4. Discussion
obesity, diabetic angiopathy, venous diseases, arterial insufficiency, hyperlipidemia, ulcers, necrotic, venous leg ulcers, pain, lower limb amputations, ulcer, arterial occlusive disease, diabetes
OBESITY, RECURRENCE, HEALED ULCER, ULCERS, ADVERSE EFFECTS, PERIPHERAL ARTERIAL DISEASE, VENOUS LEG ULCER, HYPERLIPIDEMIA, PROLIFERATION, INFLAMMATION, NECROTIC, HAND SWELLING, DIABETES, ARTERIAL INSUFFICIENCY, VENOUS DISEASE, ULCER, ARTERIAL OCCLUSIVE DISEASE, COMPLICATIONS, INFECTED WOUNDS, DIABETIC ANGIOPATHY, LEG ULCERS, ARTERIAL LEG ULCERS, DISEASE, CHRONIC LEG ULCERS, MALNUTRITION
The knowledge of the use of various treatment methods in the case of hard-to-heal wounds, including leg ulcers, is systematically and continuously expanded and updated. The modern concept of wound treatment involves a comprehension of the underlying disease and is aimed at creating conditions conducive to healing, e.g., by eliminating risk factors responsible for the abnormal course of healing such as obesity, diabetes, malnutrition, hyperlipidemia or nicotinism [It should be emphasized that in patients with complications of peripheral arterial disease—also in the form of arterial leg ulcers—the most important treatment is vascular revascularization, which enables the restoration of a possibly physiological blood supply. In patients who are not eligible for vascular revascularization for various reasons, recommended and effective methods should be implemented, among which, dressings are considered the standard of local treatment; however, there is a rise in innovative methods in the field of physical medicine (physiotherapy), which could also be effective. This comprehensive, coordinated approach, while taking into account various methods of action, is intended to accelerate the healing process, facilitate the cleansing of necrotic tissue from ulcers, reduce exudation and swelling, and support granulation processes. However, the effects of the treatment of hard-to-heal wounds are still not fully satisfactory, as they often do not ensure complete wound healing [Currently, the greatest hopes are associated with dressings that contain active substances. The developed concept of an “ideal” dressing assumes that it should not only have a defensive function and provide a sufficiently moist environment, but also directly stimulate cell regeneration [Eleven specialists in the management of various types of wounds discussed best practices, recommendations, and guidelines for the management of the main types of chronic wounds. An analysis of the collected literature showed that significant progress has been made in the understanding of wound healing processes over the past decade. There have also been many publications emphasizing the importance of medical dressings and various forms of therapy. Experts also point out that more emphasis should be placed on making the right diagnosis and choosing the right dressing and appropriate therapy. Such a holistic approach to the treatment of the patient and the wound bed is aimed at achieving the best therapeutic result while preventing the recurrence of wounds [Bowers and Franco, however, disagree. These authors believe that patients with arterial ulcers should be immediately referred to a vascular surgeon who should consider appropriate intervention [In our study, we used specialized active dressings containing silver ions, the effect of which resulted in a statistically significant reduction in the surface area of the treated ulcers, thus accelerating the healing process in both assessed groups of patients. The therapeutic effect obtained was greater in the group of patients who additionally received local HBOT treatments. It was most likely related to the synergistic therapeutic effect of simultaneously used therapies. HBOT treatments improve tissue metabolism and their increased oxygenation, which translate into higher results. In hyperbaric treatment, hemoglobin is more saturated with oxygen; the oxygen concentration dissolves physically and is not bound to hemoglobin increase in the serum, thereby resulting in significantly accelerated healing processes. The proper course of the wound healing process involving leg ulcers requires the right amount of oxygen supply to the tissues. At the stage of inflammation, oxygen affects the intensity of migration and proliferation of fibroblasts. If the supply of the appropriate amount of oxygen and nutrients involved in the tissue regeneration process is limited, the healing process is disturbed and thus significantly prolonged [In the analysis conducted by Bouza et al., the authors analyzed the scientific evidence confirming the effectiveness of modern dressings used in the treatment of leg ulcers by searching the available databases. As in our case, the authors did not find any studies that focused solely on arterial ulcers. The results of the analysis showed no statistically significant differences in the percentage of healed ulcers or reduction in wound size for both modern and conventional dressings. As in the case of hyperbaric oxygen therapy treatments, it can be inferred that the current medical literature is poor in terms of research regarding this topic. There is insufficient scientific evidence to determine whether the choice of a specific type of dressing has the most beneficial effect on the course of ulcer healing [In one of the older articles, the authors evaluated randomized clinical trials to determine whether applied topical agents and dressings affect the rate of healing of arterial ulcers of the lower extremities. Only one study met the inclusion criteria and was analyzed. The authors emphasize that the study included a group that was too small in number of participants to be analyzed, and the observation period was too short. On this basis, it cannot be concluded whether there was any difference in cure rates [Mosti et al. compared the treatment efficacy of a microbiological binding (MB) dressing with a silver-containing hydrofiber (SCH) dressing. The study group consisted of 20 patients (15 patients with venous leg ulcers and 5 with arterial leg ulcers). An assessment was made on the bacterial load of heavily colonized or locally infected wounds. The analysis of the obtained results showed that both types of dressings are effective in reducing the bacterial load in critically colonized or locally infected chronic leg ulcers. However, MB dressings showed a higher efficiency. No adverse effects were found [Unfortunately, the available literature also lacks current papers that would explicitly discuss the therapeutic benefits of HBOT in the treatment of arterial ulcers. Therefore, we could not compare our preliminary results or assess the safety of the therapy used in relation to other scientific reports.In one of the few articles by Kranke et al. in 2015, they reviewed the available results of randomized trials, in which they tried to answer the following questions: (1) does hyperbaric oxygen therapy (HBOT) increase the percentage of patients with healed chronic wounds and (2) does the need to perform lower limb amputations subsequently decrease? Most of the studies were concerned with ulcers related to diabetes and venous diseases, which confirm the effectiveness of HBOT therapy in terms of wound healing. The authors did not find any data confirming or disproving the effect of HBOT on the healing of arterial ulcers [In turn, Heyboer et al. conducted a retrospective analysis on a group of patients who received hyperbaric oxygen therapy treatments for ulcers caused by arterial insufficiency that did not heal despite standard treatment. Eighty-two patients were analyzed. The overall cure rate was 43.9% and the amputation rate was 17.1%. According to the authors, hyperbaric oxygenation may constitute a positive role in the treatment of leg ulcers of arterial etiology, which failed standard treatment [Beric et al. conducted a prospective clinical trial with 80 patients. The patients were divided into two groups: (group 1) 40 patients with arterial occlusive disease and lower limb wounds, with a subgroup (n = 20) treated with HBO therapy, and (group 2) 40 patients with diabetic angiopathy and lower limb wounds, with a subgroup (n = 20) treated with HBO therapy in addition to standard therapy. In both groups, statistically significantly higher results were found in patients who underwent HBO treatments as an addition to the standard therapy [The analysis of the obtained results also showed beneficial therapeutic effects related to the reduction in pain in both study groups. The mechanisms of the analgesic effect of HBOT include, among others: stimulating the secretion of endogenous endorphins and inhibiting the activity of the local inflammatory process.John et al. summarized in their article the available scientific reports on the non-surgical treatment of arterial leg ulcers, topical therapies, pharmacological agents, apparatus and available devices. Only randomized clinical trials and meta-analyses were included. The results showed that, despite some limitations of these methods and side effects, their use should be considered in each case because these procedures are characterized as having good tolerance, accessibility, and impact on the reduction in pain ailments [Taking into account the good tolerance of the treatments and the small number of contraindications to the use of local hyperbaric oxygen therapy, when used together with active specialized dressings, these treatments can be a valuable supplement to pharmacological treatment. Moreover, it should be emphasized that local HBOT can be conducted at home and is preferred for people with limited mobility who, for various reasons, cannot be treated in specialist stationary centers. Furthermore, this method reduces pain and also improves tissue oxygen perfusion.These positive preliminary therapeutic effects should allow for the optimization of future therapeutic procedures and the refinement of the treatment of chronic arterial ulcers of the lower limbs.