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12 Compression Therapy inUlcer Care
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Fig. 12.6 Compression pressure recording of an adjustable compression wrap device. Also, with this device
compression pressure increase by dorsiexions, standing
up, and walking is high overcoming the intravenous pressure (red line) and restoring a kind of valve mechanism.
The succession of small circles and ellipses represents
veins narrowing/occluding at every muscle contraction
When these options are not available, for different reasons (from lack of educated personnel
to lack of suitable materials), elastic kits may
offer an alternative effective solution, especially
in case of small ulcers of recent onset.
12.1.7 Ulcer Recurrence Prevention
VLUs may recur, and the recurrence rate may be
as high as 78% at 3 years [63]. Surgical correction
during physical exercise. DSI: Dynamic Stiffness Index is
the difference between diastolic pressure and systolic
pressure performing foot dorsiexions in supine position;
SSI: Static Stiffness Index is the difference between
standing and supine positions. WPA: Walking pressure
amplitude is the difference between systolic pressure and
diastolic pressure while walking
of supercial venous incompetence combined
with compression therapy was shown to prevent
ulcer recurrence more effectively than compression therapy alone with a signicant difference
[64, 65]. Compression therapy is anyway effective
in VLU recurrence prevention. Elastic stockings
are used in this indication with the highest tolerable compression [66]. Compliance with compression by elastic stockings must be taken into
consideration as it was shown to be even more
important than compression pressure [67].
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G. Mosti
Fig. 12.7 Compression pressure recording of an adjustable compression wrap device with an air bladder sewed
in the inner part and inatable at a preset pressure of
40–50mmHg. Also, with this device, compression pressure increase by dorsiexions, standing up, and walking is
high overcoming the intravenous pressure (red line) and
restoring a kind of valve mechanism. Notice that stiffness
indexes (SSI and DSI) are higher than with the standard
wrap (Fig.12.6) despite a lower compression at applica-
12.2 Special Circumstances
12.2.1 Compression Therapy
andMixed Leg Ulcers
An arterial impairment affects about 15–20% of
patients with venous leg ulcers [4, 68], causing a
delayed healing. Only a minority of these patients
are affected by critical limb ischemia that must
be considered an absolute contraindication for
compression therapy and represent a clear indication for surgical referral for the limb revascularization. In all other cases, when the patients suffer
from a moderate peripheral arterial disease, CT
tion. The succession of small circles and ellipses represent
veins narrowing/occluding at every muscle contraction
during physical exercise. DSI: Dynamic Stiffness Index is
the difference between diastolic pressure and systolic
pressure performing foot dorsiexions in supine position;
SSI: Static Stiffness Index is the difference between
standing and supine positions. WPA: Walking pressure
amplitude is the difference between systolic pressure and
diastolic pressure while walking
improves venous hemodynamics and arterial
inow even if it is still considered possibly harmful for arterial inow and still represents a contraindication for CT in many papers [69].
Actually, some data conrm that compression
therapy is possible in patients with mixed ulcers
and moderate arterial impairment dened by an
ankle-brachial pressure index <0.8 but >50 or
ankle perfusion pressure > 60 mmHg. In these
circumstances, it was shown that a reduced
compression pressure, not >40 mmHg, does not
impair toe pressure [70], exerts benecial effects
on arterial ow both in the peri-wound skin and
distally to the bandage [71] and is well tolerated
12 Compression Therapy inUlcer Care
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133
[72]. In addition, this modied reduced compression by inelastic material signicantly increases
venous ejection fraction [71] and may be considered as the basic treatment modality in managing
patients with mixed ulcers. In conclusion, several
papers support the effectiveness of increasing the
healing rate of mixed ulcers by a reduced compression therapy, mainly by inelastic material
[68, 70–75] but also by graduate [76] or progressive [77] elastic compression stockings.
12.2.2 Compression Therapy
inVasculitic Ulcers
Compression therapy is not only effective in
improving the impaired venous hemodynamics
and improving arterial inow. It is also effective
in improving microcirculation and signicantly
increasing blood cell velocity [78], which in general improves tissue perfusion (always benecial)
and, specically, could reduce circulating immunocomplex deposition another pathophysiologic
mechanism in vasculitic ulcers. Another very
important effect of compression therapy is the
reduction in inammatory mediators and the
increase in anti-inammatory mediators [79, 80].
These mediators have an important role in promoting the progression of the ulcer from the
inammatory to the granulation and reepithelization phase increasing the healing rate of
all leg ulcers including the vasculitic ulcers.
12.2.3 Elastic or Inelastic Bandages
inPatients withLeg Ulcers
andRestricted Mobility?
Many patients with leg ulcers are in the middle or
advanced age and may have some comorbidities.
These patients tend to remain in sitting position
for many hours during the day. An old dogma
reports that inelastic material would work only
during exercise resulting in ineffective in patients
with restricted or absent mobility. In case of completely immobile and bedridden patient, a simple
thromboprophylactic stocking exerting a pres-
sure of about 20mmHg is enough to occlude the
veins, but in case the patient is able to perform
some physical activity and sit in a chair, a higher
compression pressure is necessary to occlude the
veins: around 50 mmHg in the sitting position
and 70 mmHg in the standing position [51]. In
this case, only inelastic material is able to exert
this pressure without causing pain or any other
skin damage.
In conclusion, elastic compression, even with
a low pressure, is effective in completely immobile bedridden patients but when they are partially immobile and still maintain some mobility
they would need inelastic compression [81, 82].
12.2.4 Contraindications
toCompression Therapy
They are very few. Practically, we can say that the
only true contraindications to compression therapy are limited to severe arterial disease, the socalled critical limb ischemia, severe heart failure,
and severe diabetic neuropathy with sensory loss
or microangiopathy [83]. Critical limb ischemia
is characterized by severe pain at rest and acral
skin necrosis, ankle-brachial ankle pressure<0.5, and ankle pressure below 50mmHg.
Severe heart failure classied as class IV of the
NewYork Heart Association is characterized by
inability to carry on any physical activity without
discomfort and symptoms of heart failure at rest.
When any physical activity is undertaken, discomfort increases. Regarding diabetes, compression therapy is possible in diabetic patients
without clinically apparent sensory loss or microangiopathy. It was shown extremely effective in
improving microcirculation [84], promoting
VLU or mixed ulcers healing [85, 86], and in
treating leg edema [87]. The fourth important
contraindication is allergy to compression material. This contraindication is extremely rare as
compression materials and dyes have been tested
for ages and products that were shown to be allergenic are not anymore on the market. Anyway, it
can easily be solved by changing the compression product.
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G. Mosti
12.3 Conclusions
Compression therapy is extremely effective in
promoting ulcer healing and improving the quality of life in patients with venous leg ulcers.
There are convincing pieces of evidence that
inelastic is more effective than elastic material in
improving venous hemodynamics, which is
impaired in venous incompetence/obstruction.
As a consequence, inelastic compression
“should” be more effective than elastic compression in increasing the healing rate of ulcers whose
pathophysiology is a venous hemodynamic
impairment even if we miss consistent data.
Inelastic bandages are also very well tolerated as
they exert a relatively low and tolerable pressure
at rest and a much higher pressure in standing
position and during walking.
In order to achieve the best results compression therapy by inelastic bandages must be correctly applied and requires adequate education. It
should be applied with strong pressure in patients
with venous leg ulcers and with reduced pressure
in patients with mixed ulcers or when pathophysiology does not involve a venous disease. Using
ACW, it is possible to achieve similar results as
with inelastic bandages. Adjustable compression
wraps offer the advantage of being easy to use,
even by the patients themselves, but more extensive pieces of evidence on their effectiveness in
achieving high ulcer healing rate are necessary.
Inelastic bandages are indicated also in
patients with mixed ulcers provided they are
applied with reduced compression pressure and
in partially immobile patients.
Elastic stockings are effective in ulcer recurrence prevention, while elastic kits can be an
effective treatment modality in small ulcer of
recent onset.
Unfortunately, despite all the reported pieces
of evidence, compression therapy is largely underused even in Western countries, ranging from 15
to 53% of patients who would need it [88, 89].
Inelastic compression is even less used and generally poorly applied. A big effort in nding more
and more pieces of evidence and in increasing the
education of health providers seems to be
mandatory.
Conicts of Interest The author declares no conicts of
interest.
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Part III
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Instrumental Treatments in Wounds
Scientic Principles andClinical
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Application ofNegative Pressure
Wound Therapy (NPWT)
FrancoBassetto andScarpaCarlotta
13
Since ancient times, the “vacuum treatment” has
been widely used; indeed, there are multiple
pieces of evidence of its application [1–3]: rstly
with “wound suckers” who were people “dedicated” to sucking wounds in order to remove
infectious and necrotic tissue, and later, in
Chinese medicine, with the “hot cups” that were
used in order to stimulate vascularization and uids’ drainage, but it was not until the second half
of the last century when this kind of treatment
was studied and proposed for many pathologies
and in particular for acute and chronic wounds;
before exploring its mechanisms of action, we
have to consider a “recent” concept that has been
described in 1990s: the mechanobiology.
In 1997 [4], Donald Ingber described on
FASEB the so-called theory of “mechanobiology–
mechanotransduction,” a fundamental concept for
an adequate understanding of the functioning of
negative pressure therapy. This concept exposes
the possibility of driving cell fate, both in an apoptotic, proliferative, and differentiative sense, by
means of a tensile and/or mechanical stress.
Why is this concept so important to understand the abilities of the negative pressure
therapy?
F. Bassetto
University of Padova, Padua, Italy
e-mail: franco.bassetto@unipd.it
S. Carlotta (*)
University of Padova, Padova, Italy
e-mail: carlotta.scarpa@unipd.it
To answer this question, we must consider
that, in normal skin, cells are subjected to isometric tension due to the adherence between the cells
and the extracellular matrix; this tension is fundamental to provide cells’ proliferation [5–9]. In
chronic wounds, there is a loss of structural features and the cells lose their adherence becoming
round and consequently more prone to apoptosis.
If we consider this short description, it becomes
clear that the tension is fundamental for cells’
survival and proliferation, but how does negative
pressure work and what are the results?
13.1 The Mechanisms ofAction
Even if the rst clinical application has been
reported in 1979in Russia, it was only in 1997
when Argenta and Morykwas [3] used the term
VAC therapy describing a new technique called
vacuum- assisted closure, which was featured by
the application of an occlusive dressing, consisting of a polyurethane sponge, with open cells,
connected to a device capable of creating and
controlling a subatmospheric pressure equal to
−125mmHg. Since that rst description, many
studies have been carried out to verify not only
the mechanisms of action, but also the clinical
indications, the methods of pressure delivery
(whether intermittent or continuous), which
interfaces are most suitable and what could the
biological effects be.
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
M. Maruccia et al. (eds.), Pearls and Pitfalls in Skin Ulcer Management,
https://doi.org/10.1007/978-3-031-45453-0_13
141
142
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F. Bassetto and S. Carlotta
In the beginning, invitro and invivo studies
(animal models) have been carried out demonstrating that the negative pressure could stimulate
angiogenesis, but it is thanks to the studies that
followed in the rst decade of the 2000s and that
it is currently possible to identify the main mechanisms of action of VAC therapy with the processes of macro- and microdeformation both of
the cells and the wound bed [8, 9].
Consequent to the suction effect exerted by
the device (mechanically or with the aid of a battery/power supply), which causes the polyurethane sponge interface to collapse, these
processes stimulate the wound bed macro- and
micromechanically.
Specically, macromechanical stimulation
allows for the contraction of the edges of the
lesion with consequent reduction in the wound
area; otherwise, the micromechanical stimulation,
having a microscopic effect on the wound bed,
through the application of tensile, compression,
shear, and hydrostatic forces, allows to [10–20]:
1. “Activate the cytoskeleton” with the initia-
tion of the cell proliferation and migration
phase.
2. Recall interstitial uids and reduce hydrostatic and osmotic pressure and consequently
the amount of exudate and edema.
3. Stabilize the microenvironment with the
removal of inammatory mediators, including
matrix metalloproteases (MMPs) 2 and 9,
often responsible, when overproduced, for the
chronicization of the wound itself.
It has also been demonstrated that the vacuum
effect caused by negative pressure also locally
causes hypoxia with activation and increase in vascular endothelial growth factor (VEGF) and subsequently neoangiogenesis increasing both
microvessel density and lymphatic drainage
[18–22]. These last mechanisms induce better tissue
perfusion and oxygenation of the area also increasing the preparation of the wound bed and the formation of active granulation tissue (Fig.13.1).
There are other mechanisms that have been
reported in the last few years. It was reported
indeed that the microdeformation effect can also
enhance local neurogenesis-stimulating nerve
growth factor [17]; furthermore, hypoxia not
only stimulates cell proliferation of broblasts
and keratinocytes, but it can also increase the
ab
Fig. 13.1 Knee ulcer at high risk of joint prosthesis exposition. (a) Pretreatment and (b) good granulation issue after
21days of negative pressure wound therapy
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