What is a leg wound (ulcer)?

One of the most common places where non-healing (chronic) wounds can appear is the legs. If the wound on the leg, despite all types of treatment, does not heal within 4-6 weeks, it is necessary to find out the root cause of its appearance and plan treatment depending on the cause.

Wounds or ulcers on the legs are often caused by poor circulation. Our legs have 3 types of circulatory systems and vascular structures. Disturbances within these vascular systems result in non-healing wounds. These vascular systems are:

1. Arterial vessels (arteries) that carry pure blood (blood rich in oxygen and nutrients).
2. Venous vessels (veins) that carry dirty blood (blood that gives oxygen and nutrients to tissues and takes carbon dioxide and metabolic products from tissues).
3. Protein-rich white blood vessels (lymphatic vessels) and carrier cells that play an important role in the body's fight against foreign organisms and microbes.

Any discomfort in any of these veins may cause leg injury or non-closure of the wound. In some patients, several of these vascular systems may be impaired at the same time, and if all of these disorders cannot be eliminated, it is usually not possible to heal the wounds. These wounds are called mixed ulcers.

What wounds or leg ulcers result from arterial diseases?

In diseases of the arterial vessels that carry pure blood to our organs and limbs such as arms and legs, these arteries are damaged or become insufficient to carry pure blood. In this case, wounds form in the target organ, and the existing ones cannot heal. If the blood flow is insufficient to provide the nutrients and oxygen needed for the tissue to survive, the target tissue loses its vitality and dies off. As a result, the skin and subcutaneous tissue cannot heal on their own, and non-healing wounds develop.

What diseases cause arterial occlusion? 

Narrowing or blockage of the arteries occurs in inflammatory diseases of the arteries (vasculitis), such as diabetes, atherosclerosis, and Buerger's disease.

How are arterial occlusion wounds treated? 

When treating wounds resulting from occluded arteries, it is necessary to provide blood supply to the wound area. The provision of blood supply is carried out in two ways: employing an open operation or closed angiographic procedures. In open surgery, pure blood is transferred to the target area by shunting through an artificial vein or a vein taken from the patient's body. In the angiographic technique, the occluded vessel is opened with a balloon or stent, with or without drug-eluting. Nowadays, in parallel with the development of technology and techniques, angiographic methods have become more common, while the success rate in good clinics is quite high. 

What causes a diabetic wound (diabetic foot)? 

Foot wounds in diabetic patients are one of the most common and important problems. Studies have shown that approximately 15% of people with diabetes will develop a foot injury at some point in their lives. Estimated studies show that out of 70 million Turkish people, about 10-11 million people have diabetes. This means that 1-1.5 million people with diabetes will someday experience this wound. The worst consequence of this wound is limb amputation. Research shows that diabetics are 15 times more likely to be amputated than non-diabetics. As a rule, half of the patients with amputated limbs lose another limb within 2 years and die within 4 years. That is why the treatment of diabetes mellitus and related wounds requires a much more serious attitude than in a situation with other diseases.

In diabetic patients, two major ailments play an important role in wound development. The first and most important of these is nerve damage called neuropathy, and the other is vasculopathy, that is, vascular damage. Motor neuropathy causes weakness and wasting of the leg muscles in the patient, sensory neuropathy leads to loss of pain, and autonomic neuropathy causes dry feet, standing defects, inability to feel pain, and dry, calloused skin on which the wound opens faster. The patient usually does not feel the formation of a callus on the leg and pain from a wound caused by a callus. The wound becomes infected and grows inside the foot. Finally, when there is discharge outside, the patient notices the wound, but at this stage it already reaches a size that threatens the limb, and treatment becomes difficult. This is why, in diabetic patients, taking precautions before the wound forms is the main treatment. Thus, overcoming serious illness in an inexpensive and simple manner is only possible by informing the patient under the supervision of an experienced wound care professional.

Regular analysis of blood sugar (hemoglobin A1C) for 3 months, regular examination of the foot by the patient and/or a relative of the patient, use of insoles and shoes made in accordance with the patient's foot anatomy, adherence to hygiene rules, and a specialist examination of the foot every 6 months - these are the main measures that must be taken to prevent wound formation. 

How are vasculitis-related wounds treated? 

Some rheumatic diseases can also be accompanied by disorders of the vascular systems. These vascular diseases are called vascular inflammation (vasculitis). People with vasculitis may have leg ulcers or skin problems. The diagnosis of vasculitis is made on the basis of a detailed history of the patient, examination, blood tests, skin, and subcutaneous samples (biopsy) taken from the wound. In difficult cases, treatment with corticosteroids is prescribed. The treatment of such wounds requires qualified assistance and a long time. 

How do venous-related ulcers and varicose wounds occur? 

The vessels that carry dirty blood that has lost oxygen and contains metabolic products from the legs to the heart are called venous vessels, or veins. Inside these vessels are valves that open and close in the same direction. Thanks to these valves, the blood on its way from the feet to the heart always follows from the bottom up, i.e. against gravity, it does not run backward. With occlusion of venous vessels, called deep vein thrombosis, after childbirth, with obesity, cancer, genetic or congenital diseases, with standing or sedentary work, or after some previous infections, the structure of these valves deteriorates and they stop closing completely. After a while, some of the blood cannot reach the heart and accumulates in the legs. Because of this congestion, the veins expand, swelling like a ball, and lose their normal shape, turning into varicose veins. As the disease progresses, vascular cracks appear due to increased intravascular pressure at the capillary level. Blood seeps out of these cracks under the skin, and hemosiderin accumulates there, which gives the blood red color. Due to this accumulation, the legs of patients who have suffered from varicose veins for a long time acquire a brownish tint. Both the swelling of the legs and the accumulation of this substance under the skin lead to a lack of skin nutrition. As a result of scratching any sore or constant itching, the integrity of the skin is violated and a wound appears. Subsequently, following the same mechanisms, the resulting wounds may not heal for a long time, and over time they become infected and become larger. 

How are varicose wounds treated? 

For the successful treatment of any wound, first of all, it is necessary to determine what type it belongs to and eliminate the causes leading to its formation. With varicose wounds (or varicose ulcers), it is necessary to reverse the wound formation mechanism. It is necessary to apply treatment procedures to reduce the swelling caused by the backflow of blood in the leg. In addition to these procedures, the wound should be kept clean with regular bandaging, the resulting discharge should be protected from environmental influences, and the skin around the wound should not be neglected. The following methods are used to reduce leg swelling: 

1. Varicose vein removal surgery.

Laser or radiofrequency ablation is a method of removing a varicose vessel through open surgery or the use of adhesives. There are several basic criteria to consider when applying these methods. The condition of the diameter of the vessel in question, the degree of leakage above a certain level, the absence of occlusions in deep venous vessels are the basis of these criteria. A patient with varicose wounds can be operated on at any stage of treatment, however, it is important that the wound is not infected at the time of the operation. In a patient who has undergone surgery to remove varicose veins, the wound may recur. In half of the non-operated patients with varicose wounds, even after its complete healing, the wound may appear again within two years. However, out of four patients who underwent surgery, within two years, only one of them develops a wound again. This means that the risk is halved. 

2. Applying a bandage with an elastic band.

Special bandages are applied to the wound, the legs are wrapped with 2 or 4 layers of bandage. Depending on the condition of the skin and the amount of discharge from the wound, this procedure must be repeated with the help of specialists at least 2 times a week. 

3. Wearing compression stockings.

If it is not possible to use bandages, or the wound has decreased to a certain extent, then after applying a dressing, the patient can wear two-layer compression stockings with a high level of pressure. 

4. Using an intermittent pneumatic compression device.

This device consists of air-filled pads. The device is put on the leg, the specialist controls it with a given frequency and pressure. As these pillows inflate and descend, they compress and relax the leg, directing the blood that has accumulated in the lower leg to the heart. 

5. Ready-made bandage systems are applied by the patients themselves.

In these systems, which are new for our country and have not yet become widespread, self-adhesive bandages with standard compression are used, taking into account the parameters of the patient's leg. Thanks to the ability to make dressings every day, this system facilitates the treatment process for both the patient and the doctor. 

How are wounds caused by lymphatic disease (lymphedema) treated? 

The vessels that carry the cells responsible for the body's fight against foreign organisms and the protein-rich lymphatic fluid are called white blood (lymphatic) vessels. When these very thin vessels, which are common throughout the body, are damaged and occluded, or when there is a disease (eg, cancer, infection, trauma, surgery, radiation therapy), fluid stops collecting from the limbs, causing the limb to swell. This edema becomes permanent and progressive. If the patient does not follow the precautions, then after a while it will become difficult for him to move, and wounds will open on the swollen limb due to malnutrition of the skin. The treatment focuses on relieving swelling and skincare. Treatments for varicose wounds and lymphatic massage performed by specialists help reduce edema. 

What are other treatments for leg wounds (ulcers)? 

When treating and healing a wound, it is necessary to take into account its cause and condition. When determining the treatment to be applied to the wound, it is important to know such details as the location of the wound, how long has passed since its appearance, whether it is infected, its depth and size, the amount of discharge, smell, color and health characteristics of the patient. When treating wounds on the legs, the following methods are used: 

1. Hyperbaric oxygen therapy

In a closed pressure chamber, oxygen is supplied to the patient under high pressure. The inhaled oxygen mixes with the patient's circulation and reaches the tissues through the blood, ensuring good oxygenation of the wound. In our country, it is an effective adjuvant treatment method, paid by state insurance together with sick leave twice a year. 

2. Ozone therapy 

Ozone, which affects many different healing mechanisms in the body, is widely used in wound healing both by injecting it directly into the bloodstream and by applying it to the wound area. 

3. Vacuum-Assisted Closure (VAC) therapy 

A sponge is covered with adhesive dressings that are impervious to air and water. This sponge is connected to an electric pump with a closed hose system. With the help of this pump, discharge from the wound is collected in a reservoir and removed from the wound. This is a very effective treatment method. Besides, it provides less painless and aesthetic dressing to the patient. The wound is kept clean and odorless. Wound healing time is shortened. In the last few years, this treatment has been further developed and the wound washing feature has been added to the system. This flushing VAC system is particularly effective for draining and infected wounds. When the treatment is applied in the hospital, it is covered by the SSI. 

4.  Larval therapy (maggot therapy) 

This treatment uses only 4 types of black fly worms. Obtained under sterile conditions, these worms are placed on the wound and left there for 3 days. Within 3 days, these larvae eat dead and infected tissue in the wound, softening them with secretions extracted from their mouths. These secretions, in addition to softening and dissolving dead tissue, promote wound healing in various ways and mechanisms. 

5. Laser therapy 

A laser beam aimed at the area of the wound not only kills the microorganisms that cause infection but also stimulates the mechanisms in our body that allow the wound to heal. Thus, the wound healing process is accelerated. 

6. Growth hormone therapy 

A hormone called epidermal growth factor, which allows many tissues in our body to regenerate and grow, is applied both topically to the wound and injected into the wound. It is effective for all types of wounds. The drug (Heberprot-p), injected into the wound, is imported into our country from Cuba; for patients with diabetes, all treatment is paid for by state insurance. This is a very effective method of treatment, but it should not be applied to patients with cancer. 

7. Honey therapy 

Honey application to the wound is perhaps the first form of wound treatment used by man. Various enzymes and substances contained in honey keep the wound clean and provide the necessary moistness, increasing the wound healing. Some types of honey are known to be able to heal wounds more. When treating wounds, a special type of honey that has a medical form of application is used.

What is gangrene? What is amputation?

If not enough oxygen and nutrient-rich pure blood is supplied to the legs, arms, fingers/toes, irreversible tissue death, or gangrene is caused. The tissues in which gangrene develops and which lose their vitality must be removed from the body as soon as possible. Surgical removal of an extremity such as a finger, leg, or hand with developing gangrene is called amputation. Amputation should be the last option for wound healing, but in some late cases, for some patients, amputation may be the healthiest and best choice. Amputation may be the most appropriate treatment to prevent the spread of infection in the body and save the life of the patient, especially in cases with infected wounds; also so that a limb with excessive tissue death due to gangrene does not provoke the death of the remaining healthy tissue.

DIABETIC FOOT WOUND (DIABETIC WOUND)

Foot wounds in diabetic patients are one of the most common and important problems. Studies have shown that approximately 10-15% of people with diabetes will develop a foot injury at some point in their lives. Estimated studies show that out of 70 million Turkish people, about 10-11 million people have diabetes. This means that 1-1.5 million people with diabetes will someday experience this wound. The worst consequence of this wound is limb amputation. Research shows that diabetics are 15 times more likely to be amputated than non-diabetics. As a rule, half of the patients with amputated limbs lose another limb within 2 years and die within 4 years. That is why the treatment of diabetes mellitus and related wounds requires a much more serious attitude than in a situation with other diseases.

In diabetic patients, two major ailments play an important role in wound development. The first and most important of these is nerve damage called neuropathy, and the other is vasculopathy, that is, vascular damage. Motor neuropathy causes weakness and wasting of the leg muscles in the patient, sensory neuropathy leads to loss of pain, and autonomic neuropathy causes dry feet, standing defects, inability to feel pain, and dry, calloused skin on which the wound opens faster. The patient usually does not feel the formation of a callus on the leg and pain from a wound caused by a callus. The wound becomes infected and grows inside the foot. Finally, when there is discharge outside, the patient notices the wound, but at this stage it already reaches a size that threatens the limb, and treatment becomes difficult. This is why, in diabetic patients, taking precautions before the wound forms is the main treatment. Thus, overcoming serious illness in an inexpensive and simple manner is only possible by informing the patient under the supervision of an experienced wound care professional.

Regular analysis of blood sugar (hemoglobin A1C) for 3 months, regular examination of the foot by the patient and / or a relative of the patient, use of insoles and shoes made in accordance with the patient's foot anatomy, adherence to hygiene rules and a specialist examination of the foot every 6 months - these are the main measures that must be taken to prevent wound formation.

MODERN WOUND CARE PRODUCTS

Nowadays, there are many types of products available for the care of a wide variety of types of wounds. While many wounds can be treated with the old methods, these modern wound care products not only shorten the healing time but also improve patient comfort. When you take into account the side effects that can occur during the treatment period and calculate the additional costs caused by these side effects (such as infection), it becomes clear that the cost of these modern wound care products is low. These remedies help to make up for deficiencies in the wound healing process and also contribute to the continuation and acceleration of healing if the process has stopped.

Benefits of wound care products:

1. Control and prevention of discharge and odor.
2. Elimination and prevention of infection.
3. Providing fast healing.
4. Providing more accurate healing from a cosmetic point of view.
5. Providing a moist environment for the wound.
6. Reducing pain.
7. Visual relief of the patient by closing the wound.

Choosing a wound care product:

Among modern wound care products, there is no single one that is suitable for every wound. The remedy used depends on the condition of the wound, the amount of discharge, smell, place, cause, age of the patient, his general condition, financial capacity, history of the wound and many other reasons. This choice is made by a professional wound care specialist.

Products used include antibacterial agents such as films, hydrogels, foams, alginates and silver, collagen, honey products, growth hormone products or injections, enzymatic wound care products, barrier creams that prevent infection from entering a wound or opening a new wound, as well as 2 or 4-layer bandages.

In addition to the passive wound closure devices listed above, active systems and devices are available. Among these, the most commonly used are hyperbaric oxygen therapy and local negative pressure or vacuum closure (VAC).

Ozone therapy, laser therapy, larval therapy, local oxygen therapy, electrostimulation, ultrasound therapy, stem cell therapy, and treatment with a vacuum jet irrigation system are also widespread.

What are wounds from prolonged lying (bedsores/decubitus ulcers)?

Lying on your back, on your stomach, or on your side for extended periods of time in places subject to pressure, such as bony ridges, creates wounds called bedsores from continuous or prolonged pressure and friction. In these areas, the skin and subcutaneous tissue is damaged.

Who can get pressure sores?

Although these wounds usually occur in older people, they sometimes occur in people who, for various reasons, regardless of age, must be in a supine position. Pressure ulcers can develop in people who are bedridden due to neurological conditions, malnutrition, and cancer treatment, people with diabetes who have a weakened immune system and cannot move, and people who are restricted in movement due to excessive weight, urinary, and fecal incontinence.

How does a pressure sore occur?

In bedridden patients who are constantly lying or sitting, in the skin and subcutaneous tissue squeezed under the weight of the body between the bony protrusions and the bed at the points of contact with the bed, blood circulation is compressed. As a result, blood circulation is impaired and these tissues are damaged. Although at first this damage appears only as pain and redness, as the pressure on it increases, eventually a wound forms on the skin. Stretching of the skin due to friction when moving in bed, excessive moistness, and the high temperature that occurs during illness contribute to the further progression of pressure ulcers.

Where do bedsores form?

When sitting, bedsores often form in places where there are protrusions of the bones of the body, such as the tailbone, thigh, head of the shoulder, shoulder blades, elbow, heel; in the prone position - in places that touch the bed, namely: head, shoulders, shoulder blades, tailbone, hips, heels and elbows; in a lateral position - on the head, ears, shoulder, on the protrusions of the pelvic bones, near the knees and on the protrusions of the ankles.

What should be done to prevent pressure ulcers?

To prevent pressure sores, the first step is to protect the skin from pressure and friction at the sites of compression. For this, the patient in bed needs to move more. These movements will prevent muscle loss and joint calcification, as well as improve circulation and relieve pressure. Also, it is important to change the position of the patient as often as possible.

The periods between position changes should not exceed 2 hours. The change of position should be regular and not interrupted even at night. When changing the position of the patient, it is advisable to lift him from his place, not drag or pull.

In addition, the patient needs a protein-rich diet and a sufficient amount of fluids. Care of the patient's skin is also very important. The skin should not be dry or excessively damp. For dry skin, moisturizers should be used. Damp skin should not be rubbed, it should be dried by tamponing with soft tissue, such as a towel.

If the patient uses diapers, a protective cream should be applied to the area of ​​exposure to moisture and contact with feces. It is not recommended to use skincare products containing alcohol. The patient's bed should be, if possible, on an inflatable or foam mattress. The formation of folds in the bed should be controlled and prevented. Small folds in the sheet can create new pressure points and cause small wounds on the skin, so the sheets that the patient is lying on should be well taut.

Particularly in patients lying on their side, touching body parts such as the knees should be checked frequently for redness.

In order to reduce friction and pressure, support accessories such as a pillow should be placed between the areas in contact with each other. Controlling the flow of urine and stool in the patient will prevent the development of infection. Special care should be taken to prevent skin contact with urine and feces.

What are the treatment options for pressure ulcers?

Pressure ulcer prevention is essentially an integral part of treatment. Comprehensive treatment of pressure ulcers include an increase in the patient's movements, frequent position changes, adjustment of the patient's nutrition and fluid intake (if necessary, the introduction of food and vitamin supplements), the use of an inflatable or foam mattress, effective and regular cleansing of the patient from urine and stools, the use of protective cream to prevent the appearance of new wounds on healthy skin. When caring for a wound, it is important to keep the wound and the area around it clean and also to remove dead tissue from the wound. The wound should be cleaned and treated in accordance with the instructions of qualified wound care personnel. Depending on the stage of the wound, a cream, healing fluid, saline solution, modern dressings for wound care or a vacuum-assisted closure system (VAC) can be used for treatment. Antibiotics can be taken if signs of infection appear. In some rare cases, once the wound has been completely removed, it can be closed with reconstructive surgery (such as skin grafts or flaps).