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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3938_Библиотеки_им_академика_М_И_Перельмана
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78 Compression Therapy in Venous Leg Ulcers
stocking, which then has to be frequently washed, causing a weakening of
the stocking fi bers.
Recently, some randomized controlled trials have reported favorable
results of ulcer healing using different kinds of compression stockings.
5–7
Light compression stockings may be used for keeping the local ulcer
dressing in place. A class II compression stocking placed on top will not
only add its pressure to that of the underlying light stocking but will also
increase the stiffness of the fi nal kit.
8
Several ulcer stockings consisting of
two layers have been introduced (Venotrain®, Bauerfeind, Medi Ulcertec®,
Ulcerkit® Gloria, Saphenamed UCV®, Hartmann). The basic layer
keeping the ulcer dressing in place stays on the leg overnight, while the
second stocking is donned over the basic liner during the daytime. This
regime allows the patient to clean the ulcer and change the dressing when-
ever necessary. This treatment modality is very cost effective, since no
specialized medical personnel are required to perform the dressing
changes.
Stockings with a zip have been introduced in the United States (Ulcer-
care®, Jobst-Baiersdorf). A ready-made tubular device, which can be
washed and reused, was introduced in some European countries under the
name Tubulcus® or Rosidal mobil®.
5
Usually, below-knee stockings are prescribed. Strong compression
stockings exerting a pressure of more than 30 mmHg at ankle level are
recommended.
After the ulcers are healed, compression stockings are essential in order
to prevent recurrence.
2,9
Compliance with the daily use may be a problem,
especially in elderly patients who have diffi culties applying elastic stock-
ings. In order to facilitate the application of a stocking, some helpful
TABLE 7-1 Types of Compression Devices
• Graduated compression stockings
Custom made
Standard size
Knee length
Thigh length
Compression tights
• Bandages
Single component—multiple components
Inelastic—elastic
• Intermittent pneumatic compression
Single chamber
Sequential chambers
Foot-pump
Lower leg
Full leg, trunk
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Compression Therapy in Venous Leg Ulcers 79
devices have been introduced. Nylon or silk socks (e.g., Easy slide ®) help
to slide the stocking over the foot.
Medical compression stockings are differentiated into several compres-
sion classes according to the pressure they are supposed to exert on the
leg. Unfortunately, there are considerable discrepancies between different
national standards, as shown in Table 7-2. A class II stocking is defi ned by
a pressure range at ankle level between 15 and 20 mmHg in France,
between 18 and 24 mmHg in the UK, between 20 and 30 mmHg in
the United States, and between 23 and 32 mmHg in Germany and other
European countries.
Also, the descriptive terms vary considerably: A stocking called
“medium or moderate” in European countries may be called “strong” in
the United States.
For a better international understanding, it has therefore been recom-
mended to use the pressure range in mmHg rather than the compression
class and also to specify the description of “mild, light,” “medium, moder-
ate,” and “strong, fi rm, or extra fi rm” by adding the pressure range.
10
COMPRESSION BANDAGES
For the routine management of venous ulcers, stockings cannot replace
compression bandages, which may exert much higher pressures.
Table 7-3 shows values of interface pressure of bandages measured on
the distal leg according to the British standard, which is the only existing
standard for bandages
11
in comparison to new proposals from a consensus
conference on compression bandaging.
12
TABLE 7-2 Pressure Ranges of Medical Compression Stockings According to
Different National Regulations*
Compression
Class EU (CEN) USA UK France Germany
A 10–14 (light)
I15–21
(mild)
15–20
(moderate)
14–17
(light)
10–15 18–21
(light)
II 23–32 20–30 18–24 15–20 23–32
(moderate) (fi rm) (medium) (medium)
III 34–46 30–40 25–35 20–36 34–46
(strong) (extra fi rm) (strong) (strong)
IV
>49 40+>36 >49
(very strong) (very strong)
* The values indicate the pressure (mmHg) that should be exerted by the hosiery at a
hypothetical cylindrical ankle.
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80 Compression Therapy in Venous Leg Ulcers
The pressure values indicated by the consensus group are clearly higher
than those from the British Standard, which come closer to the stocking
regulations.
It has to be stressed that all pressure values from Table 7-3 are entirely
based on experiments performed in the laboratory and not measured on
the human leg.
Interface Pressure and Stiffness Measured on the Leg
The pressure on the leg is one deciding parameter that determines the
effi cacy of a bandage. Another important feature is stiffness, which char-
acterizes the elastic property of the material and which is defi ned by the
increase of pressure due to an increase of the circumference of the leg
during movement.
13
Both parameters can be assessed by measurements on the individual leg
using simple, battery-powered, portable transducers like the Kikuhime
tester® (MediTrade; Soro, Denmark) or the Sigat-tester® (Ganzoni;
Winterthur, Switzerland). Such measurements will be indispensable in
future trials comparing different compression products and for training
purposes.
A preferred measuring point is the area on the leg that shows the most
pronounced changes of curvature and of circumference by active standing
and by walking, which is about 8–12 cm above the inner malleolus.
13,14
A
comparison between in vivo and in vitro measurements of pressure and
stiffness of compression stockings revealed a good correlation.
8
ELASTIC AND INELASTIC BANDAGES
Table 7-4 shows a differentiation of compression material based on the
elastic properties of single layers.
TABLE 7-3 Interface Pressure Ranges (mmHg)
Exerted by Compression Bandages on the Distal Leg in the
Supine Position*
Consensus Group BS 7505
Light compression
<20 <20
Moderate compression 20 –40 21–30
Strong compression 40–60 31–40
Ver y strong compression
>60
41–60
* The defi nitions proposed by a consensus group
12
are
compared with those of the British Standard 7505.
11
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Compression Therapy in Venous Leg Ulcers 81
• Elastic compression bandages: Bandages that incorporate
materials which exert pressure when applied with stretch.
• Inelastic compression bandages: Bandages that exert pressure
which increases when movement causes the calf muscle to contract.
Elastic, long stretch material is relatively easy to handle and can be used
also by the patients. In contrast to the inelastic material, these bandages
produce an active force by the elastic constriction of their fi bers. The pres-
sure drop after some hours is minimal. Therefore, such bandages may
cause pain and discomfort when the patient sits or lies down, especially
when they have been applied too tightly. Single-component elastic ban-
dages or compression stockings are therefore applied in the morning, pref-
erably before getting up and are removed before going to bed at night.
During walking, the peak pressure waves are lower than with inelastic
material.
Inelastic material produces a much higher increase when the patient is
standing up and performing dorsifl exion than does the elastic material
(Figure 7-1). The pressure increase from standing up and the amplitudes
during ankle movement are useful parameters for characterizing
stiffness.
For a practical differentiation between elastic and inelastic material, it
had been proposed to defi ne the difference between standing and supine
pressure measured with a small pressure transducer at the medial gaiter
region as the so-called Static stiffness index (SSI).
13
Values higher than 10
are indicative of inelastic material, while values lower than 10 are typical
for elastic material.
15
This parameter signifi es the range between an effec-
tive working pressure and a tolerable resting pressure.
A good compression bandage is characterized by a well-tolerated resting
pressure and high pressure peaks during walking. An inelastic bandage
achieving pressure peaks of 80 mmHg will compress superfi cial and deep
veins intermittently. This can be demonstrated by compressing the leg with
blood pressure cuffs containing an ultrasound permeable window. Using
a Duplex instrument, it can be demonstrated that in the upright position,
a pressure of 40–60 mmHg will narrow the leg veins.
16
Dorsifl exion leading
TABLE 7-4 Elastic Property of Single-Layer Compression Material
Inelastic/Nonstretch Inelastic/Short Stretch Elastic/Long Stretch
Stretch 0
<100% >100%
Stiffness Very high High Low
Application Trained staff Trained staff Every patient
Stays on the leg Day and night Day and night Daytime
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82 Compression Therapy in Venous Leg Ulcers
to intermittent pressure peaks of 60–80 mmHg causes intermittent occlu-
sions of the veins.
Two main disadvantages of inelastic bandages have to be considered:
• One is the loss of bandage pressure starting immediately after
bandage application. After only 1 hour, the initial resting pressure
will drop by about 25%, mainly due to an immediate decrease of
the volume of the limb.
• The second disadvantage is the fact that the application of a good
inelastic compression bandage is not easy and should be learned
and trained. Due to the fast loss of pressure, bandages with inelastic
material should be applied with much higher initial tension than
elastic bandages. An inadequate bandaging technique with inelastic
bandages is likely the main reason for the poorer clinical outcome
described in some studies.
1
SINGLE-LAYER AND MULTILAYER BANDAGES
Usually, single-layer bandages are applied with an overlap of about
50%. Single-layer bandages (e.g., one Ace bandage) are insuffi cient to treat
a venous leg ulcer.
Some randomized controlled trials have clearly shown that multilayered
compression was more effective in healing venous ulcers than single-layer
compression.
1
Rosidal sys
Druckverlauf bei verschiedenen Bewegungsabläufen
30
40
50
60
70
80
90
100
Druck (mmHg)
Sitzen
Dorsalextension
neguebe
i
n
K
dn
at
s
ne
heZ
oR.rD5002.80
.
30
Perfekta fein
Druckverlauf bei verschiedenen Bewegungsabläuf
e
30
40
50
60
70
80
90
100
0 102030405060
Zeit (s)
Druck (mmHg)
Sitzen
Dorsalextension
d
n
a
t
sneh
e
Z
Sitting Standing Sitting Standing
Inelastic Elastic
6
FIGURE 7-1 Sub-bandage pressure (mmHg) with inelastic and elastic material, both
applied with a resting pressure of 50 mmHg on the distal lower leg in the sitting position.
During up and down movement of the feet, the pressure gradient between muscle systole
(peak values) and muscle diastole (lowest values) is much higher for the inelastic than for
the elastic material. When the patient is standing up, the pressure rises with the inelastic
bandage by 22 mmHg and only by 8 mmHg with the elastic bandage.
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Compression Therapy in Venous Leg Ulcers 83
A multilayer bandage may consist of one or several components of dif-
ferent compression materials.
SINGLE-COMPONENT AND MULTIPLE-
COMPONENT BANDAGES
Bandages consisting of different materials are called multiple-compo-
nent bandages or compression bandaging systems. They may be provided
by companies in one package, so-called kits.
11
It has to be stressed that multiple layers will not only increase the pres-
sure but will also change the elastic property toward a stiffer fi nal bandage.
The same is true if multiple layers of different materials are used. Such
multicomponent bandages will act like an inelastic bandage even when the
single components are elastic and may also stay on the leg overnight.
EXAMPLES OF COMPRESSION
BANDAGING SYSTEMS
Zinc paste (unna boot) bandages are examples of completely nonstretch
material with high stiffness that may remain on the leg for several days up
to 2 weeks (Figure 7-2).
In contrast to many other institutions, we prefer to apply the unna boot
layers with considerable tension and cover the zinc paste with an outer layer
of an inelastic cotton wool bandage (Rosidal® or Comprilan®), thereby
producing a multilayer, multicomponent inelastic bandage.
FIGURE 7-2 Unna boot bandage (10 meters applied under considerable tension) and
wrapped over by an inelastic bandage (Rosidal K®). In order to avoid wrinkles and folds
during application, the zinc paste bandage has to be cut and molded to the leg.
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84 Compression Therapy in Venous Leg Ulcers
The force used during bandaging depends on the amount of edema, the
walking ability of the patient, and the leg circumference. In contrast to
bandages containing elastic fi bers, the resulting interface pressure is solely
produced by the strength during application of the bandage, which should
be much higher when used with elastic material.
In a patient with severe edema, the inelastic bandage should be modeled
with a pressure of about 60 mmHg to the distal portion of the lower leg.
As with every compression treatment, it is mandatory to exclude arterial
occlusive disease before such high pressure bandages are applied.
An even pressure distribution can be achieved by applying several
layers. Due to the increasing circumference of the leg toward the calf, the
applied pressure will decrease even when the bandager applies the bandage
with the same strength as at the ankle. This is explained by Laplace’s
law, stating that the pressure on a cylinder is indirectly proportional to its
radius.
Velcro-band gaiters like Circ-Aid®,
17,18
consisting of completely non-
stretch material, can be applied by instructed patients themselves and can
be readjusted when the bandages get loose due to edema reduction.
The Pütter bandage, consisting of several layers of inelastic cotton
bandages (e.g., Rosidal K®, Comprilan®), is an example of a multilayer,
single-component compression bandage. Usually, two 5-m long bandages
are used to cover a lower leg. More important than the details of
application in terms of spirals and the amount of overlap is the high
resting pressure on the distal lower leg, which should diminish over the
proximal parts in order to create a pressure gradient from distal to
proximal.
Rosidal sys® is another inelastic bandaging system offered as kit; it
contains a foam-padding layer, two Rosdal K® bandages, and a hose for
protection.
Such bandages are frequently used in continental Europe. Routinely,
they are changed every week; in the case of strong exudation in the initial
phase, they are changed after a few days. The bandages can be washed and
reused. Thereby, they increasingly lose their elastic properties, which make
the bandages more and more inelastic.
A new inelastic two-component system was recently developed, consist-
ing of a basic layer and an adhesive bandage (Coban two-layer bandage®,
3M).
New materials with special elastomeric properties (Vari-Stretch system
used in Pro-Guide®) try to overcome the problem of inadequate pressure
produced by an inexperienced bandager.
19
The sub-bandage pressure gen-
erated by this system remains relatively constant as the tension with which
the bandage is applied increases. In order to provide guidance to the user
on the optimal tension and ensure that two bandage-turns applied with
a 50% overlap achieve a satisfactory pressure, the outer bandage layer
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Compression Therapy in Venous Leg Ulcers 85
contains ovals that change into circles when the level of tension is applied
to the fabric.
Several elastic bandages have been supplied with cohesive (self-adher-
ing) or adhesive basic sticky layers in order to prevent slipping down of the
bandage. Due to the high friction between several layers, such bandages
act like inelastic material. They are also able to maintain prolonged
compression.
20
The four-layer bandage (e.g., Profore®) contains several layers of four
materials: cotton wool, crepe, elastic, and self-cohesive. These bandages
are relatively easy to apply and have gained considerable widespread use,
especially in the UK, where ulcers are treated mainly by nurses.
21
The fi nal
bandage that should exert a pressure of about 40 mmHg on the distal leg
shows a relatively high stiffness. Therefore, such multilayer bandages may
also stay on the leg for several days. In centers that are experienced with
applying inelastic material, no signifi cant superiority of four-layer ban-
dages could be found.
22
INTERMITTENT PNEUMATIC COMPRESSION
The application of intermittent pneumatic compression in addition to
the use of compression bandages is able to accelerate ulcer healing.
23
This
adjunctive treatment may be very helpful in patients who have edema and
are unable to walk or who suffer from a stiff ankle, especially when
concomitant arterial disease is also present. In such cases, there is often a
vicious circle starting with pain and inability to walk, sitting for many
hours, and progression of edema, which reduces the arterial skin perfusion,
which in turn will worsen the pain. Bed rest with leg elevation will not be
tolerated in this situation. Intermittent pneumatic compression is able to
reduce edema and to enhance arterial blood fl ow.
24,25
One deciding point that intermittent compression may be benefi cial in
patients with arterial occlusive disease while sustained compression with
bandages or stockings is contraindicated is the pressure-free interval
between the pressure cycles, in which short periods of reactive hyperemia
develop.
PELOTTES AND PADS
Venous ulcers are frequently localized behind the inner malleolus or on
the fl at areas of the medial lower leg. The pressure of a bandage or a stock-
ing will be low in these areas due to Laplace’s law, which states that the
pressure is indirect proportional to the radius. A local increase of pressure
can be achieved by applying rubber foam pads over the ulcer region,
thereby decreasing the radius of the leg segment (Figure 7-3). Care should
be taken that the edges of such pelottes should be fl attened in order to
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86 Compression Therapy in Venous Leg Ulcers
avoid sharp impressions into the skin by theses devices (Figure 7-4a and
Figure 7-4b).
PREVENTION OF ULCER RECURRENCE
Management of leg ulcers consists of two phases:
1. The healing phase until epithelialization is obtained;
2. The maintenance phase after ulcer healing in which a frequently
occurring recurrence should be prevented.
In general, it is often easier to heal a venous ulcer than to keep it
healed.
To keep the ulcer healed, continuous compression is essential (“main-
tenance phase”) . Medical c ompression below-knee stockings , 30 –45 mmHg,
are the preferred method of choice. Patients who are unable to put on
the stockings may use elastic bandages instead. Eradication of venous
refl uxes by surgery or sclerotherapy should be considered in every single
patient.
COMPRESSION TECHNIQUES
Many different techniques of compression bandaging have been
described. Some general rules are as follows:
FIGURE 7-3 Rubber foam pad to increase the local bandage pressure over an ulcer in
the retromalleolar region.
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Compression Therapy in Venous Leg Ulcers 87
• Elastic bandages are easier to handle than inelastic bandages
and may also be applied by staff that is not specifi cally trained and
by the patients themselves. This is also true for compression
stockings.
• Inelastic material like zinc paste should be applied with much
higher resting pressure in a kind of modeling work, pressing the
bandage roll toward the leg. To obtain a homogenous pressure
FIGURE 7-4 A. Venous ulcer due to a post-thrombotic syndrome behind the inner
malleolus.
B. After 16 weeks of compression therapy using Unna boot bandages and a rubber foam
pad, the ulcer is healed. (The impression of the pad can still be seen.) Consideration to
abolish venous refl uxes by surgery or by sclerotherapy and wearing of compression stockings
is essential to keep the ulcer closed.
https://t.me/med1917
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