Edema is a major impediment to proper and timely wound healing. Accordingly, our expert panelists discuss how to work up and manage lower extremity wounds with edema, and share their insights on effective compression bandages.
What is the basic assessment and workup that you do with patients with leg edema?
Kazu Suzuki, DPM, CWS, says clinicians often cannot pinpoint a single cause for edema as there are many possible factors. Both he and Kathleen Satterfield, DPM, believe problems with the heart (congestive heart failure), kidney (end-stage renal disease), liver (hepatitis), varicose veins (i.e. venous insufficiencies), malignancy or congenital or acquired lymphedema can all be possible sources of lower extremity edema.
Due to the variety of possible etiologies for edema, Dr. Satterfield will perform a thorough medical workup in addition to her standard podiatric workup. She says the clinical exam will catch the venous stasis aspect of the disease. Dr. Suzuki’s edema workup also consists of a basic medical history and physical. He documents pitting or non-pitting as well as the amount of pitting (+1 degree for every 5 mm depression).
In his workup, Eric Lullove, DPM, includes a vascular exam, specifically for venous reflux. He will perform a venous reflux ultrasound if the patient has not received one in the previous three months. Dr. Lullove will also evaluate skin integrity and perform assessments for gait/walking and dexterity. Bilateral circumferential measurements of the foot, ankle, high calf and thigh are also part of Dr. Lullove’s exam. He will also determine the patient’s exercise, elevation of lower limbs and compression failures in the four weeks before presentation.
Dr. Satterfield’s exam is mostly hands-on. She will also use a Doppler but notes that with a severe case of lymphedema, the Doppler can be futile since the density of the tissues will not allow the reflected sound waves to move freely through the huge mass of fluid-filled muscle and fat.
Dr. Suzuki’s wound care center uses the Sensilase (Vasamed) laser Doppler to obtain the skin perfusion pressure (SPP) and pulse volume recordings (PVRs) to rule out leg ischemia at the initial visit prior to debriding the wounds and applying compression bandages. He cites the importance of assessing arterial perfusion in order to avoid compression of ischemic legs.
How do you treat or control the wounds with leg edema?
Dr. Satterfield emphasizes that one must first and foremost control the edema in order to help facilitate wound healing. For Dr. Suzuki, treatment begins with medical management and he will communicate and collaborate with primary care physicians, cardiologists and nephrologists. Since leg wounds will not heal if the edema is uncontrolled, he advises adding or increasing diuretics, even temporarily, to eliminate the excess water that the patient is retaining.
“I also give a face-to-face educational lecture to the patient, telling (him or her) about reading the food label to minimize the sodium intake and removing the salt shaker from the table,” says Dr. Suzuki. “Also, I do a quick ‘show and tell’ by drawing a small wound on a balloon, inflating and deflating the balloon, to show how detrimental the leg edema can be for the wound healing.”
Following treatment for medical problems, one should choose among various methods of leg compressions that are acceptable for the particular patient, suggests Dr. Suzuki.
When it comes to these compression methods, Dr. Lullove primarily employs compression bandaging to manage wounds with leg edema. He prefers to use short-stretch multilayer compression, such as Coban 2 or Coban 2 Lite (3M), with the appropriate wound contact layer to control drainage, infection, etc.
Dr. Satterfield will prescribe manual lymphatic drainage (MLD), which was offered through her physical therapy department by a specially trained therapist, and combine that with Profore (Smith and Nephew).
In contrast, Dr. Lullove is moving away from MLD. He says it is more important to “wrap and walk” patients with chronic venous insufficiency edema in comparison to those with traditional lymphedema.
Dr. Satterfield says she will not use silver sulfadiazine (Silvadene, Monarch Pharmaceuticals) under dressings on venous stasis ulcers because Silvadene increases exudates.
“Exudative wounds under a compressive dressing can be a death knell,” emphasizes Dr. Satterfield.
She says significant advances in treatment have given clinicians a variety of different treatment options for lower extremity wounds with edema.
“What a difference 10 years have made in being able to answer this question,” comments Dr. Satterfield. “A decade ago, the answer would have been an Unna Boot and not much else but now there are so many great modalities.”
What is your compression bandage of choice to treat leg edema?
Both Drs. Satterfield and Suzuki use Profore. Dr. Satterfield calls Profore her first choice due to its air permeability. She says Co-Flex, which does not have air permeability, is her backup choice. Dr. Satterfield cites an advantage of Co-Flex in that its printed guide provides an indicator of how much pressure to apply with the bandage, although she notes clinicians will have a pretty good feel of that themselves.
In addition, Dr. Suzuki will also use Dyna-Flex (Systagenix Wound Management) and Coban 2 layer. He cites the ability of these bandages to accommodate wound dressings and various leg shapes while providing reliable graduated compression in the form of higher compression at the ankle. Patients can wear the bandages for up to one week and Dr. Suzuki notes that he sees most of his patients once a week.
As for the primary dressing, Dr. Suzuki frequently uses the foam dressing Mepilex (Molnlycke Healthcare) as well as the antimicrobial dressing Mepilex Ag (Molnlycke Healthcare), which he places underneath the compression bandages. When the situation calls for a maximally absorbent dressing, Dr. Suzuki uses Xtrasorb™ dressing (Derma Sciences). While this dressing is thin, Dr. Suzuki says it offers an extremely absorbent primary dressing that absorbs a lot more exudates than regular ABD pads.
Dr. Lullove’s preferred compression bandage for leg edema is Juzo (Juzo USA). He notes the high quality bandages do not have the same short lifespan of other compression stockings. He adds that Juzo also has silicone beading at the top of the stocking to prevent slippage.
Dr. Lullove is in private practice in Boca Raton and Delray Beach, Fla. He is a Staff Physician at West Boca Medical Center in Boca Raton. Dr. Lullove is a Fellow of the American College of Certified Wound Specialists.
Dr. Satterfield is an Adjunct Associate Professor at the Western University College of Podiatric Medicine in Pomona, Calif. She is a Fellow and President-Elect of the American College of Foot and Ankle Orthopedics and Medicine.
Dr. Suzuki is the Medical Director of Tower Wound Care Center at the Cedars-Sinai Medical Towers. He is also on the medical staff of the Cedars-Sinai Medical Center in Los Angeles and is a Visiting Professor at the Tokyo Medical and Dental University in Tokyo, Japan.
For further reading, see “How To Manage Venous Stasis Ulcers” in the May 2007 issue of Podiatry Today or “Vascular Intervention In Difficult Wounds” in the July 2002 issue.
To access the archives, visit www.podiatrytoday.com.