Leg Ulcers

Recommendations

Identify and Treat the Cause
1 Take a careful history (venous/ arterial characteristics, other diagnoses, infection, medication, coexisting diseases, factors that may impair wound healing) Level of Evidence
5
2 Perform a bilateral lower leg physical assessment including an ankle-brachial pressure index (ABPI). Level of Evidence
1a
3 Determine the cause(s) and for possible chronic venous insufficiency based on etiology: abnormal valves (reflux), obstruction, or calf-muscle-pump failure. Level of Evidence
5
4 Treat the cause and implement appropriate compression therapy for venous disease in the absence of arterial predominant disease. Level of Evidence
1a
5 Implement appropriate medical therapy. Level of Evidence
5
6 Consider surgical management (for venous (if significant superficial or perforator vein disease exists in the absence of deep venous disease) or arterial disease (bypass, dilation, or stent). Level of Evidence
Not Assessed
7 For nonhealable or maintenance wounds, provide support, pain control and modified local care (conservative debridement, bacterial and moisture reduction) Level of Evidence
1a


Address patient-centered Concerns
8 Communicate (patients, family, caregivers) to establish a social support system with realistic expectations for healing and to prevent leg ulcer recurrences. Level of Evidence
5
9 Assess / Control pain and optimize activities of daily living Level of Evidence
Not Assessed


Provide Local Wound Care
10 Assess and document the wound at regular intervals. Level of Evidence
Not Assessed
11 Optimize local wound care: debridement, inflammation / infection control, and moisture balance. Consider biopsy of appropriate active (including biologicals) & adjunctive therapies if the wound is not healing at the expected rate. Level of Evidence
1a


Provide Organizational Support
12 Consult appropriate disciplines to maximize healing (e.g. mobility and nutrition). Level of Evidence
1a


Background

Leg ulcers are common in the population in general. The differential diagnoses and frequencies of various types of leg ulcers vary with the population studied. Vascular pathology is associated with the majority of leg ulcers. Almost 70% of leg ulcers have a venous etiology; approximately 20–25% are due to arterial insufficiency; and some of these have a mixed vascular etiology. The remaining leg ulcers have a variety of less common causes, including infection, malignancy, vasculitis and other conditions. The Canadian Medical Advisory Secretariat reported the prevalence of leg ulcers to be 0.12 – 0.32% of the general population. Other reports indicate a prevalence of 1–2% of adults. The prevalence of leg ulcers increases with age, with most patients at least 65 years of age. Comorbidities are common in this population, and many leg ulcer patients having multiple health problems.

Venous leg ulcers result from venous hypertension due to valve dysfunction, venous obstruction, and/or failure of calf muscle pump function. They often take a prolonged time to heal, frequently months to more than a year, and they commonly recur. Prevention of recurrence is based on definitive surgery or the lifelong use of compression or support stockings. Patients with venous leg ulcers experience increased stress, pain; they may have difficulty coping due to decreased mobility, sleep and social interaction.

Arterial leg ulcers, which are due to arterial insufficiency, are seen most commonly in the elderly, among people with diabetes and in smokers. Inadequate perfusion perpetuates these ulcers; they generally do not heal in the absence of revascularization. As arterial disease is progressive, and sometimes rapidly progressive, early diagnosis and definitive management are necessary to prevent further tissue loss. A bilateral lower leg physical assessment that includes ankle-brachial pressure index (ABPI) measurement helps to determine ulcer cause.

Clearly, complex clinical management challenges can be expected in treating the population with leg ulcers. Leg ulcers are associated with both a significant quality-of-life impact for patients and their families and a substantial economic impact for the healthcare system.

Costs associated with managing leg ulcers are high. A Canadian 4-week costing study estimated the annual nursing costs of managing leg ulcers in 192 patients at approximately $1 million and wound-care supplies at $260,000. Evidence-based care strategies have the potential to reduce these costs by increasing healing. A community-based study found that implementing an evidence-based protocol for leg ulcer management had the following impact, comparing the year before and the year after implementation:
• 3-month healing rates increased from 23% to 56%
• Decrease in median nursing visits per case from 37 to 25
• Decrease in median supply cost ($CDN) per case from $1923 to $406

An aging population will only increase the importance of effective management of leg ulcers. Broader knowledge and implementation of evidence-based strategies for management of leg ulcers can reduce both the economic and personal impact of this significant health problem.

A systematic literature search for clinical practice guidelines on leg ulcer prevention and treatment was completed using the Medline, CINAHL, and Embase databases and 46 guideline clearinghouses. A librarian was involved in identifying the appropriate keywords and search strategies to ensure that all guidelines on the topic were found.

31 leg ulcer prevention and treatment clinical practice guidelines were found in the English literature from 2002 until May 2007. 19 (61.3%) of these published articles were excluded because they were: not specifically addressing leg ulcers (11), supplemental documents of a guideline (3), research studies or studies that were appraisals of the implementation of the guidelines (3), evaluations of guidelines (1) and evaluations of the health care system in general (1).

Of the identified papers, 12 guidelines were appraised by a minimum of three reviewers using the AGREE instrument (http://www.agreecollaboration.org/instrument/). The AGREE instrument has six domains: scope and purpose, stakeholder involvement, rigour of development, clarity and presentation, applicability, and editorial independence. It is not recommended that the scores obtained for the domains be aggregated. Instead the guidelines that received the highest scores for most of the domains and particularly for rigour of development were ranked highest and their recommendations will be reported throughout this diabetic foot ulcer stream.

The most highly ranked guidelines were developed by the Registered Nurses Association of Ontario (RNAO) on assessment and management of leg ulcers (2004); a guideline by Graham et al on adapting national and international leg ulcer practice guidelines for local use (2005); a New Zealand guideline for people with chronic leg ulcers (1999); one by the Wound Ostomy Continence Nurses (WOCN) on the management of wounds in patients with lower-extremity venous disease (2005); one by Association for the Advancement of Wound Care (AAWC) that provides an algorithm for venous ulcer care with annotations of available evidence (2005).

The following figure indicates the AGREE domain scores for these leg ulcer guidelines.



The following recommendations are intended to help busy clinicians provide excellent care. They are based on the high ranking guidelines that are referenced.

References

High Ranking Guidelines
1 Assessment and management of venous leg ulcers Quality Indicator
 Type: CPG (Clinical Practice Guideline)
Registered Nurses Association of Ontario (RNAO). Assessment and management of venous leg ulcers. Toronto (ON): Registered Nurses Association of Ontario (RNAO); 2004 Mar. 115 p.
This is a very well-developed clinical practice guideline that provides clear and succinct recommendations for clinical practice and indicates their supporting evidence. Although this guideline was developed for nurses, its recommendations would be useful to clinicians from other disciplines, e.g., family physicians, physical and occupational therapists, dietitians.
2 Adapting guidelines for local use Quality Indicator
 Type: CPG (Clinical Practice Guideline)
Graham ID, Harrison MB, Lorimer K, Piercianowski T, Friedberg E, Buchanan M, Harris C. Adapting national and international leg ulcer practice guidelines for local use: the Ontario Leg Ulcer Community Care Protocol. Adv Skin Wound Care. 2005 Jul-Aug;18(6):307-18. Review.
This guideline is the result of an adaptation of existing guidelines that employed rigorous methods. The article provides a Protocol Reference Guide (Figure 2) that indicates the levels of evidence for the various recommendations and would be useful to clinicians in community care.
3 General leg ulcer guideline Quality Indicator
 Type: CPG (Clinical Practice Guideline)
Care of People with Chronic Leg Ulcers: An evidence based guideline. New Zealand Guideline Group: December 1999.
This guideline was published nearly 10 years ago but it is still relevant. The information about infection is basic and other sources could be explored. The recommendations are very specific and detailed, and could be implemented easily using the application tools. The presentation style is easy to follow.
4 Management of venous leg ulcers Quality Indicator
 Type: CPG (Clinical Practice Guideline)
Wound, Ostomy, and Continence Nurses Society (WOCN). Guideline for management of wounds in patients with lower-extremity venous disease. Glenview (IL): Wound, Ostomy, and Continence Nurses Society (WOCN); 2005. 42 p. (WOCN clinical practice guideline; no. 4).
This is a recent guideline for which the search strategy for evidence was very thorough.
5 Algorithm for venous ulcer care Quality Indicator
 Type: CPG (Clinical Practice Guideline)
Association for the Advancement of Wound Care (AAWC). Summary algorithm for venous ulcer care with annotations of available evidence. Malvern (PA): Association for the Advancement of Wound Care (AAWC); 2005. 25 p.
This is a recent guidline with the recommendations laid out in an organized manner so it is easy to follow.


Enablers for practice

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