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Chronic Wound
Management
TheSignificance ofEvidence
and Technology
RajMani
Editor
123
Chronic Wound Management
Raj Mani
Editor
Chronic Wound
Management
The Significance of Evidence
and Technology
123
Editor
Raj Mani
Shanghai Jiao Tong University
Shanghai, China
ISBN 978-3-031-26109-1 ISBN 978-3-031-26110-7 (eBook)
https://doi.org/10.1007/978-3-031-26110-7
© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature
Switzerland AG 2023
This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether
the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of
illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and
transmission or information storage and retrieval, electronic adaptation, computer software, or by similar
or dissimilar methodology now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this
publication does not imply, even in the absence of a specific statement, that such names are exempt from
the relevant protective laws and regulations and therefore free for general use.
The publisher, the authors, and the editors are safe to assume that the advice and information in this
book are believed to be true and accurate at the date of publication. Neither the publisher nor the
authors or the editors give a warranty, expressed or implied, with respect to the material contained
herein or for any errors or omissions that may have been made. The publisher remains neutral with regard
to jurisdictional claims in published maps and institutional affiliations.
This Springer imprint is published by the registered company Springer Nature Switzerland AG
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
Contents
Chronic Wound Management—A Continuing Challenge ............ 1
Georgina Gethin and Raj Mani
The Role of Technology in Managing Vascular Wounds
............ 7
Bodo Erhardt Günther and Raj Mani
The Diabetic Foot, Its Complications, Role of Technology
in Evidence-Based Management
............................... 45
Danielle Dixon and Michael Edmonds
Role of Technology for wound Care in Diabetic Foot
.............. 67
V. Viswanathan and R. Mirshad
Biologic Transducers in Wound Healing
........................ 77
Biao Cheng and Xiaobing Fu
Physical, Electromagnetic, Biologic Devices
...................... 107
Alberto Piaggesi
Medicinal Plants and Products from Traditional Medicine System s
Contribute to Clinical Wound Management
...................... 117
Tuhin Kanti Biswas, Shrabana Chakrabarti, Srikanta Pandit, and Raj Mani
Innovation in Laboratory Evaluations of the Performance
of Treatment and Prophylactic Dressings Under Clinically-Relevant
Usage Conditions
.......................................... 141
Amit Gefen
Atypical Wounds and Wounds Resulting from Infection
............ 153
Massimo Papi and Ersilia Fiscarelli
Biofilms and Impaired Wound Healing: How Do We Detect
the Presence of Biofilms in Chronic Wounds Non-invasively
......... 195
Ida C. Thaarup and Thomas Bjarnsholt
Update on Technology and Evidence-Based Management of Scars
Luc Téot, Hester Colboc, and Sylvie Meaume
.... 229
v
vi Contents
Surgical Flaps in Wound Healing—An Update on Evidence-Based
Management
.............................................. 247
Joon Pio Hong and Asli Datli
Wound Measurement is an Essential Part of Wound Management
Valentina Dini, Giammarco Granieri, Alessandra Michelucci,
and Marco Romanelli
Translation of Wound Devices into Practice—A Myth? Translation
is the Process of Taking an Invention Through to Clinical
Practice—How Successful Are We?
............................ 285
Mark Richardson and Raj Mani
Pain in Chronic Wounds: Mechanism and Management
............ 297
Aakansha Giri Goswami, Praveen Talawar, Somprakas Basu,
and Vijay Kumar Shukla
.... 263
Chronic Wound Management—A
Continuing Challenge
Georgina Gethin and Raj Mani
This book “Chronic Wound Management—the significance of evidence and technology” examines the benefits of innovation to manage an enormous clinical and
therapeutic challenge. Chronic wounds are those cutaneous wounds which fail to
follow a predictable course of healing. Since the use of Doppler ultrasound to
measure ankle brachial pressure index (ABI)—a reliable measure of the blood flow
into the ankle and foot—in the early 1980s, evidence emerged to the effect that a
great proportion of such wounds present on the lower extre mities or legs and feet
and are of vascular and/or diabetic in origin. A range of innovative technology to
diagnose as well to manage wounds appeared on the scene, some were widely
accepted and available and led to objective evidence. Study designs in the form of
randomised controlled studies emerged and penetrative data analysis using
meta-analysis appeared, pioneered by the Cochrane Wounds Group, became
available. It was possible to define the concept of standardised care. Journals
dedicated to the clinical science and management of wounds were launched
innervating communications that were indexed in the Web of Science, Pub Med,
G. Gethin
Alliance for Research and Innovation in Wounds, Galway, Ireland
e-mail: georgina.gethin@universityofgalway.ie
CURAM (SFI Centre for Research in Medical Devices), Galway, Ireland
School of Nursing and Midwifery, University of Galway, Galway, Ireland
HES-SO University of Applied Sciences and Arts, Delémont, Switzerland
Journal of Wound Management—Official Journal of EWMA, Frederiksberg, Denmark
School of Nursing and Midwifery, Aras Moyola, University of Galway, Galway, Ireland
R. Mani (&)
Shanghai Jiao Tong University School of Medicine, Shanghai, China
e-mail: rajgopalmani47@gmail.com
© 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_1
1
2 G. Gethin and R. Mani
and such other data bases. Numerous books were also published as learned societies
also grew, initially in Europe and USA, later in many countries. All these developments raised expectations of improving healing outcomes. What is the current
order of the problem?
It is difficult to be precise about the prevalence of wounds of all aetiologies. In
the United States 3% of the population >65 years have open wounds and an estimated 2% of the total population are affected by wounds (Sen 2019). In the United
Kingdom (UK) it was estimated that in the year 2017/2018, 3.8 million adults had a
wound, equivalent to 7% of the adult population (Guest et al. 2020). In Spain, an
incidence and prevalence study over the years 2010–2014 among people over
40 years of age, reported prevalence and incidence increase over the years, doubling in those aged over 65 years (Berenguer Perez et al. 2019). Incidence increased
from 0.5 new cases per 1,000 people/year in 2010 to 1 new case for every 1,000
people/year in 2014. A meta-analysis of eleven studies representing 15,748,658
people reported an estimated total prevalence of chronic wounds of 1.67 per 1,000
population (Martinengo et al. 2019). Subgroup analysis based on the type of
wounds revealed a combined prevalence of 2.21 per 1000 population for studies
reporting ulcers of more than one aetiology (Martinengo et al. 2019).
The average age of patients with chronic wounds is around 65–70 years with
67% of those in one study being <65 years (Guest et al. 2020; Hopman et al. 2016;
Apollonio et al. 2016; Walker et al. 2014; Gethin 2020) and while they may
‘technically’ be classed as ‘elderly’ they still represent the working age for many
adults. This is important. Additionally, with high recurrence rates of many wound
types, and life expectancy increasing in many countries this reflects a long number
of years during which an individual may be impacted by chronic wounds, thus
underscoring the importance of prevention, early diagnosis and treatment, and
prevention of recurrence.
Wound Aetiology
In 2011 a study among 72 wound care physicians, reported on 31,619 patients with
chronic wounds (Korber et al. 2011). Of these, 79.7% had ulcers due to chronic
venous insufficiency or peripheral arterial insufficiency and that 20.3% of all
patients had wounds of other aetiologies including vasculitis, pyoderma gangrenosum, infectious diseases and more. In a different study also from Germany,
similar patterns of venous and atypical aetiology were reported (Jockenhofer et al.
2016). In an Italian study, data on 1,163 patients in outpatient settings reported that
54.9% of ulcers were venous in origin, 25.2% mixed aetiology and 8.3% diabetic
(Apollonio et al. 2016). No reference was made to atypical wounds in the latter
study. In Australia, analysis of all patients (n = 1,762) with wounds in one regio n
showed that while the maj ority of wounds were acute/surgical/trauma wounds
(54%), 13% of all wounds were leg ulcer with 14% a being due to other aetiologies
including malignancy, irradiation and drain tubes (Walker et al. 2014).
Chronic Wound Management—A Continuing Challenge 3
A Complex Profile
The profile of patients with chronic wounds is often overlooked, particularly when
considering treatment strategies and healing outcomes. Chronic wounds are often
complicated by comorbidities with patients having an average of four and at least
one comorbidity (Sen 2019; Guest et al. 2020; Hopman et al. 2016; Walker et al.
2014; Kelly and Gethin 2019). Of these co-morbidities, hypertension, diabetes,
obesity, cardiovascular disease prevails (Jockenhofer et al. 2016; Kelly and Gethin
2019). Of all co-morbidities, diabetes and obesity are significant factors in the risk
for wounding and the risk for healing. According to the International Diabetes
Federation, there are 61 million people living with diabetes in Europe in 2021
representing 1 in 11 adults, this figure is projected to rise to 69 million by 2045, an
increase of 13% (IDF Diabetes Atlas, http://diabetesatlas.org). DFU is the commonest reason for admission to hospital with 15–35% of patients with DM
developing DFU during their lifetime(O'Loughlin et al. 2010). Obesity continues to
impact on the lives of many individuals and estimates among patients with venous
leg ulcers reported approximately 34% as being obese (Body mass Index >30)
(Gethin 2020).
Patient factors that have been less well researched in clinical trials and require a
greater focus of attention are those related to lifestyle factors and risk factors for
chronic illness such as poor nutrition, physical activity, sleep, stress, tobacco use,
alcohol misuse and illicit drug use (Gethin et al. 2022). These factors impact on
healing as well as the risk of non-healing: these are also risk factors for chronic
illness prevalent among the population susceptible to chronic wounds. In addition
to the above, clinicians and researchers need to be cognisant of the lack of, or
limited, levels of health literacy in the population in general and among those with
chronic wounds. Health Literacy is the knowledge, motivation and competences to
access, understand, appraise and apply health information in order to make judgments and take decisions in everyday life concerning health care, disease prevention
and health promotion to maintain or improve quality of life throughout the course of
life (Sorensen et al. 2012).
The 2015 European Health literacy survey (HLS-EU) reported that there are
specific subgroups where the proportion of people with limited health literacy
exceeds the average (47.6%) for the overall sample (Sorensen et al. 2015). This is
true for people with poor health status, high use of health care services, low
socio-economic status, lower education, and older age. The highest proportion of
limited health literacy was observed for people who reported a self-assessed health
status of ‘very bad’ (78.1%) or ‘bad’ (71.8%), for those with more than one-long
term illness (61%) and those reporting six or more doctor visits in the last
12 months (58.9%). Therefore, poorer health and thus higher demands for health
services seem to be accompanied by lower levels of health literacy. We know that
those affected by chronic wounds have elevated levels of chronic illness and have
more frequent clinical visits due to ongoing prevention and treatment regimes.
4 G. Gethin and R. Mani
Health literacy is also important in the context of the increased use of technology
in wound management, whether this is in relation to education or treatment
strategies (Goldrick and Gethin 2021). Patients’ have shown an acceptance towards
the use of wearable sensors but are concerned with the perceived loss of contact
with their health care professionals. There is a need therefore to involve patients and
family members in the design of wearable devices in order to ensure high user
acceptance and uptake of innovations (Goldrick and Gethin 2021).
Economic Impact
A systematic review of published literature in 2019 from across the globe, taking
data from inpatient, outpatients, community and primary care perspectives estimated annual cost of wound care to the health services (Olsson et al. 2019). Diabetes—related amputations reported the largest proportion of costs for chronic
wounds, a cost associated with additional inpatient days when hospitalized compared to non-diabetic patients and these costs ranged from US $12,851 to US
$16,267 per patient admitted. Costs for leg ulcers in inpatient and outpatient settings ranged from US $449 to US $2,307 annually per patient and between US
$13,334 to US $13,761 from a societal perspective. The annual levels of resource
use attributable to wound management to the National Health Service (NHS) in the
UK in 2017/2018 was £8.3 billion of which 81% of the cost occurred in the
community (Guest et al. 2020). This cost has increased by 48% in five years from
2012/2013 to 2017/2018 (Guest et al. 2020).
Human Impact
Poorer health related quality of life (HRQoL) for people with chronic wounds are
well documented (Hopman et al. 2016; Olsson et al. 2019). This is worst for
physical pathologies and is similar or markedly lower in some HRQoL domains
when compared to other chronic conditions (Hopman et al. 2016; Olsson et al.
2019). Pain and reduced mobility are reported as the main problem areas for
patients with wounds (Hopman et al. 2016; Olsson et al. 2019). Those with long
wound duration and or large wound size have poorer HRQoL (Olsson et al. 2019),
again underscoring the need for early diagnosis and treatment.
Healing Outcomes
Healing outcomes for a range of chronic wounds are hard to quantify as they
depend on many factors including those of the wound itself, patient co-factors,
service provision and the methods and timing used to assess such outcomes.
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