Head-to-heal wounds—particularly diabetic lower-extremity wounds—remain among the most challenging and resource-intensive problems in contemporary healthcare, with five-year recurrence rates of 40–65% and a trajectory toward amputation that is frequently driven by three interacting and often under-recognised failures: inadequate perfusion; unrecognised bacterial burden; and unaddressed biomechanical deformity. Near-infrared spectroscopy (NIRS) and bacterial autofluorescence (BAF)—two point-of-care optical imaging technologies—now permit objective, real-time characterisation of the two dominant modifiable barriers to healing: tissue oxygenation and bacterial load. PRISM (perfusion imaging, regional bacterial status, infection staging, structural correction, and maintenance and monitoring) is a structured, imaging-first algorithm that organises these technologies into a single, sequential pathway for hard-to-heal wound assessment and management. This article reviews the operating principles and clinical evidence for NIRS and BAF, expands each of the five PRISM components in a stepwise clinical description, and presents an integrated decision matrix-tree that translates combined imaging findings into actionable, point-of-care interventions. By anchoring every clinical decision in real-time imaging data rather than clinical impression alone, PRISM offers a reproducible framework for earlier identification of healing barriers, more targeted therapy, antimicrobial stewardship, objective longitudinal monitoring and limb preservation.
Objective: Revascularisation is central to limb salvage in chronic limb-threatening ischaemia (CLTI) and diabetic foot ulceration (DFU); however, the optimal method for selecting target vessels remains uncertain. The angiosome model has traditionally guided revascularisation planning, while the emerging woundosome concept emphasises wound-level perfusion, collateral circulation, microvascular function, wound severity and multidisciplinary care. This review evaluated whether current evidence supports angiosome-guided revascularisation alone or a more wound-centred approach. Method: A structured review of PubMed/MEDLINE, Embase, Scopus and Cochrane Library databases was conducted from inception to May 2026. Eligible studies included guidelines, systematic reviews, meta-analyses, randomised trials and comparative cohort studies reporting wound healing, limb salvage, major amputation, amputation-free survival or mortality in adults with CLTI and/or DFU undergoing revascularisation. Results: Direct angiosome revascularisation was associated with improved wound healing and limb salvage compared with indirect revascularisation without collateral support. Across multiple evidence syntheses, direct revascularisation and indirect revascularisation with preserved collaterals achieved comparable outcomes and both outperformed indirect revascularisation without collaterals. Functional measures of perfusion, particularly wound blush, were stronger predictors of healing and limb salvage than angiosome alignment alone. Wound severity, assessed by Wound, Ischaemia, Foot Infection (WIfI) stage classification, independently predicted outcomes, whereas the significance of direct angiosome perfusion diminished after adjustment for wound characteristics. Contemporary guidelines emphasise maximising perfusion to the wound bed rather than strict anatomic angiosome targeting. Conclusion: The angiosome model remains an important anatomical framework but does not fully account for perfusion heterogeneity, collateral circulation and wound-specific factors. The woundosome concept may complement angiosome-guided planning by emphasising functional wound-level perfusion. Current evidence supports an integrated strategy that prioritises direct revascularisation when feasible while incorporating collateral assessment, wound blush, WIfI staging and multidisciplinary care. Prospective validation of the woundosome concept is warranted.
Objective: Diabetic foot ulcers and venous leg ulcers (VLUs) frequently recur after closure, and because the underlying disease persists, a more meaningful endpoint to consider is durable healing: sustained closure with low recurrence and fewer complications. Mechanistically, topical wound oxygen supports antimicrobial defence, angiogenesis and collagen cross-linking, while cyclical compression reduces oedema and enables timely resolution of inflammation, improving the structural quality of repaired tissue rather than merely closing the wound. Combining both modalities in one device offers a plausible mechanism for the durability observed across diverse wound aetiologies and comorbid populations. Method: Clinical and mechanistic evidence was synthesised on the durability of healing achieved by intermittent cyclically pressurised topical wound oxygen (CPTWO) therapy in hard-to-heal (chronic) lower extremity wounds. Results: In a double-blind randomised trial, adjunctive CPTWO therapy doubled the proportion of ulcers closed at 12 months (56% versus 27%) and tripled 12-week closure (41.7% versus 13.5%; adjusted odds ratio: 6.00). In refractory VLUs, an observational comparative study reported 36-month recurrence with CPTWO of 5.9% versus 46.7% without. In a large retrospective cohort study among 3126 previously refractory wounds, 64.8% healed completely with 2.7% recurrence-related retreatment with CPTWO, and a propensity score-matched Veterans Affairs cohort showed 73% fewer amputations and 82% fewer hospitalisations. As most meta-analyses pool mechanistically different oxygen devices, durability-specific evidence rests uniquely on the CPTWO studies. Conclusion: Randomised, real-world, and mechanistic evidence converge in support of durable healing with reduced recurrence in hard-to-heal lower extremity wounds. Together with its home-based, patient-administered delivery, these findings favour earlier, durability-focused adoption of CPTWO therapy in refractory wounds.
Objective: Hard-to-heal (chronic) lower extremity ulcers represent a significant clinical challenge with substantial morbidity and healthcare costs. Extracorporeal shockwave therapy (ESWT) has emerged as a promising adjunctive treatment modality for hard-to-heal wounds, though evidence for combined electromagnetic transduction therapy (EMTT) and ESWT remains limited. The aim of this study was to describe wound healing and pain outcomes associated with combined EMTT and ESWT, used as an adjunct to standard of care (SoC), in patients with hard-to-heal lower extremity ulcers, and to investigate whether the outcomes warrant further prospective study. Method: This retrospective chart review analysed consecutive patients with hard-to-heal post-Mohs excisional lower extremity wounds that had failed primary closure after four weeks of SoC, treated with combined Storz Medical AG EMTT (Storz Medical AG, Switzerland) and ESWT using the Storz Medical AG ESWT with C-ACTOR device (Storz Medical AG, Switzerland) between December 2025 and March 2026. All patients received twice-weekly treatments for four weeks (eight treatments in total). Ankle–brachial pressure index (ABPI) was measured at baseline to assess arterial perfusion. Following completion of shockwave therapy, all patients underwent surgical debridement and received standardised wound dressings consisting of non-adherent foam, gauze and Conforming Stretch Gauze Bandage (Medline, US). Primary outcomes included wound surface area (WSA) reduction at weeks 4 and 8, time to complete wound closure, and pain scores at baseline, at week 4 and at wound closure. Results: The cohort consisted of 15 patients (mean age: 82.2±7.1 years; 66.7% female; 80.0% White; 20.0% Hispanic). Mean baseline ABPI was 1.05±0.13 (range: 0.82–1.33). Mean WSA decreased from 2.89±1.08cm 2 at baseline to 0.88±0.93cm 2 at week 4 (p<0.001), representing a 69.5% reduction. A total of 13 patients (86.7%) achieved complete wound closure, with a mean time to closure of 5.2±1.3 weeks (range: 3–8 weeks). Visual analogue pain scores decreased from 8.1±1.2 at baseline to 2.3±0.9 at week 4 (p<0.001), representing a 71.9% reduction in pain severity. All patients who achieved complete wound closure reported complete pain resolution. All patients completed the full eight-treatment protocol without reported adverse events. Conclusion: In this small, retrospective, uncontrolled, single-centre case series of 15 patients, combined EMTT/ESWT used as an adjunct to SoC was associated with wound closure (86.7%) and positive pain outcomes (71.9% reduction). Because the study lacked a comparator group, randomisation and blinding, these findings should be interpreted as a preliminary hypothesis rather than as evidence of efficacy. They warrant confirmation in prospective controlled studies.
This collection of cases demonstrates the use of microbial-binding dressings as part of a pathway for infection prevention, control and treatment in closed surgical incisions. This pathway follows new international guidance that emphasises early intervention supporting antimicrobial stewardship in wound care. Declaration of interest: This supplement was supported by Essity AB, Sweden. The authors received honoraria for their contributions. Essity AB could provide feedback on product-related content, with implementation at the authors' discretion.
