Objectives: Wide local excision and meshed split skin grafting is used to treat refractory leg ulcers. Good early results have been widely reported, but long-term studies are lacking. The aim of this study was to determine the shortand long-term success of wide local excision and application of meshed split thickness skin grafts in the treatment of chronic leg ulcers. The effect of different aetiologies and ulcer size on the outcome was also assessed. Methods: A retrospective analysis was performed on all patients who had excision and mesh grafting for chronic leg ulcer ulceration between 1996 and 2004. Recurrence was classified as any breakdown of the ulcer during follow-up. Results were analysed using a Kaplan/Meier life table and logrank test. Results: Sixty-two patients with 100 leg ulcers underwent surgery. More than two-thirds of these ulcers were venous (n1⁄4 72) with a mean ulcer size of 35 cm (range 1.5–192 cm). Only three patients left the hospital with their ulcers unhealed; 55% of all ulcers remained healed at five years’ follow-up. Two-thirds of all ulcer recurrences occurred in the first two months, 28% had a recurrence by two months and a further 17% had recurred after five years (Figure 1). There was no difference between the recurrence rate of venous ulcers and chronic ulcers of other aetiologies, P value1⁄4 0.98 as shown in Figure 2. There was also no difference between the recurrence rate of large ulcers (more than 10 cm) and small ulcers, P value1⁄4 0.65 as shown in Figure 3. Conclusion: Wide local excision and application of meshed split skin graft gives good results in over half of the patients treated. Recurrence is most likely to occur 0 2 4 6 8 0 H ea le d u lc er % 100

Objective. To define the pressures and gradients achieved by different bandages when applied by alternative bandaging techniques.Methods. An experienced bandager applied six bandages to the same leg of a volunteer using three application techniques. Pressure measurements were taken at the ankle, gaiter, calf and upper calf in three postures.Results. All bandages gave consistent pressures with all standard deviations falling below 7 mmHg. The percentage increase in pressure from resting leg to standing Was inversely related to bandage elasticity. Pressures were similar at the upper calf among the bandages for each application technique in each posture (differences < 10 mmHg). Small differences in pressure among the bandages (4-15 mmHg) occurred at the ankle for the resting leg with a reduction in pressure between 6 and 63% at the upper calf compared to the ankle. These differences in ankle pressure were more inarked on sitting (differences 15-18 mmHg) and standing (differences 15-27 mmHg), which resulted in substantial differences in gradients.Conclusions. Striking variations in pressures and gradients were observed between bandages of different physical properties applied using alternative application techniques. In order to achieve clinical benefits without tissue damage, it is essential that the therapist appreciates how a bandage will react with a specific application technique.

Objective: To compare the consistency of the pressure measurements and the practical aspects of three manometers (Salzman MST; Oxford Talley and Diastron) measuring sub-bandage pressures. Methods: Five bandages (tubular elastic straight, tubular elastic graduated, short stretch non-elastic, long stretch elastic, cohesive elastic) were applied to standard models comprising foam-covered 9.5 cm, 12.5 cm diameter plastic tubes and a cone by a single expert bandager using a standard spiral technique with 50% overlap for the non-tubular bandages (NTB). The probes of all three machines were positioned at equidistant points around the circumference of each model at three levels corresponding to the ankle, gaiter and mid-calf measuring points of the MST probe. Two readings were taken for each of three separate applications of each bandage. Statistical analysis utilised ANOVA with Bartlett's test. Results. A total of 135 readings were made for each machine and 81 for each type of bandage. Mean pressures among the five bandages types ranged from 12.2 to 35.5 mmHg. A pressure gradient was apparent when NTB bandaging the straight tubes (means 24.7, 23.5, 22.4 mmHg) but not with the cone. There was a statistically significant difference between the three machines (Bartlett's test 23.6, p<0.0001), with the lowest variances for the MST and similar variances for the Oxford and Diastron. Conclusion. In terms of measurement variance this experiment indicates that the MST is the preferred machine for future experiments.

Objective To determine whether pentoxifylline 400 mg (Trental 400) taken orally three times daily, in addition to ambulatory compression bandages and dressings, improves the healing rate of pure venous ulcers. Design Randomised, double blind placebo controlled trial, parallel group study of factorial design, permitting the simultaneous evaluation of alternative pharmaceutical, bandaging, and dressings materials. Setting Leg ulcer clinics of a teaching and a district general hospital in southern Scotland. Participants 200 patients with confirmed venous ulcers and in whom other major causal factors were excluded. Interventions Pentoxifylline 400 mg three times daily or placebo. Main outcome measure Complete healing (full epithelialisation) of all ulcers on the trial leg. Results Complete healing occurred in 65 of the 101 (64%) patients receiving pentoxifylline and 52 of the 99 (53%) patients receiving placebo. Conclusions The difference in the healing rates between patients taking pentoxifylline and those taking placebo did not reach statistical significance.

It Is essential for nurses to develop their skills in the education of patients with leg ulcers. No ulcer will be healed, or prevented, unless the patient co-operates with, and participates in, the treatment. Full compliance is more likely if the patient understands what is being done, and why. Teaching patients the self-help skills which they should practise for the rest of their lives to promote healing and prevent ulcer recurrence requires patience, skill and an understanding of the individual's personal circumstances1.

This case study details the treatment of a patient with pyoderma gangrenosum on the shins of both legs.

Objective: To determine whether elastic or non-elastic bandaging is more effective in healing chronic venous ulcers.Design: Randomized trial with factorial design and interaction analysis, enabling independent evaluation of both bandaging and dressings within the single-trial format. The duration of treatment was 12 weeks or until ulcer-healing, whichever occurred sooner.Setting: The Leg Ulcer Clinics of Edinburgh and Falkirk and District Royal Infirmaries, Scotland.Patients: 132 patients with chronic leg ulcers and clinical evidence of chronic venous disease, and excluding those with Doppler ultrasound ankle/brachial pressure indices of less than 0.8, diabetes or rheumatoid disease. There were 28 withdrawals who were classified for analysis as treatment failures.Interventions: Elastic or non-elastic multilayer bandage systems were applied using similar application techniques by a team of trained nurse specialists. All other treatments were standardized, including the randomization of dressings to either a knitted viscose or a hydrocellular polyurethane dressing.Main outcome measure: Complete ulcer healing.Results: In the elastic group 35 out of 65 ulcers (54%) healed within 12 weeks compared with 19 out of 67 (28%) in the non-elastic group (95% confidence limits for percentage healed, 9% to 42%). Ulcer pain was also reported significantly less often in the elastic group (48% of visits versus 29%; p=0.03).Conclusion: When applied by similar multilayer bandaging techniques, elastic bandaging was significantly better than non-elastic bandaging in the treatment of chronic venous leg ulcer.

Objective: To compare a new 'advanced' hydrocellular polyurethane dressing (HPD) (Allevyn) with a traditional simple non-adherent knitted viscose dressing (KDV) (Tricotex) in the treatment of chronic venous leg ulcers. Design: A randomized trial of factorial design, with interaction testing, to allow the evaluation of two different therapeutic components (dressing and bandages) within a single trial. The treatment period was 12 weeks or until healing, whichever occurred sooner. Setting: The Leg Ulcer Clinics of Edinburgh and Falkirk and District Royal Infirmaries, Scotland. Patients: 132 patients with chronic venous leg ulcers were randomized, 66 to HPD and 66 to KVD. Principal exclusions were patients with diabetes, rheumatoid disease or Doppler ankle/brachial pressure indices of less than 0.8. There were 28 withdrawals (15 KVD, 13 HPD). These were considered as treatment failures. Interventions: Dressings and bandaging were applied by specialist leg ulcer nurses using standard techniques throughout, the bandaging being randomized to either elastic or non-elastic multilayer systems. Main outcome measure: The principal end-point was ulcer healing. Also monitored were healing rates, pain and the frequency of dressing changes. Results: Pain relief was significantly better in the HPD group (p=0.01). Thirty-one (47%) of the HPD patients healed within 12 weeks compared with only 23 (35%) of the those treated with KVD (95% confidence limits for difference, -5% to +29%). The higest healing rates (61% for all ulcers and 74% for those less than 10 cm2) were observed in the subgroup in which HPD was used in combination with an elastic bandaging system. Conclusion: Patients treated with HPD did significantly better in terms of pain relief, although the higher healing rates observed in this group failed to reach significance at the 5% level.