Guideline:
Chronic wounds of the lower extremity
National Guideline Clearinghouse (NGC). Guideline summary: Chronic wounds of the lower extremity In: National Guideline Clearinghouse (NGC) [Web site]. Rockville (MD): cited 2007 May. Available: http://www.guideline.gov.
Bibliographic Source(s)
- American Society of Plastic Surgeons. Evidence-based clinical practice guideline: chronic wounds of the lower extremity. Arlington Heights (IL): American Society of Plastic Surgeons; 2007 May. 21 p. [132 references]
Guideline Status
This is the current release of the guideline.
Guideline Category
Evaluation
Management
Treatment
Intended Users
Advanced Practice Nurses
Health Care Providers
Physician Assistants
Physicians
Guideline Objective(s)
To conduct a systematic review of existing scientific literature addressing the assessment and treatment of chronic wounds of the lower extremity and to develop recommendations that fairly reflect current accepted medical standards
Target Population
Patients with chronic wounds of the lower extremity
Interventions and Practices Considered
Assessment
- Medical history and physical exam
- Assessment for venous insufficiency using physical findings Doppler ultrasonography Duplex scanner plethysmography and venography
- Assessment for arterial occlusive disease (history and ankle brachial index [ABI])
- Assess for comorbidities of diabetes
- Assess history and characteristics of wound including evaluation for infection
- Assess for confounding factors allergies osteomyelitis remote or systemic infection and comorbid risk factors
- Assess pain functional status and quality of life
- Regular follow-up
Treatment/Management
- Debridement
- Pressure relief
- Infection control
- Management of exudate
- Management of complications including osteomyelitis and infection
- Measures to prevent recurrence including patient education therapeutic modalities and exercise programs
Major Outcomes Considered
Not stated
Methods Used to Collect/Select Evidence
Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases
Description of Methods used to Collect/Select the Evidence
Literature Search and Admission of Evidence
This study was carried out using a prospective systematic method for identifying and evaluating current literature on the treatment of chronic wounds of the lower extremities. To identify relevant literature a comprehensive search of the following databases was performed: OVID Medline CINAHL Embase the Cochrane Wounds Group database within the Cochrane Collaboration Library the Agency for Healthcare Research and Quality (AHRQ) Clinical Practice Guidelines and the National Guideline Clearinghouse.™ Additionally the World Wide Web was searched using meta-search engines for national and international guidelines. The search term combination captured the concept "practice-guidelines AND wound" using a wide range of indexing terms free text words and word variants. Search limits restricted results to English-language manuscripts.
Articles were selected if they met the following criteria: guideline systematic review consensus statement care protocol or healthcare technology assessment produced by national or international professional organizations and societies or governmental agencies; subject: comprehensive management of wounds of the lower extremity. From this list key articles were identified and corresponding bibliographies hand searched for citations and manuscripts relevant to clinical questions about patient assessment treatment follow-up and prevention of wound recurrence.
Excluded from the search were articles that specifically addressed assessment and treatment of patients with burn wounds of the lower extremity patients whose wounds were surgically closed and patients with uncomplicated wounds that heal by primary intention (matrix deposition contraction and epithelialization).
Number of Source Documents
Not stated
Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence
Evidence Rating Scale for Diagnostic Studies
| Level of Evidence | Qualifying Studies |
|---|---|
| I | High-quality multi-centered or single-centered cohort study validating a diagnostic test (with "gold" standard as reference) in a series of consecutive patients; or a systematic review of these studies |
| II | Exploratory cohort study developing diagnostic criteria (with "gold" standard as reference) in a series of consecutive patients; or a systematic review of these studies |
| III | Diagnostic study in nonconsecutive patients (without consistently applied "gold" standard as reference); or a systematic review of these studies |
| IV | Case-control study; or any of the above diagnostic studies in the absence of a universally accepted "gold" standard |
| V | Expert opinion; case report or clinical example; or evidence based on physiology bench research or "first principles" |
Evidence Rating Scale for Prognostic Studies
| Level of Evidence | Qualifying Studies |
|---|---|
| I | High-quality multi-centered or single-centered prospective cohort study with adequate power; or a systematic review of these studies |
| II | Lesser-quality prospective cohort study; retrospective study; untreated controls from a randomized controlled trial; or a systematic review of these studies |
| III | Case-control study; or a systematic review of these studies |
| IV | Case series |
| V | Expert opinion; case report or clinical example; or evidence based on physiology bench research or "first principles" |
Evidence Rating Scale for Therapeutic Studies
| Level of Evidence | Qualifying Studies |
|---|---|
| I | High-quality multi-centered or single-centered randomized controlled trial with adequate power; or a systematic review of these studies |
| II | Lesser-quality randomized controlled trial; prospective cohort study; or a systematic review of these studies |
| III | Retrospective comparative study; case-control study; or a systematic review of these studies |
| IV | Case series |
| V | Expert opinion; case report or clinical example; or evidence based on physiology bench research or "first principles" |
Methods Used to Analyze the Evidence
Systematic Review
Description of the Methods Used to Analyze the Evidence
Critical Appraisal of the Literature
Relevant articles were categorized by study type: randomized controlled trial systematic review cohort study and case-control study. Each article was critically appraised for study quality according to criteria referenced in key publications on evidence-based medicine. Depending on type (prognostic diagnostic or therapeutic) and quality of study each article was assigned a corresponding level of evidence according to the American Society of Plastic Surgeons (ASPS) Evidence Rating Scales (see "Rating Scheme for the Strength of the Evidence" above) which were modified from scales developed by other surgical specialties and authorities on evidence-based medicine.
Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations
Development of Clinical Practice Recommendations
Practice recommendations were developed through critical appraisal of the literature and consensus of the American Society of Plastic Surgeons (ASPS) Health Policy Committee. Recommendations are based on the strength of supporting evidence and were graded according to the ASPS Grades of Recommendation Scale (see "Rating Scheme for the Strength of the Recommendations" below) which was modified from scales used by other surgical specialties and authorities in the practice of evidence-based medicine.
Rating Scheme for the Strength of the Recommendations
| Grade | Descriptor | Qualifying Evidence | Implications for Practice |
|---|---|---|---|
| A | Strong Recommendation | Level I evidence or consistent findings from multiple studies of levels II III or IV | Clinicians should follow a strong recommendation unless a clear and compelling rationale for an alternative approach is present. |
| B | Recommendation | Levels II III or IV evidence and findings are generally consistent | Generally clinicians should follow a recommendation but should remain alert to new information and sensitive to patient preference. |
| C | Option | Levels II III or IV evidence but findings are inconsistent | Clinicians should be flexible in their decision-making regarding appropriate practice although they may set bounds on alternatives; patient preference should have a substantial influencing role. |
| D | Option | Level V; little or no systematic empirical evidence | Clinicians should consider all options in their decision-making and be alert to new published evidence that clarifies the balance of benefit versus harm; patient preference should have a substantial influencing role. |
Cost Analysis
A formal cost analysis was not performed and published cost analyses were not reviewed.
Method of Guideline Validation
Peer Review
Description of Method of Guideline Validation
Approved by the Executive Committee of the American Society of Plastic Surgeons May 2007
Major Recommendations
Definitions for the levels of evidence for diagnostic prognostic and therapeutic studies (I–V) and the strength of the recommendations (A–D) are provided at the end of the "Major Recommendations" field.
| Recommendations for Patient Assessment | Supporting Evidence | Grade |
|---|---|---|
| General Medical History:
| Expert Opinion | D |
| Venous Insufficiency | ||
Historical findings suggestive of venous insufficiency include:
| (Baker et al. 1991; Berard et al. 2002; Blomgren et al. 2001; Labropoulos et al. "Patterns" 2007; Fink et al. 2002; Dajani et al. 1988) | B |
Physical findings suggestive of venous insufficiency include:
| (Blomgren et al. 2001; Labropoulos et al. "Patterns" 2007; Wong Duncan & Nichols 2003) | B |
Diagnostic Tests:
| (Shami et al. 1993; Alguire & Mathes1997; Wong Duncan & Nichols 2003; Baxter & Polak 1993) | B |
| Determine severity of venous insufficiency | Expert Opinion | D |
| Arterial Occlusive Disease | ||
Assess for a history of arterial occlusive disease:
| (Wipke-Tevis et al. 2000; Dormandy & Murray 1991; Jelnes et al. 1986; Criqui et al. 1985; Marston et al. 2006; Hiatt Hoag & Hamman 1995; Khan et al. 2006; Wang et al. 2005; Henke et al. 2005) | B |
Assess for factors suggestive of arterial compromise:
| (Khan et al. 2006) | B |
Diagnostic Tests:
| (Baxter & Polak 1993; Dormandy & Murray 1991; Jelnes et al. 1986; Stoffers et al. 1997; Marston et al. 2006; Hiatt Hoag & Hamman 1995; Khan et al. 2006; de Vries et al. 2006; Ouwendijk et al. 2005) | B |
Determine severity of arterial occlusive disease:
| (Marston et al. 2006; O'Meara et al. 2000) | B |
Diabetes
| (Marston et al. 2006; Hiatt et al. 1995; Pham et al. 2000; Abbott et al. 1998; Yasuhara et al. 2002) | B |
| History and Characteristics of the Wound | ||
Document history of the wound:
| Expert Opinion | D |
Document characteristics of the wound:
| (Marston et al. 2006; O'Meara et al. 2000) | B |
Evaluate wound for evidence of infection
| (Cutting 1998; Gardner et al. 2001) | B |
For atypical and/or recalcitrant wounds rule out other less common causes of ulceration (biopsy may be necessary)
| (Labropoulos et al. "Uncommon leg ulcers" 2007) | B |
| Additional Considerations: | ||
Assess for confounding factors:
| (Wipke-Tevis et al. 2000; Jelnes et al. 1986; Khan et al. 2006; O'Meara et al. 2000) | B |
| Assess and document allergies | (Saap et al. 2004; Lim et al. 2007; Tavadia et al. 2003; Machet et al. 2004) | B |
Assess for the presence of osteomyelitis:
| (Shih Shih & Wong 2005; Senneville et al. 2006) | B |
| Determine the presence of remote site or systemic infection (septicemia endocarditis prosthesis infection): Anatomic risk factors include:
| (El-Ahdab et al. 2005) | B |
Comorbid risk factors:
| (El-Ahdab et al. 2005) | B |
Pain Functional Status and Quality of Life
| Expert Opinion | D |
| Recommendations for Treatment | Supporting Evidence | Grade |
|---|---|---|
Debridement:
| (Thow & Smith 2003; Smith 2002; Granick et al. 2007) | B |
Pressure Relief
| (Duby et al. 1993; Cullum et al. 2001; Cullum et al. 2004) | B |
Infection Control
| (Gentry et al. 1989; White Cutting & Kingsley 2006; Nelson et al. 2006; Vermeulen et al. 2005; O'Meara et al. 2000; Vermeulen et al. 2007) | B |
Management of Exudate
| (Embil et al. 2000; Vermeulen et al. 2005; O'Meara et al. 2000; Vermeulen et al. 2007; Bergin & Wraight 2006; Jones & Nelson 2007) | B |
| Recommendations for Management of Complications | Supporting Evidence | Grade |
|---|---|---|
Osteomyelitis
| (Henke et al. 2005; Bach et al. 2007; Eren Ghofrani & Reifenrath 2001; Embil et al. 2006; Freeman et al. 2007) | B |
Antibiotic Prophylaxis
| (Henke et al. 2005) | B |
| Recommendations for Follow-up | Supporting Evidence | Grade |
|---|---|---|
Patient with Chronic Wounds:
| Expert Opinion | D |
Patients with Venous Insufficiency:
| (Baker et al. 1991; Berard et al. 2002; Blomgren et al. 2001) | B |
Patients with Peripheral Arterial Disease:
| (Stoffers et al. 1997; Stein et al. 2006) | B |
Patients with Diabetes:
| (Dormandy & Murray 1991; Jelnes et al. 1986; Pham et al. 2000; Dolan et al. 2002) | B |
Patients with History of Osteomyelitis:
| Expert Opinion | D |
| Recommendations for Prevention of Recurrence | Supporting Evidence | Grade |
|---|---|---|
Patient Education:
| Expert Opinion | D |
Therapeutic Modalities:
| (Duby et al. 1993; Cullum et al. 2001; Cullum et al. 2004; Cullum et al. "Compression for venous leg ulcers" 2000; Nelson Bell-Syer & Cullum 2000; Cullum et al. "Compression bandages" 2000; Ibegbuna et al. 2003; Zajkowski et al. 2002) | B |
Exercise Programs Improve:
| Expert Opinion | D |
Definitions:
Scale for Grading Recommendations
| Grade | Descriptor | Qualifying Evidence | Implications for Practice |
|---|---|---|---|
| A | Strong Recommendation | Level I evidence or consistent findings from multiple studies of levels II III or IV | Clinicians should follow a strong recommendation unless a clear and compelling rationale for an alternative approach is present. |
| B | Recommendation | Levels II III or IV evidence and findings are generally consistent | Generally clinicians should follow a recommendation but should remain alert to new information and sensitive to patient preference. |
| C | Option | Levels II III or IV evidence but findings are inconsistent | Clinicians should be flexible in their decision-making regarding appropriate practice although they may set bounds on alternatives; patient preference should have a substantial influencing role. |
| D | Option | Level V; little or no systematic empirical evidence | Clinicians should consider all options in their decision-making and be alert to new published evidence that clarifies the balance of benefit versus harm; patient preference should have a substantial influencing role. |
Evidence Rating Scale for Diagnostic Studies
| Level of Evidence | Qualifying Studies |
|---|---|
| I | High-quality multi-centered or single-centered cohort study validating a diagnostic test (with "gold" standard as reference) in a series of consecutive patients; or a systematic review of these studies |
| II | Exploratory cohort study developing diagnostic criteria (with "gold" standard as reference) in a series of consecutive patients; or a systematic review of these studies |
| III | Diagnostic study in nonconsecutive patients (without consistently applied "gold" standard as reference); or a systematic review of these studies |
| IV | Case-control study; or any of the above diagnostic studies in the absence of a universally accepted "gold" standard |
| V | Expert opinion; case report or clinical example; or evidence based on physiology bench research or "first principles" |
Evidence Rating Scale for Prognostic Studies
| Level of Evidence | Qualifying Studies |
|---|---|
| I | High-quality multi-centered or single-centered prospective cohort study with adequate power; or a systematic review of these studies |
| II | Lesser-quality prospective cohort study; retrospective study; untreated controls from a randomized controlled trial; or a systematic review of these studies |
| III | Case-control study; or a systematic review of these studies |
| IV | Case series |
| V | Expert opinion; case report or clinical example; or evidence based on physiology bench research or "first principles" |
Evidence Rating Scale for Therapeutic Studies
| Level of Evidence | Qualifying Studies |
|---|---|
| I | High-quality multi-centered or single-centered randomized controlled trial with adequate power; or a systematic review of these studies |
| II | Lesser-quality randomized controlled trial; prospective cohort study; or a systematic review of these studies |
| III | Retrospective comparative study; case-control study; or a systematic review of these studies |
| IV | Case series |
| V | Expert opinion; case report or clinical example; or evidence based on physiology bench research or "first principles" |
Clinical Algorithm(s)
None provided
References Supporting the Recommendations
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- Alguire PC Mathes BM. Chronic venous insufficiency and venous ulceration. J Gen Intern Med 1997 Jun;12(6):374-83. [112 references] PubMed
- Bach AD Leffler M Kneser U Kopp J Horch RE. The versatility of the distally based peroneus brevis muscle flap in reconstructive surgery of the foot and lower leg. Ann Plast Surg 2007 Apr;58(4):397-404. PubMed
- Baker SR Stacey MC Jopp-McKay AG Hoskin SE Thompson PJ. Epidemiology of chronic venous ulcers. Br J Surg 1991 Jul;78(7):864-7. PubMed
- Baxter GM Polak JF. Lower limb colour flow imaging: a comparison with ankle: brachial measurements and angiography. Clin Radiol 1993 Feb;47(2):91-5. PubMed
- Berard A Abenhaim L Platt R Kahn SR Steinmetz O. Risk factors for the first-time development of venous ulcers of the lower limbs: the influence of heredity and physical activity. Angiology 2002 Nov-Dec;53(6):647-57. PubMed
- Bergin SM Wraight P. Silver based wound dressings and topical agents for treating diabetic foot ulcers. Cochrane Database Syst Rev 2006;(1):CD005082. [79 references] PubMed
- Blomgren L Johansson G Siegbahn A Bergqvist D. Coagulation and fibrinolysis in chronic venous insufficiency. Vasa 2001 Jul;30(3):184-7. PubMed
- Criqui MH Fronek A Klauber MR Barrett-Connor E Gabriel S. The sensitivity specificity and predictive value of traditional clinical evaluation of peripheral arterial disease: results from noninvasive testing in a defined population. Circulation 1985 Mar;71(3):516-22.
- Cullum N McInnes E Bell-Syer SE Legood R. Support surfaces for pressure ulcer prevention. Cochrane Database Syst Rev 2004;(3):CD001735. [101 references] PubMed
- Cullum N Nelson EA Flemming K Sheldon T. Systematic reviews of wound care management: (5) beds; (6) compression; (7) laser therapy therapeutic ultrasound electrotherapy and electromagnetic therapy. Health Technol Assess 2001;5(9):1-221. [184 references] PubMed
- Cullum N Nelson EA Fletcher AW Sheldon TA. Compression bandages and stockings for venous leg ulcers. Cochrane Database Syst Rev 2000;(2):CD000265. [30 references] PubMed
- Cullum N Nelson EA Fletcher AW Sheldon TA. Compression for venous leg ulcers. Cochrane Database Syst Rev 2000;(3):CD000265. [51 references] PubMed
- Cutting KF. Identification of infection in granulating wounds by registered nurses. J Clin Nurs 1998 Nov;7(6):539-46. PubMed
- Dajani OM Haddad FF Hajj HA Sfeir RE Khoury GS. Injury to the femoral vessels--the Lebanese War experience. Eur J Vasc Surg 1988 Oct;2(5):293-6. PubMed
- de Vries M Ouwendijk R Flobbe K Nelemans PJ Kessels AG Schurink GH van der Vliet JA Heijstraten FM Cuypers PW Duijm LE van Engelshoven JM Hunink MG de Haan MW. Peripheral arterial disease: clinical and cost comparisons between duplex US and contrast-enhanced MR angiography--a multicenter randomized trial. Radiology 2006 Aug;240(2):401-10. PubMed
- Dolan NC Liu K Criqui MH Greenland P Guralnik JM Chan C Schneider JR Mandapat AL Martin G McDermott MM. Peripheral artery disease diabetes and reduced lower extremity functioning. Diabetes Care 2002 Jan;25(1):113-20. PubMed
- Dormandy JA Murray GD. The fate of the claudicant--a prospective study of 1969 claudicants. Eur J Vasc Surg 1991 Apr;5(2):131-3. PubMed
- Duby T Cherry G Hoffman D Dobloff-Brown D Ryan T. A randomized trial in the treatment of venous leg ulcers comparing short stretch bandages four layer bandage system and a long stretch-paste bandage system. Wounds 1993;5(6):276-9.
- El-Ahdab F Benjamin DK Jr Wang A Cabell CH Chu VH Stryjewski ME Corey GR Sexton DJ Reller LB Fowler VG Jr. Risk of endocarditis among patients with prosthetic valves and Staphylococcus aureus bacteremia. Am J Med 2005 Mar;118(3):225-9. PubMed
- Embil JM Papp K Sibbald G Tousignant J Smiell JM Wong B Lau CY. Recombinant human platelet-derived growth factor-BB (becaplermin) for healing chronic lower extremity diabetic ulcers: an open-label clinical evaluation of efficacy. Wound Repair Regen 2000 May-Jun;8(3):162-8. PubMed
- Embil JM Rose G Trepman E Math MC Duerksen F Simonsen JN Nicolle LE. Oral antimicrobial therapy for diabetic foot osteomyelitis. Foot Ankle Int 2006 Oct;27(10):771-9. PubMed
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- Gentry LO Ramirez-Ronda CH Rodriguez-Noriega E Thadepalli H del Rosal PL Ramirez C. Oral ciprofloxacin vs parenteral cefotaxime in the treatment of difficult skin and skin structure infections. A multicenter trial. Arch Intern Med 1989 Nov;149(11):2579-83. PubMed
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- Hiatt WR Hoag S Hamman RF. Effect of diagnostic criteria on the prevalence of peripheral arterial disease. The San Luis Valley Diabetes Study. Circulation 1995 Mar 1;91(5):1472-9. PubMed
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- Jelnes R Gaardsting O Hougaard Jensen K Baekgaard N Tonnesen KH Schroeder T. Fate in intermittent claudication: outcome and risk factors. Br Med J (Clin Res Ed) 1986 Nov 1;293(6555):1137-40. PubMed
- Jones JE Nelson EA. Skin grafting for venous leg ulcers. Cochrane Database Syst Rev 2007 Apr 18;(2):CD001737. [7 references] PubMed
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- Labropoulos N Patel PJ Tiongson JE Pryor L Leon LR Jr Tassiopoulos AK. Patterns of venous reflux and obstruction in patients with skin damage due to chronic venous disease. Vasc Endovascular Surg 2007 Feb-Mar;41(1):33-40. PubMed
- Lim KS Tang MB Goon AT Leow YH. Contact sensitization in patients with chronic venous leg ulcers in Singapore. Contact Dermatitis 2007 Feb;56(2):94-8. PubMed
- Machet L Couhe C Perrinaud A Hoarau C Lorette G Vaillant L. A high prevalence of sensitization still persists in leg ulcer patients: a retrospective series of 106 patients tested between 2001 and 2002 and a meta-analysis of 1975-2003 data. Br J Dermatol 2004 May;150(5):929-35. [29 references] PubMed
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- Senneville E Melliez H Beltrand E Legout L Valette M Cazaubiel M Cordonnier M Caillaux M Yazdanpanah Y Mouton Y. Culture of percutaneous bone biopsy specimens for diagnosis of diabetic foot osteomyelitis: concordance with ulcer swab cultures. Clin Infect Dis 2006 Jan 1;42(1):57-62. PubMed
- Shami SK Sarin S Cheatle TR Scurr JH Smith PD. Venous ulcers and the superficial venous system. J Vasc Surg 1993 Mar;17(3):487-90. PubMed
- Shih HN Shih LY Wong YC. Diagnosis and treatment of subacute osteomyelitis. J Trauma 2005 Jan;58(1):83-7. PubMed
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- Tavadia S Bianchi J Dawe RS McEvoy M Wiggins E Hamill E Urcelay M Strong AM Douglas WS. Allergic contact dermatitis in venous leg ulcer patients. Contact Dermatitis 2003 May;48(5):261-5. PubMed
- Thow J Smith J. Update of systematic review on debridement. Contact Dermatitis 2003;1:12.
- Vermeulen H Ubbink DT Goossens A de Vos R Legemate DA. Systematic review of dressings and topical agents for surgical wounds healing by secondary intention. Br J Surg 2005 Jun;92(6):665-72. [6 references] PubMed
- Wang JC Criqui MH Denenberg JO McDermott MM Golomb BA Fronek A. Exertional leg pain in patients with and without peripheral arterial disease. Circulation 2005 Nov 29;112(22):3501-8. PubMed
- White RJ Cutting K Kingsley A. Topical antimicrobials in the control of wound bioburden. Ostomy Wound Manage 2006 Aug;52(8):26-58. [180 references] PubMed
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- Wong JK Duncan JL Nichols DM. Whole-leg duplex mapping for varicose veins: observations on patterns of reflux in recurrent and primary legs with clinical correlation. Eur J Vasc Endovasc Surg 2003 Mar;25(3):267-75. PubMed
- Yasuhara H Naka S Yanagie H Nagawa H. Influence of diabetes on persistent nonhealing ischemic foot ulcer in end-stage renal disease. World J Surg 2002 Nov;26(11):1360-4. PubMed
- Zajkowski PJ Proctor MC Wakefield TW Bloom J Blessing B Greenfield LJ. Compression stockings and venous function. Arch Surg 2002 Sep;137(9):1064-8. PubMed
Type of Evidence supporting the Recommendations
The type of supporting evidence is identified and graded for each recommendation.
Potential Benefits
Appropriate treatment and management of chronic wounds of the lower extremity
Potential Harms
- Overuse of antibiotics for uncomplicated soft tissue infections risks tangible harm by promoting antimicrobial resistance.
- There is a risk of contact dermatitis following the use of topical antibiotics.
Contraindications
Debridement is contraindicated in the presence of dry gangrene or a stable dry ischemic wound until vascular status is evaluated. If vasculitis or pyoderma gangrenosum is suspected sharp debridement is not recommended.
Qualifying Statements
- Clinical practice guidelines are strategies for patient management and are developed to assist physicians in clinical decision making. This guideline based on a thorough evaluation of the scientific literature and relevant clinical experience describes a range of generally acceptable approaches to diagnosis management or prevention of specific diseases or conditions. This guideline attempts to define principles of practice that should generally meet the needs of most patients in most circumstances.
- However this guideline should not be construed as a rule nor should it be deemed inclusive of all proper methods of care or exclusive of other methods of care reasonably directed at obtaining the appropriate results. It is anticipated that it will be necessary to approach some patients' needs in different ways. The ultimate judgment regarding the care of a particular patient must be made by the physician in light of all circumstances presented by the patient the available diagnostic and treatment options and other available resources.
- This guideline is not intended to define or serve as the standard of medical care. Standards of medical care are determined on the basis of all facts or circumstances involved in an individual case and are subject to change as scientific knowledge and technology advance and as practice patterns evolve. This guideline reflects the state of knowledge current at the time of publication. Given the inevitable changes in the state of scientific information and technology periodic review updating and revision will be done.
Description of Implementation Strategy
An implementation strategy was not provided.
IOM Care Need
Getting Better
Living with Illness
IOM Domain
Effectiveness
Patient-centeredness
Bibliographic Source(s)
- American Society of Plastic Surgeons. Evidence-based clinical practice guideline: chronic wounds of the lower extremity. Arlington Heights (IL): American Society of Plastic Surgeons; 2007 May. 21 p. [132 references]
Adaptation
Not applicable: The guideline was not adapted from another source.
Source(s) of Funding
American Society of Plastic Surgeons
Guideline Committee
Health Policy Committee of the American Society of Plastic Surgeons
Composition of Group that Authored the Guideline
Not stated
Financial Disclosures/Conflicts of Interest
Not stated
Guideline Status
This is the current release of the guideline.
Guideline Availability
Electronic copies: Available in Portable Document Format (PDF) from the American Society of Plastic Surgeons Web site.
Print copies: Available from the American Society of Plastic Surgeons 444 East Algonquin Road Arlington Heights IL 6005-4664
Availability of Companion Documents
The following is available:
- Description and development of evidence-based practice guidelines. American Society for Plastic Surgeons. Electronic copies: Available from the American Society of Plastic Surgeons Web site.
Print copies: Available from the American Society of Plastic Surgeons 444 East Algonquin Road Arlington Heights IL 6005-4664
Patient Resources
None available
NGC STATUS
This NGC summary was completed by ECRI Institute on October 15 2007. The information was verified by the guideline developer on October 23 2007. This summary was updated by ECRI Institute on July 28 2008 following the U.S. Food and Drug Administration advisory on fluoroquinolone antimicrobial drugs.
COPYRIGHT STATEMENT
This NGC summary is based on the original guideline which is subject to the guideline developer's copyright restrictions.
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The National Guideline Clearinghouse™ (NGC) does not develop produce approve or endorse the guidelines represented on this site.
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Guidelines represented on the NGC Web site are submitted by guideline developers and are screened solely to determine that they meet the NGC Inclusion Criteria which may be found at http://www.guideline.gov/about/inclusion.aspx .
NGC AHRQ and its contractor ECRI Institute make no warranties concerning the content or clinical efficacy or effectiveness of the clinical practice guidelines and related materials represented on this site. Moreover the views and opinions of developers or authors of guidelines represented on this site do not necessarily state or reflect those of NGC AHRQ or its contractor ECRI Institute and inclusion or hosting of guidelines in NGC may not be used for advertising or commercial endorsement purposes.
Readers with questions regarding guideline content are directed to contact the guideline developer.
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Details
1
FDA Warning
- Category:
- Dermatology, Family Practice, Plastic Surgery, Surgery
- Conditions:
- Chronic wounds of the lower extremity including vascular (e.g. arterial venous or mixed ulcers) pressure ulcers and neuropathic (e.g. diabetic ulcers)
- Published:
- 2007 May
- Endorsed by:
- American Society of Plastic Surgeons