An Evidence-Based Algorithm for Treating Venous Leg Ulcers Utilizing the Cochrane Database of Systematic Reviews

Howard M. Kimmel, DPM, MBA, FACFAS; Angela L. Robin, DPM

Disclosures

Wounds. 2013;25(9):242-250. 

In This Article

Compression Therapy

The cornerstones of the VLU management algorithm are wound debridement; management of exudate; and wound moisture, infection control, and management of concurrent systemic conditions. Lower limb compression is the standard of care for patients with VLUs without concurrent arterial disease and provides the basis for the initial treatment recommendation in the VLU algorithm. In 2009, the Cochrane Database reported an extensive evaluation of the clinical effectiveness of compression bandage or stocking systems in the treatment of VLU.[33] The analysis was designed to determine if the application of compression bandages or stockings aid VLU healing, and if so, which compression bandage or stocking is the most effective. A total of 39 randomized clinical trials that evaluated any type of compression bandage system or compression hosiery were included in the analysis. The evidence strongly suggests that VLUs heal more rapidly with compression than without, and that multicomponent compression achieves better healing outcomes than single-component systems. When competing systems comprising 2 components were compared, there was some evidence suggesting those including an elastic component may be more effective than those composed mainly of inelastic constituents; a similar finding was noted for alternative 3-component systems.[33]

A substantial proportion of patients with VLUs are not helped by compression bandaging, or are unwilling or unable to wear it. Other patients with VLUs may be unsuitable candidates for compression bandaging due to concurrent arterial disease. Intermittent pneumatic compression (IPC) is an alternative method of delivering compression that utilizes an air pump to periodically inflate/deflate bladders incorporated into sleeves applied to affected limbs. Multiple techniques for providing IPC are available using single or multiple chambers/bladders, different types of pumps and compression cycles, and variations in inflation and deflation times.

Clinical evidence of the effectiveness of IPC in increasing healing rates in patients with VLUs was extensively reviewed by Nelson et al[34] and reported in the Cochrane Database. A total of 7 randomized controlled trials including 367 patients were included in the analysis. Compared with no compression, IPC was associated with a 2.27-fold increase in the likelihood of VLU healing. Trials of IPC and compression vs compression alone provided inconsistent results, with no differences in healing rates reported in some trials, and modest benefits of combination treatment reported in others. Rapid IPC was associated with greater VLU healing rates and shorter time to complete VLU healing than slow IPC. No significant differences in pain scores were observed between patients receiving IPC and those treated with Unna's boot.

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