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INTRODUCTION

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Chronic wounds and ulcers are frequently encountered in patients with peripheral vascular disease (PVD) who often have insufficient distal arterial perfusion for wound healing. If the obstructed or stenosed inflow arteries can be bypassed or dilated, the wounds usually heal. However, the wound itself must be addressed surgically and medically along with revascularization. Until recently, wound care has not always been adequately emphasized in undergraduate medical programs.

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This chapter addresses much of the current wound treatment available today. How one may incorporate these methods in one's practice and when referral to a wound treatment center (WTC) may be appropriate for problem wounds will vary with each clinician and his practice environment.

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BASIC HEALING PROCESS

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Wound repair and regeneration following acute injury begins within minutes with spasm of blood vessels, coagulation of bleeding surfaces, and accumulation of platelets on the damaged cells. A fibrinous layer derived from activated fibrinogen, collagen, and other trapped cells fills the injured surface. Factors released from platelets activate monophages and leucocytes which remove debris and bacteria. This debris is ingested or destroyed using peroxidase, which is oxygen-dependent. The necessary proliferation of fibroblasts, leucocytes, and keratinocytes, as well as collagen production by fibroblasts also requires sufficient oxygen. If microvascular profusion of oxygen and nutrients is insufficient, the wound will not heal.

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Most surgical incisions or other wounds heal rapidly in less than 30 days. Clinical treatment of wounds in healthy patients usually requires only cleaning with saline or antiseptic solutions and sterile wound coverage. If there is significant inflammation clinically associated with the wound one may add topical zinc oxide, or silver in addition to systemic antibiotics.1

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PROBLEM WOUNDS

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Wounds that fail to heal or to progress normally toward healing over a 30-day period may be defined as "chronic" or "problem" wounds. There are multiple factors that combine in most patients to cause problem wounds. These factors may be local or systemic. Photography or measurement of wounds allows for an objective method to analyze wound evolution.

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Local factors involve the tissue immediately surrounding the wound. Examples of local factors include scars from past trauma, fractures, pressure points, diabetic neuropathy with sensory loss and foot deformity, arthritis, and bunions of feet. Fibrotic changes related to radiation, lupus, venous hypertension, and lymphedema may be present as well. Patients may have chronic ischemia from peripheral arterial disease (PAD) or acute ischemia of embolic nature to fingers, toes, and other areas of the body. Bacterial infection of the wound with inadequate or inappropriate treatment allows accumulation of necrotic infected biofilm or eschar. Lack of sharp or enzymatic debridement, poor choice of topical agents, inappropriate dressings, or inadequate tissue cultures are local factors related to inadequate medical care or patient neglect.

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Systemic factors include malnutrition, poorly controlled diabetes, renal, or liver failure, age, chemotherapy, steroids, morbid obesity, ...

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