiasm for attacking venous reflux by several methods in venous ulcer patients by evidence based medicine.

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Combined superficial and deep vein reflux in venous ulcers: operative strategy

Giorgio Guarnera Department of Vascular Surgery and Pathology Istituto Dermopatico dell’Immacolata Roma Italy Correspondence: Giorgio Guarnera Via Oderzo 34 00182 Roma gguarnera@tiscali.it g.guarnera@idi.it

Abstract A venous ulcer is caused by venous hypertension related to a pathology that involves the three venous systems (superficial, deep, perforators) in different ways. Duplex Scanning is the examination of choice in order to identify haemodynamic patterns of reflux. Superficial venous reflux may be frequently combined with a deep venous reflux. The effect of deep venous incompetence on the ulcer healing is unclear, but the current literature suggests that superficial venous surgery is associated with similar rates of ulcer healing to compression alone, but with less recurrence. Saphenous vein ablation results in resolution of a segmental deep reflux (according to overload theory) in about 50% of cases. In the case of an axial deep venous reflux, the rate of reflux resolution is lower (about 30% of cases). In selected patients a deep venous reconstructive procedure might be considered.

Introduction Venous ulcers represent about 70% of all leg ulcers and constitute a significant problem from both a clinical and social point of view (1, 2, 3). They are painful, reduce the quality of life and have the tendency to recur despite compression therapy, and this causes significant financial costs (4, 5). The main pathophysiologic mechanism of the venous ulcer is venous hypertension and its prevalence increases with increasing levels of ambulatory venous pressure (6). The three venous systems (deep, superficial and perforators) may be involved in different combination. In past years many studies focused on the role of Duplex Scanning in identifying the distribution of reflux in patients with venous ulcers.

Patterns of venous reflux The most frequent haemodynamic pattern is represented by the superficial reflux (mean incidence 46%), followed by a combined deep, superficial and perforator reflux (44%). The isolated deep venous reflux is relatively rare (5%), but its overall involvement is 49% (7 and references herein). Some reports underline the possible presence, often wrongly identified, of combined reflux and obstruction in deep venous system (8). Deep venous insufficiency Deep venous insufficiency (DVI) may be either primary or secondary in aetiology. Primary venous disorders are associated with a congenital anomaly (venous segment aplasia or valveless conduit) or a primary deep venous insufficiency (PDVI) which consists of valve leaflet elongation secondary to primitive weakness of the bulb venous wall. The secondary aetiology results from a previous episode of acute deep venous thrombosis (post-thrombotic syndrome: PTS). In PDVI the haemodynamic pattern is usually reflux alone, in PTS, however, most often there is a combination of obstruction and reflux. The effect of DVI on the ulcer healing aetio logy is unclear, but a number of Authors have reported reduced healing rates in patients with venous ulcers in the presence of DVI (9). Deep venous reflux and superficial venous surgery Deep venous reflux may be segmental or axial (with involvement of femoral and popliteal veins) (10) (Figure 1). Abolishment of deep venous reflux after great saphenous vein surgery was reported first by Walsh (11) and Sales (12) in 93% and 94% of the cases respectively. They hypothesized that the superficial venous incompetence might cause overflow into the deep system through the perforating veins

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Figure 1. Descending phlebography shows a deep venous reflux on the right and a combined superficial and deep venous reflux on the left.

and cause dilatation and then incompetence of the deep veins (“overload theory”). It must be underlined that most patients of these series had segmental deep reflux. Adam (13) demonstrated resolution of segmental deep venous reflux in 49% of the cases by post-operative Duplex. In Dix series (14) segmental deep incompetence resolved in 52% of the limbs after surgery compared to 29% of the cases with multi-segmental incompetence. The Author underlines the predictive value of ambulatory venous pressure (AVP) with a tourniquet test. Moreover, other Authors showed that a high post-operative AVP may indicate high risk of recurrent ulcers (15). Ting (16) found reduction in common femoral vein incompetence (from 68% to 28% of the cases at one month and to 32% at one year) after concomitant subfascial endoscopic perforating vein surgery and superficial vein surgery. In the experience

Table 1

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of these Authors, in a good percentage of the cases, the volume/pressure overload from superficial reflux may justify deep segmental incompetence and its resolution by superficial venous surgery (Table 1). This theory is also supported by the observation that segmental deep reflux is also reversed in some legs treated with compression alone (17). ESCHAR study compared venous superficial surgery and compression with compression alone in 500 consecutive patients affected by chronic venous ulceration. Overall 24-week healing rates were similar in the two groups (65% vs 65% in case of isolated superficial reflux, 56% vs 57% in case of combined superficial and segmental deep reflux), but the 12-month ulcer recurrence rates were significantly reduced in the compression and surgery group (12% vs 28%) (18). In the same patients, examining recurrence rates with the two methods at 12 months and at three years (19) in three different subgroups of patients, according to different haemodynamic patterns (superficial reflux alone, superficial + segmental deep reflux, superficial + total deep reflux), we have different results. No significant difference in recurrence rate was seen in patients with mixed superficial and total deep reflux (19% vs 31%, p=0.42 at 12 months, 32% vs 46%, p=0.33 at 3 years) (Table 2). In another study, in most patients with deep venous reflux after superficial surgery, no statistically significant improvement in reflux velocity and time was found (20). In extremities with deep axial reflux the rate of reflux resolution was reported at about 30% (14, 16, 20). Moreover, a residual axial deep reflux was indicated as a risk factor of  ulcer recurrence (15).

Table 2

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Deep venous surgery The majority of venous ulcers related to deep venous reflux must be treated with sustained high compression bandaging. A deep vein reconstructive procedure may have a role in carefully selected patients. The indications for this surgery are represented by venous ulcers with total deep venous reflux, failure of conservative therapy, young patients reluctant to wear permanent compression, and poor quality of life of the patients. The best results are achieved in PDVI, in which valve leaflets are elongated and stretched, even if normally formed. The uppermost superficial femoral valve is most frequently repaired. A wide variety of techniques is available to achieve valve competence in relation to the stages of PDVI. The first stage, when the vein is dilated and the valve borders are merely detached, may be managed by placing a Dacron sleeve as a cuff around the vein: the valve circumference is decreased and the valve cusps are Figure 2. Descending phlebography shows a short femoro-iliac venous brought closer together to produce competence. obstruction combined with a deep venous reflux on the left. In more advanced stages, an external valvuloplasty is performed by placing transluminal sutures along the that superficial surgery and post-operative compression valve attachment lines: in this way the valve attachment therapy was less effective than combined superficial and angle is closed and simultaneously the valve cusps are deep surgery and compression therapy in patients affected tightened. When the valve leaflets are frankly prolapsed, by recalcitrant chronic venous ulcers and deep venous inan internal valvuloplasty has to be considered. It involves competence (25% vs 87% healing rates). However, the a venotomy at the level of the valve: the redundant valve value of a deep venous valve repair remains to be proved cusp is shortened by placing a suture at each commissure. in randomized controlled studies. Moreover, the Authors report worse surgical results in Such surgery is not often indicated and the surgical procedures are performed by few specialised centres worldwide. patients affected by PTS, which has been shown to be an In these centres ulcer healing is reported in a variable rate adverse prognostic factor in the healing of venous ulcers from 60% to 90% after more than five years follow-up (21, 23). (21 and references herein). Sottiurai (22) demonstrated References 1. Bergqvist D, Lindholm C, Nelzén O: Chronic leg ulcers: the impact of venous disease. J Vasc Surg 1999;29:752-55 2. Nelzén O: Leg ulcers: economic aspects. Phlebology 2000;15:110-14 3. Philips TJ: Chronic cutaneous ulcers; aetiology and epidemiology. J Invest Dermatol 1994;102:38S-41S 4. Ryan S, Eager C, Asibbald RG: Venous leg ulcer pain. Ost Wound Man 2003;49(4 Suppl):16-23 5. Margolis DJ, Berlin JA, Strom BL: Risk factors associated with the failure of a venous leg ulcer to heal. Arch Dermatol 1999;135:920-26 6. Nicolaides AN, Hussein MK, Szendro G et al: The relation of venous ulceration with ambulatory venous pressure measurements. J Vasc Surg 1993;17:414-19 7. Guarnera G: Ulcera venosa: modelli emodinamici e scelte terapeutiche. In: Guarnera G, Papi M: L’ulcera cutanea degli arti inferiori. Monti Ed., Saronno 2000, pp189-209 8. Labropoulos N, Patel PJ, Tiongson JE et al: Patterns of venous reflux and obstruction in patients with skin damage due to chronic venous disease. J Vasc Endovasc Surg 2007;41(1):33-40 9. Howard DPJ, Howard A, Kothari A et al: The role of superficial venous surgery in the management of venous ulcers: a systematic review. Eur J Vasc Endovasc Surg 2008 In Press

10. Labropoulos N, Tassiopoulos AK, Kang SS et al: Prevalence of deep venous reflux in patients with primary superficial vein incompetence. J Vasc Surg 2000;32;663-68 11. Walsh JC, Bergan JJ, Beeman S et al: Femoral venous reflux abolished by greater saphenous vein stripping. Ann Vasc Surg 1994;8:566-70 12. Sales CM, Bilof ML, Petrillo KA et al: Correction of lower extremity deep venous incompetence by ablation of superficial venous reflux. Ann Vasc Surg 1996;10:186-9 13. Adam DJ, Bello M, Hartshorne T et al: Role of superficial venous surgery in patients with combined superficial and segmental deep venous reflux. Eur J Vasc Endovasc Surg 2003;25:469-72 14. Dix FP, Picton A, Mc Collum CN: Effect of superficial venous surgery on venous function in chronic venous insufficiency. Ann Vasc Surg 2005;19:678-85 15. Magnusson MB, Nelzén O, Volkmann R: Leg ulcer recurrence and its risk factors: a duplex ultrasound study before and after vein surgery. Eur J Vasc Endovasc Surg 2006;32:453-61 16. Ting ACW, Cheng JWK, Pei Ho et al: Reduction in deep vein reflux after concomitant subfascial endoscopic perforating vein surgery and superficial vein ablation in advanced primary chronic venous insufficiency. J Vasc Surg 2006;43:546-50 17. Gohel MS, Barwell JR, Poskitt KR et al: Re: Role of superficial venous surgery in patients with combined superficial and segmental deep venous reflux. Eur J Vasc Endovasc Surg 2004;27:106-7

18. Barwell JR, Deacon J, Harvey K et al: Comparison of surgery and compression with compression alone in chronic venous ulceration ( ESCHAR study ): r andomised controlled trial. The Lancet 2004;363:1854-59 19. Gohel MS, Barwell JR, Taylor M et al: Long term results of compression therapy alone versus compression plus surgery in chronic venous ulceration ( ESCHAR ): randomised controlled trial. BMJ 2007;335:83-87 20. Puggioni A, Lurie F, Kistner R et al: How often is deep venous reflux eliminated after saphenous vein ablation? J Vasc Surg 2003;38:517-21 21. Raju S: Surgical treatment of deep venous valvular incompetence. In: Rutherford R: Vascular Surgery, 5th Edition, WB Saunders Company Ed, Philadelphia 2000, chapter 149, pp 2037-49 22. Sottiurai V: Surgical correction of recurrent venous ulcer. J Cardiovasc Surg 1991;32:104-9 23. Brittenden J, Bradbury AW, Allan PL et al: Popliteal vein reflux reduces the healing of chronic venous ulcer. Br J Surg 1998;85:60-62 24. Neglen P, Hollis KC, Raju S: Combined saphenous ablation and iliac stent placement for complex severe chronic venous disease. J Vasc Surg 2006;44:828-33 25. Meissner MH, Eklof B, Coleridge Smith P et al: Secondary chronic venous disorders. J Vasc Surg 2007;46(6 Suppl 1):68-83

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Complex haemodynamic pictures An axial deep venous reflux may coexist with an obstruction in the femoro-iliac or popliteal segments or with an incompetence of pelvic veins (Figure 2). Recently, endovascular interventions have been performed with increasing frequency in venous occlusive disease. Combined saphenous ablation and iliac vein stenting achieved ulcer healing in 26 (68%) of 38 limbs with a cumulative ulcer-healing rate of 64% at 48 months (24). In patients affected by PTS and recurrent venous ulcers resistant to standard medical and surgical therapy an artificial venous valve may be an interesting option. Valve cusps made of autogenous vein are the only currently available substitutes, as nonautogenous artificial valves have either failed or remain under development (25). However, there are open problems concerning dimensions, materials and insertion modalities. Conclusions Coexistent superficial and deep venous reflux is a common finding in venous ulcers. Segmental reflux in deep veins is reversed in about 50% of cases by ablative superficial venous surgery. In the presence of an axial deep venous reflux the rate of resolution is about 30% of cases. In a selected number of these patients deep valve reconstructive surgery might have a role. In more complex haemodynamic pictures vein stenting represents an interesting prospect. m

Implications for Clinical Practice n In venous ulcers an accurate Color Duplex Scanning is mandatory to identify the patho genetic role of the three venous systems. n Superficial venous reflux is the most frequent haemodynamic pattern. Its abolition by surgery reverses a concomitant segmental deep reflux in most cases. n An axial deep venous reflux may require deep venous reconstructive surgery in selected cases. Further research Future research should investigate patients at risk of ulceration as well as, post-operatively, risk of recurrence. n Future research is needed to determine the long- term haemodynamic significance of axial or persistent segmental deep reflux after super ficial surgery. n

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National Wound Prevalence Studies

s stated by Marco Romanelli in “The Implementation Challenge” on p. 51, one of the largest challenges within wound healing is the implementation of existing knowledge and recognition by politicians of the burden of illness. In this respect, objective health economics data is vital. Thus, based on the discussions and experiences from the work in the AWCG of Eucomed as well as on lessons learned from the Patient Outcome Group and the Leg Ulcer Project (more information about these projects at www.ewma.org), EWMA has decided to work actively on creating the “European map of leg ulceration”. As in the Leg Ulcer Project, the most obvious project partners for the national wound prevalence studies are the national wound management associations, which are already collaborating with EWMA through EWMA Cooperating Organisations. A finance model for implementation of a wound prevalence study in a number of larger European countries will combine: n A contribution by 1-2 international industry partners to cover the fixed costs of designing and setting-up the study design; n Additional grants by national industry partners and/or research funding institutions to cover the variable costs of each individual national study. The research design will include elements, such as identification of national project responsible and data collection responsible/team, definition of the catchment population, definition of leg ulceration, identification of patients, establishment of a patient coding system, data collection and analysis etc. A “European map of leg ulceration” will clarify and substantiate the burden of leg ulceration towards decisionmakers and it will illustrate where education is needed as well as which types of education. For more information, please contact EWMA Business Office at ewma@ewma.org By Professor Peter Franks

EBWM

ABSTRACTS OF RECENT COCHRANE REVIEWS Publication in The Cochrane Library Issue 1, 2009

Compression for venous leg ulcers

Sally Bell-Syer, MSc Review Group Co-ordinator Cochrane Wounds Group Department of Health Sciences Area 2 Seebohm Rowntree Building University of York York, United Kingdom sembs1@york.ac.uk

Susan O’Meara, Nicky A Cullum, E Andrea Nelson This record should be cited as: O’Meara S, Cullum NA, Nelson EA. Compression for venous leg ulcers. Cochrane Database of Systematic Reviews 2001, Issue 2. Art. No.: CD000265. DOI: 10.1002/14651858.CD000265. ABSTRACT Background: Around one percent of people in industrialised countries will suffer from a leg ulcer at some time. The majority of these leg ulcers are due to problems in the veins, resulting in an accumulation of blood in the legs. Leg ulcers arising from venous problems are called venous (varicose or stasis) ulcers. The main treatment has been a firm compression garment (bandage or stocking) in order to aid venous return. There is a large number of compression garments available and it is unclear whether they are effective in treating venous ulcers and which compression garment is the most effective. Objectives: To undertake a systematic review of all randomised controlled trials of the clinical effectiveness of compression bandage or stocking systems in the treatment of venous leg ulceration. Specific questions addressed by the review are: 1. Does the application of compression bandages or stockings aid venous ulcer healing? 2. Which compression bandage or stocking system is the most effective? Search strategy: For this update we searched the Cochrane Wounds Group Specialised Register (14/10/08); The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 4 2008); Ovid MEDLINE (1950 to October Week 1 2008); Ovid EMBASE (1980 to 2008 Week 41) and Ovid CINAHL (1982 to October Week 1 2008). No date or language restrictions were applied. Selection criteria: Randomised controlled trials recruiting people with venous leg ulceration that evaluated any type of compression bandage system or compression hosiery were eligible for inclusion. Comparators included no compression (e.g. primary dressing alone, non-compressive bandage) or an alternative type of compression. Trials had to report an objective measure of ulcer healing in order to be included (primary outcome for the review). Secondary outcomes of the review included ulcer recurrence, costs, quality of

life, pain, adverse events and withdrawals. There was no restriction on date, language or publication status of trials. Data collection and analysis: Details of eligible studies were extracted and summarised using a data extraction table. Data extraction was performed by one review author and verified independently by a second review author. Main results: Overall, 39 RCTs reporting 47 comparisons were included. Review question 1: there was reasonable evidence from seven RCTs that venous ulcers heal more rapidly with compression than without. Review question 2: findings from six trials of singlecomponent compression suggested that this strategy was less effective than multi-component compression. Evidence from compression systems with two components (3 trials) and three components (4 trials) suggested better outcomes when an elastic component was included. Different versions of compression with four-components (based on the Charing Cross fourlayer bandage system) have similar effectiveness (3 trials). Compression with four components (variants of the Charing Cross four-layer bandage) is more effective than multi-component compression that includes a short-stretch bandage (6 trials). It is difficult to determine the relative effectiveness of the four-layer bandage compared with paste bandage systems because of differences in the paste systems (5 trials). There was no difference in effectiveness between the adjustable compression boot and compression bandages (2 trials) or between single-layer compression stockings and paste bandages (2 trials). Two-layer stockings appeared more effective than the shortstretch bandage (2 trials). The relative effectiveness of tubular compression when compared with compression bandages was not clear from current evidence (2 trials). Three trials reported ulcer recurrence; because of sparseness of data and trials not being primarily designed to assess this outcome, firm conclusions could not be drawn. Although several trials included cost data, only one reported a rigorously conducted cost-effectiveness analysis with findings suggesting that the four-layer bandage was more cost-effective than multi-component compression comprising a shortstretch bandage. Seven trials assessed health-related quality of life and none observed significant differences between treatment groups. Several trials evaluated pain either as a stand-alone outcome, or as part of the assessment of adverse events. In general, the data did EWMA

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ELECTRONIC SUPPLEMENT JANUARY 2009

not indicate clear differences between treatment groups. It is possible that stockings could be associated with less pain than bandages but in view of scarcity of available data this requires further evaluation. Many of the trials reported adverse events and / or withdrawals. Overall, these outcomes appeared similar across different treatment groups.

The Electronic Supplement is the accompanying online issue of EWMA Journal. Each January edition features a yearly status from EWMA Cooperating Organisations, each May issue features oral and poster abstracts from the annual EWMA conference, and each October issue features articles from a European wound journal translated into English.

Authors’ conclusions: Compression increases ulcer healing rates compared with no compression. Multi-component systems are more effective than single-component systems. Multi-component systems containing an elastic bandage appear more effective than those composed mainly of inelastic constituents.

The January 2009 edition of the EWMA Journal Electronic Supplement includes articles with news from EWMA Cooperating Organisations along with presentations of new Cooperating Organisations. All organisations have been invited to contribute with information about their recent activities, research projects and meetings, as well as their political and scientific involvement in wound care on a national level. New organisations provide an overview of their history, member activities and goals for the future.

Plain language summary Compression bandages and stockings to aid the healing of venous leg ulcers: Venous leg ulcers occur when the blood returning from the veins in the legs to the heart is slow or obstructed. These ulcers can take a long time to heal (weeks or months) and can cause distress to patients as well as being very costly for the health service. Compression bandages help to aid venous return and there is a number of types of bandages available, some of which are just a single type of bandage whilst others involve the application of several different bandages to the leg. Compression stockings are sometimes used as an alternative to compression bandages. This review examines the effectiveness of compression bandages versus no compression, and compares different types of compression bandages and stockings. We have looked at how well these different treatments work in terms of ulcer healing. We found that applying compression was better than not using compression and that multi-component bandages worked better than single-component systems. Multi-component systems (bandages or stockings) appear to perform better when one part is an elastic (stretchy) bandage.

News from: 1. Francophone Nurses Association in Stoma Therapy, Healing and Wounds (AFISCeP) 2. Italian Nurses Cutaneous Wounds Association (AISLeC) 3. Italian Association for the study of Cutaneous Ulcers (AIUC)  4. German Society of Wound Healing and Wound Treatment (DGfW) 5. Finnish Wound Care Society (FWCS) 6. Malta Association of Skin and Wound Care (MASC) 7. National Association of Tissue Viability Nurses, Scotland (NATVNS) 8. Swedish Wound Care Nurses Association (SSiS) 9. Icelandic Wound Healing Society (SumS) 10. Tissue Viability Society (TVS) 11. Association for Wound Management of Bosnia and Herzegovina (URuBiH) 12. Wound Management Association of Ireland (WMAOI) 13. Wound Management Association of Turkey (WMAT)

http://ewma.org/english/ewma-journal/ electronic-supplement.html

WWW.EWMA.ORG EWMA

Journal 2009 vol 9 no 1

FINNISH WOUND CARE SOCIETY

Salla Seppänen, MNSc President Finnish Wound Care Society www.suomen haavanhoitoyhdistys.fi

The Finnish Wound Care Society was established on November 17 1995 in Helsinki by Professor M.D. Sirpa Asko-Seljavaara, Head Nurse Helvi Hietanen, Assisting Head Nurse Raija Hietikko and Assisting Head Nurse Päivi Äikää from the plastic surgery unit in Helsinki University Hospital along with 54 other professionals interested in wound care. The number of individual members of FWCS increased rapidly; in 1996 the society had 300 members and by 2000 over 1550 members. In 2006 the magic limit of over 2000 members was achieved and now FWCS has 2700 individual members. The corporate members also have an important role in supporting the activities of FWCS. The number of corporate members is 47, including wound product manufacturers, marketing companies, pharmaceutical companies and some private health care organisations.

Next year the participants of the national conference are invited to participate in the EWMA 2009 Conference HELP IN HELSINKI. In addition to the national conference FWCS has arranged 1-3 regional educational seminars per year, which aim to bring knowledge of wound care geographically and financially nearer to members with regional locations and low participation fees. These regional seminars are planned and implemented together with active members of FWCS in the region. This enables FWCS to take into the consideration the special regional needs for knowledge and information in regional areas.

The aims of FWCS are n to promote multiprofessional co-operation in the prevention of wound problems and in the holistic care of wound patients. n to promote good quality of care of the wound patients. n to promote multidisciplinary research and experiments for the development of wound care. n to promote professional education in wound care. The activities of FWCS are lead by its president, vice president and board members (6-8 persons). The activities are divided across four committees; Research and development, Education and the National Conference, International co-operation and Journal Haava (=Wound). The board has 1012 meetings per year and the committees have their own meetings when needed. Since 1997 FWCS has organised an annual conference, which gathers together about 800–1000 professionals from all parts of Finland. This year the theme was Modern Wound Management.

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(FWCS)

In the field of research and development FWCS is also active. The society participated in the International Pain Study conducted by professor Patricia Price and this year also published the results of the controlled questionnaire study ”Wound care product availability for patients in Finland in years 2006-2007”. The study was conducted by FWCS. The results of study showed that the free distribution of wound care products from health care centers varies and results in uneven patient care. The Finnish Wound Care Society is a partner in the national project “Inno Haava”, which aims to develop standards in the digital photographing of wounds and models of distant consulting in wound care. The project is lead by University of Jyväskylä, Chydenius Centre in Kokkola and funded by ERDF. The project covers the northern part of Finland combining education and clinical practice.

This year FWCS celebrates the 10th anniversary of its journal HAAVA. HAAVA is published four times a year and all members get the journal included with their membership fee. which is only 25€. The HAAVA is also distributed to many hospital and university libraries. The printing is 3500 copies. You can read more about HAAVA in the article below by the Editor Ansa Livanainen. In 2003 FWCS appointed an accreditation workgroup, which defined the criteria for professional qualifications of TVN and described the application process. In the accreditation workgroup were representatives of educators, clinical practitioners and the Ministry of Social and Health care. The aim was to unify the competences of TVN and officially recognise wound management as a specialised area in Finnish nursing disciplines. Since 2004 it has been possible for registered nurses to apply for the accreditation. The prerequisites are that a nurse has at least 30 credits higher education studies in wound management and three years working experience in wound management including clinical care, consultancy, education and development and research activities. The accredation is applied by portfolio, which is assessed by a multiprofessional group of specialists in wound care. The register of TVN is held by FWCS and the re-evaluation of the competence is done every third year by sending information concerning the working time in wound care, minimum 12 months, and additional education in wound management, a minimum 10 days in three years. According to the follow up study on the impact of accreditation, carried out in 2006, the accreditation has increased the recognition of nurses’ competences in wound management and profiled TVN as a clinical nurse specialist among the other specialists in health care.

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Future challenges for FWCS Finland is a Nordic country with more than five million inhabitants. We are a so called welfare state and quality health care services are available with high standards for everyone. In the future the national challenge is how to keep the status of the welfare state. The problem of our ageing population is huge. In 2030 every fourth Finn will be over 65 years old and every tenth will be older than 75. The second challenge is the increased incidence of chronic diseases like diabetes, heart failure etc. In particular the incidence of type 2 diabetes is increasing rapidly; 2,8% annually. According to the Finnish National Diabetes Federation every tenth adult Finn is diabetic. About 280,000 of them are treated, but 200,000 of them have not been dignosed and thus fall outside the treatment, programme. Based on these facts the biggest future challenge for FWCS is to promote the prevention of chronic wounds and support effective treatments of wounds by providing education and facilitating research of wound management. I believe that many national wound care/ management associations and societies in European countries can share this future challenge with FWCS. Thus it is very important that national organisations co-operate and share their knowledge and experiences with each other – and learn from each other. The EWMA conference is a great opportunity for all professionals in the field on wound care to share and learn. On behalf of the Finnish Wound Care Society I have the pleasure of inviting you to the EWMA 2009 conference, 20-22 May, 2009 in Helsinki. You are all warmly welcome!

Salla Seppänen

The first decade of

Haava Ansa Iivanainen, RN, LicNSc Editor of Haava Mikkeli University of Applied Sciences ansa.iivanainen@mamk.fi

SHORT HISTORY When the Finnish Wound Care Society (FWCS) was established in 1995 it was decided to establish a national quarterly journal on wound care. At the same time it was realised that the first priority was to decide on the structure of the Society and build up the member base. Thus the publication was delayed. The matter was discussed in several board meetings but there were concerns about costs as well as the new competences needed in publishing. The first issue was published in November 1998. The executive committee, after some lively pondering, arrived at a simple title Haava (Wound). At the time the Society did not have a logo, so the title’s typography was designed together with the printing house. It was also decided that the motif of the cover page must be taken from nature. The first issue had 24 pages and the introductory print of 2000 was meant for marketing. The first editorial was written by MP Sirpa Asko-Seljavaara From the start, the Journal has been in four colours to keep the picture quality high. The costs of the first print were covered by advertisements. After the first issue the publication has continued quarterly. Haava is distributed to members of the society included in their membership fee. Organisations, non-members and libraries can also order it. The articles of the magazine cover hands-on experience, research, studies, surveys, theory of wound healing, anatomy of skin, the care of wounds, dressings etc. as well as education, conferences and congresses in Finland and abroad. The cover page presents the theme of the issue. There have been themes on diabetic foot ulcers, psychiatric patients and wound care, internationality, surgical wounds, nutrition, wounds of the elderly, chronic wounds, acute wounds, leg ulcers, burns and the use of products. Every year there is one issue dedicated to the Annual National Wound Care Conference. In 2009 the congress of EWMA will be in Finland and the Haava issue number three is the dedicated conference issue.

Journal

From the first issue the magazine has featured regular columns; the leading article, greetings from the editor and chairperson, a feature on education, the resolutions of executive committee of FWCS and discussion of new wound products. Articles have been written by medical doctors, nurses (RN), physiotherapists, occupational therapists, nutritional therapists, podiatric therapists and practical nurses. On the 1922 cumulative pages up to the end of 2008 there have been 319 authors. Today the number of copies published is 3500 per issue. Haava is an important part of FWCS, because it keeps the contact between the society and its members. The three reader surveys (2000, 2005, 2007) indicate that the journal is seen as an important source of information and education. Editorial Board Members 2009 Ansa Iivanainen, Editor Heidi Castrén, RN Anja Huovinen, RN Taina Kelakorpi, RN Tiina Pukki, RN Päivi Salminen-Peltola, MD Mikko Tuuliranta, MD

CELEBRATION The decennial celebration was held in Helsinki in November 2008 with invited guests from Finland and abroad including MP, honorary FWSC president Sirpa Asko-Seljavaara, honorary FWSC president Helvi Hietanen, senior inspector Maire Kolimaa Ministry of Health, professor Christina Lindholm from Sweden and Teresa Krausman and Bent Bürke from EWMA, executive committee of FWCS, editorial board members of Haava, invited members of FWCS and companies in the Finnish wound care industry. Congratulations were received and published in Haava 4/2008 from President Marco Romanelli, Professor Finn Gottrup and Professor Christina Lindholm. m

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CALL FOR ABSTRACTS

EARLY REGISTRATION DEADLINE 1 MARCH 2009

EWMA Patient Outcome Group The EWMA Patient Outcome Group was officially established in October 2008. The primary objective of this working group will be to redefine the perception of outcome within wound healing and wound management. Types of outcome lacking sufficient focus are for example health economics and patientâ&#x20AC;&#x2122;s quality of life. As part of this initiative, the group will propose and implement a set of European consensus guidelines and tools for evaluation of clinical trials within the area. The initiative is partly based on the current debate about evidence in wound healing. In relation to this, attention has been brought to the barriers related to creating sufficient evidence to secure use of the right products in the most efficient treatment setup. The group will have a clinical scientific platform, including both clinicians and representatives from companies working within wound healing. This collaboration will Âsecure the crucial support of the guidelines needed to reach the implementation of a true European standard for both treatment as well as clinical trials. Clinical members: Finn Gottrup, Chair Marco Romanelli Jan Apelqvist

Luc Gryson Hugo Partsch Patricia Price

The objectives of EWMA Patient Outcome Group are specified in the following four activity areas: 1. Identification of barriers: With a starting point in the current debate on evidence in wound healing and the Cochrane levels of evidence, the group will define the primary barriers (as experienced by clinicians and companies) related to creating and implementation of evidence based guidelines in wound healing. 2. Proposing guidelines for clinical data collection: The objective will be to define how existing guidelines for clinical trials can be adapted to wound management, e.g. by including other end points such as number of dressing changes, health economics, QOL, education of staff and structure of treatment. 3. Participating in the public debate & policy making: The working group will present a common viewpoint on clinical trials of wound management products in relation to the debate. This will be done on national as well as European level. A primary goal will be to influence the decision making processes concerning approval and reimbursement of wound management products. 4. Creating and implementing consensus: Other interested parties (clinicians, companies, reimbursement authorities, European collaborative groups and institutions) should be involved in order to create consensus within the area. Finn Gottrup

Industry members:

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EWMA

New EWMA Focus: The Implementation Challenge In the future, EWMA has decided to focus on implementation of guidelines rather than producing more guidelines. This means that EWMA will not publish a new Position Document in 2009, instead EWMA will initiate activities to further implementation of existing guidelines. Read more about this in “The implementation Challenge” by the President of EWMA, Marco Romanelli, on the right hand side of this page. EWMA Position Documents

The Implementation Challenge

veryday we learn more and more about how to treat chronic wounds in the most efficient way with great focus on the outcome for the patient. A number of consensus based guidelines have been produced, describing these treatment rationales. EWMA now finds that the time has come to direct the focus to how we implement what we know. Over the past years, efforts have been made to produce and reach consensus on methods and structures for treatment of different types of chronic wounds. Evidence of consensus based guidelines now exists in almost all wound areas. This work is of great value for all clinicians involved in the continuous development of wound management and for all patients suffering from a chronic wound. To maximise the outcome of the great work put into the development of these guidelines, it is crucial that they are followed by an extensive implementation plan – we need to do more than just disseminate the message through the traditional means of communication such as presentation at national and international conferences and articles in wound care journals.

Editor: Christine Moffatt The EWMA Position Documents are available in English, French, German, Italian and Spanish, and can be downloaded from www.ewma.org It is possible to obtain permission to translate the EWMA Position Documents into other languages. Please contact EWMA Business Office.

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For further details contact MEP Ltd, 53 Hargrave Road, London N19 5SH. www.mepltd.co.uk or EWMA Business Office, Congress Consultants, Martensens Allé 8, 1828 Frederiksberg, Denmark Tel: +45 7020 0305 Fax: +45 7020 0315 ewma@ewma.org

Implementation is not an easy task. It requires that we all take the responsi bility for the practical implementation and follow up activities, which should not only include “translation” but also the educational and organisational development required. The European Wound Management Association, EWMA, sees it as a primary objective in the coming years to support this important work Professor Marco Romanelli EWMA President 51

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Christine Moffatt – An Appreciation Christine Moffatt has been a key person in the development of the European Wound Management Association, serving on Council since 1995 and acting as the society’s President from 1999 to 2002. During this period she, with other Executive members, forged a truly independent umbrella wound care organisation that links together local, national and specialist interest wound care groups throughout Europe. Christine navigated EWMA skillfully through the difficult transition from a publishing house-linked, largely UKbased society, to a fully-fledged independent association with roots across Europe. During her term of office the society gained financial security and has developed its own independent voice. When I succeeded Christine as the societies President in 2002 the Association had a structure, direction and purpose, an inheritance I hope I was able to pass on to my successors. Christine’s skills within wound care practice and research are internationally recognised. She used this expertise to develop a series of initiatives that are synonymous with EWMA and represent a number of the society’s lasting key strategies. She was, for example, the launch editor of the EWMA Journal in 2001 and was responsible for developing the concept of the EWMA Position Documents, the first of which “Pain at wound dressing change”, was published in 2002. Since then Christine has acted as senior editor on a further six very successful position documents, all published in a minimum of five European languages. It is not only within EWMA that Christine’s professionalism has been recognised. She was awarded both a Fellowship of the Royal Collage of Nursing for her contribution to the art and science of nursing, and a CBE for her contributions to the field of tissue viability and nursing in 2006. She also received a lifetime achievement award from the World Union of Wound Healing Societies in 2008. I know that I speak for my colleagues on Council when I say that we will miss Christine’s contribution to the direct running of the Association. She will, I am sure, maintain a keen interest in the continued development of EWMA and its many co-operating organisations. Christine will no doubt remain a familiar face at EWMA conferences for many years to come. Thank you Christine for more than 12 years work on behalf of the Association. I believe that you can truly be proud of your and EWMA’s achievements. Professor Peter Vowden

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Healing Chronic Wounds -

Completely. Topical Wound Oxygen therapy utilizes a unique cyclical pressurized oxygen approach to completely heal venous, diabetic, arterial and pressure ulcers.

• Proven safe non-invasive therapy • Greater than 80% complete wound closure rates • Stimulates angiogenesis and collagen production • Effective infection control by eliminating pathogens • Significant reduction in wound related pain • So simple-to-use that you can treat patients in their home • Significant cost savings To learn more and review references, go to:

www.aotinc.net/references

Wound Care Solution Excellence info@aotinc.net • www.aotinc.net

EWMA

This year’s AGM marked the end of term in EWMA Council for Peter Franks, Christina Lindholm, Deborah Hofman and Christine Moffatt, as well as Judit Daróczy and Zbigniew Rybak.

Peter Franks

Deborah Hofman

Peter Franks has served on EWMA Council since 1997 and was President from 2005 to 2007. He is an epidemiologist with an interest in health economics by background which has provided a good balance to Council. He has been instrumental developing the Leg Ulcer Project in Eastern Europe and a great ambassador for EWMA attending a number of national conferences around Europe to showcase EWMA activity. He has also been a valuable member of the Editorial Board of the Journal and will continue as a member of the Scientific Review Panel.

Deborah Hofman has been a member of EWMA since 1996. With her background as a Clinical Nurse Specialist, she has contributed to the work of several EWMA Committees such as the Education Committee, the Editorial Board and the Scientific Committee. Deborah was the Recorder from 1998-2001, a time of transition in EWMA’s history, when very little support was available to undertake the work for much of this time. Despite this, Deborah and the rest of the Scientific Committee delivered very successful conferences each year.

Christina Lindholm

Judit Daróczy and Zbigniew Rybak

Christina Lindholm has, except for a short break, been a member of EWMA Council since 1994. As President of the Swedish Wound Care Nurses Association and a Professor of Nursing and Former Research Chief at the Karolinska University Hospital in Sweden, Christina has contributed greatly to the work in EWMA Council and especially on the EWMA Education Committee. She has brought a passion for improving wound care, her considerable experience of undertaking large research studies and practical common sense to our meetings which has been much appreciated.

Judit Daróczy, Professor of Dermatology in Hungary and Zbigniew Rybak, Surgeon, Wrocław Medical University, Poland were both elected to Council as representatives of the Co-operating Societies and for them, the constitution only permits one term of office for three years. Despite this short period of time, they have been valuable members of Council and participated fully in both the meetings and EWMA committees.

EWMA is only successful because of the hard work and dedication of council members and I would like to thank all of them for their hard work in EWMA Council and in EWMA Committees and wish them all every success in the future. Marco Romanelli, President

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Support European Wound Care

Become a Member of EWMA European Wound Management Association EWMA

Support European Wound Care

Founded in 1991, The European Wound Management Association (EWMA) is an umbrella organisation that brings together individuals and organisations with the aim of addressing clinical and scientific issues in order to improve wound management in Europe.

The most important aspect of becoming a member of EWMA is that you support a very important cause – you support the improvement and development of wound care in Europe. Furthermore, a membership of EWMA will give you influence on this development. As a EWMA member you can vote and, after 1 year’s membership, you can even stand for election to the EWMA Council, which will give you direct influence on the future development of wound care in Europe.

The main objectives of the association are: 1. To promote the advancement of education and research into epidemiology, pathology, diagnosis, prevention and management of wounds of all — aetiologies. 2. To arrange conferences on aspects of wound management throughout Europe. 3. To arrange multi-centre, multi-disciplinary training courses on topical aspects of wound healing. 4. To create a forum for networking for all individuals and organisations interested in wound management. These objectives are mainly achieved through the 42 Cooperating Organisations (national wound management associations in Europe) of EWMA, the EWMA Education initiatives, the EWMA projects and the EWMA conferences. EWMA is the largest wound management association in Europe and the annual EWMA Conferences attract 1500-2500 participants.

Benefits of your EWMA Membership n You support the development and n n n n n

improvement of wound care in Europe EWMA Journal sent directly to you three times a year 15% discount on your registration fee for EWMA Conferences Right to apply for EWMA travel grants Right to vote and stand for EWMA Council Updates on activities and developments within EWMA via email

Membership Registration A membership only costs 25 EUR a year. You can register online at www.ewma.org and pay by credit card as well as via bank transfer. Members of EWMA can also renew their membership online.

Please register as a EWMA member at

WWW.EWMA ORG EWMA Business Office Danske Bank, London Cash Management· 75 King William Street, London EC4N 7DT, UK Account No: 93406336. IBAN: GB69DABA30128193406336 BIC/SWIFT: DABAGB2L. Sort code 301281

EWMA Journal

Previous Issues

Volume 8, no 3, May 2008 Eucomed – Advanced Wound Care Sector (AWCS). Positioning of advanced wound care Hans Lundgren A Laboratory Survey of the Antimicrobial Properties of Honey-Containing Dressings Rowena Jenkins Topical negative pressure versus conventional treatment of deep sternal wound infection in cardiac surgery Martin Šimek Quality of Life in the Patients with Chronic Leg Ulcers – A Preliminary Report Veronika Slonkova Compression therapy for venous leg ulcers – how to get more value for money Susan F. Jørgensen Abstracts of recent C ochrane Reviews Sally Bell-Syer The EWMA University Conference Model: Lessons learned from Lisbon Zena Moore

International Journals The section on International Journals is part of EWMA’s attempt to exchange information on wound healing in a broad perspective. English

Advances in Skin & Wound Care, vol. 21, no 12, 2008 www.aswcjournal.com An Evidence-Based Model Comparing the Costeffectiveness of Platelet-Rich Plasma Gel to Alternative Therapies for Patients with Nonhealing Diabetic Foot Ulcers Edward J. Dougherty Skin Perfusion Pressure in Chronic Venous Disorders Teresa J. Kelechi, Diane E. Neal Herpes Zoster: Prevention, Diagnosis, and Treatment – 2008 Update Denise D. Wilson

Finnish

Haava, no 4, 2008 www.suomenhaavanhoitoyhdistys.fi Optimising Wound Healing Teemu Murtola, Mikko Tuuliranta Wound Healing – an internal point of view Heidi Castrén Implementation of Asepthic in Wound Management Ansa Iivanainen, Eija Skarp, Maija Alahuhta Guidelines and Problems in Wound Management Vesa Juutilainen, Elina Heikkilä Educating Patients with Leg Ulcers in Home Care Settings Ira Halonen Developing the Risk Assessment Scale of Pressure Ulcers Mervi Lepistö Multidisciplinary Teamwork in Management of Diabetic Foot Ulcer Arja Tiippana, Anne Suuronen Resin of Spruce – From traditional treatment to pharmacy Arno Sipponen Experiences of Differences Between Finnish and Canadian Treatment of Burn Injuries Anthony Papp Physio- and Occupational Therapy – Multiprofessional Marko Kelavuori, Eeva Nupponen Practical Nurse In The Role of Wound Care Specialist Marja Korhonen Hemostatic drugs Paul Eskelinen Integration of Sexuality Through The Mind Eija Himanen Discharged with a Wound – Where to get the Support? Hanne-Mari Seppälä Child As A Stoma Patient Leila Uusimaa

Spanish

Helcos vol.19, no 3, 2008 Pressure ulcer risk assessment scales García Fernandez FP; Pancorbo PL; Soldevilla JJ; Blasco C. The use of amtimicrobial agent PHMB to prevent wound infection Moore K; Gray D. Turning point: from risk or damage of skin integrity to tissue integrity Carrasco JM; Dumont E; Galvez F; Gutierrez M; Montesinos P; Garcia Gonzalez MA.

English

Journal of Wound Care, April issue, vol. 17, no 4, 2008 www.journalofwoundcare.com; jwc@emap.com A rapid molecular method for characterising bacterial bioburden in chronic wounds An observational study of the use of a soft silicone silver dressing on a variety of wound types Influence of bioengineered skin substitutes on diabetic foot ulcer and venous leg ulcer outcomes Critical evaluation of the reliability and validity of ABPI measurement in leg ulcer assessment Efficacy and efficiency of a streamlined multidisciplinary foot ulcer service

Volume 8, no 2, May 2008 Treatment of chronic wounds with autologous platelet-rich plasma Marcus Gürgen Polyhexanide (PHMB) and Betaine in wound care management Kurt Kaehn, Thomas Eberlein Patients’ experience of w ound-related pain: An international perspective Elizabeth J Mudge Efficacy of honey as a desloughing agent: overview of current evidence Georgina Gethin Abstracts of recent C ochrane Reviews Sally Bell-Syer

Volume 8, no 1, January 2008 Problem drug injecting: Wound care, harm reduction and social impact Angela D Guild Larval therapy in the treatment of diabetic foot wounds – A review of the literature Frank L Bowling Opinion piece: Wound healing in hot climates Terence J Ryan Developing research capacity and capability in skin breakdown Jim Dick

Volume 7, no 3, October 2007 Vacuum assisted closure for chronic wounds: a review of the evidence E. Andrea Nelson General practitioner support to care homes: collaboration with a tissue viability nurse specialist and prescribing support pharmacist Lynne Watret, Rachel Bruce Integrated system of chronic wound care healing – creating, managing and cost reduction Heinz J. Janßen, Roland Becker Guidelines for the management of partial-thickness burns in general hospital-recommendation of a European working party Bjarne Alsbjørn, Annelea Buntzen Diabetic Foot Ulcer – From Fiction to Management. The development of global guidelines Jan Apelqvist, Karel Bakker, Gerlof D Valk Wound Healing in Medieval England Carol Dealey Development of Clinical Practice Guideline on Pressure Ulcers Katrien Vanderwee

The EWMA Journals can be downloaded free of charge from www.ewma.org

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English

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The International Journal of Lower Extremity Wounds vol. 7, no 4, 2008 http://ijlew.sagepub.com Evidence and Its Use Raj Mani High Levels of Plasma Malondialdehyde, Protein Carbonyl, and Fibrinogen Have Prognostic Potential to Predict Poor Outcomes in Patients With Diabetic Foot Wounds: A Preliminary Communication Roma Rattan and Debashish Nayak Spermatheca Gland Extract of Snail (Telescopium telescopium) Has Wound Healing Potential: An Experimental Study in Rabbits Saurabh Kumar, Debaki Ghosh, Tuhin Kanti Biswas, Uttam Dutta, Partho Das, and Subarna Kundu Leg Wound Infections Following Greater Saphenous Vein Harvesting: Minimally Invasive Vein Harvesting Versus Conventional Vein Harvesting James F. Reed Pretibial Injury: Key Factors and Their Use in Developing Laboratory Test Methods R.M. Laing, D.J. Carr, C.A. Wilson, S.T. Tan, B.E. Niven, C. Davis, and A. Bialostocki The Diabetic Foot in 2008: An Update From the 12th Malvern Diabetic Foot Meeting Agbor Ndip, Frank Bowling, Daryl Stickings, Gerry Rayman, and Andrew J. M. Boulton Mortality and Diabetes Mellitus in Amputations of the Lower Limbs for Gas Gangrene: A Case Report José Maria Pereira de Godoy, Janalice Vasconcelos Ribeiro, and Lívia Andrioli Caracanhas

International Wound Journal, Vol. 5, Issue 4, 2008 Novel cryoprecipitate for wound healing and skin grafts in rats Thomas Scholz, Joshua Waltzman, Garrett A Wirth, Senait W Dyson, William J Owens, Edward Shanbrom, Gregory RD Evans Topical negative pressure effects on coronary blood flow in a sternal wound model Sandra Lindstedt, Malin Malmsjö, Bodil Gesslein, Richard Ingemansson Topical negative pressure wound therapy: a review of its role and guidelines for its use in the management of acute wounds Estas Bovill, Paul E Banwell, Luc Teot, Elof Eriksson, Colin Song, Jim Mahoney, Ronny Gustafsson, Raymund Horch, Anand Deva, Ian Whitworth The pro-inflammatory environment in recalcitrant diabetic foot wounds Jorge Berlanga Acosta, Diana Garcia del Barco, Danay Cibrian Vera, William Savigne, Pedro Lopez-Saura, Gerardo Guillen Nieto, Gregory S Schultz Wound dressing components degrade proteins detrimental to wound healing Brett Baskovich, Edith M Sampson, Gregory S Schultz, Laura KS Parnell Microgravity and the implications for wound healing Ramin Mostofizadeh Farahani, Luisa A DiPietro Use of chlorhexidine on pin sites Annette W-Dahl, Maria Vincent Pressure transduction to the thoracic cavity during topical negative pressure therapy of a sternotomy wound Christian Torbrand, Richard Ingemansson, Lotta Gustafsson, Per Paulsson, Malin Malmsjö Correlation between Braden Scale and Palliative Performance Scale in advanced illness Vincent Maida, Francis Lau, Michael Downing, Ju Yang

Journal of Tissue Viability, vol. 17, no 4, 2008 Abstracts of the Tissue Viability Society Annual Meeting, Peterborough, 2008 Multi-frequency bioelectrical impedance analysis of skin rubor with two-electrode technique. Tomoka Uchiyama, Shoko Ishigame, Junko Niitsuma, Yoshihiro Aikawa, Yuji Ohta Prevalence of pressure ulcers in three university teaching hospitals in Ireland Paul Gallagher, Pat Barry, Irene Hartigan, Pat McCluskey, Kieran O'Connor, Mike O'Connor Risk assessment for prevention of morbidity and mortality: Lessons for pressure ulcer prevention T.M. Reynolds

Journal 2009 vol 9 no 1

Swedish

Sår vol. 2, no 4, 2008 Staff at Acute and Emergency Department against violence Guidelines for wound management- multidimensional tools Care of patients with malodorous fungating wounds Prevalence studies in pressure ulcers – to know what we do and to do what we know Injustices for many wound care products scrutinized Case repost: Patient with open abdomen and colonic fistula Intensive education autumn- report from a number of wound management educational activities Congratulations Haava- Finnish Wound Management Journal 10 years

English

Wound Repair and Regeneration, vol 16, no 6 2008 Guidelines to aid healing of acute wounds by decreasing impediments of healing Michael G. Franz; Martin C. Robson; David L. Steed; A drian Barbul; Harold Brem; Diane M. Cooper; David Leaper; Stephen M. Milner; Wyatt G. Payne; Thomas L. Wachtel; Laurel Wiersema-Bryant Original Research – Clinical Science Autologous platelet-rich fibrin matrix as cell therapy in the healing of chronic lower-extremity ulcers Sean M. O’Connell; Theresa Impeduglia; Karen Hessler; Xiu-Jie Wang; Richard J. Carroll; Herbert Dardik Pilot study using doxycycline-releasing stents to ameliorate postoperative healing quality after sinus surgery Wouter Huvenne; Nan Zhang; Edze Tijsma; Britt Hissong; Judtih Huurdeman; Gabriele Holtappels; Sofie Claeys; Paul Van Cauwenberge; Hans Nelis; Tom Coenye; Claus Bachert Original Research – Basic Science Hedgehog signaling is essential for normal wound healing Huong Le; Rebecca Kleinerman; Oren Z. Lerman; Daniel Brown, Robert Galiano; Geoffrey C. Gurtner; Stephen M. Warren; Jamie P. Levine; Pierre B. Saadeh Conservative surgical debridement as a burn treatment: Supporting evidence from a porcine burn model Xue-Qing Wang; Margit Kempf; Pei-Yun Liu; Leila Cuttle; Hong-En Chang; Olena Kravchuk; Julie Mill; Gael E. Phillips; Roy M. Kimble A poly-herbal formulation accelerates normal and impaired diabetic wound healing Asheesh Gupta; Nitin K. Upadhyay; R.C. Sawhney; Ratan Kumar S163 is critical for FXYD5 modulation of wound healing in airway epithelial cells Timothy J. Miller; Pamela B. Davis Antibacterial effect of dressings containing multivalent silver ion carried by zirconiumphosphate on experimental rat burn wounds Gaoxing Luo; Jin Tang; Weifeng He; Jun Wu, MD; Bing Ma; Xihua Wang; Xiwei Chen; Shaoxuan Yi; Xiaorong Zhang; Xianchang Li; Mark Fitzgerald In vitro multispecies Lubbock chronic wound biofilm model Yan Sun; Scot E. Dowd; Ethan Smith; Dan D. Rhoads; Randall D. Wolcott Localization of small leucine-rich proteoglycans and transforming growth factor-b in human oral mucosal wound healing Dariush Honardoust; Ameneh Eslami; Hannu Larjava; Lari Häkkinen

German

Wund Management, vol. 2, no 6, 2008 English abstracts are available from www.mhp-verlag.de Is there a link between woundhealing and psychological disorders? Psychneuroimmunology and immun response: what we can learn for wound treatment Wound healing disturbance – narrative treatment

Scandinavian

Wounds (SÅR) vol.16, no 4, 2008 www.saar.dk Bacterial biofilm in wounds – Status and challenges Klaus Kirketerp-Møller, Anders Schou Andersen Hand hygiene with outpatients and inpatients at Copenhagen Wound Healing Center Britta Østergaard Melby, Benedikte Pio Norwegian wound management course endorsed by EWMA – a flexible offer for improvement of skills Edda Johansen, Jill Flo

Corporate Sponsor Contact Data Corporate A

Coloplast Holtedam 1-3 DK-3050 Humlebรฆk Denmark Tel: +45 49 11 15 88 Fax: +45 49 11 15 80 www.coloplast.com

ConvaTec Europe Harrington House Milton Road, Ickenham, Uxbridge UB10 8PU United Kingdom Tel: +44 0 1895 62 8300 Fax: +44 0 1895 62 8362 www.convatec.com

Covidien 154, Fareham Road PO13 0AS Gosport United Kingdom Tel: +44 1329 224479 Fax: +44 1329 224107 www.covidien.com

Systagenix Wound Management Gargrave North Yorkshire BD23 3RX United Kingdom Tel: +44 1756 747200 Fax: +44 1756 747590 www.systagenix.com

KCI Europe Holding B.V. Parktoren, 6th floor van Heuven Goedhartlaan 11 1181 LE Amstelveen The Netherlands. Tel: +31 0 20 426 0000 Fax: +31 0 20 426 0097 www.kci-medical.com

Lohmann & Rauscher P.O. BOX 23 43 Neuwied D-56513 Germany Tel: +49 0 2634 99-6205 Fax: +49 0 2634 99-1205 www.lohmann-rauscher.com

Mรถlnlycke Health Care Ab Box 13080 402 52 Gรถteborg, Sweden Tel: +46 31 722 30 00 Fax: +46 31 722 34 08 www.molnlycke.com

Use the EWMA Journal to profile your company Deadline for advertising in the May 2009 issue is 1 March 2009

EWMA

Journal 2009 vol 9 no 1

EWMA

Corporate B 3M Health Care Morley Street, Loughborough LE11 1EP Leicestershire United Kingdom Tel: +44 1509 260 869 Fax: +44 1 509 613326 www.mmm.com

B. Braun Medical 204 avenue du Maréchal Juin 92107 Boulogne Billancourt France Tel: +33 1 41 10 75 66 Fax: +33 1 41 10 75 69 www.bbraun.com

Life Wave 1 Azrieli Center, Round Tower 41st floor Tel Aviv 67021 Israel Tel: +972-3-6095630 Fax: +972-3-6095640 sales@life-wave.com www.life-wave.com

AOTI Ltd. Qualtech House Parkmore Business Park West Galway, Ireland Tel: +353 91 660 310 Fax: +353 1 684 9936 info@aotinc.net www.aotinc.net

Ferris Mfg. Corp. 16W300 83rd Street Burr Ridge, Illinois 60527-5848 U.S.A. Tel: +1 (630) 887-9797 Toll-Free: +1 (630) 800 765-9636 Fax: +1 (630) 887-1008 www.polymem.com

ArjoHuntleigh 310-312 Dallow Road Luton Bedfordshire LU1 1TD United Kingdom Tel: +44 1582 413104 Fax: +44 1582 745778 www.ArjoHuntleigh.com

Paul Hartmann AG Paul-Hartmann-Strasse D-89522 Heidenheim Germany Tel: +49 0 7321 / 36-0 Fax: +49 0 7321 / 36-3636 www.hartmann.info

Healthpoint 3909 Hulen Street Fort Worth, Texas 76107 USA www.healthpoint.com

EWMA

Journal 2009 vol 9 no 1

Sorbion AG Hobackestraße 91 D-45899 Gelsenkirchen Tel: +49 0 2 09-95 71 88-0 Fax: +49 0 2 09-95 71 88-20 www.sorbion.com

Laboratoires Urgo 42 rue de Longvic B.P. 157 21300 Chenôve France Tel: +33 3 80 44 70 00 Fax: +33 3 80 44 71 30 www.urgo.com

Völker AG Wullener Feld 79 58454 Witten Tel: +49 23 02 960 96 0 Fax: +49 23 02 960 96 16 info@voelker.de www.voelker.de

EWMA Travel Grants EWMA is committed to the advancement of wound care and wound management in Europe and it encourages international understanding and learning between nurses, doctors and other healthcare workers. Therefore, EWMA provides travel grants to young practitioners who wish to develop their skills within wound care and wound management abroad. The travel grants will primarily be given for educational purposes or clinical experiences outside the applicants’ own countries. Novice practitioners have priority, but more experienced applicants are also accepted. Requirements: • Applicants must have been a member of EWMA for 1 year. • The grants are limited to travelling within Europe. • The maximum amount that can be applied for per applicant is 3000 EUR • All grant receivers must write a report of 1-2 pages about their stay abroad. This report will be published in EWMA Journal How to apply: 1. Write a letter in English to EWMA stating a. the purpose of your travels b. what you aim to achieve during your travels c. where you are traveling to (address(es), institution(s) etc.) d. dates and duration of your stay 2. Attach a letter of acceptance from centre/institution to be visited 3. Address the letter to Zena Moore, Chair of the Travel Grant Committee and send the letter and the letter of acceptance e lectronically and via regular post to: EWMA Business Office c/o Congress Consultants Martensens Allé 8 DK-1828 Frederiksberg C Denmark ewma@ewma.org Deadline for submission of applications is 15 February 2009 You will receive notification of whether or not you have been given a travel grant by 15 March 2009.

After your travels: 1. It is obligatory to write a report (1-2 pages) about your travels and what your outcome of the stay was. This report will be published in EWMA Journal. 2. Please send this report to EWMA Business Office Fur forther information about travel grants please contact EWMA Business Office at ewma@ewma.org

EWMA

Journal 2009 vol 9 no 1

Conferences

Conference Calendar Conferences

Theme

2009

Days

City

Country

Nationale des Plaies et Cicatrisations (SFFPC)

XIIème Conférence

Jan

18-20

Paris

France

The Norwegian Wound Healing Association (NIFS) Annual Meeting: Wound Infections

Wound Infections

Feb

5-6

Bodø

Norway

Association Francophone d’Infirmiers(ères) en Stomathérapie, Cicatrisation et Plaies (AFISCeP.be)

Congrés 2009

Mar

Apr

21-23

First International Lymphoedema Framework (LF) The Hellenic Society of Wound Healing

4th National Congress in Wound Healing

Apr

2-4

European Academy of Dermatology and Venereology (EADV)

6th Spring Symposium

Apr

23-26

Belgium

Royal Ascot, United Kingdom Berkshire Greece Bucharest

Romania

Wound Healing Society (WHS)

Symposium on Advanced Wound Care 2009

Apr

26-29

Grapevine

USA

Tissue Viability Society (TVS) Annual C onference

Care – Science and Practice

Apr

27-28

Llandudno

Wales

Chronic Wounds Initiative (ICW)

Deutscher Pflegekongress/Deutscher Wundkongress

May

6-7

Bremen

Germany

Grupo A ssociativo de Investigacao em Feridas (GAIF)

National Meeting

May

14-15

19th Conference of the European Wound Management Association (EWMA)

HELP – Healing, Education, Learning and Preventing in Wound Care

May

20-22

Helsinki

Finland

Austrian Wound Association (AWA) & Swiss Asso- Treatment of Wounds: Recommendationes ciation for Wound Care (SAfW) Annual Meeting for Best Practice in Wound Healing

Jun

19-20

Zürich

Switzerland

Annual National Congress of the German Wound Lymphology and Compression Healing Society (DGfW)

Jun

25-27

Kassel

Germany

European Tissue Repair Society & The Wound Healing Society

Aug

25-29

Limoges

France

5th Joint Meeting

Portugal

European Burns Association (EBA)

Congress

Sep

2-5

Lausanne

Switzerland

12th Annual European Pressure Ulcer Meeting,

Pressure ulcers – not just a disease of the elderly – are your patients at risk?

Sep

3-5

Amsterdam

The Netherlands

Italian Association for Cutaneous Ulcers (AIUC)

National Meeting

Sep

23-26

Florence

Italy

Diabetic Foot Study Group (DFSG) of the EASD

8th Scientific Meeting

Sep

25-28

Bled

Slovenia

Wound Management Association of Ireland (WMAOI)

Bi-annual national meeting

Oct

6-7

Athlone

Ireland

European Academy of Dermatology and Venereology (EADV)

18th Congress

Okt

7-11

Berlin

Germany

Danish Wound Healing Society

Annual Meeting

Nov

For web addresses please visit www.ewma.org

8th Scientific Meeting of the

Diabetic Foot Study Group of the EASD 25-28 September 2009 Bled, Slovenia

www.dfsg.org

Denmark

Cooperating Organisations AFIScep.be

GNEAUPP

AISLeC

ICW

AIUC

LBAA

APTFeridas

LUF

Francophone Nurses’ Association in Stoma Therapy, Wound Healing and Wounds

Italian Nurses’ Association Cutaneous Wounds Association www.aislec.it

Italian Association for the study of Cutaneous Ulcers www.aiuc.it

Portuguese Association for the Treatment of Wounds www.aptferidas.com

AWA

Austrian Wound Association www.a-w-a.at

BFW

Belgian Federation of Woundcare www.befewo.org

BWA

Bulgarian Wound Association

National Advisory Group for the Study of Pressure Ulcers and Chronic Wounds www.gneaupp.org

Chronic Wounds Initiative www.ic-wunden.de

Latvian Wound Treating O rganisation

The Leg Ulcer Forum www.legulcerforum.org

LWMA

Lithuanian Wound Management Association

MASC

Maltese Association of Skin and Wound Care

MST

Hungarian Wound Care Society www.euuzlet.hu/mskt/

CNC

Clinical Nursing Consulting – Wondzorg www.wondzorg.be

CSLR

Czech Wound Management Society www.cslr.cz

CWA

Croatian Wound Association www.kbd.hr/index.php?id=799

DGfW

German Wound Healing Society www.dgfw.de

DSFS

Danish Wound Danish Wound Healing Society Healing Society www.dsfs.org

FWCS

Finnish Wound Care Society www.suomenhaavanhoitoyhdistys.fi

GAIF

Associated Group of Research in Wounds www.gaif.net

MWMA

Macedonian Wound Management Association

NATVNS

National Association of Tissue Viability Nurses, Scotland www.natvns.com

NIFS

Norwegian Wound Healing Association www.nifs-saar.no

NOVW

Dutch Organisation of Wound Care Nurses www.novw.org

PWMA

Polish Wound Management Association www.ptlr.pl

ROWMA

Romanian Wound Management Association www.artmp.ro

EWMA

Journal 2009 vol 9 no 1

Organisations

SAfW

SWHS

Swiss Association for Wound Care www.safw.ch www.safw-romande.ch

Swedish Wound Healing Society www.sarlakning.se

TVS

SAWMA

Tissue Viability Society www.tvs.org.uk

Serbian Advanced Wound Management Association

URuBiH

SEBINKO

Association for Wound Management of Bosnia and Herzegovina

Hungarian Association for the Improvement in Care of Chronic Wounds and Incontinentia www.sebinko.hu

WMAOI

Wound Management A ssociation of Ireland www.wmaoi.org

SFFPC

The French and Francophone Society of Wounds and Wound Healing www.sffpc.org

WMAK

Wound Management Association of Kosova

SSiS

Swedish Wound Care Nurses Association www.sarsjukskoterskor.se

WMAS

Wound Management Association Slovenia

SSOOR

Slovak Association for Wound Care

WMAT

Wound Management A ssociation Turkey www.yaradernegi.org

SUMS

Iceland Wound Healing Society www.sums-is.org

SWHS

Serbian Wound Healing Society www.lecenjerana.com

For more information about EWMA’s Cooperating Organisations please visit www.ewma.org

Associated Organisations Leg Club

Lindsay Leg Club Foundation www.legclub.org

Lymphoedema Framework www.lymphoedemaframework.org

LSN

The Lymphoedema Support Network www.lymphoedema.org/lsn

Present your national wound management organisation or write a report about your organisation’s latest meeting. ewma@ewma.org

Deadline for submitting papers for the May 2009 issue is 15 February 2009

EWMA

Journal 2009 vol 9 no 1

3 Editorial

Carol Dealey

Science, Practice and Education 5 Wound related pain: evaluating the impact of education on nursing practice Helen Hollinworth

17 Does surgery heal venous ulcers? Giorgio Guarnera

19 The CEAP classification and its evolution Pier Luigi Antignani, Claudio Allegra

26 The role of incompetent perforators Olle Nelzén

33 Hemodynamic patterns of venous reflux in patients with leg ulcers Hugo Partsch

40 Combined superficial and deep vein reflux in venous ulcers: operative strategy Giorgio Guarnera

43 National Wound Prevalence Studies Peter Franks

EBWM 44 Abstracts of recent Cochrane reviews Sally Bell-Syer

EWMA 46 Finnish Wound Care Society (FWCS) Salla Seppänen

48 The first decade of HAAVA Journal Ansa Iivanainen

50 EWMA Patient Outcome Group Finn Gottrup

51 The Implementation Challenge Marco Romanelli

56 EWMA Journal Previous Issues 56 International Journals 58 EWMA Corporate Sponsor Contact Data 60 EWMA Travel Grants

Conferences 61 Conference Calendar

Organisations 62 Cooperating and Associated Organisations