Leg Ulcers: Diagnosis and Management S Sacchidanand, Shilpa K, Eswari L
INDEX
Page numbers followed by b refer to box, f refer to figure, fc refer to flow chart, and t refer to table.
A
Abdomen 71
and pelvis, ultrasonography 103
Acellular dermal regenerative matrix 161f
advantages of 161t
disadvantages of 161t
Acellular regenerative tissue scaffold 160
Aching 40
Acid glycerol lysis test 110
Acid-fast bacilli, multiple 106f
Acne 80
Activated partial thromboplastin time 108
Adalimumab 83
Alcohol 29
Alginate 158
dressing 53, 130
covered 134
Allergic contact dermatitis 91
Allergic diathesis 43
Allergy
to sclerosant 42
to stocking material 128
Allograft 160
Alpha-benzopyrones 42, 120
Ambulatory venous pressure 96, 98
Aminolevulinic acid 163
methyl ester 163
Amorphous hydrogel 132
Amputation 79
prevention 56
Anakinra 83
Anaphylactic shock 44
Anemia 66, 74
Angiogenesis 23, 24, 148
stage of 25f
Angiogram 104
Angiography 100, 102
Angiotensin-converting enzyme 110
Ankle 30
edema 38
flare 39, 39f
perforator 10, 11
pressure 99
systolic pressure, ratio of 71
Ankle brachial
index 51, 99
pressure
clinical category 100t
index 39, 71, 72f
Antibacterial agents 53
Antibiotic 41, 42, 76, 120, 121
therapy, guidelines on 53t
use of 52
Anticardiolipin 108
antibody 89
Antiembolism stockings 127
Antiglomerular basement membrane 103
Anti-infectives, use of 52
Anti-inflammatory action 163
Antimicrobial activity 163, 163t
Antimicrobial photodynamic therapy 162
Antineutrophilic cytoplasmic autoantibody 104
Antinuclear antibody 89, 103, 110
Antioxidant agent 26
Antiphospholipid antibodies
presence of 37
workup, complete 103
Antiphospholipid syndrome 68
Anti-rheumatic drugs, disease modifying 84, 138
Antiseptic 41
Antistreptolysin O titers 103
Antithrombin 108
deficiency of 37
Aortic coarctation 68
Aorto-bifemoral bypass 78
Arch vein 6
posterior 6
Arm-foot venous pressure 96
Arterial brachial pressure index 128
Arterial disease 39, 48, 68
management of peripheral 77, 77t
peripheral 45, 47, 68, 73t, 99, 114
Arterial insufficiency 30, 32, 32f
evaluation for 33
Arterial leg ulcers 68
pathophysiology of 15fc
Arterial occlusive disease, peripheral 28, 42, 128
Arterial reconstruction surgery 76, 91
Arterial ulcer 40t, 72, 72t, 73, 74t, 91, 138
management of 76, 76t
pathophysiology of 14
treatment 68
Arteriography 74, 100
Arteriosclerosis obliterans 68
Arteriovenous
fistulae 37
malformation 34, 68
Artery 34
Aspirin 41, 42, 90, 121
Asthma 43
Atherectomy 79
Atheromatous embolism, investigations for 102, 103b
Atherosclerosis 14, 68, 69, 73, 138
development of 68
pathophysiology of 69f
Atmospheres absolute 163
Atrophic blanche 30, 32, 39, 89
Atrophic papulosis, malignant 16, 110
Auscultation 34
Autoamputation 29
Autoimmune disease 84, 114
Autolytic debridement 89
Autonomic nerve 62
fibers 16
Autonomic neuropathy 48
Azathioprine 83
B
Bacterial index 105
Bacterial infection, levels of 21f
Balneotherapy 155, 162
Basal cell carcinoma 2, 13, 17
B-cell lymphoma 17
Becaplermin 76
Bedside tests 31
Bedsores 1
Behcet's disease 16, 110
Bicuspid valves 8
Bilayer cellular construct 54
Biochemical profile 74
Bioelectric dressings 164
Bioengineered skin substitutes 116
Biopharmaceutical agents 156
Biopsy 103
Blood
culture 103
pressure 71
tests, routine 103, 110
vessels 23
Blood sugar
and hypertension, control of 91
estimation 96
random 65
Blood urea 96
nitrogen 99
Body mass index
high 40
increased 37
Bone marrow
biopsy 110
sampling 110
Bony prominences 50
Bowel bypass syndrome 29
Boyd's perforators 10
Brodie-Trendelenburg test 33, 33f, 33t, 38
Buerger's angle 34
Buerger's disease 138
Buerger's test 34, 71
Bullous diseases 16
Bullous pemphigoid 110
Bullous pyoderma gangrenosum 81f
Bullous vasculitis 15f
Burns 2, 62
C
Cadaveric allografts from skin bank 147
Cadexomer iodine 115
Calciphylaxis 29, 109, 114
Calcium
channel blockers 90
dobesilate 42, 90, 120, 122
Calf muscle functioning, insufficient 37
Canakinumab 83
Capillary refill
normal 40
time 71
Carbon dioxide angiography 102
Cardiovascular system 71
Catheter-based intravascular ultrasound 102
Causative organism 80
Cell cultures 146
Cell mediated immunity, defective 80
Center for disease control and prevention 2
Central nervous system 108
Cerebrospinal fluid 107, 108
Cerebrovascular accident 71
Charcoal dressings 133, 134
Charcot arthropathy 56, 57
Charcot foot 49f, 50, 56
basic treatment algorithm 57fc
Charcot fracture 57
Charcot joint 107
Charcot neuroarthropathy 49
Charcot neuropathic osteoarthropathy 50
Charcot's deformity 32
Charcot-Marie-Tooth disease 107
Chilblains 16
Chlamydia 14
Chlorambucil 83
Chlorhexidine 90
impregnated dressings 90
Chlorine 163
Cholesterol 104
emboli 68
Chromate glycerine 42
Churg-Strauss syndrome 85
Cilostazol 123
Clammy extremities 29
Claudication 100
pain 29, 88
Claw toes 63
Clofazimine 83
Clotting disorders 17, 108
Colchicine 83
Cold 29
leg 32
Collagen
dressings 132
vascular disorders 29
Common femoral artery, color Doppler of right 100f
Common iliac artery, right 100f, 101f
Compartment syndrome, chronic 73
Complement deficiency 81
Complete blood count 65, 99, 103, 108, 109
Compression stockings 128
types of 126, 127t
Compression therapy 41, 91, 126
and dressings 126
Computed tomography
angiography 74, 101
venography 94
Concealed ulcer, stage of 62
Connective tissue
disease-associated ulcers, mixed 85t
growth factor 148, 157
remodeling of 23, 25
stage of 26f
Connexins 157
Coombs test 110
Corona phlebectatica 39
Coronary artery disease 29
Cosmetic issues 146
Cosmetically unacceptable linear swellings 28
Cosmetic-spider webs 42
Cough impulse test 31
C-reactive protein 65, 68, 103, 138
Creatine phosphokinase 103
Creatinine 99
Critical limb ischemia
clinical signs of 71t
symptoms of 70t
Cryofibrinogenemia 68
Cryofibrinogens 89
Cryoglobulinemia 13, 17, 17f
Cryoglobulins 89, 104
Cryoproteins 15
Cutaneous discoid 16
Cutaneous T-cell 17
Cyclophosphamide 83
Cyclosporine 83
Cysteine proteinase 25
Cytokine 117
dysregulation 37
inflammation and release of 14
Cytomegalovirus 14
D
Da Vinci vein 6
Dakin's solution 138
Dapsone 83, 121
D-dimer assays 95
Deep fascial plexus group 9
Deep fungal infections 82
Deep mycotic infections 17
Deep venous
competence of 97
plexus 5
of lower limb 9f
system 9
thrombosis 10, 13, 37, 40, 42, 43, 73, 126
diagnosis of 94
Deep wound biopsy 75, 76
Defibrotide 42, 123
Deformities 65
Dehydrated amniotic membrane allograft 161
Deoxyribonucleic acid 106
Dermal neutrophilia, epidermal necrosis with 16f
Dermal regeneration, scaffold for 156
Dermal substitutes 117, 146
Dermal tissue 118
Dermatitis 40
chronic 91
contact 16
Dermatological manifestations 38
Dermis 137
DeWeese's test 34
Diabetes 2, 13, 29, 75
long standing 42
mellitus 29, 40, 45, 61, 68, 74, 88, 104
related amputations 55
Diabetic foot 51
disease 47
infection 47
system of 49t
pathology, multifactorial etiology of 48f
physical examination 50
surgery classification 55f
ulcer 2, 15, 30, 32, 47, 48, 51t, 56, 61, 63, 104
classification systems 51
ulceration, etiology of 47
Diabetic revascularization 57
Diabetic ulcer 2, 138
classification 51
Digital subtraction angiography 75, 101
Diosmine 120
Donor site 146
considerations 144
dressing 145
Dorsiflexors, clinical test for 36f
Doxycycline 121
Dragging pain 28
Dressing 52, 129, 162
advances in 155
aim of 129
change, first 144
choice of 134
types of 129, 130t, 131f
Drug 17
delivery systems 156, 159f
novel 155, 156
eluting stents 79
Dry foam 44
Dry skin 62
Duplex Doppler ultrasonography 96
Duplex ultrasonography 94, 100
Duplex ultrasound 40
scan 74
Dyslipidemia 68
Dysproteinemia 17
E
Ecthyma gangrenosum 21
Eczema 32
gravitational 38
Eczematous pigmented skin 32f
Edema 32, 42, 44
gross 128
mild 128
Egyptian eye 8f
Electric stimulation 155, 164
Electrocardiogram 103
Electrocardiography 110
Electrolyte 99
Electromyography 103
Electroneuromyography 104, 107
Embolism, investigations for 102
Emission tomography scans, positive 51
Endocrine disorders 29
Endothelial cell 156
proliferation 141
Endothelial progenitor cell 155, 156
therapy 156
Endovascular laser therapy 92
Endovenous ablation 45
Enterobacter 19
Enterococcus 19
Enzymatic debridement 89
Enzyme linked immunosorbent assay 95
Enzyme, topical 54
Eosin-5’-maleimide binding test 110
Eosinophil count, absolute 103
Eosinophilia 103
Epidermal growth factor 24, 148, 157
inhibitor 80
receptor inhibitor 16
Epidermal stem cells 24
Epidermal substitutes 117
Epidermis 136
layers of 137f
Epithelial autografts, cultured 117, 146
Epithelializing wounds 134
Epithelioid cell infiltrate 105f
Epithelioma 17
Ergotamine 17
Erysipelas 21
Erythema 44, 108
elevatum diutinum 16, 110
exudativum multiforme 16
induratum 16
Erythermalgia 16
Erythrocyte sedimentation rate 103, 104, 109, 138
Erythromelalgia 16
Escherichia coli 19, 50
European Society of Vascular Surgeons 69
Exercise therapy 77
Extensor hallucis longus 34
Extracellular matrices 116, 159
Eye of horus 8f
F
Factitious panniculitis 82
Familial neuropathies 29
Fasciectomy, lateral 164
Fat necrosis 16
Fegan's technique 43
Femoral artery, superficial 79
Femoral vein
common 95f
left deep 95f
superficial 9
Fever 20, 108
Fibrin cuff
around capillaries 14f
theory 14, 37
Fibrinogen 103
Fibrinoid necrosis of vessel wall 15f
Fibrinolytic enhancers 123
Fibroblast growth factor 24, 148, 157, 163
Fibroplasia 23
Flattened plantar arch 63
Flavonoids 122
address deficiencie 122
Foam
dressings 130
types of 44
Foam preparation 45f
injection of 45f
Foam sclerotherapy 44
advantages of 44
disadvantages of 44
Follicular unit
extraction 165f
grafting 164
Fontaines classification of critical ischemia 70t
Foot 10, 16
and ankle, perforating veins of 6f
architectural changes in 32
infection 51
perforators 11
pressures 50
reducing pressure on 65
ulcers, surgical management of complicated 66
Footwear 66
type of 63
Fossa ovalis 32f
Frequency-rhythmic electrical modulation system 118
Frostbite 62
Frozen autologous plasma 123
G
Gamma-benzopyrones 42, 120
Gangrene 100
dry 71
gas 21
wet 71
Gastrointestinal diseases 29
Gastrointestinal disorders 122
Gelatinases 25
Gelatine 158
General health and nutrition 87
Glucose deficiency 26
Glucose-6-phosphate dehydrogenase 110
deficiency 17
Glycation, advanced 26
Gout 109
Graduated compression stockings 127f
Graft, type of 142
Gram's stain 21f
Granular casts 103
Granulating wounds 134
Granulation tissue, formation of 25, 25f
Granulocyte
colony-stimulating factor 17, 65, 80
macrophage colony 115
stimulating factor 90, 157
stimulating factor 16
Granulomatosis 85
Great saphenous vein 5, 31, 42, 45, 97, 98f
Growth factor 53, 54, 148, 156, 157, 157t
at cellular level 149fc
beta, transforming 37, 148, 155
insulin like 148
role of 90
transforming 14
H
Hair follicle
parts of 137f
punch grafts 164
Hair loss 32
Hallux rigidus 63
Halogenoderma 82
Halogens 17
Hammer toes 63
Hansen's disease 29, 35, 35f
Healing 23
by first intention 27
by second intention 27
Healthcare, cost of 2
Heart failure, decompensated 128
Hemangioma 16
Hemangiosarcoma 17
Hematological disorders 17, 29
Hematoma 145
Hematoproliferative disorders 76
Hemoglobin 104
electrophoresis 110
estimation 96
spray, topical 116
Hemogram, complete 103
Hemosiderin staining 40
Hemostasis 23
Heparin 83
Hepatitis 81
B 103
C 103
Hepatocyte growth factor 155
Hereditary sensory
motor neuropathy 61
neuropathy 107
Hereditary spherocytosis 17, 110
Herpes virus 14
Hidradenitis suppurativa 80
Hodgkin disease 17
Holiday ulcers 61
Homocysteine 14
levels 74
Homocystinuria 109
Honey 65
impregnated dressings 54, 133
Horse chestnut extract 42
Horus eye 7
Human amniotic cellular 155, 161
Human immunodeficiency virus 61, 80
infection 17
test 103
Human leukocyte antigen 16
Human skin equivalents 54
Hyaluronic acid, topical 158
Hydrated polymer dressings 132
Hydrocolloid dressing 53, 131, 134
Hydrogel 156, 158
dressings 53, 132, 134
impregnated 132
wound dressings 132t
Hydrosurgical debridement 64
Hydroxyethylrutosides 122
Hydroxyureum 17
Hyperbaric oxygen 54
therapy 83, 139, 155, 163
Hypercoagulability 43
Hypercoagulable disorders 17
Hypercoagulable state 68
Hypercoagulable status with embolization 29
Hyperglycemia 16, 26, 48
role of 16
Hyperhomocysteinemia 37, 68
Hyperimmunoglobulin E syndrome 81
Hyperlipidemia 29
Hyperoxaluria 109
Hypertension 13, 29, 40, 68, 75
control 77
Hyperthyroidism 42
Hypertonic saline 42, 43
dextrose 42
Hyperviscous state 68
Hypogammaglobinemia 81
Hypostatic ulcer 37
Hypoxia 88
inducible factor 155
I
Ibroblasts 23
Iliac artery
endofibrosis of external 68
proximal external 101f
right external 101f
syndrome 68
Iliac spine, anterior-superior 34
Iliac vein thrombus, common 95f
Immobility 42
Immunohistochemical reaction 104, 106
Immunomodulatory activity 163
Impregnated dressings 134
Infected ulcer, investigations in suspected 65b
Infection 13, 19, 48, 82, 88, 114, 145
control 114
local 42
management of secondary 64
signs of 20b
Infectious diseases 17
Infectious Diseases Society of America classification 49t
Inflammation 14, 23, 24
laboratory markers of 103
Inflammatory bowel disease 76, 80
Infliximab 83
Infra-inguinal revascularization 78
Innate immunity, aberrant response of 80
Insect bites 16, 82
Interleukin 10 157
Interstitial collagenases 25
Intradermal reaction 104, 105
Intralesional injection 17
Intravascular ultrasound 102
Intravenous immunoglobulin 83
Iodine 90
impregnated dressings 133
Iodozyme 162
Iron profile 104
Ischemia 51
acute 100
Ischemic arterial ulcers 68
Ischemic leg ulcer, etiology of 68b
Ischemic subcutaneous arteriolosclerosis 75
Ischemic ulcer
classification of 68t
hypertensive 76
pathogenesis of 69fc
risk factors for 68b
Isotretinoin 16, 80
Itching 40
J
Jaundice 140
Joint contractures 50
K
Kaposi sarcoma 17
Keratinocyte 117
cell cultures 147f
growth factor 155
photoactivation, marginal 163
proliferation of 23
Keratosis actinica 16
Kidney transplant 75
Klebsiella 19
Klippel-Trenaunay syndrome 28
Knee
compression stockings, below 127f
perforators 11
Kyrle's disease 29
L
Laboratory screening tests 108
Lactic-co-glycolic acid 163
Laser therapy 44
low-level 65, 163
Leg
acute ischemia of 99
edema, chronic 126
elevation 41
extreme deformity of 128
fracture, history of 37
heaviness of 28
perforators 11
Leg ulcer 1, 3, 13, 18, 20, 84, 85, 85t, 87, 87t, 88, 89t, 94, 110, 115, 120, 128, 155
arterial cause of 99
case of 87
causes of 2t, 13t, 108, 110t
chronic 1, 13, 87, 92, 114, 136
nonhealing 1
venous 37
complications of 19
due to antineutrophil cytoplasmic antibody-associated vasculitis 85t
etiology of 13
examination in chronic 28
formation, chronic 69f
in rheumatoid arthritis 84t
indication in 142
infectious causes of 108
investigating atypical 108
investigation for 94
management of 88, 114, 136, 148
principles of 87
metabolic causes of 108, 109t
microbiology of 19
microbiota of 19
pathology of 13
radiological diagnosis of 94
systemic therapy of 120
topical therapy for 114
treatment
of chronic 28
of nonhealing 28
Leishmaniasis 17
Lepromatous leprosy 106, 106f
borderline 106
Leprosy 2, 61, 104
mid borderline 106
trophic ulcers 13, 63
Leukemia 17, 80, 110
Leukocyte 14, 148
adhesion molecules 15
counts, differential 104
entrapment theory 37
Leukocytosis 103
Levamisole 121
Lichen planus 16
Light emitted diode 163
Light-based therapy 155
Limb edema 40
Limb ischemia
acute 70t
critical 69, 138
Limited joint mobility 50, 63
Lipedema 16
Lipid carriers, nanostructured 158
Lipid control 77
Lipid nanocarriers 158
Lipid nanoparticles 156
Lipodermatosclerosis 10, 30, 32, 38
Lipoprotein 68
low-density 15
Liver
biopsy 109
failure, chronic 61
function test 103, 104, 110
Local therapy 83
Lorenzo Tessari's tourbillon technique 44
Lower extremity
pain, left 94f
ulcer, management of 28
venous anatomy of 5
Lower limb
eponymous perforators of 10f
lymphatic insufficiency of 126
microcirculation of 5
motor power of 35
motor weakness of 36t
nerve examination 36t
swelling of 28
vessels, anatomical landmark for 34t
Lupus anticoagulant 89, 108
Lymphangiosarcoma 17
Lymphangitis 20
Lymphatic obstruction 29
Lymphedema 16, 114, 126
Lymphocytes 24
Lymphoma 17
leukemia 82
Lymphosarcoma 17
M
Macrophages 24
Maggot debridement therapy 64
Magnetic resonance imaging 65, 94, 107, 110
of spine 107
techniques 95
Magnetic resonance venography 95
Malleolar flare 39
Malnutrition 66
Mantoux test 103
Maritime pine tree extract 42, 120
Marjolin ulcer 17
Martorell's ulcer 72f
Mass spectroscopy 110
Matrix metalloproteinases 13, 25, 26, 64, 116, 132, 157, 163
Maturation 141
McConkey agar, culture on 20f
Mechanical blistering disorders 29
Mechanical debridement 89
Medication glucocorticoids 26
Melanoma, malignant 13, 17
Mesalazine 83
Mesenchymal stem cell 155
therapy 155
Mesher for meshing skin graft 142f
Mesoglycans 123
Metabolic disorders 29
Metastasis 17
Methicillin-resistant Staphylococcus aureus 90, 133
Methotrexate 17, 83
Methylene blue 163
dressings 133
Methylprednisone pulse 83
Metronidazole 53
Mezlocillin 83
Microangiopathy theory 37
Microbial culture 65
Microcellular rubber 66
Microhematuria 103
Micronized purified flavonoid fraction 42, 120, 122, 124
Microthrombotic disease 68
Migraine 43
Minocycline 83
Moisture 88
balance 114
Monoclonal gammopathy 80
Morphological index 105
Motor nerves, involvement of 61
Motor neuropathy 16, 48
Multidisciplinary team, structure of 58b
Multiglycoside 83
Muscle cramps 28
Mycobacteria, atypical 17
Mycobacterium leprae 104
bacillus 104, 106
Mycophenolate mofetil 83
Myelodyplasia 80
Myeloproliferative disease 80
Myocardial decompensation 43
Myocardial infarction 71
Myxedema 16
N
Nanofibrous structures 156, 158
Necrobiosis lipoidica 2, 13, 109
Necrosis 88
Necrotic ulcers 134
Necrotizing fasciitis 21
Neonatal human foreskin fibroblasts 118
Neovascularization 141
Nerve
accompanying 10
conduction studies 103
examination of peripheral 35
Neuropathic ulcer 31, 34, 63, 64f, 138
causes of 61, 61t, 108t
infection in 64b
Neuropathy 48
advanced peripheral 128
minor peripheral 128
peripheral 47, 61
Neutrophilic dermatoses 82
of dorsal hand 81
Neutrophilic dysfunction 80
Neutrophilic infiltration 15f
Neutrophils 24, 80
release nitric oxide 116
New endovascular techniques 79
New omental transfer surgery 76
Nicorandil 82
Nitric oxide 15
Nodules 89
Nonmedical support hosiery 127
Nutritional deficiencies 29
O
Obesity 26, 40, 68
Open ulcer, stage of 62
Open venous surgery 45
Oral corticosteroid cover 83
Oral nutritional supplements 155, 162
Osmotic fragility 110
Osteoarthritis 81
diagnosis of 52
Oxygenation 88
P
Pain 42, 70, 73
associated with heel raising 33
increased 20
onset of 73
relief of 73
type of 73
uncontrolled 45
Palpable purpura 89
Pancreatic fat necrosis 16
Panniculitis 13, 16, 110
PAPA syndrome 16
Papillary dermal plexus 5
Paraplegia 61, 108
Paraproteins 15
Paratibial perforators 10
Paravasal injection 17
Patch testing 41
Peak systolic velocity 100
Pegfilgrastim 80
Pemphigoid 16
Pentoxifylline 41, 42, 120
Percussion test 33
Perforator incompetence, evaluation of 97
Perforator reflux 42
Perforator vein 11
Periarteritis nodosa 16
Periodic acid-Schiff stain 109
Peristomal pyoderma gangrensoum 83
Perniosis 16
Peroneal nerves, superficial 35f, 36
Persistent sciatic artery 68
Perthes test 33
demonstration of 34f
interpretation of 33t
modified 33
Pes cavus 63
Phagedenisme geometrique 80
Phase-contrast techniques 95
Phenothiazine derivative 163
Phenytoin 115
sodium 65
topical 115
Phlebography 97
Phlebotonics 122
Phlegmasia cerulea dolens 128
Photodynamic antimicrobial chemotherapy 162
Photodynamic inactivation 162
Photodynamic therapy 155, 162
Photonic technology 163
Photoplethysmography 40
Placing test tube in centrifuge 151f
Plantar ulceration, mechanisms of 62b
Plasma spectrofluorimetry 109
Plasminogen activator inhibitor 123
Platelet derived
growth factor 148
products, role of 148
Platelet factor-4 148
Platelet rich
fibrin 90, 148, 151, 153f
preparation of 152fc
treatment with 152f
plasma 41, 90, 123, 149
preparation of 149fc
role of 148
test tube with 149f
Platelet-derived
fibrin 65
growth factor 65, 116, 157
Plethysmographic techniques 96
Plethysmography 100
Polar tuberculoid leprosy 105
Polidocanol 42, 43
Poliomyelitis 61, 108
Polyangiitis 85
microscopic 85
Polyarteritis nodosa 13
Polycythemia 17, 74
vera 68, 80
Polyiodinated iodine 42
Polylactic-co-glycolic acid 158
Polymerase chain reaction 106, 108
Polyurethane
films 53
foam 53
Popliteal entrapment 68
Popliteal nerves, lateral 35f, 36
Popliteal vein 9
Porcine small intestine submucosa 54
Porphyria cutanea tarda 109
Post-sclerotherapy compression 44
Post-thrombotic
syndrome 94, 126
venous insufficiency 128
Potassium iodide 83
Prealbumin levels 104
Precursor of keratin 136
Prednisolone 83
Prednisone 122
Pregnancy 40, 126
first trimester 42
Pressure measurement 99
Pressure off-loading 91
Pressure sites 30
Pressure wound therapy, negative 139, 139f, 140f, 155, 163
Pricking and burning sensation 29
Prolidase deficiency 109
Propylthyuracil 80
Prostacycline analoges 123
Prostaglandin 123
Protein
C 108
deficiency 37
topical 90
deficiency 26
S 108
deficiencies 37
Proteinuria
mild 103
urinalysis for 103
Proteus 19
Prothrombin mutation 37
Prothrombin time 108
Protozoa 13
Provocative tests 34
Pruritus 28
Pseudoclaudication 73
Pseudoepitheliomatous hyperplasia 17
Pseudo-Kaposi sarcoma 17
Pseudomonas aeruginosa 90, 163
Pseudoxanthoma elasticum 68
Psoriatic arthritis 80
Pulses, peripheral 40, 73
Pyoderma gangrenosum 2, 13, 16, 16f, 29, 30, 31f, 32, 68, 72, 73, 80, 82, 82b, 83b, 114, 122
associations of 80b
classical ulcer of 81f
clinical course of 81t
differential diagnosis of 82b
treatment of 83b
types of 81b
ulcer 166
Pyoderma ulcers 138
Pyogenic arthritis 80
Pyostomatitis vegetans 81
Q
Quantiferon gold test 103
R
Radionuclide scintigraphy 96
Recurrent phlebitis 40
Red blood cells 15
extravasation of 15f
Renal disease 29
Renal disorders 29
Renal failure 61
dialysis in 66
Renal function test 65, 103, 104, 109, 110
Renal insufficiency, chronic 68
Rest pain 70, 100
Reticular vein 43, 44
Retiform purpura 32, 89
Rheumatoid
arthritis 76, 80, 84
factor 89
polyarthritis 128
Ridley's logarithmic scale 105
Rifampicin 83
Right dressings, selection of 134
Rocker bottom foot 50
S
Saphenofemoral junction 6, 7, 33, 42, 97, 98f
Saphenopopliteal junction 7, 97
Saphenous fascia 6f
Saphenous femoral artery, right 101f, 102f
Saphenous nerve 10
Saphenous vein 6f
accessory 7
lesser 31
long 5, 42
short 45, 97
small 6, 7
tributaries of 7f
Saponins 42, 120
Sarcoidosis 16, 80, 110
Sarcoma 17
Scaffold 156, 158
Scar 30, 32
formation 23
Scarless healing 26
Scleroderma 16, 85t, 110
Sclerosis, multiple 108
Sclerotherapy 41, 45
complications of 44
injection, technique of 44f
Sedentary lifestyle 68
Semipermeable film dressing 134
Semmes-Weinstein filaments 34
Sensorimotor neuropathy, peripheral 91
Sensory
nerves, involvement of 61
neuropathy 16
test 34
Septic phlebitis 128
Serological testing 104, 106
Seroma 145
Serum
creatinine 96
electrophoresis 110
glucose 104
imbibition 141
Sevoflurane, topical 162
Sheet hydrogel 132
Sickle cell
anemia 2, 17, 68, 110
disease 13
Sickling test 110
Sigg's technique 43, 44
Silver compounds 90
Silver impregnated dressings 133
Simvastatin, topical 161
Single-photon emission computed tomography 51
Skin
and peripheral nerve 104
applied anatomy of 136
around ulcers, examination of 29
autoimmune blistering disorders of 29
biopsy 109, 110
changes 32t
condition 71
dryness of 29
irritation 28
layers of 137f
pigmentation 28
regeneration 137
replacement, recent advances in 146
smear microscopy 105
wounds, healing of 27
Skin graft 45, 76, 136, 140, 141, 144f
advantages of 141
contraindications for 140
disadvantages of 141
donor sites for 145f
full-thickness 143
harvest 141
harvesting split 142f
methods of fixing 143
role of 136, 138
split thickness 136
stages of 141f
storage 145
substitutes, biologically active 159
types 141
advantages of different 142t
disadvantages of 142t
Slit skin smear 104
Sloughy wounds 134
Smoking 40
avoidance of 65
cessation 77
Sodium
dodecyl sulfate 110
hypochlorite 138
morrhuate 42, 43
tetradecyl sulfate 42, 43
Soleus muscle pump 9
Solid lipid nanoparticles 158
Spider veins 30
Spina bifida 61, 108
Split skin graft, techniques of 142
Spondylitis 80
Squamous cell carcinoma 2, 13, 17
Standard Doppler examination 96
Stanozolol 42, 90, 123
Staphylococcus aureus 19, 50, 52
Staphylococcus epidermidis 163
Stasis dermatitis 11, 38, 39f, 42
Stasis eczema 89
Stasis ulcer 37
Stellate scarring 32
Stem cell 159
in skin 137
role of 155
therapy, role of 155
Sterilization procedures 160
Steroid 17
topical 116
Stewart-Bluefarb syndrome 16
Stratum corneum 164
Streptococcus pyogenes 17
Streptococcus sanguis 17
Strokes 29
Stromeolysins 25
Subcutaneous plexus group 5
Subepidermal bulla 15f
Submuscular plexus 9
Sudomotor dysfunction 48
Suflamethyoxy pyridazine 83
Sulfapyridine 83
Sulfasalazine 83
Sulodexide 123
Supra-inguinal revascularization 78
Sural nerve 10, 36
examination of 35f
Surgery, role of 91
Surgical methods 55
Surgical therapy 164
Swabbed material, culture of 20f
Sweet's syndrome, atypical 82
Synthetic phlebotonics 42, 120
Syphilis 61
Syringomyelia 2, 13, 61, 108
Systemic disease, severe 42
Systemic examination 71
Systemic involvement 87
Systemic lupus erythematosus 13, 16, 110
Systemic steroids 83, 122
Systemic therapy 83
T
Tabes dorsalis 2, 107
Tacrolimus 83
Takayasu's disease 80
Tap test 33
Telangiectasia 42, 44
Tetracyclines 83
Thalassemia 17, 110
Thalidomide 83
Thermal injuries 62
Threatened ulcer, stage of 62
Throbbing 40
Thromboangiitis 68
obliterans 68, 73, 103
diagnosis of 103
Thrombocythemia 74
essential 17
Thrombocytopenia 103
Thrombophilia 43
screen 74
Thrombophlebitis, superficial 10, 126
Thrombosis 10
acute 68
Thrombotic thrombocytopenic purpura 17
Thrombus 95f
Thyroid
disease 29
disorders 29, 81
Tibia, anterior 30
Tibial nerve, posterior 35f, 36
Timolol maleate 161
Tissue
based products 155, 161
engineered skin equivalents 155, 159, 160t
inhibitors 26
injury, external 82
ischemia 88
processing 160
removal 114
Tobacco 14
use 29
Toe 30
brachial index 71
in Hansen's patient, second 31f
typically unilateral 30
Topical regimen, choice of 52
Topical therapy 161
Total contact cast 55, 55f, 65
Transcutaneous pressure of oxygen 100
Transesophageal echocardiography 103
Trauma 40, 114
acute 68
Trendelenburg test 33
modified 33
Triglycerides 104
Tripterygium wilfordii 83
Tuberculoid leprosy, borderline 105
Tuberculosis 2, 103
Tulle dressings 53
Tumor 13
necrosis factor-alpha 14
pressing on arteries 29
U
Ulcer 29, 40, 45, 62, 63, 71, 75, 76, 78, 79, 150f
atypical distribution of 45
biopsy in diagnosis 75t
cause of 30
chronic 72f, 129
chronicity of 37
common 138
developments 63
examination 29
formation
sequence of chronic 63fc
stages of 62
gravitational 37
irregular large and deep 31f
ischemic 68
liable 61
local care of 76
management of 63
multiple 81f
neuropathic 88t
of various etiologies 30t
prone 61
size, increased 20
stages of 62f, 139f
trophic 61
type of 134
vaccination 17
venous 88t
with heavy discharge 83
with purulent discharge 83
Ulcerating pyoderma 21
Ulcerating skin diseases 16, 110, 110t
Ulcerating tumors 17
Ulceration 28, 30, 100, 126
Ulcerative pyoderma gangrenosum 81
Ulcus rodens 17
Ulcus tropicum 17
Ultrasound machine 96f
University of Texas classification system 51
Unna boot 134
Urinary albuminuria levels 104
Urine 109
dipstick 103
for albumin 96
for sugar 96
Ustekinumab 83
V
Vacuum compression therapy 76
Vacuum therapy 54
Vacuum-assisted closure 138
therapy 64, 139
Valsalva, junction on 96f
Valves 8
Valvular incompetence 13
Valvular system of superficial veins 8f
Vancomycin 83
resistant Enterococcus 133
Varicography 97
Varicose ulcer 37
Varicose veins 10, 32, 37, 40, 43, 126
complication 42
during pregnancy 128
early 128
emptying of 33
gross 128
interventional treatment of 126
of medium severity 128
sclerotherapy for 42, 44
superficial 128
uncomplicated 126
Varicosities 40
of lateral venous system 42
Vascular disease 40
management of peripheral 78, 79
peripheral 16, 47, 61, 68
Vascular endothelial growth factor 115, 148, 155, 163
Vascular insufficiency 48
Vascular tumors, primary 68
Vasculitic ulcer 15, 30, 68, 83, 138
management of 86fc
Vasculitis 2, 13, 15, 29, 31f, 32, 68, 8284, 114
disease 84
exclude 104
mimics, exclusion of 103
screen 74
type of 104
Vasculopathy 17f
Veins
direct perforating 9f
superficial 5
Venae comitantes 9
Venereal disease research laboratory test 107
Venography 96, 97
Venous disease 40, 82
classification of chronic 97t
primary chronic 126
signs of 38
Venous eczema 38, 126
Venous hypertension 13, 37, 38
and stasis 13
Venous insufficiency 28, 30, 32, 32f, 96b
chronic 11, 37, 38t, 42, 87, 98, 126
classification of chronic 38
symptoms of 28b
Venous leg ulcer 13, 37, 45, 120, 156
pathophysiology of 13, 14f, 13fc
Venous reflux 97
ablation trial, early 164
Venous sinuses 9
Venous system, superficial 5
Venous thromboembolism, prevention of 126
Venous ulcer 2, 37, 39, 40f, 40t, 42, 72, 73, 73f, 96, 138
chronic 39
etiology of 37
recurrence 45
surgery for 45
Venous ulceration 11, 76
risk factors for 37t
Venulectasia vein 44
Vitamin
A deficiency 26
C 26
deficiency 26
E 26
deficiency 26
K antagonists 76
von Kossa stain 109
W
Wagner and Texas classification systems 51t
Wagner classification 51
Wagner method 51
Waldenstrom disease 110
Wave Doppler ultrasonography 96
Wearing footwear 29
Wegener's granulomatosis 85, 104
White blood cells 14
Wound 51
bed, optimization of 138
chronic 26
cleansing 88
closure with healing 63
contraction 146
debridement 52, 89, 138f
dressing 41, 89
impregnated 133
transparent 132
edge of 114
healing 23, 26, 27, 52, 148t
mechanism of delayed 21f
infected 134
management 64
of leg, chronic 13
ready for skin grafting 140f
strength 27
types of 134t
Wound-related factors 134
X
Xenograft 136, 160
Z
Zinc 42, 90, 121
phthalocyanine derivative 163
×
Chapter Notes

Save Clear


Epidemiology and Socioeconomic ImpactCHAPTER 1

Shashi Kumar BM,
Savitha AS
 
INTRODUCTION
Leg ulcers are a common problem causing great physical and mental distress to patients. Ulcers are defined as wounds with full thickness defect and slow healing tendency. Ulcers of skin can result in complete loss of the epidermis, often portions of the dermis and even subcutaneous fat.1 A chronic wound, which is below the knee and does not show any tendency to heal even with appropriate therapy for 3 months or is still not fully healed at 12 months is chronic lower limb ulcer.2 Chronic nonhealing leg ulcers occupy considerable space in surgical wards. Often these ghastly looking ulcers emit offensive smell posing difficulty in daily dressing for the surgeon. These ulcers involve a wide variety of spectrum of severity, etiology, and pathology with significant morbidity and mortality. Leg ulcers also significantly interfere with the lifestyle of the patient causing considerable loss of work hours and enormous healthcare costs.3
 
EPIDEMIOLOGY
The prevalence of chronic leg ulcers (CLUs) in the community ranges from 1.9% to 13.1% causing significant morbidity.4 Almost, 10% of the population have the risk of developing a chronic wound in the course of a lifetime, with a wound-related mortality rate of 2.5%.5 Wide geographical variations exist in both the etiology and prevalence of chronic wounds. Studies from India are limited. In a study by Shukla VK et al., the estimated the prevalence of chronic wounds was 4.5 per 1,000 population and incidence of acute wounds was more than double at 10.5 per 1,000 population.6 In the UK and Switzerland, the estimated annual incidence of leg ulcers are 3.5 and 0.2 per 1,000 individuals, respectively. In the US, about 15% of the elderly population suffer from chronic wounds. The main causes of chronic ulcers in them are pressure ulcers (bedsores), venous stasis ulcers, and diabetic (neuropathic) foot ulcers. Every year, 2–3 million more Americans are diagnosed with various types of chronic wounds.7,8
 
Age
With the increase in the elderly population due to good healthcare, the incidence of ulceration is also rising. Atherosclerotic risk factors like obesity, diabetes, and smoking are high in the elderly. CLUs affect 0.6–3% of those aged over 60 years, increasing to over 5% of those aged over 80 years.9 Strandness et al. observed the average age of patient with nondiabetic ulcer to be 63 years and Tassiopoulos et al. in their study of 1,249 limbs recorded the mean age of patients to be 59 years.10,11 According to the study in Ireland, the overall prevalence was 0.12% but it was 1.03% in the patients aged 70 years and over.12 Mukherjee et al. in their study of nondiabetic leg ulcers found predominantly patients in age group of 30–50 years.3
 
Sex
Sex incidence varies. The overall difference in incidence of leg ulcers between women and men probably reflects the greater number of women with longer lifespan, thereby increasing the overall rate for women.13
 
ETIOLOGY
The most common type of leg ulcer is venous ulcer, the others being neuropathic ulcer and arterial ulcers according to most of the Western and European studies.9 Venous 2diseases accounted for majority of cases (81%) of ulcers followed by arterial disease (16.3%), while ulceration due to diabetic neuropathy and rheumatoid vasculitis was unusual in a study from Ireland.12 Another study reported a 35.5% prevalence of varicose veins and 1.5% prevalence of severe chronic venous insufficiency with an ulcer or ulcer scar.14 A study from Germany made the observation that venous insufficiency was the predominant causative factor in 47.6% and arterial insufficiency in 14.5% and 17.6% of ulcers were due to combined arterial and venous insufficiency.15 A study from one center in India reported leprosy (40%), diabetes (23%), venous disease (11%), and trauma (13%) as causes of lower-extremity wounds. Other causes included atherosclerosis and tuberculosis. Inappropriate treatment of acute traumatic wounds was the foremost cause for wounds becoming chronic.6 The etiology of chronic wounds in the hospital setting is different from that seen in the community. While hospital-based studies are easier to carry out, they do not reflect the true population-based statistics. In a community-based study from Northern India, the prevalence of chronic wounds was 4.48 per 1,000 population with lower-extremity involvement being much more common than the involvement of the upper extremity.16 The most common etiology for chronic ulcers in the above study was untreated or improperly treated acute traumatic wound followed by diabetes. In contrast, most studies indicate that diabetic ulcers are the most common cause of lower-extremity ulceration in the hospital setting.17 Table 1 lists the causes of leg ulcers.
Table 1   Causes of leg ulcers.
Acute
Trauma
Injury
Burns
Vascular
Vasculitis
Arterial
Infections
Bacterial
Hematological
Sickle cell anemia
Chronic
Vascular
Venous
Arterial
Infections
Fungal
Protozoal
Leprosy
Neuropathic
Diabetes
Leprosy
Syringomyelia
Tabes dorsalis
Tumors
Basal cell carcinoma
Squamous cell carcinoma
Others
Pyoderma gangrenosum
Necrobiosis lipoidica
 
SOCIAL AND ECONOMIC IMPACT
Chronic leg ulcers impact virtually every aspect of daily life:
  • Pain is common
  • Sleep is often impaired
  • Mobility and work capacity tend to be restricted
  • Personal finances are often adversely affected
  • Chronic leg ulcer is usually associated with significant morbidity, high cost of healthcare, loss of productivity, and reduced quality of life.9
 
Cost of Healthcare
 
Venous Ulcer
Venous diseases are consuming 1–2% of the healthcare budgets of European countries. In France too, the costs of venous disease represented 2.6% of the total healthcare budget in 1995, thus confirming other data from European studies and an early health survey in the United States.18 Similarly in the United States, treatment costs for venous ulcers in more than 6 million patients approached $2.5 billion (£1.6 billion; €1.8 billion), and 2 million workdays were lost annually because of venous ulcer disease.19 A recent prospective study performed in 23 specialized wound centers throughout Germany calculated the mean total cost of a venous ulcer per patient per year to be €9,569 [€8,658 (92%) direct costs and €911 (8%) indirect costs].20
 
Diabetic Ulcer
According to the Center for Disease Control and Prevention, in 2007, diabetes and its complications cost the exchequer $174 billion of which $116 billion were in direct costs and the rest $58 billion were indirect costs such as loss of productivity, disability, and early mortality. In a study in which patients with diabetic foot ulcers (DFUs) were prospectively followed up, it was shown that 54% patients healed in 2 months, 19% healed in 3–4 months, and 27% healed in more than 5 months. Healing without amputation costs an average of $6,664 against healing by amputation, which averaged $44,790.19 Presence of vascular disease and neuropathy adds to the costs of treating DFUs. In India, the expenditure incurred in treating DFUs varied from ₹10,000 in patients in urban areas to ₹6,260 in patients in rural areas. Patients in urban areas spent a significantly higher amount on medications as well as for laboratory tests and consultations than patients in rural areas. The median costs of surgical treatment were also considerably higher in urban patients (₹21,000 vs ₹6,500). Expenditure increased with increased duration of diabetes as well as with the number of complications in both groups. In a 3recently published study, the cost of treating DFU in five different countries was estimated based on a hypothetical model. While the cost of treatment varied from the lowest in Tanzania to the highest in the United States for two different types of DFUs, the burden for the patient cannot be determined by the adjusted absolute cost but by the patients’ responsibility for bearing the cost. The cost to the patient is a function of both insurance cover and annual per capita purchasing power parity (PPP) adjusted gross domestic product (GDP). The authors concluded that India is the most expensive country for treatment of DFU, where approximately 5.7 years of income are required to pay for treatment compared to only 3 months of income in Chile and in China.21
 
Risk of Amputation and Economic Loss
In the United States, nearly 71,000 lower-limb amputations were performed in people with diabetes in 2004 costing approximately 3 billion dollars per year. 67% of all lower-extremity amputations have diabetes. Every year, 5% of diabetics develop foot ulcers and 1% require amputation. Recurrence rate of DFUs is 66%, and the amputation rate rises to 12% with subsequent ulcerations. Amputation rates also rise with increasing age varying from 3.9 per 1,000 in diabetics who are less than 65 years of age to 7.9 per 1,000 in diabetics more than 75 years of age. The 5-year survival rate after a major lower-extremity amputation is about 50%. Once amputation occurs, 50% will develop an ulcer in the contralateral limb within 5 years. According to estimates, a staggering $9 billion were spent on the treatment of DFUs in 2001.22
 
Loss of Work
Loss of work may be either due to inability to carry out the work because of disability or forced abstainism from work for medical management. The loss of income results in huge economic burden on patient and family. Venous ulcers are responsible for a staggering $2 billion in lost wages. Accurate assessment, prompt treatment, and suitable follow-up are essential for minimizing the long-term disability caused by chronic wounds.23
 
PSYCHOLOGICAL PROBLEMS
Severe pain in ulcers can lead to irritation, depression, and reduced social activity. Bad odor can have adverse psychological effects like self-loathing and feelings of disgust. Limitations of routine activities due to pain and immobility increase the dependence on others, which hampers social life. Guarnera et al. reported that women with venous ulcers had more pain and worse quality of life than men. Visual analog scale showed a higher value during dressing change. There was direct correlation between pain and quality of life, being worse for ulcers with longer duration and larger area.24 It has been documented that elderly had worse health-related quality-of-life issues as did those with pain and nonhealing ulcers. Pain, itching, altered appearance, loss of sleep, functional limitation, and disappointment with treatment were identified as the psychological effects of chronic ulceration.25
Health-related quality of life (HRQOL) is worse in diabetics with complications than in diabetics without complications. The reduced mobility and restriction of daily activities caused by foot ulcers adversely affect HRQOL. DFU patients suffer from huge negative psychological and social effect including reduction in social activities, increased family tensions for patients and their caregivers, limited employment, and financial hardship.26
Due to the above reasons, wound management should also include recommendations to improve quality of life in these patients.
 
CONCLUSION
Leg ulcers tend to be chronic and debilitating causing a huge impact on the personal, social, and economic life of patient. Venous leg ulcers are the most commonly reported ulcers to date, but with the increase in the incidence of diabetes, diabetic ulcers will be more prevalent in future.
REFERENCES
  1. Van Gent WB, Wilschut ED, Wittens C. Management of venous ulcer disease. Br Med J. 2010;341(7782):1092–6.
  1. Kahle B, Hermanns HJ, Gallenkemper G. Evidence based treatment of chronic leg ulcers. Dtsch Arztebl Int. 2011;108(14):231–7.
  1. Mukherjee S, Raza MA, Bansal P, et al. A prospective, open label, clinical study for evaluation of management of chronic non-healing, non-diabetic leg ulcers in a tertiary care hospital. Int Surg J. 2015;2(4):560–5.
  1. Rayner R, Carville K, Keaton J, et al. Leg ulcers: atypical presentations and associated comorbidities. Wound Pract Res. 2009;17(4):168–85.
  1. Sasanka CS. Venous ulcers of the lower limb: where do we stand? Indian J Plast Surg. 2012;45(2):266–74.
  1. Shukla VK, Ansari MA, Gupta SK. Wound healing research: a perspective from India. Int J Low Extrem Wounds. 2005;4(1):7–8.
  1. Cheng CF, Sahu D, Tsen F, et al. A fragment of secreted Hsp90α carries properties that enable it to accelerate effectively both acute and diabetic wound healing in mice. J Clin Invest. 2011;121(11):4348–61.

  1. 4 Mekkes J, Loots MA, Van Der Wal AC, et al. Causes, investigation and treatment of leg ulceration. Br J Dermatol. 2003;148(3): 388–401.
  1. Agale SV. Chronic Leg Ulcers: Epidemiology, Aetiopathogenesis, and Management. Ulcers. 2013;2013:9.
  1. Strandness DE, Priest RE, Gibbons GE. Combined clinical and pathologic study of diabetic and non-diabetic peripheral arterial disease. Diabetes. 1964;13:366–72.
  1. Tassiopoulos AK, Golts E, Oh DS, et al. Current concepts in chronic venous ulceration. Eur J Vasc Endovasc Surg. 2000;20(3):227–32.
  1. O'Brien JF, Grace PA, Perry IJ, et al. Prevalence and aetiology of leg ulcers in Ireland. Irish J Med Sci. 2000;169(2):110–2.
  1. Margolis DJ, Bilker W, Santanna J, et al. Venous leg ulcer: incidence and prevalence in the elderly. J Am Acad Dermatol. 2002;46:381–6.
  1. Faria E, Blanes L, Hochman B, et al. Health-related quality of life, self-esteem, and functional status of patients with leg ulcers. Wounds. 2011;23(1):4–10.
  1. Korber A, Klode J, Al-Benna S, et al. Etiology of chronic leg ulcers in 31,619 patients in Germany analyzed by an expert survey University Clinic. J Dtsch Dermatol Ges. 2011;9(2):116–21.
  1. Gupta N, Gupta SK, Shukla VK, et al. An Indian community based epidemiological study of wounds. J Wound Care. 2004;13:323–5.
  1. Sen CK, Gordillo GM, Roy S, et al. Human skin wounds: a major and snowballing threat to public health and the economy. Wound Repair Regen. 2009;17(6):763–71.
  1. Gupta SK. Impact of ulceration. In: Khanna AK, Tiwary S (Eds). Ulcers of lower extremity. New Delhi: Springer;  2016: p. 10.
  1. Phillips T, Stanton B, Provan A, et al. A study of the impact of leg ulcers on quality of life: financial, social, and psychological implications. J Am Acad Dermatol. 1994;31:49–53.
  1. Purwins S, Herberger K, Debus ES, et al. Cost-of-illness of chronic leg ulcers in Germany. Int Wound J. 2010;7:97–102.
  1. Cavanagh P, Attinger C, Abbas Z, et al. Cost of treating diabetic foot ulcers in five different countries. Diabetes Metab Res Rev. 2012;28(Suppl 1):107–11.
  1. Driver VR, Fabbi M, Lavery LA, et al. The costs of diabetic foot: The economic case for the limb salvage team. J Vasc Surg. 2010;52:17S–22S.
  1. Alexander SJ. Time to get serious about assessing and managing psychosocial issues associated with chronic wounds. Curr Opin Support Palliat Care. 2013;7:95–100.
  1. Guarnera G, Tinelli G, Abeni D, et al. Pain and quality of life in patients with vascular leg ulcers: an Italian multicentre study. J Wound Care. 2007;16(8):347–51.
  1. Goodridge D, Trepman E, Embil JM. Health-related quality of life in diabetic patients with foot ulcers: literature review. J Wound Ostomy Continence Nurs. 2005;32(6):368–77.
  1. Fejfarova V, Jirkovska A, Dragomirecka E, et al. Does the diabetic foot have a significant impact on selected psychological or social characteristics of patients with Diabetes mellitus? J Diab Res. 2014;2014:371938.