Current Options In Treating Chronic Venous Ulcers
- Volume 17 - Issue 9 - September 2004
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Reviewing The Various Treatment Options
After obtaining wound measurements and photographs, and the results of tissue cultures and tissue biopsy, one can start to formulate a treatment plan. First, one has to ensure control of any comorbidities. One can reduce edema with elevation, compression wraps and/or stockings, compression pumps or physical therapy edema reduction programs.
When it comes to perforating ulcers, one should seek a vascular consult for possible lentin or SEPS procedures. Vein sucrosing therapy is becoming popular for venous wounds but I have found limited results with this modality in my experience.
One would subsequently address the wound itself. You may control bacterial counts with appropriate topical, oral and/or IV antibiotics. However, pain often becomes a barrier to weekly debridement or compression, both of which are necessary to achieve secondary healing.
To overcome the pain barrier, one should consider alternative coverage techniques. There are many ways to cover a clean venous stasis ulceration and all of these alternatives can reduce pain. These options include Apligraf (Organogenesis), Dermagraft (Smith & Nephew) and cadaveric homografts. Cadaveric homografts should not be confused with skin grafts. Cadaveric homografts offer a very cost-effective biologic dressing that adheres and allow epithelialization to take place but keep in mind that they do not “take.”
Apligraf and Dermagraft are commercially available dressings that deliver biologic products to the wound. Apligraf delivers collagen, growth factors, keratinocytes and fibroblasts to the wound. Dermagraft is adequate for delivering growth factors but does not deliver collagen.
More recently, I have been covering the clean venous stasis wound with GraftJacket (Wright Medical), a unique allograft product that is freeze-dried instead of frozen. This prevents the collagen from being denaturalized. The GraftJacket is also taken specifically from cadaveric banks in order to improve graft quality.
Preparation for application is dependent on the product. Instead of rehydrating the GraftJacket in saline or sterile water, our team has been hydrating it with the patient’s own platelet rich plasma (PRP). One can achieve this via gravitational blood separation systems such as Biomet’s Gravational Platelet Separation (GPS) or Harvest Technologies’ SmartPReP system. In my opinion, the GraftJacket should be meshed on a 1:1.5 mesh after rehydration. Theoretically, the platelets should be absorbed into the graft and subsequently facilitate a concentrated release of the patient’s own growth factors due to collagen exposure. Since the product is acellular, there is a reduced risk for rejection.
In conclusion, I find that venous stasis ulcerations heal best with some type of graft coverage. Many commercial products are emerging to fill this purpose. My favorite on properly diagnosed, well prepared venous stasis ulcerations is the GraftJacket. Although all these products seem to reduce patient discomfort and speed epithelialization, the GraftJacket recipe seems to be the most consistent at this time.
Dr. Baker is board-certified in foot and ankle surgery. He practices at the West View Wound Care Center in Indianapolis, Ind.
Dr. Burks is a Fellow of the American College of Foot and Ankle Surgeons and is board-certified in foot and ankle surgery. Dr. Burks practices in Little Rock, Ark.