Operative Debridements of Chronic Wounds

  • Andrew M. Hanflik
  • Michael S. Golinko
  • Melissa Doft
  • Charles Cain
  • Anna Flattau
  • Harold Brem


The term “chronic wound” does not refer to duration over time, but rather describes a wound that is physiologically impaired. All venous, pressure, and diabetic foot ulcers are defined as chronic wounds. Elderly patients are more likely to experience venous and pressure ulcers,1–4 which lead to more than half of all lower extremity amputations in persons with diabetes.5 Chronic wounds heal at the same frequency of closure in elderly populations as they do in younger populations, but may heal at a slower rate, primarily because of comorbidities associated with age.6–9 The comorbidities that delay healing are prevalent among older populations and include venous insufficiency and diabetes. Although there are age-related changes to the skin, it has yet to be shown, clinically, that age alone decreases an elderly person’s ability to heal.7,10,11 A synergistic effect of advanced age and diabetes significantly slows healing.12


Peripheral Arterial Disease Pressure Ulcer Chronic Wound Spinal Cord Injury Patient Venous Ulcer 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


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  1. 1.
    Walker N, Rodgers A, Birchall N, Norton R, MacMahon S. The occurrence of leg ulcers in Auckland: results of a population-based study. NZ Med J 2002;115:159–162.Google Scholar
  2. 2.
    Livesley NJ, Chow AW. Infected pressure ulcers in elderly individuals. Clin Infect Dis 2002;35:1390–1396.PubMedCrossRefGoogle Scholar
  3. 3.
    Margolis DJ, Bilker W, Santanna J, Baumgarten M. Venous leg ulcer: incidence and prevalence in the elderly. J Am Acad Dermatol 2002;46:381–386.PubMedCrossRefGoogle Scholar
  4. 4.
    Selvin E, Erlinger TP. Prevalence of and risk factors for peripheral arterial disease in the United States: results from the National Health and Nutrition Examination Survey, 1999–2000. Circulation 2004;110:738–743.PubMedCrossRefGoogle Scholar
  5. 5.
    Data & Trends. National Diabetes Surveillance System. Hospitalizations for nontraumatic lower extremity amputation, 1980–2003: Centers for Disease Control (CDC). Available at: byAgetable1_2.htm. Accessed September 30, 2006.Google Scholar
  6. 6.
    Brem H, Tomic-Canic M, Tarnovskaya A, et al. Healing of elderly patients with diabetic foot ulcers, venous stasis ulcers, and pressure ulcers. Surg Technol Int 2003;11:161–167.PubMedGoogle Scholar
  7. 7.
    Gosain A, DiPietro LA. Aging and wound healing. World J Surg 2004;28:321–326.PubMedCrossRefGoogle Scholar
  8. 8.
    Margolis DJ, Allen-Taylor L, Hoffstad O, Berlin JA. Diabetic neuropathic foot ulcers: predicting which ones will not heal. Am J Med 2003;115:627–631.PubMedCrossRefGoogle Scholar
  9. 9.
    Margolis DJ, Allen-Taylor L, Hoffstad O, Berlin JA. The accuracy of venous leg ulcer prognostic models in a wound care system. Wound Repair Regen 2004;12:163–168.PubMedCrossRefGoogle Scholar
  10. 10.
    Van de Kerkhof PC, Van Bergen B, Spruijt K, Kuiper JP. Age-related changes in wound healing. Clin Exp Dermatol 1994;19:369–374.PubMedCrossRefGoogle Scholar
  11. 11.
    Thomas DR. Age-related changes in wound healing. Drugs Aging 2001;18:607–620.PubMedCrossRefGoogle Scholar
  12. 12.
    Brem H, Tomic-Canic M, Entero H, et al. The synergism of age and db/db genotype impairs wound healing. Exp Gerontol 2007 Jan 31.Google Scholar
  13. 13.
    Di Maio VJ, Di Maio TG. Homicide by decubitus ulcers. Am J Forensic Med Pathol 2002;23:1–4.PubMedCrossRefGoogle Scholar
  14. 14.
    Attinger CE, Janis JE, Steinberg J, Schwartz J, Al-Attar A, Couch K. Clinical approach to wounds: debridement and wound bed preparation including the use of dressings and wound-healing adjuvants. Plast Reconstr Surg 2006; 117:72S–109S.PubMedCrossRefGoogle Scholar
  15. 15.
    National Institute of Diabetes and Digestive and Kidney Diseases. National diabetes statistics fact sheet: general information and national estimates on diabetes in the United States, 2005. Bethesda, MD: U.S. Department of Health and Human Services, National Institute of Health. Available at: Accessed February 8, 2007.Google Scholar
  16. 16.
    Klein SA, Bond SJ, Gupta SC, Yacoub OA, Anderson GL. Angiogenesis inhibitor TNP-470 inhibits murine cutaneous wound healing. J Surg Res 1999;82:268–274.PubMedCrossRefGoogle Scholar
  17. 17.
    Data & Trends. National Diabetes Surveillance System. Annual number (in thousands) of new cases of diagnosed diabetes among adults aged 18–79 years, United States, 1997–2004: Centers for Disease Control (CDC). Available at: htm. Accessed September 30, 2006.Google Scholar
  18. 18.
    Wild S, Roglic G, Green A, Sicree R, King H. Global prevalence of diabetes: estimates for the year 2000 and projections for 2030. Diabetes Care 2004;27:1047–1053.PubMedCrossRefGoogle Scholar
  19. 19.
    Pecoraro RE, Reiber GE, Burgess EM. Pathways to diabetic limb amputation. Basis for prevention. Diabetes Care 1990;13:513–521.PubMedCrossRefGoogle Scholar
  20. 20.
    Boyko EJ, Ahroni JH, Stensel V, Forsberg RC, Davignon DR, Smith DG. A prospective study of risk factors for diabetic foot ulcer. The Seattle Diabetic Foot Study. Diabetes Care 1999;22:1036–1042.PubMedCrossRefGoogle Scholar
  21. 21.
    Abbott CA, Carrington AL, Ashe H, et al. The North-West Diabetes Foot Care Study: incidence of, and risk factors for, new diabetic foot ulceration in a community-based patient cohort. Diabet Med 2002;19:377–384.PubMedCrossRefGoogle Scholar
  22. 22.
    Aguiar ME, Burrows NR, Wang J, Boyle JP, Geiss LS, Engelgau MM. History of foot ulcer among persons with diabetes—United States, 2000–2002. MMWR Morb Mortal Wkly Rep 2003;52:1098–1102.Google Scholar
  23. 23.
    Prompers L, Huijberts M, Apelqvist J, et al. High prevalence of ischaemia, infection and serious comorbidity in patients with diabetic foot disease in Europe. Baseline results from the Eurodiale study. Diabetologia 2007;50(1): 18–25.PubMedCrossRefGoogle Scholar
  24. 24.
    Klamer TW, Towne JB, Bandyk DF, Bonner MJ. The influence of sepsis and ischemia on the natural history of the diabetic foot. Am Surg 1987;53:490–494.PubMedGoogle Scholar
  25. 25.
    Cevera JJ, Bolton LL, Kerstein MD. Options for diabetic patients with chronic heel ulcers. J Diabetes Complications 1997;11:358–366.PubMedCrossRefGoogle Scholar
  26. 26.
    Pressure ulcers prevalence, cost and risk assessment: consensus development conference statement—The National Pressure Ulcer Advisory Panel. Decubitus 1989; 2:24–28.Google Scholar
  27. 27.
    Margolis DJ. Definition of a pressure ulcer. Adv Wound Care 1995;8:Suppl 8–10.PubMedGoogle Scholar
  28. 28.
    Russo CA, Elixhauser A. Hospitalizations Related to Pressure Sores, 2003 HCUP Statistical Brief #3. Rockville, MD: Agency for Healthcare Research and Quality; 2006.Google Scholar
  29. 29.
    Whittington KT, Briones R. National Prevalence and Incidence Study: 6-year sequential acute care data. Adv Skin Wound Care 2004;17:490–494.PubMedCrossRefGoogle Scholar
  30. 30.
    Brem H, Nierman DM, Nelson JE. Pressure ulcers in the chronically critically ill patient. Crit Care Clin 2002;18: 683–694.PubMedCrossRefGoogle Scholar
  31. 31.
    Brandeis GH, Ooi WL, Hossain M, Morris JN, Lipsitz LA. A longitudinal study of risk factors associated with the formation of pressure ulcers in nursing homes. J Am Geriatr Soc 1994;42:388–393.PubMedGoogle Scholar
  32. 32.
    Allman RM, Goode PS, Patrick MM, Burst N, Bartolucci AA. Pressure ulcer risk factors among hospitalized patients with activity limitation. JAMA 1995;273:865–870.PubMedCrossRefGoogle Scholar
  33. 33.
    Eachempati SR, Hydo LJ, Barie PS. Factors influencing the development of decubitus ulcers in critically ill surgical patients. Crit Care Med 2001;29:1678–1682.PubMedCrossRefGoogle Scholar
  34. 34.
    Mecocci P, von Strauss E, Cherubini A, et al. Cognitive impairment is the major risk factor for development of geriatric syndromes during hospitalization: results from the GIFA study. Dement Geriatr Cogn Disord 2005;20: 262–269.PubMedCrossRefGoogle Scholar
  35. 35.
    Berlowitz DR, Brandeis GH, Anderson J, Du W, Brand H. Effect of pressure ulcers on the survival of long-term care residents. J Gerontol A Biol Sci Med Sci 1997;52: M106–110.PubMedGoogle Scholar
  36. 36.
    Dale MC, Burns A, Panter L, Morris J. Factors affecting survival of elderly nursing home residents. Int J Geriatr Psychiatry 2001;16:70–76.PubMedCrossRefGoogle Scholar
  37. 37.
    Thomas DR, Goode PS, Tarquine PH, Allman RM. Hospital-acquired pressure ulcers and risk of death. J Am Geriatr Soc 1996;44:1435–1440.PubMedGoogle Scholar
  38. 38.
    Redelings MD, Lee NE, Sorvillo F. Pressure ulcers: more lethal than we thought? Adv Skin Wound Care 2005;18: 367–372.PubMedCrossRefGoogle Scholar
  39. 39.
    Anderson RN, Smith BL. Deaths: leading causes for 2002. Natl Vital Stat Rep 2005;53:1–89.PubMedGoogle Scholar
  40. 40.
    Angus DC, Linde-Zwirble WT, Lidicker J, Clermont G, Carcillo J, Pinsky MR. Epidemiology of severe sepsis in the United States: analysis of incidence, outcome, and associated costs of care. Crit Care Med 2001;29:1303–1310.PubMedCrossRefGoogle Scholar
  41. 41.
    Baker SR, Stacey MC, Jopp-McKay AG, Hoskin SE, Thompson PJ. Epidemiology of chronic venous ulcers. Br J Surg 1991;78:864–867.PubMedCrossRefGoogle Scholar
  42. 42.
    Abbade LPF, Lastoria S. Venous ulcer: epidemiology, physiopathology, diagnosis and treatment. Int J Dermatol 2005;44:449–456.PubMedCrossRefGoogle Scholar
  43. 43.
    Margolis DJ, Bilker W, Santanna J, Baumgarten M. Venous leg ulcer: incidence and prevalence in the elderly. J Am Acad Dermatol 2002;46:381–386.PubMedCrossRefGoogle Scholar
  44. 44.
    Brem H, Kirsner RS, Falanga V. Protocol for the successful treatment of venous ulcers. Am J Surg 2004;188:1–8.PubMedCrossRefGoogle Scholar
  45. 45.
    Wissing U, Ek AC, Unosson M. Life situation and function in elderly people with and without leg ulcers. Scand J Caring Sci 2002;16:59–65.PubMedCrossRefGoogle Scholar
  46. 46.
    Valencia IC, Falabella A, Kirsner RS, Eaglstein WH. Chronic venous insufficiency and venous leg ulceration. J Am Acad Dermatol 2001;44:401–421; quiz 422–424.PubMedCrossRefGoogle Scholar
  47. 47.
    Capitao LM, Menezes JD, Gouveia-Oliveira A. A multivariate analysis of the factors associated with the severity of chronic venous insufficiency [in Portuguese]. Acta Med Port 1993;6:501–506.PubMedGoogle Scholar
  48. 48.
    Delis KT. Perforator vein incompetence in chronic venous disease: a multivariate regression analysis model. J Vasc Surg 2004;40:626–633.PubMedCrossRefGoogle Scholar
  49. 49.
    Scott TE, LaMorte WW, Gorin DR, Menzoian JO. Risk factors for chronic venous insufficiency: a dual case-control study. J Vasc Surg 1995;22:622–628.PubMedCrossRefGoogle Scholar
  50. 50.
    van Haarst EP, Liasis N, van Ramshorst B, Moll FL. The development of valvular incompetence after deep vein thrombosis: a 7 year follow-up study with duplex scanning. Eur J Vasc Endovasc Surg 1996;12:295–299.PubMedCrossRefGoogle Scholar
  51. 51.
    Falanga V, Eaglstein WH. The “trap” hypothesis of venous ulceration. Lancet 1993;341:1006–1008.PubMedCrossRefGoogle Scholar
  52. 52.
    Higley HR, Ksander GA, Gerhardt CO, Falanga V. Extravasation of macromolecules and possible trapping of transforming growth factor-beta in venous ulceration. Br J Dermatol 1995;132:79–85.PubMedCrossRefGoogle Scholar
  53. 53.
    Kweon SS, Shin MH, Park KS, et al. Distribution of the ankle-brachial index and associated cardiovascular risk factors in a population of middle-aged and elderly Koreans. J Korean Med Sci 2005;20:373–378.PubMedCrossRefGoogle Scholar
  54. 54.
    Rhee SY, Guan H, Liu ZM, et al. Multi-country study on the prevalence and clinical features of peripheral arterial disease in Asian type 2 diabetes patients at high risk of atherosclerosis. Diabetes Res Clin Pract 2007;76: 82–92.PubMedCrossRefGoogle Scholar
  55. 55.
    Cimminiello C. PAD: epidemiology and pathophysiology. Thromb Res 2002;106:V295–V301.PubMedCrossRefGoogle Scholar
  56. 56.
    Doubeni CA, Yood RA, Emani S, Gurwitz JH. Identifying unrecognized peripheral arterial disease among asymptomatic patients in the primary care setting. Angiology 2006;57:171–180.PubMedCrossRefGoogle Scholar
  57. 57.
    Brem H, Tsakayannis D, Folkman J. Time dependent suppression of wound healing with the angiogenesis inhibitor, AGM-1470. J Cell Biol 1991;115:403a.Google Scholar
  58. 58.
    O’Reilly MS, Brem H, Folkman J. Treatment of murine hemangioendotheliomas with the angiogenesis inhibitor AGM-1470. J Pediatr Surg 1995;30:325–330.PubMedCrossRefGoogle Scholar
  59. 59.
    Bond SJ, Klein SA. TNP-470 reduces collagen and macrophage accumulation in expanded polytetrafluoroethylene tube implants. J Surg Res 2001;101:99–103.PubMedCrossRefGoogle Scholar
  60. 60.
    Rivard A, Berthou-Soulie L, Principe N, et al. Agedependent defect in vascular endothelial growth factor expression is associated with reduced hypoxia-inducible factor 1 activity. J Biol Chem 2000;275:29643–29647.PubMedCrossRefGoogle Scholar
  61. 61.
    Rivard A, Fabre JE, Silver M, et al. Age-dependent impairment of angiogenesis. Circulation 1999;99:111–120.PubMedGoogle Scholar
  62. 62.
    Swift ME, Kleinman HK, DiPietro LA. Impaired wound repair and delayed angiogenesis in aged mice. Lab Invest 1999;79:1479–1487.PubMedGoogle Scholar
  63. 63.
    Nathan CF. Secretory products of macrophages. J Clin Invest 1987;79:319–326.PubMedCrossRefGoogle Scholar
  64. 64.
    Cohen BJ, Danon D, Roth GS. Wound repair in mice as influenced by age and antimacrophage serum. J Gerontol 1987;42:295–301.PubMedGoogle Scholar
  65. 65.
    Plowden J, Renshaw-Hoelscher M, Engleman C, Katz J, Sambhara S. Innate immunity in aging: impact on macrophage function. Aging Cell 2004;3:161–167.PubMedCrossRefGoogle Scholar
  66. 66.
    Ballas CB, Davidson JM. Delayed wound healing in aged rats is associated with increased collagen gel remodeling and contraction by skin fibroblasts, not with differences in apoptotic or myofibroblast cell populations. Wound Repair Regen 2001;9:223–237.PubMedCrossRefGoogle Scholar
  67. 67.
    Yoshikawa TT. Perspective: aging and infectious diseases— past, present, and future. J Infect Dis 1997;176:1053–1057.PubMedCrossRefGoogle Scholar
  68. 68.
    Gregg R, Smith CM, Clark FJ, et al. The number of human peripheral blood CD4 CD25 regulatory T cells increases with age. Clin Exp Immunol 2005;140:540–546.PubMedCrossRefGoogle Scholar
  69. 69.
    Dejaco C, Duftner C, Schirmer M. Are regulatory T-cells linked with aging? Exp Gerontol 2006;41(4):339–345.PubMedCrossRefGoogle Scholar
  70. 70.
    Naylor K, Li G, Vallejo AN, et al. The influence of age on T cell generation and TCR diversity. J Immunol 2005; 174:7446–7452.PubMedGoogle Scholar
  71. 71.
    Colonna-Romano G, Aquino A, Bulati M, et al. Impairment of gamma/delta T lymphocytes in elderly: implications for immunosenescence. Exp Gerontol 2004;39: 1439–1446.PubMedCrossRefGoogle Scholar
  72. 72.
    Brem H, Lyder C. Protocol for the successful treatment of pressure ulcers. Am J Surg 2004;188:9–17.PubMedCrossRefGoogle Scholar
  73. 73.
    Brem H, Sheehan P, Rosenberg HJ, Schneider JS, Boulton AJ. Evidence-based protocol for diabetic foot ulcers. Plast Reconstr Surg 2006;117:193S–209S; discussion 210S-211S.PubMedCrossRefGoogle Scholar
  74. 74.
    Berlowitz DR, Wilking SV. Risk factors for pressure sores. A comparison of cross-sectional and cohort-derived data. J Am Geriatr Soc 1989;37:1043–1050.PubMedGoogle Scholar
  75. 75.
    Bergstrom N, Braden B. A prospective study of pressure sore risk among institutionalized elderly. J Am Geriatr Soc 1992;40:747–758.PubMedGoogle Scholar
  76. 76.
    Breslow RA, Hallfrisch J, Guy DG, Crawley B, Goldberg AP. The importance of dietary protein in healing pressure ulcers. J Am Geriatr Soc 1993;41:357–362.PubMedGoogle Scholar
  77. 77.
    Niazi K, Khan TH, Easley KA. Diagnostic utility of the two methods of ankle brachial index in the detection of peripheral arterial disease of lower extremities. Catheter Cardiovasc Interv 2006;68:788–792.PubMedCrossRefGoogle Scholar
  78. 78.
    Schroder F, Diehm N, Kareem S, et al. A modified calculation of ankle-brachial pressure index is far more sensitive in the detection of peripheral arterial disease. J Vasc Surg 2006;44:531–536.PubMedCrossRefGoogle Scholar
  79. 79.
    Carter SA, Tate RB. The relationship of the transcutaneous oxygen tension, pulse waves and systolic pressures to the risk for limb amputation in patients with peripheral arterial disease and skin ulcers or gangrene. Int Angiol 2006; 25:67–72.PubMedGoogle Scholar
  80. 80.
    ACC/AHA 2005 Practice Guidelines for the Management of Patients with Peripheral Arterial Disease (Lower Extremity, Renal, Mesenteric, and Abdominal Aortic): A Collaborative Report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients with Peripheral Arterial Disease): Endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; and Vascular Disease Foundation. Circulation 2006;113:e463–654.Google Scholar
  81. 81.
    Silvestro A, Diehm N, Savolainen H, et al. Falsely high ankle-brachial index predicts major amputation in critical limb ischemia. Vasc Med 2006;11:69–74.PubMedCrossRefGoogle Scholar
  82. 82.
    Williams DT, Harding KG, Price P. An evaluation of the efficacy of methods used in screening for lower-limb arterial disease in diabetes. Diabetes Care 2005;28:2206–2210.PubMedCrossRefGoogle Scholar
  83. 83.
    Laird JR, Zeller T, Gray BH, et al. Limb salvage following laser-assisted angioplasty for critical limb ischemia: results of the LACI multicenter trial. J Endovasc Ther 2006; 13:1–11.PubMedCrossRefGoogle Scholar
  84. 84.
    Costanza MJ, Queral LA, Lilly MP, Finn WR. Hemodynamic outcome of endovascular therapy for transatlantic intersociety consensus type B femoropopliteal arterial occlusive lesions. J Vasc Surg 2004;39:343–350.PubMedCrossRefGoogle Scholar
  85. 85.
    Becquemin J-P, Favre J-P, Marzelle J, Nemoz C, Corsin C, Leizorovicz A. Systematic versus selective stent placement after superficial femoral artery balloon angioplasty: a multicenter prospective randomized study. J Vasc Surg 2003;37:487–494.PubMedCrossRefGoogle Scholar
  86. 86.
    Faglia E, Mantero M, Caminiti M, et al. Extensive use of peripheral angioplasty, particularly infrapopliteal, in the treatment of ischaemic diabetic foot ulcers: clinical results of a multicentric study of 221 consecutive diabetic subjects. J Intern Med 2002;252:225–232.PubMedCrossRefGoogle Scholar
  87. 87.
    Kudo T, Chandra FA, Ahn SS. The effectiveness of percutaneous transluminal angioplasty for the treatment of critical limb ischemia: a 10-year experience. J Vasc Surg 2005; 41:423–435.PubMedCrossRefGoogle Scholar
  88. 88.
    Steed DL. Debridement. Am J Surg 2004;187:S71–S74.CrossRefGoogle Scholar
  89. 89.
    Elias SM, Frasier KL. Minimally invasive vein surgery: its role in the treatment of venous stasis ulceration. Am J Surg 2004;188:26–30.PubMedCrossRefGoogle Scholar
  90. 90.
    Puggioni A, Kalra M, Gloviczki P. Superficial vein surgery and SEPS for chronic venous insufficiency. Semin Vasc Surg 2005;18:41–48.PubMedCrossRefGoogle Scholar
  91. 91.
    Ting AC, Cheng SW, Ho P, Poon JT, Wu LL, Cheung GC. Reduction in deep vein reflux after concomitant subfascial endoscopic perforating vein surgery and superficial vein ablation in advanced primary chronic venous insufficiency. J Vasc Surg 2006;43:546–550.PubMedCrossRefGoogle Scholar
  92. 92.
    Barwell J, Davies CE, Deacon J, et al. Comparison of surgery and compression with compression alone in chronic venous ulceration (ESCHAR study): randomised controlled trial. Lancet 2004;363:1854–1859.PubMedCrossRefGoogle Scholar
  93. 93.
    TenBrook J, John A, Iafrati MD, et al. Systematic review of outcomes after surgical management of venous disease incorporating subfascial endoscopic perforator surgery. J Vasc Surg 2004;39:583–589.PubMedCrossRefGoogle Scholar
  94. 94.
    Roka F, Binder M, Bohler-Sommeregger K. Mid-term recurrence rate of incompetent perforating veins after combined superficial vein surgery and subfascial endoscopic perforating vein surgery. J Vasc Surg 2006;44: 359–363.PubMedCrossRefGoogle Scholar
  95. 95.
    Kantor J, Margolis DJ. Efficacy and prognostic value of simple wound measurements. Arch Dermatol 1998;134: 1571–1574.PubMedCrossRefGoogle Scholar
  96. 96.
    Edmonds M, Foster A. The use of antibiotics in the diabetic foot. Am J Surg 2004;187:25S–28S.PubMedCrossRefGoogle Scholar
  97. 97.
    Weigelt J, Kaafarani HM, Itani KM, Swanson RN. Linezolid eradicates MRSA better than vancomycin from surgical-site infections. Am J Surg 2004;188:760–766.PubMedCrossRefGoogle Scholar
  98. 98.
    Ruiz de Gopegui E, Oliver A, Ramirez A, Gutierrez O, Andreu C, Perez JL. Epidemiological relatedness of methicillin-resistant Staphylococcus aureus from a tertiary hospital and a geriatric institution in Spain. Clin Microbiol Infect 2004;10:339–342.CrossRefGoogle Scholar
  99. 99.
    Fridkin SK, Hageman JC, Morrison M, et al. The Active Bacterial Core Surveillance Program of the Emerging Infections Program Network. Methicillin-resistant Staphylococcus aureus disease in three communities. N Engl J Med 2005;352:1436–1444.PubMedCrossRefGoogle Scholar
  100. 100.
    Zacur H, Kirsner RS. Debridement: rationale and therapeutic options. Wounds Sep 2002;14:2S–6S.Google Scholar
  101. 101.
    Saap LJ, Falanga V. Debridement performance index and its correlation with complete closure of diabetic foot ulcers. Wound Repair Regen 2002;10:354–359.PubMedCrossRefGoogle Scholar
  102. 102.
    Steed DL, Donohoe D, Webster MW, Lindsley L. Effect of extensive debridement and treatment on the healing of diabetic foot ulcers. Diabetic Ulcer Study Group. J Am Coll Surg 1996;183:61–64.PubMedGoogle Scholar
  103. 103.
    Williams D, Enoch S, Miller D, Harris K, Price P, Harding KG. Effect of sharp debridement using curette on recalcitrant nonhealing venous leg ulcers: a concurrently controlled, prospective cohort study. Wound Repair Regen 2005;13:131–137.PubMedCrossRefGoogle Scholar
  104. 104.
    Stojadinovic O, Brem H, Vouthounis C, et al. The role of the beta-catenin and c-myc in pathogenesis of cutaneous wound healing. Am J Pathol 2005;167:59–69.PubMedGoogle Scholar
  105. 105.
    Steed DL. Foundations of good ulcer care. Am J Surg 1998;176:20S–25S.PubMedCrossRefGoogle Scholar
  106. 106.
    Mueller MJ, Diamond JE, Sinacore DR, et al. Total contact casting in treatment of diabetic plantar ulcers. Controlled clinical trial. Diabetes Care 1989;12:384–388.PubMedCrossRefGoogle Scholar
  107. 107.
    Armstrong DG, Nguyen HC, Lavery LA, van Schie CH, Boulton AJ, Harkless LB. Off-loading the diabetic foot wound: a randomized clinical trial. Diabetes Care 2001; 24:1019–1022.PubMedCrossRefGoogle Scholar
  108. 108.
    Armstrong DG, Short B, Espensen EH, Abu-Rumman PL, Nixon BP, Boulton AJM. Technique for fabrication of an “instant total-contact cast” for treatment of neuropathic diabetic foot ulcers. J Am Podiatr Med Assoc 2002;92: 405–408.PubMedGoogle Scholar
  109. 109.
    Boulton AJ, Kirsner RS, Vileikyte L. Clinical practice. Neuropathic diabetic foot ulcers. N Engl J Med 2004; 351:48–55.PubMedCrossRefGoogle Scholar
  110. 110.
    Nelson EA, Iglesias CP, Cullum N, Torgerson DJ. Randomized clinical trial of four-layer and short-stretch compression bandages for venous leg ulcers (VenUS I). Br J Surg 2004;91:1292–1299.PubMedCrossRefGoogle Scholar
  111. 111.
    Fletcher A, Cullum N, Sheldon TA. A systematic review of compression treatment for venous leg ulcers. BMJ 1997; 315:576–580.PubMedGoogle Scholar
  112. 112.
    Marston WA, Hanft J, Norwood P, Pollak R. The efficacy and safety of Dermagraft in improving the healing of chronic diabetic foot ulcers: results of a prospective randomized trial. Diabetes Care 2003;26:1701–1705.PubMedCrossRefGoogle Scholar
  113. 113.
    Veves A, Falanga V, Armstrong DG, Sabolinski ML. Graftskin, a human skin equivalent, is effective in the management of noninfected neuropathic diabetic foot ulcers: a prospective randomized multicenter clinical trial. Diabetes Care 2001;24:290–295.PubMedCrossRefGoogle Scholar
  114. 114.
    Steed DL. Clinical evaluation of recombinant human platelet-derived growth factor for the treatment of lower extremity diabetic ulcers. Diabetic Ulcer Study Group. J Vasc Surg 1995;21:71–78; discussion 79–81.PubMedCrossRefGoogle Scholar
  115. 115.
    Steed DL. Clinical evaluation of recombinant human platelet-derived growth factor for the treatment of lower extremity ulcers. Plast Reconstr Surg 2006;117:143S–149S; discussion 150S-151S.PubMedCrossRefGoogle Scholar
  116. 116.
    Falanga V, Margolis D, Alvarez O, et al. Rapid healing of venous ulcers and lack of clinical rejection with an allogeneic cultured human skin equivalent. Human Skin Equivalent Investigators Group. Arch Dermatol 1998;134: 293–300.PubMedCrossRefGoogle Scholar
  117. 117.
    Goyal P, Puri GD, Pandey CK, Srivastva S. Evaluation of induction doses of propofol: comparison between endstage renal disease and normal renal function patients. Anaesth Intensive Care 2002;30:584–587.PubMedGoogle Scholar
  118. 118.
    Reiber GE, Vileikyte L, Boyko EJ, et al. Causal pathways for incident lower-extremity ulcers in patients with diabetes from two settings. Diabetes Care 1999;22:157–162.PubMedCrossRefGoogle Scholar
  119. 119.
    Curtin CM, Gater DR, Chung KC. Autonomic dysreflexia: a plastic surgery primer. Ann Plast Surg 2003;51:325–329.PubMedCrossRefGoogle Scholar
  120. 120.
    Assadi F, Czech K, Palmisano JL. Autonomic dysreflexia manifested by severe hypertension. Med Sci Monit2004;10: CS77–79.PubMedGoogle Scholar
  121. 121.
    Adam S, Forrest S. ABC of intensive care: other supportive care. BMJ 1999;319:175–178.PubMedGoogle Scholar
  122. 122.
    Padberg J, Frank T, Johnston MV, Sisto SA. Structured exercise improves calf muscle pump function in chronic venous insufficiency: a randomized trial. J Vasc Surg 2004; 39:79–87.PubMedCrossRefGoogle Scholar
  123. 123.
    Freedman G, Cean C, Duron V, Tarnovskaya A, Brem H. Pathogenesis and treatment of pain in patients with chronic wounds. Surg Technol Int 2003;11:168–179.PubMedGoogle Scholar
  124. 124.
    Freedman G, Entero H, Brem H. Practical treatment of pain in patients with chronic wounds: pathogenesis-guided management. Am J Surg 2004;188:31–35.PubMedCrossRefGoogle Scholar
  125. 125.
    World Health Organization. Cancer pain relief. Geneva: World Health Organization; 1996.Google Scholar
  126. 126.
    Scott EM, Leaper DJ, Clark M, Kelly PJ. Effects of warming therapy on pressure ulcers—a randomized trial. AORN J 2001;73:921–927, 929–933, 936–938.PubMedCrossRefGoogle Scholar
  127. 127.
    Aronovitch S. Hospital acquired pressure ulcers: a comparison of costs in medical versus surgical patients, 1–18 First Annual OR-Acquired Pressure Ulcer Symposium. Atlanta, GA, 1998.Google Scholar
  128. 128.
    Scott EM, Buckland R. Pressure ulcer risk in the perioperative environment. Nurs Stand 2005;20:74, 76, 78 passim.PubMedGoogle Scholar
  129. 129.
    Hoshowsky VM, Schramm CA. Intraoperative pressure sore prevention: an analysis of bedding materials. Res Nurs Health 1994;17:333–339.PubMedCrossRefGoogle Scholar
  130. 130.
    Schoonhoven L, Defloor T, Grypdonck MH. Incidence of pressure ulcers due to surgery. J Clin Nurs 2002;11:479–487.PubMedCrossRefGoogle Scholar
  131. 131.
    De Keyser G, Dejaeger E, De Meyst H, Eders GC. Pressure-reducing effects of heel protectors. Adv Wound Care 1994;7:30–32, 34.PubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2008

Authors and Affiliations

  • Andrew M. Hanflik
    • 1
  • Michael S. Golinko
    • 2
  • Melissa Doft
    • 3
  • Charles Cain
    • 4
  • Anna Flattau
    • 5
  • Harold Brem
    • 2
  1. 1.Keck School of MedicineUniversity of Southern CaliforniaLos AngelesUSA
  2. 2.Department of Surgery—Wound Healing ProgramColumbia University Medical CenterNew YorkUSA
  3. 3.Surgical Resident Department of SurgeryColumbia University Medical CenterNew YorkUSA
  4. 4.Department of AnesthesiologyColumbia University Medical CenterNew YorkUSA
  5. 5.Department of Surgery and Family Medicine—Wound Healing ProgramColumbia University Medical CenterNew YorkUSA

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