Wounds that are delayed in healing due to a number of underlying problems, do not show normal healing stages, often require more than three months to heal, do not respond well to treatment are called chronic wounds. It is a big problem for patients as well as health workers and the health system. Due to the increasing elderly population, the incidence of chronic wounds, which are more common in older ages, is also increasing.
In terms of chronic wound development, diabetics, the elderly and obese are in the risk group. Although very different factors such as the underlying disease, age and care conditions of the person play a role in wound healing disorder, we can talk about the effect of four important factors in general. These are; inadequate tissue oxygenation, tissue damage, the presence of an underlying disease such as diabetes, and bacterial infections. Chronic wounds can be examined in three basic groups as diabetic ulcers, venous ulcers and pressure sores. . Treatment approaches are fundamentally similar
Diabetic ulcers: At the heart of treatment is strict blood sugar control. If there is a vascular occlusion that can be intervened, therapeutic revascularization should be considered Prevention of infection by cleaning dead tissues, ensuring proper moisture balance in the wound by removing excess exudate and preventing pressure on the wound bed are the steps of primary wound treatment.
Skin grafts and their bioengineered skin equivalents can be used for treatment-resistant, non-healing wounds. Cell therapies such as growth factors, stem cell therapies can also be used in treatment. Venous ulcers: A number of changes occur as a result of significant physiological changes caused by venous hypertension in the capillary and lymphatic microcirculation, such as capillary leakage, fibrin accumulation, erythrocyte and leukocyte accumulation, thrombocytosis and inflammation. This process disrupts the oxygenation of the skin and subcutaneous tissue.
This condition is reflected in the clinic as edema, hyperpigmentation, fibrosis of the subcutaneous tissues and the development of ulcers. It is seen in approximately 1% of the whole population, with advanced age and more common in women. They are more superficial ulcers compared to diabetic and pressure ulcers. The pain in these wounds is so high that it affects the patient’s social life as well as the quality of life. Treatment of these wounds that develop as a result of chronic venous insufficiency is very difficult and laborious.
For this reason, identifying patients at risk for venous insufficiency and taking preventive measures are the most effective treatment. As with other chronic wounds, patient compliance is important in success. The goal in the treatment of chronic venous ulcer should be the reduction of symptoms, the relief of edema, the treatment of lipodermatosclerosis and the improvement of the ulcer. Prevention and treatment approaches include exercise, weight loss, compression therapies and elevation, lymphatic drainage, skin moisturizing, vascular surgery, wound debris.
With exercises, the posterior group of muscles in the leg contract (pump function) to prevent the blood from pooling in the lower extremities. In order to prevent backward leakage in the transport of blood to the proximal portion, the venous valves must be intact. Nutrition: These patients are mostly obese and less mobile patients, they should be encouraged to lose weight.
Compression therapies and elevation: Intermittent pneumotic compression can be applied for those who cannot tolerate it.
Manual lymphatic drainage therapy: It consists of stretching and massage treatments to reduce lymphedema and congestion. From the third week, noticeable narrowing is achieved around the extremities.
Patients with dry skin, itching and eczematous symptoms should be treated with moisturizing topical creams (lanolin) and, if necessary, corticosteroids with moderate potency. Vascular surgery: It is mostly ablation applications of superficial venous systems. For this, it must be shown that the deep venous system is intact. The morbidity of these operations is low, but surgery alone is never enough, it must be supported by combining it with conservative treatments.
Wound debridement: It is one of the basic elements in the treatment of venous ulcers. The presence of necrotic tissue is a risk factor for local bacterial infection and sepsis. It leads to a delay in wound healing, a decrease in the effectiveness of topical therapy and systemic antibiotic therapy. Debridement contributes to the formation of granulation tissue and acceleration of reepithelialization .
Skin equivalents (Apligraph®) and skin grafts: If the wound has not healed for more than 30 days, they are the second line of treatment methods to close the wound. The effectiveness of topical antibiotics, enzyme preparations with debrisible properties, growth factor use in treatment has not been proven.
There is information that aspirin use accelerates chronic venous ulcer healing.
Other methods include phototherapy, acoustic and electrotherapy, VAC, hyperbaric oxygen (HBO) therapy.
Recurrence in venous ulcers is frequent, even almost the rule. It is important that patients are well informed to continue compression therapy for life.
Pressure sores: While diabetic and venous ulcers are often seen in the elderly population, the age scale of pressure ulcer patients is quite wide. Spinal cord injuries develop as a result of traffic accidents in the young population and pressure ulcers occur in an average of 1/3 of these patients. Due to the fact that the skin’s tolerance to ischemia is higher than that of muscle, the necrosis that occurs in the deep tissues of pressure wounds is dramatically higher than in the skin. The wound, which mostly occurs on the skin, is the tip of the iceberg. Treatment of pressure ulcers has two stages: conservative and surgical treatments. With conservative treatment, small wounds can heal completely, especially in patients who can walk, while larger cavitary wounds are also made suitable for surgery.
Conservative treatments: First of all, the patient’s Diabetes mellitus and malnutrition status should be corrected. The patient’s diet should be enriched in protein, supplemented with multivitamin preparations (especially vitamin C) and zinc. The use of air mattresses and change of position are at the heart of conservative treatments. With the removal of the pressure on the wound, the progression of necrosis in the existing wound is prevented. Position changes every two hours also prevent the patient from opening new wounds.
In patients with spinal cord injury, resolving the muscular spasm is necessary to position the patient. Muscle relaxant agents can be used to resolve the spasm, but when an inadequate response is received, it may be necessary to provide the flaccid condition with nerve blocks or rhizotomies. Dead tissues in the pressure wound should be removed from the wound at regular intervals. In this way, the wound is prevented from being a suitable environment for bacteria that can lead to infection. Pressure sores can often be contaminated or infected with skin flora or enteric bacteria.
Prevention and eradication of infection is possible by ensuring the moisture balance of the wound by selecting the appropriate dressing materials as well as debris. For example, it is appropriate to use alginate derivatives for cavitary, abundant exuding wounds, while it is more appropriate to use agents that penetrate escara, such as silvadene or sulfonylon, on wounds with eschar formation. VAC is another dressing method that can be used for the preparation of surgery of cavitary wounds or for the healing of superficial wounds. Although it is theoretically predicted that it will regulate the hypoxic wound environment, the benefit of hyperbaric oxygen on pressure ulcers has not been demonstrated. Surgical treatment: Providing preoperative optimal conditions is directly related to the success of the surgery.
Surgery should not be planned until at least 2 weeks after smoking cessation and HbA1c <6% and albumin >2g/dl target values have been achieved. In stage 1 ulcers, the approach should be preventive measures and closing the wound with transparent films. In stage 2 ulcers, the wound bed should be kept moist and dressed. Stage III and IV compression ulcers require surgical intervention for wound closure. In general, flap operations with various plastic surgical techniques are recommended after the ulcerated area is completely excised. In the first 15 days after surgery, weight should not be placed on the flap, again the use of air mattresses and position changes are important. Recurrence develops in approximately p of pressure ulcers, more so in iscial wounds. Especially in patients younger than 45 years of age, poorly controlled diabetics, serum albumin <3>
Chronic wounds are also open wounds. In open wounds, there are problems such as infection, dryness, heat loss, unprotected underlying tissues, loss of wound surface. For these reasons, wound care and treatment are important. The purpose of wound care; to protect living tissues, to prevent further tissue destruction and infection development in the traumatized area, to accelerate healing, to increase the functions of the injured area, to prevent skin integrity and complications that may occur in other organs and systems.
Surgically, debridement and amputation are the main treatment approaches in chronic wounds. With debridement, necrotic tissues, foreign substances, bacteria that cause or may cause infection and their products are removed from acute and chronic wounds. Color, consistency, capillary bleeding and contractility are important in debridement. Bleeding during debridement is the most important indicator of vitality for muscle tissue. Dead muscle tissue is dark in color, softened and does not contract when involved with forceps. Pulsatil lavage is effective alongside surgical debridement for the removal of bacteria from contaminated wounds.
Amputation is the separation of the limb where the wound is located from the body. Amputation can be at various levels such as below the knee, above the knee, below the elbow, above the elbow etc. Disarticulation is the amputation at the joint level. The aim of amputation is to eliminate the damage or obstacle of the non-functional limb to the body. In determining the level of amputation, age, activity status, functional status and circulatory status of the patient are taken into account. Circulation can be determined by radiological examinations such as Doppler ultrasonography and angiography. Certain methods are used to decide on amputation and determine its level.
Due to the advancing medical approaches with developing technology, limb-sparing surgeries have come to the forefront. Many cases that used to be decided to be amputated can now be treated primarily with limb-sparing surgeries.
