By Chinenye Queen Ezike and James McGuire DPM, PT, CPed, FAPWHc
Venous Leg Ulcers (VLUs) are the most common cause of lower extremity ulcerations, affecting about 1% of the US population1. Recurrence rates for VLUs are also extremely high and ulcers can remain for weeks to years, even with appropriate treatment. More often than not, however, they are treated with inadequate compression and are complicated by poor patient compliance.
They are often referred to as painless in literature comparing them to arterial ulcers, however these wounds can be associated with a great deal of pain. With high levels of drainage, odor and biofilm formation, these wounds can make it difficult for patients to be in public places and reduce their quality of life. Venous leg ulcers are caused by venous insufficiencies secondary to valvular incompetence of both the superficial and deep systems. This causes blood pooling and consequent edema, reduced nutrient and oxygen flow to the tissues, and results in the eventual break down of the skin with ulceration of the leg.
Multilayer compression therapy is the accepted standard of care for the treatment of VLUs2. It works by applying graduated pressure to the treated leg. The greatest pressure is applied to the foot and ankle with decreasing pressure as you move more proximally. This promotes lymphatic fluid movement toward the knee and upper leg and improves venous return to the heart. The subsequent reduction in edema facilitates healing of the ulcer and reduces pain. Optimum compression pressure for VLU treatment ranges from 30-40mmHg3.
The JOBST® Comprifore bandaging system4 is a four layer bandage system with proven efficacy in the treatment of VLUs. The multilayer system is regarded as the gold standard for VLU treatment5. Unlike inelastic bandages such as the Unna boot, JOBST® Comprifore has both long and short stretch elastic properties, which allows for sustained compression both at rest and during ambulation. This allows the dressing to be used for both mobile and immobile patients.
Each of the dressing's four layers plays an important role in the functionality of the compression system. Before applying the dressing assess the patient's ankle brachial index (ABI) and refrain from compression if the ABI is less than 0.7.
The first bandage layer is a synthetic cast padding material applied over the wound dressings. It pads bony prominences, absorbs drainage, wicks perspiration away from the skin, and helps smooth out the contours of the leg before compression is applied. With the ankle held at 90 degrees throughout the application process, layer 1 is wrapped under low tension from the base of the toes to just below the knee with a 50% overlap.
The second bandage layer is a non-stretch wrap that enhances absorption and padding and helps to enhance fluid movement during ambulation. It is also wrapped from the base of the toes to just below the knee using a basket weave overlapping pattern. Light tension is applied that is just enough to extend the bandage to its maximum length.
The third bandage layer is a long-stretch wrap that provides sustained graduated elastic compression. This layer generates approximately half of the total compression of the dressing. Application is similar to that of layer 2, with a figure eight technique for the ankle and a basket weave overlap up the leg. The material should be stretched to approximately 50% of its full stretch as it is applied. The changing contour of the limb is used to achieve a graduated reduction in total pressure. When the limb is cylindrical with no difference in diameter between the ankle and the calf, the clinician must manually reduce tension as they move proximally.
The fourth layer is a cohesive wrap similar to Coban™ that is also applied with 50% tension from the base of the toes to the knee. This completes the compression, holds the dressing together, and prevents unraveling. This layer is a bit tacky and we usually cover it with a nylon stocking or stockinette to prevent rolling of the cohesive layer during daily activities.
Included in the bandaging system is an antimicrobial layer, Cutimed® Sorbact® WCL, which is a hydrophobic contact layer with microbe binding capability to reduce biofilm formation and promote healing. If we require more exudate absorption, our clinic uses Cutimed® Siltec®. This combination dressing consists of a silicone contact layer with an absorbent foam with super absorbent sodium polyacrylate beads embedded in the material to enhance fluid capacity. This prevents lateral movement of exudate in the dressing, reducing wound edge maceration often seen with traditional foam dressings.
JOBST® Comprifore multilayer compression system is an excellent dressing for VLU treatment. Care must be taken to provide sufficient pressure when the applying the wrappings as providing adequate pressure is the real key to improved wound healing. The compression system encourages patient compliance as the system is changed just once or twice per week based on the amount of drainage. The unique combination of a hydrophobic microbe binding layer with a multilayer bandage system makes the JOBST® Comprifore one of our two preferred multilayer compression systems.
To learn more about this company and product visit http://www.woundsource.com/company/bsn-medical-inc
1. Collins L, Seraj S. Diagnosis and Treatment of Venous Ulcers. American Family Physician.2010; 81(8):989-996.
2. Herschthal J, Kirsner RS. Current management of venous ulcers: an evidence-based review. Surg Technol Int. 2008;17:77-83.
3. Blair SD, Wright DD, Backhouse CM, Riddle E, McCollum CN. Sustained compression and healing of chronic venous ulcers. BMJ 1998;297:1159-1161.
4. BSN Medical. Jobst Comprifore. http://www.bsnmedical.us/fileadmin/z-countries/United_States/PDF/produc…. Accessed October 8, 2014.
5. Iglesias C, Nelson EA, Cullum NA, Torgerson DJ. A randomized controlled trial of two types of bandage for treating venous leg ulcers. Health Technol Assess. 2003;8(29):1-105.
About the Authors:
Chinenye Queen Ezike is a third year podiatric student at Temple University School of Podiatric Medicine. She received her BS in Behavioral Neuroscience.
Dr. James McGuire is the director of the Leonard S. Abrams Center for Advanced Wound Healing and an associate professor of the Department of Podiatric Medicine and Orthopedics at the Temple University School of Podiatric Medicine in Philadelphia.
The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.
The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, HMP Global, its affiliates, or subsidiary companies.