Welcome to NGC. Skip directly to: Search Box, Navigation, Content.


Brief Summary

GUIDELINE TITLE

Chronic wounds of the lower extremity.

BIBLIOGRAPHIC SOURCE(S)

  • American Society of Plastic Surgeons. Evidence-based clinical practice guideline: chronic wounds of the lower extremity. Arlington Heights (IL): American Society of Plastic Surgeons; 2007 May. 21 p. [132 references]

GUIDELINE STATUS

This is the current release of the guideline.

** REGULATORY ALERT **

FDA WARNING/REGULATORY ALERT

Note from the National Guideline Clearinghouse (NGC): This guideline references a drug(s) for which important revised regulatory and/or warning information has been released.

BRIEF SUMMARY CONTENT

 ** REGULATORY ALERT **
 RECOMMENDATIONS
 EVIDENCE SUPPORTING THE RECOMMENDATIONS
 IDENTIFYING INFORMATION AND AVAILABILITY
 DISCLAIMER

 Go to the Complete Summary

RECOMMENDATIONS

MAJOR RECOMMENDATIONS

Definitions for the levels of evidence for diagnostic, prognostic, and therapeutic studies (I–V) and the strength of the recommendations (A–D) are provided at the end of the "Major Recommendations" field.

Recommendations for Patient Assessment Supporting Evidence Grade
General

Medical History:
  • Assess comorbidities, medications, allergies, and family history
Physical exam:
  • Assess cardiovascular status (pulse, blood pressure)
  • Perform focused examination of the legs
Expert Opinion D
Venous Insufficiency
Historical findings suggestive of venous insufficiency include:
  • Prior history of thrombophlebitis, venous thromboembolism, and/or deep vein thrombosis
  • History of symptomatic varicosities during pregnancy
  • Surgical history of lower extremity trauma, vascular injury or previous varicose vein surgery
  • Hypercoagulable states (e.g., cancer, infection, Factor VIII excess)
(Baker et al., 1991; Berard et al., 2002; Blomgren et al., 2001; Labropoulos et al., "Patterns," 2007; Fink et al., 2002; Dajani et al., 1988) B
Physical findings suggestive of venous insufficiency include:
  • Edema
  • Wound presentation as shallow ulcer in the lower third of leg
  • Venous dermatitis
  • Lipodermatosclerosis
  • Varicose veins
(Blomgren et al., 2001; Labropoulos et al., "Patterns," 2007; Wong, Duncan, & Nichols, 2003) B
Diagnostic Tests:
  • Doppler ultrasonography
  • Duplex scanner plethysmography and venography
(Shami et al., 1993; Alguire & Mathes,1997; Wong, Duncan, & Nichols, 2003; Baxter & Polak, 1993) B
Determine severity of venous insufficiency Expert Opinion D
Arterial Occlusive Disease
Assess for a history of arterial occlusive disease:
  • Arterial peripheral vascular disease
  • Ischemic complaints
  • Rest pain
(Wipke-Tevis et al., 2000; Dormandy & Murray, 1991; Jelnes et al., 1986; Criqui et al., 1985; Marston et al., 2006; Hiatt, Hoag, & Hamman, 1995; Khan et al., 2006; Wang et al., 2005; Henke et al., 2005) B
Assess for factors suggestive of arterial compromise:
  • Cold, pale feet (in warm environment)
  • Shiny, taut skin
  • Dependent rubor
  • Punched out appearance of ulcer
(Khan et al., 2006) B
Diagnostic Tests:
  • Ankle brachial index (ABI)
  • If <0.8, referral to specialist may be necessary to assess for arterial occlusive disease
(Baxter & Polak, 1993; Dormandy & Murray, 1991; Jelnes et al., 1986; Stoffers et al., 1997; Marston et al., 2006; Hiatt, Hoag, & Hamman, 1995; Khan et al., 2006; de Vries et al., 2006; Ouwendijk et al., 2005) B
Determine severity of arterial occlusive disease:
  • ABI 0.6 to 0.8, suggestive of peripheral arterial occlusive disease
  • ABI <0.5, suggestive of critical ischemia
  • ABI >1.2, suggestive of calcification and noncompressibility of arterial wall
  • Consider vascular intervention or reconstruction
  • Contrast arteriography (or magnetic resonance angiography)
  • Refer to vascular specialist, if needed
(Marston et al., 2006; O'Meara et al., 2000) B
Diabetes
  • Assess for comorbidities (microangiopathy, neuropathy, impaired immune response)
  • Assess for sensory derangement (e.g., Semmes-Weinstein)
(Marston et al., 2006; Hiatt et al., 1995; Pham et al., 2000; Abbott et al., 1998; Yasuhara et al., 2002) B
History and Characteristics of the Wound
Document history of the wound:
  • Date and site(s) current ulceration began
  • Date and site(s) of previous ulcers
  • Prior duration to heal
  • Length of prior disease-free interval(s)
  • Prior treatments
  • Past surgical history of venous operation
  • Use of compression garments
Expert Opinion D
Document characteristics of the wound:
  • Size
  • Nature of wound base tissue
  • Amount of drainage
(Marston et al., 2006; O'Meara et al., 2000) B
Evaluate wound for evidence of infection
  • Necrotic tissue
  • Purulent drainage
  • Odor
  • Induration
  • Cellulitis
(Cutting, 1998; Gardner et al., 2001) B
For atypical and/or recalcitrant wounds, rule out other, less common causes of ulceration (biopsy may be necessary)
  • Rheumatoid arthritis
  • Sickle cell disease
  • Pyogenic gangrenosum
  • Tumors (squamous cell and basal cell carcinomas)
(Labropoulos et al., "Uncommon leg ulcers," 2007) B
Additional Considerations:
Assess for confounding factors:
  • Impaired tissue perfusion (heart disease, obesity)
  • Tissue hypoxia
  • Metabolic disturbances (diabetes, nephropathy)
  • Impaired healing
  • Immunosuppression
  • Tobacco use
  • Infection (systemic and local)
  • Nutrition and overall state of health
(Wipke-Tevis et al., 2000; Jelnes et al., 1986; Khan et al., 2006; O'Meara et al., 2000) B
Assess and document allergies (Saap et al., 2004; Lim et al., 2007; Tavadia et al., 2003; Machet et al., 2004) B
Assess for the presence of osteomyelitis:
  • Bone exposed (or easily probed)
  • Tissue necrosis overlying bone
  • Gangrene
  • Persistent sinus tract
  • Underlying open fracture
  • Underlying internal fixation
  • Wound recurrence
Osteomyelitis evaluation:
  • Radiographic studies (plain radiographs, nuclear bone scan and/or magnetic resonance imaging)
  • If radiographic findings suggestive osteomyelitis, consider histologic evaluation and bone biopsy culture
(Shih, Shih, & Wong, 2005; Senneville et al., 2006) B
Determine the presence of remote site or systemic infection (septicemia, endocarditis, prosthesis infection):

Anatomic risk factors include:
  • Prosthetic heart valve
  • Acquired cardiac valvular dysfunction
  • Cardiac malformation
  • Hypertrophic cardiomyopathy
  • Orthopedic prosthesis
  • Central nervous system (CNS) shunts
  • Nearby arteriovenous fistula
(El-Ahdab et al., 2005) B
Comorbid risk factors:
  • History of bacterial endocarditis
  • Immune compromised or suppressed host
  • Colonization, multi-drug resistant organisms
(El-Ahdab et al., 2005) B
Pain, Functional Status, and Quality of Life
  • Assess pain level (Visual Analog Scale)
  • Validated questionnaires can assess functional status and quality of life
Expert Opinion D

 

Recommendations for Treatment Supporting Evidence Grade
Debridement:
  • Excise all necrotic, infected, and poorly vascularized soft tissue
  • May be necessary to perform serially
  • Contraindicated in cases of gangrene or stable, dry, ischemic wound (evaluation of vascular status needed)
  • Sharp debridement not recommended if vasculitis or pyoderma gangrenosum is suspected
  • Following debridement, consider irrigation with saline
  • If tissue is suspect for malignancy, perform biopsy and submit for histopathologic analysis
(Thow & Smith, 2003; Smith, 2002; Granick et al., 2007) B
Pressure Relief
  • Implement established repositioning schedule
  • Head of the bed should be maintained at lowest possible level consistent with medical condition
  • Use pressure-reducing devices
(Duby et al., 1993; Cullum et al., 2001; Cullum et al., 2004) B
Infection Control
  • Determine presence of invasive pathogens (culture and susceptibility testing of deep tissue sample; clinical presentation of induration, erythema, warmth, suppuration, and pain or tenderness)
  • If infection is confirmed or highly suspect, prescribe appropriate antimicrobial intervention (oral cephalosporins, amoxicillin-clavulanic acid, macrolides, anti-staphylococcal penicillins, and fluoroquinolones can be used; however, no evidence supports superiority of one over the others)
  • When determining the need for antibiotic treatment, consider risk of antibiotic resistance
  • For mild to moderate infections, consider surgical debridement and narrow-spectrum antibacterials
  • Wound infections that are severe and/or complicated by critical limb ischemia often necessitate hospitalization, parenteral broad-spectrum antibiosis, and surgical intervention
(Gentry et al., 1989; White, Cutting, & Kingsley, 2006; Nelson et al., 2006; Vermeulen et al., 2005; O'Meara et al., 2000; Vermeulen et al., 2007) B
Management of Exudate
  • Maintain moist environment
  • Remove soluble factors detrimental to wound healing
  • Use appropriate dressings (available evidence shows no superiority in dressing materials)
  • Consider classic dressings (gauze, foam, hydrocolloid, hydrogels)
  • Consider bioactive dressings (topical antimicrobials, bioengineered composite skin equivalent, bilaminar dermal regeneration template, recombinant human growth factor)
(Embil et al., 2000; Vermeulen et al., 2005; O'Meara et al., 2000; Vermeulen et al., 2007; Bergin & Wraight, 2006; Jones & Nelson, 2007) B

 

Recommendations for Management of Complications Supporting Evidence Grade
Osteomyelitis
  • Consider aggressive resection of infected bone
  • Implement culture-directed antibiotic therapy
  • Use well-perfused tissue (typically muscle) for coverage
(Henke et al., 2005; Bach et al., 2007; Eren, Ghofrani, & Reifenrath, 2001; Embil et al., 2006; Freeman et al., 2007) B
Antibiotic Prophylaxis
  • Routine use of systemic antimicrobials not recommended for prevention of osteomyelitis, bacterial endocarditis, or prosthesis infection
  • Endocarditis prophylaxis is indicated for high risk patients undergoing dermatologic procedures on visibly inflamed or infected wounds
(Henke et al., 2005) B

 

Recommendations for Follow-up Supporting Evidence Grade
Patient with Chronic Wounds:
  • Perform follow-up every month during wound healing
  • Assess for systemic infection
  • Assess pain, discuss pain reduction methods, and adjust pain medication accordingly
Expert Opinion D
Patients with Venous Insufficiency:
  • During wound healing, weekly follow-up may be necessary
  • After wound healing, follow-up can be performed every 3 to 6 months, depending on patient, comorbidities, and patient's ability for self care
  • Patients with worsening symptoms may require more aggressive follow-up regimen
  • Perform physical exam of lower extremities (note changes in condition, skin color, temperature, tone, and hair, and presence of swelling; note new areas of skin breakdown or maceration)
  • Order additional diagnostic studies (venous duplex, venography) as indicated
(Baker et al., 1991; Berard et al., 2002; Blomgren et al., 2001) B
Patients with Peripheral Arterial Disease:
  • Assess activity level, pain, changes in skin temperature and color; inspect skin, pulses and capillary refill of the toes
  • Obtain ABI, which may indicate angiography
  • If necessary, refer to vascular surgeon or interventional radiologist
(Stoffers et al., 1997; Stein et al., 2006) B
Patients with Diabetes:
  • Physical exam should include assessment of comorbidities (presence of bone infections, peripheral vascular disease, neuropathy, and multiple recurrences)
  • Evaluate patient's blood sugars, diet, and exercise
  • Assess skin for pressure points, ischemic changes, and skin maceration
  • Check prosthetics or shoes for abnormal wear
  • Assess for peripheral vascular disease (ABI <0.08)
  • Assess for osteomyelitis
  • Order laboratory studies (glycated hemoglobin [HbA1c], fasting glucose, lipid profile)
  • If patients have increase risk for or have diabetic neuropathy, assess for friction or pressure injuries
  • Patients with diabetic neuropathy should be seen every 3 months for assessment of skin trauma and early breakdown
  • Assess for chronic pain and consider referral to pain specialist
(Dormandy & Murray, 1991; Jelnes et al., 1986; Pham et al., 2000; Dolan et al., 2002) B
Patients with History of Osteomyelitis:
  • Perform follow-up every month during wound healing
  • Perform follow-up every 3-6 months to evaluate for recurrence of osteomyelitis
  • Evaluate lower extremities to determine need for further tests
  • Consider laboratory studies (erythrocyte sedimentation rate [ESR], C-reactive protein [CRP])
  • Consider x-rays, magnetic resonance imaging (MRI), or bone scans, depending on symptoms
Expert Opinion D

 

Recommendations for Prevention of Recurrence Supporting Evidence Grade
Patient Education:
  • Long-term nature of condition
  • Signs/symptoms of recurrence
  • Skin care (soaps, moisturizers, protective measures)
Expert Opinion D
Therapeutic Modalities:
  • For patients with venous hypertension or risk for venous insufficiency, consider Graduated Compression Stockings
  • For patients with wounds in pressure point areas, consider off-loading devices, pressure dispersing surfaces
  • For patients with wounds secondary to abnormal sensitivity or mobility, consider repositioning and support surfaces
(Duby et al., 1993; Cullum et al., 2001; Cullum et al., 2004; Cullum et al., "Compression for venous leg ulcers," 2000; Nelson, Bell-Syer, & Cullum, 2000; Cullum et al., "Compression bandages," 2000; Ibegbuna et al., 2003; Zajkowski et al., 2002) B
Exercise Programs Improve:
  • Patient mobility
  • Joint movement
Expert Opinion D

Definitions:

Scale for Grading Recommendations

Grade Descriptor Qualifying Evidence Implications for Practice
A Strong Recommendation Level I evidence or consistent findings from multiple studies of levels II, III, or IV Clinicians should follow a strong recommendation unless a clear and compelling rationale for an alternative approach is present.
B Recommendation Levels II, III, or IV evidence and findings are generally consistent Generally, clinicians should follow a recommendation but should remain alert to new information and sensitive to patient preference.
C Option Levels II, III, or IV evidence, but findings are inconsistent Clinicians should be flexible in their decision-making regarding appropriate practice, although they may set bounds on alternatives; patient preference should have a substantial influencing role.
D Option Level V; little or no systematic empirical evidence Clinicians should consider all options in their decision-making and be alert to new published evidence that clarifies the balance of benefit versus harm; patient preference should have a substantial influencing role.

Evidence Rating Scale for Diagnostic Studies

Level of Evidence Qualifying Studies
I High-quality, multi-centered or single-centered, cohort study validating a diagnostic test (with "gold" standard as reference) in a series of consecutive patients; or a systematic review of these studies
II Exploratory cohort study developing diagnostic criteria (with "gold" standard as reference) in a series of consecutive patients; or a systematic review of these studies
III Diagnostic study in nonconsecutive patients (without consistently applied "gold" standard as reference); or a systematic review of these studies
IV Case-control study; or any of the above diagnostic studies in the absence of a universally accepted "gold" standard
V Expert opinion; case report or clinical example; or evidence based on physiology, bench research, or "first principles"

Evidence Rating Scale for Prognostic Studies

Level of Evidence Qualifying Studies
I High-quality, multi-centered or single-centered, prospective cohort study with adequate power; or a systematic review of these studies
II Lesser-quality prospective cohort study; retrospective study; untreated controls from a randomized controlled trial; or a systematic review of these studies
III Case-control study; or a systematic review of these studies
IV Case series
V Expert opinion; case report or clinical example; or evidence based on physiology, bench research, or "first principles"

Evidence Rating Scale for Therapeutic Studies

Level of Evidence Qualifying Studies
I High-quality, multi-centered or single-centered, randomized controlled trial with adequate power; or a systematic review of these studies
II Lesser-quality, randomized controlled trial; prospective cohort study; or a systematic review of these studies
III Retrospective comparative study; case-control study; or a systematic review of these studies
IV Case series
V Expert opinion; case report or clinical example; or evidence based on physiology, bench research, or "first principles"

CLINICAL ALGORITHM(S)

None provided

EVIDENCE SUPPORTING THE RECOMMENDATIONS

REFERENCES SUPPORTING THE RECOMMENDATIONS

TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is identified and graded for each recommendation.

IDENTIFYING INFORMATION AND AVAILABILITY

BIBLIOGRAPHIC SOURCE(S)

  • American Society of Plastic Surgeons. Evidence-based clinical practice guideline: chronic wounds of the lower extremity. Arlington Heights (IL): American Society of Plastic Surgeons; 2007 May. 21 p. [132 references]

ADAPTATION

Not applicable: The guideline was not adapted from another source.

DATE RELEASED

2007 May

GUIDELINE DEVELOPER(S)

American Society of Plastic Surgeons - Medical Specialty Society

SOURCE(S) OF FUNDING

American Society of Plastic Surgeons

GUIDELINE COMMITTEE

Health Policy Committee of the American Society of Plastic Surgeons

COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

Not stated

FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

GUIDELINE STATUS

This is the current release of the guideline.

GUIDELINE AVAILABILITY

Electronic copies: Available in Portable Document Format (PDF) from the American Society of Plastic Surgeons Web site.

Print copies: Available from the American Society of Plastic Surgeons, 444 East Algonquin Road, Arlington Heights, IL 6005-4664

AVAILABILITY OF COMPANION DOCUMENTS

PATIENT RESOURCES

None available

NGC STATUS

This NGC summary was completed by ECRI Institute on October 15, 2007. The information was verified by the guideline developer on October 23, 2007. This summary was updated by ECRI Institute on July 28, 2008 following the U.S. Food and Drug Administration advisory on fluoroquinolone antimicrobial drugs.

COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.

DISCLAIMER

NGC DISCLAIMER

The National Guideline Clearinghouse™ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site.

All guidelines summarized by NGC and hosted on our site are produced under the auspices of medical specialty societies, relevant professional associations, public or private organizations, other government agencies, health care organizations or plans, and similar entities.

Guidelines represented on the NGC Web site are submitted by guideline developers, and are screened solely to determine that they meet the NGC Inclusion Criteria which may be found at http://www.guideline.gov/about/inclusion.aspx .

NGC, AHRQ, and its contractor ECRI Institute make no warranties concerning the content or clinical efficacy or effectiveness of the clinical practice guidelines and related materials represented on this site. Moreover, the views and opinions of developers or authors of guidelines represented on this site do not necessarily state or reflect those of NGC, AHRQ, or its contractor ECRI Institute, and inclusion or hosting of guidelines in NGC may not be used for advertising or commercial endorsement purposes.

Readers with questions regarding guideline content are directed to contact the guideline developer.


 

 

   
DHHS Logo