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258 J. P. Hong and A. Datli
or not weighing against clinical situations with systemic sepsis, major tissue loss,
significant comorbid factors, poor patient compliance, and nonreconstructable
peripheral vascular disease. A non-healing ulcer itself should not be considered an
indication for amputation but be systemically approached by various disciplines of
medicine (Apelqvist 1998; Cavanagh et al. 1998). Majority of reconstruction that
needs microsurgical reconstruction are complex defects from diabetic foot, unstable
scars, radiation ulcers, and chronic osteomyelitis as shown in Table 1.
The biggest advantage of using a flap to cover the wound is providing a well
vascularized tissue over the defect. This provides the most resembling tissue after
healing and allows to have better function and aesthetic outcome. Most of all, the
tissue provides an adequate surface reducing the risk for recurrence especially for
the foot region or wounds over the hard bone. Also compared to other modalities
for healing such as NPWT or other conservative care, using flaps for reconstruction
allows a faster healing process minimizing the time needed for care. One must be
prudent in deciding which approach is adequate for each wound. Most likely,
wounds that are deep, complex and large can be considered for flap reconstruction
as mentioned before in this chapter.
General success rate for these patients were same for other chronic wounds
whereas the diabetic foot had slightly lower success rate. However, limb salvage
from diabetic foot using microsurgical approach showed success comparable to
non-diabetic patients (Fitzgerald O’Connor et al. 2011; Hong 2006; Colen 1987;
Searles and Colen 1991; Shenaq and Dinh 1989; Oishi et al. 1993). Meta-analysis
of a systematic review of free tissue transfer in 528 diabetes patients in 18 studies
showed that flap survival was 92% and limb salvage rate of 83.4% over a
28 months average follow-up period. This study indicates that free tissue transfer in
the management of non-traumatic lower extremity wounds in patients with diabetes
may avoid amputations (Fitzgerald O'Connor et al. 2011). In our previous study, we
showed similar findings using microsurgery which achieved an overall flap survival
rate of 91.7%, limb salvage rate of 84.9% and 5-year-survival of 86.8% (Oh et al.
2013). Now with the introduction of supermicrosurgery, we are able to use small
vessels to perform recons truction even on the patients with poor vascular status. In
our recent publication of 95 cases which used the supermicrosurgery approach, we
noted 9 total loss and 12 cases of minor complication (Suh et al. 2016b). Thirty-four
patients had one or less major artery after intervention but only had 4 cases of total
failure. The lack of major vessels was not a significant risk for failure thus supporting our approach of using collateral vessels for recipients. Overall in this series,
flap survival rate was 90.5% and overall limb salvage rate was 93.7% (Suh et al.
2016b). This approach extends the possibility for reconstruction in patients with
severe ischemic diabetic foot.
In chronic osteomyelitis, our experience of microsurgical reconstruction using
perforator flaps showed a flap survival of 95.8% (Hong et al. 2017). The treatment
has similar principles that requires aggressive surgical debridement removing all
fibrotic and ischemic bone and soft tissue surrounding the wound that impedes
antibiotic delivery followed by de finitive reconstruction with the objective of
restoring ambulatory function (Attinger and Bulan 2001). In the last 3 decades,
Surgical Flaps in Wound Healing—An Update on Evidence-Based Management 259
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major surgical advancements to provide vascularized coverage to infected bone had
brought recurrence rates in chronic osteomyelitis down from 30% to10-15%
(Shannon et al. 1973; Anthony et al. 1991). Reconstruction can be complex
applying combine flaps to obliterate the dead space, reconstruct the bone defect and
resurface the skin defect. With multidisciplinary approach using proper antibiotics
and surgical approach, the recurrence rate after reconstruction was 8.3%, the primary remission rate was 91.6%, the secondary remission rate was 98.3%, and the
amputation rate was 1% in our series (Hong et al. 2017). Significant predictors of
recurrence were peripheral vascular disease and major vessel compromise, which
had 5.1 times higher odds of recurrence (Hong et al. 2017).
Unstable scars frequently go through a wax and wane progress of healing for
ulcers. It may also cause severe contracture as the scars mature during healing. It
hinders the daily activities of the patient as epithelialization can easily breakdown
despite minimal stimuli. This occurs due to the lack of padding and durability of
normal cutaneous structure. In cases of severe contracture, there is an absolute lack
of normal skin after release. When there is extensive defect after removal of
unstable scar, microsurgical reconstruct ion is required. The principle of aggressive
debridement followed by definitive surgery is applied and this problem can be
overcome. The same can be said for radiation induced scars. The outcome may be
similar to any nondiabetic microsurgical reconstruction.
Conclusion
Along with multidisciplinary approach and good principle of wounds care, the
repair and restoration strategies using flaps and microsurgery has widened the
possibilities for limb salvage from complex acute and chronic wounds.
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Wound Measurement is an Essential
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Part of Wound Management
Valentina Dini, Giammarco Granieri, Alessandra Michelucci,
and Marco Romanelli
Abstract
Wound assessment is an essential part of wound management to significantly
increase the quality of the pathway for patients with ulcerative diseases.
Nowadays, these pathologies are still an important comorbidity afflicting the
whole world in relevant epidemiological rates. Our lives are increasingly driven
by technology. In this chapter we have reviewed the most promising imaging
methods to improve the prognosis of wounds as well as the long-term quality of
life of these patients. Our intent is to provide a comprehensive overview of new
technologies and their potential and established use in wound care.
Keywords
Skin AssessmentWound size analysisHyperspectral imaging (HSI)Laser
doppler imaging (LDI)
spectroscopy (NIRS)
tomography (OCT)
(US)
(UHFUS)
V. Dini G. Granieri A. Michelucci M. Romanelli (&)
Department of Dermatology, University of Pisa, Via Roma, 67, 56126 Pisa, Italy
e-mail: m.romanelli@med.unipi.it
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
R. Mani (ed.), Chronic Wound Management,
https://doi.org/10.1007/978-3-031-26110-7_13
High frequency ultrasound (HFUS)Ultra high frequency ultrasound
Fluorescence imagingConfocal microscopyUltrasound
Laser speckle imaging (LSI)Near-infrared
ThermographyVideomicroscopyOptical coherence
263
264 V. Dini et al.
Introduction
Imaging instruments have revolutionized the history of medicine from the optical
microscope to modern methods we are able to study the human organism by
exploiting waves and sound, electromagnetic with good submillim etre definition.
Particularly in the medical field, non-invasive imaging methods are gaining popularity because of their versatility and patient safety features. Our lives are driven
by technology but nowadays, chronic diabetic foot (DF) ulcers, venous ulcers,
pressure ulcers (PUs), ischemic ulcers, and other atypical lower-extremity wounds
continue to be major therapeutic challenges.
For some time now, many imaging methods developed in other fields of medicine have taken root in dermatology and thanks to the development of modern
software are limited not only to the correct follow-up of the lesions but also provide
prognostic and therapeutic indications with increasing accuracy. An effective and
accurate monitoring of skin lesions should be performed by measuring in an
objective, precise, and reproducible way the complete status and evolution of the
wound (Romanelli et al. 2007).
Some of these systems may in the future be equipped with artificial intelligence
software and smartphone capability so that they could better guide physicians and
nurses in the correct management of patients affected by ulcers (Li et al. 2020).
By increasing the use of imaging methods that allow quantitative analysis, it will
be possible to conduct more accurate and standardized studies to guide wound care
research.
Even in wound care, imaging has made great strides since the first outlines of
wounds were drawn by hand on sheets of acetate. The latest developed technologies
can also allow for the prediction of the probability of ulcer occurrence. Exploring
wounds not only at visible light but also at invisible wavelengths to the human eye,
we are allowed to investigate bacterial species sited in lesions, invisible otherwise
(Janowska et al. 2021).
To date, research is increasingly focusing on methods that allow for etiological
analysis and provide reproducible quantitative indications through dev ices that
integrate multiple imaging methods and allow for multiparametric analysis of
lesions. Instrument miniaturization and portability are undoubtedly other key goals
in wound imaging research.
Modern software allows us to not only identify the depth and the morphological
characteristics, but also to make three-dimensional reconstructions through algorithms (Lucas et al. 2021).
In this chapter various imaging methods from the most traditional to the most
modern, focusing on the role of wound care in the study of skin micro vascularization are addressed.
Despite the increasing accuracy of the imaging methods, many therapies can still
fail in terms of recurrence of wounds, with everything that involves the patient
quality of life (QoL) towards health professionals, and the health system
, due to
Wound Measurement is an Essential Part of Wound Management 265
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many gaps in diagnostic methods that do not yet allow for an optimal differential
diagnosis involving diagnostic-therapeutic delays.
Finally, most of the digital imaging methods have allowed for the correct
management of complicated patients from centres of world excellence for this
pathology even using remote devices; like in these years of emergency due to the
pandemic, telemedicine has had a very important role due to the impossibility of
examining patients in close range (Kim et al. 2003).
In this chapter we will talk about “wound imaging” to describe the modalities in
which wound imaging can be differentiated from “wound monitoring”, term that
refers to methods of monitoring the evolution of the wound, and “wound assessment”, that encompasses all methods of assessing the status of wounds (Li et al.
2020).
Skin Assessment
Wound Size Analysis
The digitization of imaging methods has certainly revolutionized wound management. Through the acquisition of digital images, it is possible to capture details that
can escape the naked eye. Digital images are the most cost-effective (Treuillet et al.
2009), non-invasive, and the easiest approach for high-resolution wound recording
and size measurement (Queen and Harding 2020). Technology-based evidence of
wound healing can be derived from dimensional assessments of lesion area, wound
perimeter or axial length, and, in the case of neuropathic diabetic wounds, volume.
There is demonstrable benefit when caregivers have wound measurement data
available (Mani et al. 2016). The use of technology in wound measurement was
given a level of evidence and recommendation 1A by the consensus to Optimizing
Technology Use for Chronic Lower-Extremity Wound Healing.
The very high resolution, that modern digital images have reached, allows us to
have a very accurate analysis, not only of the lesion morphology, but also the
acquisition of colour images, that provides a qualitative estimate of the various
types of tissues present in the lesion and in the peri-wound skin (Jones and
Plassmann 2000). Due to its reliability, the acquisition of digital photographs has
become the gold standard for testing new imaging methods. A disadvantage of this
method, especially those performed with cheaper systems, is the inability to assess
lesion depth in two-dimensions. Without the depth, volumetric calculation of the
lesion becomes impossible.
Modern systems provide the depth parameter by means of algorithms for red,
blue, green (RGB) images processed using image-processing algorithms (segmentation, edge detection, colour processing, active contour, and volumetric
information), allowing accurate boundary delineation and enabling
three-dimensional reconstruction (Li et al. 2020). This tool is recognize d daily for
266 V. Dini et al.
its versatility in clinical practices, it is the reference method to compare new wound
imaging devices.
Through this a completely non-invasive and safe method for the patient it is
possible to draw a multitude of parameters useful in the diagnostic-therapeutic path
of the lesion. In fact, digital imaging methods provide a qualitat ive and quantitative
measure of the lesion in an accurate way. Using digital images, it is possible to
automatically or semi-automatically establish the exact size of the skin lesions in
each spatial axis, but the quantitative analysis does not stop only at the estimate of
the size of the wounds (Fig. 1) (Foltynski et al. 2013). By implementing digital
photography with special analysis software, and the integration of technologies with
accurate accuracy such as laser scanning systems, it is possible to perform a
qualitative and quantitative analysis of the wound bed and wound edges to convert
even colour scales into reproducible qualitative-quantitative measures, e.g., it is
possible to quantify necrosis, fibrin, rate of re-epithelialization, or a particular type
of infection, providing a kind of global overview of the wound with reliable and
reproducible results even over time and for different ulcers (Romanelli et al. 2008;
Wannous et al. 2011). By means of digital planning it is possible to provide a
multiparametric analysis of the lesion by studying the margins (whether regular or
irregular), the chrom atic changes (indications of hyperaemia, necrosis or hyperkeratosis) and the newly formed epithelial tissue in advance.
Wound photography and the digital wound plan can therefore provide valuable
assistance to the clinician in terms of reducing the statistical error in serial measurements. Digital photography, however, provides neither information on the
pathophysiology or the biochemistry of the wound. With the various analyses and
the use of statistical models it will also be possible to predict the trend of chronic
wounds by monitoring the trend over time.
Standardization of any imaging method is the best way to consent for the
reproducibility of this method. To meet this need, American Professional Wound
Care Association has provided many useful guidelines to follow when acquiring
images of wounds (American Professional Wound Care Association 2019):
Fig. 1 Semi-automatic digital wound size analysis with laser scanner
Wound Measurement is an Essential Part of Wound Management 267
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1. Use the same digital camera for successive images.
2. Use the same image resolution settings on the digital camera (several are
available).
3. Use the same light source, intensity, and angle.
4. Have the camera at the same angle, distance, rotation, and height from the
wound.
5. Choose either pre- or post-debridement for all images in a sequence.
6. Select the same magnification for the digital camera lens (“ zoom”).
7. Choose a naming convention and put case identification and number or date in
the image (this will not be required for a full digital solution).
8. Choose image archive software that will allow keyword searches and audio tags
with images.
9. Have the wound in the same relative position as previous images.
10. Use “fiducial” reference markers wherever possible to achieve consistency (i.e.,
patient code, date, scale).
Two other authors Sperring and Baker provided 10 tips for wound photography:
1. Use a digital camera owned by your place of work
2. Set the time and date on the camera
3. Get the light optimal
4. Take the first photograph of patient data
5. Make the wound the only focus
6. Standardise the views taken of the wound
7. Get the angle right to take a proportional image
8. Establish the wound location for the viewer
9. Close-up images establish detail for the viewer
10. Securely save and store the images
Consistent, critical components in both include the importance of light and angle
of capture. Both are imperative to ensure the photograph is as close to reality as
possible. This is especially important for any wound measurement (Queen and
Harding 2020).
Hyperspectral Imaging
Hyperspectral imaging (HSI) is a non-invasive optical imaging method, based on
acquiring a series of continuous wavelength images to reveal the absorption
spectroscopic characteristics of tissue components by recording the intensity of
scattered light reflected from ulcerated tissue. Through this method, objective
information on the phenology, physiology, and biochemistry of wound patterns can
be obtained (Xu et al. 2012).
HSI can quantify oxygenated haemoglobin and deoxygenated haemoglobin
because they are the main tissue chromophores. With this technique we can
quantify wound oxygenation and perfusion parameters (Khaodhiar et al. 2007;
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