Phlebologie 2018; 47(01): 7-12
DOI: 10.12687/phleb2406-1-2018
Review
Schattauer GmbH

Venous ulcer treatment requires inelastic compression

Die Behandlung von venösen Ulzera erfordert eine unelastische Kompression
G. Mosti
1   Head of Angiology Department, Clinica MD Barbantini, Lucca, Italy
› Author Affiliations
Further Information

Korrespondenzadresse

Giovanni Mosti
Angiology Department
MD Barbantini Clinic
Via del Calcio 2
5510 Lucca
Italy
Phone: +39058391971   
Fax +390583490050

Publication History

Eingereicht: 04 December 2017

Angenommen: 04 December 2017

Publication Date:
14 March 2018 (online)

 

Summary

Leg ulcers have a venous pathophysiology in the vast majority of cases (1–4). Superficial or deep venous insufficiency and deep vein obstruction produce ambulatory venous hypertension due to venous reflux and venous pumping function impairment. The impaired venous hemodynamics is the key pathophysiologic mechanism leading to skin damage through several intermediate steps. Fibrin cuff formation around the microvessels, impairing gases (O2, CO2) exchange (5), white cells entrapment (6) causing skin necrosis, growth factors inhibition (7) producing a stagnation of the healing process have been considered involved in ulcer onset and maintenance. The treatment of venous leg ulcers (VLU) must be based on the correction of the hemodynamic impairment which can be achieved conservatively by means of compression therapy, walking and leg elevation or by means of invasive procedures (open surgery, endovascular procedures as endovenous Laser ablation, radiofrequency, foam sclerotherapy, conservative hemodynamic treatment). Compression therapy is frequently considered the first treatment option and it is the only therapeutical procedure which achieved the grade 1A in most recent guidelines or consensus documents (8–10). The crucial point is choosing the most effective compression modality. There are clear evidences that inelastic is more effective than elastic material in counteracting the venous hemodynamic impairment (11–14) that should „ensure” a superior effectiveness in promoting a higher healing rate of VLU, which are due to venous hemodynamic impairment. When looking at evidences we have some data showing that the higher the compression pressure the higher the healing rate (9, 15–17) and this is clearly in favors of inelastic bandages which exert a much higher pressure that elastic materials. On the other side we have many papers claiming a greater effectiveness of elastic stockings or elastic bandaged compared with inelastic material (18–30). Nevertheless studies comparing elastic and inelastic devices have so many flaws that their conclusions are hard to trust (31). Aim of this work is providing updated information about compression therapy effects on venous hemodynamic and the most effective compression modality to achieve the best outcome in VLU treatment.


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Zusammenfassung

Beinulzera haben in der überwiegenden Mehrzahl der Fälle eine venöse Pathophysiologie (1–4). Eine oberflächliche oder tiefe venöse Insuffizienz und eine tiefe Venenobstruktion führen zu einer ambulanten venösen Hypertonie aufgrund einer venösen Reflux- und venösen Pumpfunktionsstörung. Die gestörte venöse Hämodynamik ist der wichtigste pathophysiologische Mechanismus, der durch mehrere Zwischenschritte zu Hautschäden führt. An der Ulkus-Entstehung und Ulkus- Unterhaltung scheinen beteiligt zu sein: Fibrin- Manschetten-Bildung um die Mikrogefäße, Beeinträchtigung des Gasaustauschs (O2, CO2) (5), Einklemmung weißer Zellen (6) (verursacht Hautnekrose), Hemmung der Wachstumsfaktoren (7), welche eine Stagnation des Heilungsprozesses verursacht. Die Behandlung von venösen Beinulzera (VLU) muss auf der Korrektur der hämodynamischen Beeinträchtigung beruhen, die konservativ mittels Kompressionstherapie, Gehen und Beinheben oder mittels invasiver Verfahren erreicht werden kann (offene Chirurgie, endovaskuläre Eingriffe als endovenöse Laserablation, Radiofrequenz-, Schaum-Sklerotherapie, konservative hämodynamische Behandlung). Die Kompressionstherapie wird häufig als erste Behandlungsoption angesehen und ist das einzige therapeutische Verfahren, das in neueren Leitlinien oder Konsensusdokumenten die Stufe 1A erreichte (8–10). Der entscheidende Punkt ist die Auswahl der effektivsten Kompressionsmodalität. Es gibt eindeutige Hinweise darauf, dass unelastisches Material wirksamer ist als elastisches Material, um der venösen hämodynamischen Beeinträchtigung entgegenzuwirken (11–14), die eine höhere Wirksamkeit bei der Förderung einer höheren Heilungsrate von VLU gewährleisten sollte, die auf eine venöse hämodynamische Beeinträchtigung zurückzuführen ist. Wenn wir uns die Evidenz anschauen, haben wir einige Daten, die zeigen, dass je höher der Kompressionsdruck ist, desto höher die Heilungsrate (9, 15–17). Dies spricht eindeutig für unelastisches Material, welches einen viel höheren Druck ausübt als elastische Materialien. Auf der anderen Seite overhaben wir viele Studien, die eine größere Wirksamkeit von elastischen Strümpfen oder elastischen Bandagen im Vergleich zu unelastischem Material (18–30) behaupten. Dennoch haben Studien, in denen elastisches und unelastisches Material verglichen werden, so viele Mängel, dass ihre Schlussfolgerungen schwer zu glauben sind (31). Ziel dieser Arbeit ist es, aktuelle Informationen über die Auswirkungen der Kompressionstherapie auf die venöse Hämodynamik und die effektivste Kompressionsmodalität bereitzustellen, um das beste Ergebnis bei der VLU-Behandlung zu erzielen.


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Conflicts of interest

The author declares no conflict of interest.

  • References

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  • 2 Shami SK, Sarin S, Cheatle TR. et al. Venous ulcers and the superficial venous system. J Vasc Surg 1993; 17: 487-490.
  • 3 Adam DJ, Naik J, Hartshorne T, Bello M, London NJ. The diagnosis and management of 689 chronic leg ulcers in a single-visit assessment clinic. Eur J Vasc Endovasc Surg 2003; May; 25 (05) 462-468.
  • 4 Körber A, Klode J, Al-Benna S. et al. Etiology of chronic leg ulcers in 31,619 patients in Germany analyzed by an expert survey. J Dtsch Dermatol Ges 2011; Feb; 09 (02) 116-121.
  • 5 Browse NL, Burnard KG. The cause of venous ulceration. Lancet 1982; 243-245.
  • 6 Coleridge PDSmith, Thomas P, Scurr JH, Dormandy JA. Causes of venous ulceration: a new hypothesis. Br Med J (Clin Res Ed) 1988; Jun 18; 296: 1726-1727.
  • 7 Falanga V, Eaglstein WH. The “trap” hypothesis of venous ulceration. Lancet 1993; Apr 17; 341 (8851): 1006-1008.
  • 8 O’Donnell TF, Passman MA, Marston WA, Ennis WJ, Dalsing M, Kistner RL. et al. Management of venous leg ulcers: Clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum. JVS 2014; 60: 3S-59S.
  • 9 Mosti G, De Maeseneer M, Cavezzi A, Parsi K, Morrison N, Nelzen O. et al. Society for Vascular Surgery and American Venous Forum Guidelines on the management of venous leg ulcers: the point of view of the International Union of Phlebology. Int. Angiol 2015; 34 (03) 212-218.
  • 10 Franks PJ, Barker J, Collier M, Gethin G, Haesler E, Jawien A, Laeuchli S, Mosti G, Probst S, Weller C. Management of Patients With Venous Leg Ulcers: Challenges and Current Best Practice. J Wound Care 2016; Jun; 25 (Suppl. 06) S1-S67.
  • 11 Mosti G, Partsch H. Duplex scanning to evaluate the effect of compression on venous reflux. Int Angiol 2010; Oct; 29 (05) 416-420.
  • 12 Mosti G, Mattaliano V, Partsch H. Inelastic compression increases venous ejection fraction more than elastic bandages in patients with superficial venous reflux. Phlebology 2008; 23 (06) 287-294.
  • 13 Mosti G, Partsch H. Measuring venous pumping function by strain-gauge plethysmography. Int Angiol 2010; Oct; 29 (05) 421-425.
  • 14 Partsch B, Mayer W, Partsch H. Improvement of ambulatory venous hypertension by narrowing of the femoral vein in congenital absence of venous valves. Phlebology 1992; 07: 101-104.
  • 15 Milic DJ, Zivic SS, Bogdanovic DC, Jovanovic MM, Jankovic RJ, Milosevic ZD, Stamenkovic DM, Trenkic MS. The influence of different sub-bandage pressure values on venous leg ulcers healing when treated with compression therapy. J Vasc Surg 2010; Mar; 51 (03) 655-661.
  • 16 Brizzio E, Amsler F, Lun B, Blättler W. Comparison of low-strength compression stockings with bandages for the treatment of recalcitrant venous ulcers. J Vasc Surg 2010; 51: 410-416.
  • 17 Cullum N, Nelson EA, Fletcher AW, Sheldon TA. Compression for venous leg ulcers. Cochrane Database Syst Rev 2001; (02) CD000265.
  • 18 Franks PJ, Moody M, Moffatt CJ. et al. Randomised trial of cohesive short-stretch versus four-layer bandaging in the management of venous ulceration. Wound Rep Reg 2004; 12: 157-162.
  • 19 Moffatt CJ, McCullagh L. O’Connor et al. Randomized trial of four-layer bandage systems in the management of chronic venous ulceration. Wound Rep Reg 2003; 11: 166-171.
  • 20 Fletcher A, Cullum N, Sheldon TA. A systematic review of compression treatment for venous leg ulcers. BMJ 1997; 315: 576-580.
  • 21 Callam MJ, Harper DR, Dale JJ. et al. Lothian Forth Valley leg ulcer healing trial—part 1: elastic versus non-elastic bandaging in the treatment of chronic leg ulceration. Phlebology 1992; 07: 136-141.
  • 22 Duby T, Hofman D, Cameron J. et al. 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; 05: 276-279.
  • 23 Ukat A, Konig M, Vanscheid W. et al. Short stretch versus multilayer compression for venous leg ulcers: a comparison of healing rates. JWC 2003; 12: 139-143.
  • 24 Scriven JM, Taylor LE, Wood AJ. et al. A prospective randomised trial of four-layer versus short stretch compression bandages for the treatment of venous leg ulcers. Ann R Coll Surg Engl 1998; 80: 215-220.
  • 25 Nelson EA, Iglesias CP, Cullum N. et al. Randomized clinical trial of four-layer and short-stretch compression bandages for venous leg ulcers. Br J Surg 2004; 91: 1292-1299.
  • 26 Mariani F, Mattaliano V, Mosti G, Gasbarro V, Bucalossi M, Blättler W. The treatment of venous leg ulcers with a specifically designed compression stocking kit. Phlebologie 2008; 37: 191-197.
  • 27 Junger M, Partsch H, Ramelet AA, Zuccarelli F. Efficacy of a ready-made tubular compression device versus short stretch bandages in the treatment of venous leg ulcers. Wounds 2004; 16: 313-320.
  • 28 Jünger M, Wollina U, Kohnen R, Rabe E. Efficacy and tolerability of an ulcer compression stocking for therapy of chronic venous ulcer compared with a below-knee compression bandage: results from a prospective, randomized, multicentre trial. Curr Med Res Opin 2004; Oct; 20 (10) 1613-1623.
  • 29 Horakova MA, Partsch H. Compression stockings in treatment of lower leg venous ulcer. Wien Med Wochenschr 1994; 144 (10–11): 242-249.
  • 30 Amsler F, Willenberg T, Blättler W. Management of venous ulcer: a meta analysis of randomized studies comparing bandages to specifically designed stockings. J Vasc Surg 2009; 50: 668-674.
  • 31 Mosti G. Elastic stockings vs inelastic bandages for ulcer healing: a fair comparison?. Phlebology 2012; Feb; 27 (01) 1-4.
  • 32 Arnoldi CC. Venous pressure in the leg of healthy human subjects at rest and during muscular exercise in the nearly erect position. Acta Chir Scand 1965; 130 (06) 570-583.
  • 33 Partsch B, Partsch H. Calf compression pressure required to achieve venous closure from supine to standing positions. J Vasc Surg 2005; 42: 734-738.
  • 34 Partsch H, Mosti G, Mosti F. Narrowing of leg veins under compression demonstrated by magnetic resonance imaging (MRI). Int Angiol 2010; 29 (05) 408-410.
  • 35 Partsch H, Clark M, Mosti G. et al. Classification of Compression Bandages: Practical Aspects. Derm Surg 2008; 34: 600-609.
  • 36 Pellicer J, Garcia-Morales V, Hernandez MJ. On the demonstration of the Young- Laplace equation in introductory physics courses. Phys Educ 2000; 35: 126-129.
  • 37 Partsch H. The static stiffness index: a simple method to assess the elastic property of compression material in vivo. Dermatol Surg 2005; 31: 625-630.
  • 38 Partsch H. The use of pressure change on standing as a surrogate measure of the stiffness of a compression bandage. Eur J Vasc Endovasc Surg 2005; 30: 415-421.
  • 39 Partsch H. Compression therapy in leg ulcers. Reviews in Vascular Medicine 2013; 01: 9-14.
  • 40 Partsch H. Compression therapy of venous ulcers. EWMA JOURNAL 2006; 02: 16-20.
  • 41 Reynolds S. The impact of a bandage training programme. JWC 1985; 08: 55-60.
  • 42 Nelson EA. et al. Improvements in bandaging technique following training. JWC 1995; 04: 181-184.
  • 43 Keller A, Müller ML, Calow T, Kern IK, Schumann H. Bandage pressure measurement and training: simple interventions to improve efficacy in compression bandaging. Int Wound J 2009; 06: 324-330.
  • 44 Zarchi K. et al. Delivery of Compression Therapy for Venous Leg Ulcers. JAMA Dermatol 2014; 150: 730-736.
  • 45 Protz K. et al. Compression therapy: scientific background and practical applications. JDDG 2014; 794-801.
  • 46 Mosti G, Partsch H. Is low compression pressure able to improve venous pumping function in patients with venous insufficiency?. Phlebology 2010; Jun; 25 (03) 145-150.
  • 47 Mosti G, Partsch H. Inelastic bandages maintain their hemodynamic effectiveness over time despite significant pressure loss. J Vasc Surg 2010; Oct; 52 (04) 925-931.
  • 48 Mosti G, Crespi A, Mattaliano V. Comparison Between a New, Two-component Compression System With Zinc Paste Bandages for Leg Ulcer Healing: A Prospective, Multicenter, Randomized, Controlled Trial Monitoring Sub-bandage Pressures. Wounds 2011; 23 (05) 126-134.
  • 49 Mosti G, Rossari S. L’importanza della misurazione della pressione sottobendaggio e presentazione di un nuovo strumento di misura. Acta Vulnol 2008; 06: 31-36.
  • 50 Partsch H, Mosti G. Comparison of three portable instruments to measure compression pressure. Int Ang 2010; Oct; 29 (05) 426-430.
  • 51 Mosti G, Mattaliano V, Partsch H. Influence of different materials in multicomponent bandages on pressure and stiffness of the final bandage. Dermatol Surg 2008; 34: 631-639.
  • 52 Partsch H. Variability of interface pressure exerted by compression bandages and standard size compression stockings. Proceedings of 20th Annual Meeting of American Venous Forum. Charleston. 20–23/February/2008
  • 53 Moffat C. Variability of pressure provided by sustained compression. Int Wound J 2008; Jun; 05 (02) 259-265.
  • 54 Milic DJ, Zivic SS, Bogdanovic DC, Jovanovic MM, Jankovic RJ, Milosevic ZD, Stamenkovic DM, Trenkic MS. The influence of different sub-bandage pressure values on venous leg ulcers healing when treated with compression therapy. J Vasc Surg 2010; Mar; 51 (03) 655-661.
  • 55 Harding K. et al. Simplifying Venous Leg Ulcer Management. Wound International. 2015
  • 56 Fife CE. et al. Why is it so hard to do the right thing in wound care?. Wound Rep Reg 2010; 18: 154-158.
  • 57 Spence RK, Cahall E. Inelastic versus elastic leg compression in chronic venous insufficiency: a comparison of limb size and venous hemodynamics. J Vasc Surg 1996; Nov; 24 (05) 783-787.
  • 58 Murthy G, Ballard RE, Breit GA, Watenpaugh DE, Hargens AR. Intramuscular pressures beneath elastic and inelastic leggings. Ann Vasc Surg 1994; Nov; 08 (06) 543-548.
  • 59 Damstra R, Partsch H. Prospective, randomized, controlled trial comparing the effectiveness of adjustable compression Velcro wraps versus inelastic multicomponent compression bandages in the initial treatment of leg lymphedema. J Vasc Surg: Venous and Lym Dis 2013; 01: 13-19.
  • 60 Mosti G, Partsch H. Self-management by firm, non-elastic adjustable compression wrap device. Veins and Lymphatics 2017; 06: 7003.
  • 61 Blecken SR, Villavicencio JL. Comparison of elastic versus nonelastic compression in bilateral venous ulcers: a randomized trial. J Vasc Surg 2005; 42: 1150-1155.
  • 62 DePalma RG, Kowallek D, Spence RK, Caprini JA, Nehler MR, Jensen J, Goldman MP. Comparison of Costs and Healing Rates of Two Forms of Compression in Treating Venous Ulcers. Vasc Surg 1999; 33: 683-690.
  • 63 Ehmann S, Whitaker JC, Hampton S, Collarte A. Multinational, pilot audit of a Velcro adjustable compression wrap system for venous and lymphatic conditions. J Wound Care 2016; 25: 513-520.
  • 64 Mosti G, Cavezzi A, Partsch H, Urso S, Campana F. Adjustable Velcro(®) Compression Devices are More Effective than Inelastic Bandages in Reducing Venous Edema in the Initial Treatment Phase: A Randomized Controlled Trial. Eur J Vasc Endovasc Surg 2015; 50: 368-374.
  • 65 McDaniel HB, Marston WA, Farber MA, Mendes RR, Owens LV, Young ML. et al. Recurrence of chronic venous ulcers on the basis of clinical, etiologic, anatomic, and pathophysiologic criteria and air plethysmography. J Vasc Surg 2002; 35: 723-728.
  • 66 Gohel MS, Barwell JR, Taylor M, Chant T, Foy C, Earnshaw JJ. et al. Long term results of compression therapy alone versus compression plus surgery in chronic venous ulceration (ESCHAR): Randomised controlled trial. BMJ 2007; 335: 83.
  • 67 Howard DPJ, Howard A, Kothari A, Wales L, Guest M, Davies AH. The Role of Superficial Venous Surgery in the Management of Venous Ulcers: A Systematic Review. Eur J Vasc Endovasc Surg 2008; 36: 458-465.
  • 68 Nelson EA, Harper DR, Prescott RJ, Gibson B, Brown D, Ruckley CV. Prevention of recurrence of venous ulceration: randomized controlled trial of class 2 and class 3 elastic compression. J Vasc Surg 2006; Oct; 44 (04) 803-808.
  • 69 Clarke-Moloney M, Keane N, O’Connor V, Ryan MA, Meagher H, Grace PA, Kavanagh E, Walsh SR, Burke PE. Randomised controlled trial comparing European standard class 1 to class 2 compression stockings for ulcer recurrence and patient compliance. Int Wound J 2014; Aug; 11 (04) 404-408.
  • 70 Partsch H, Menzinger G, Mostbeck A. Inelastic leg compression is more effective to reduce deep venous refluxes than elastic bandages. Dermatol Surg 1999; Sep; 25 (09) 695-700.

Korrespondenzadresse

Giovanni Mosti
Angiology Department
MD Barbantini Clinic
Via del Calcio 2
5510 Lucca
Italy
Phone: +39058391971   
Fax +390583490050

  • References

  • 1 Baker SR, Stacey MC, Singh G, Hoskin SE, Thompson PJ. Aetiology of chronic leg ulcers. Eur J Vasc Surg 1992; May; 06 (03) 245-251.
  • 2 Shami SK, Sarin S, Cheatle TR. et al. Venous ulcers and the superficial venous system. J Vasc Surg 1993; 17: 487-490.
  • 3 Adam DJ, Naik J, Hartshorne T, Bello M, London NJ. The diagnosis and management of 689 chronic leg ulcers in a single-visit assessment clinic. Eur J Vasc Endovasc Surg 2003; May; 25 (05) 462-468.
  • 4 Körber A, Klode J, Al-Benna S. et al. Etiology of chronic leg ulcers in 31,619 patients in Germany analyzed by an expert survey. J Dtsch Dermatol Ges 2011; Feb; 09 (02) 116-121.
  • 5 Browse NL, Burnard KG. The cause of venous ulceration. Lancet 1982; 243-245.
  • 6 Coleridge PDSmith, Thomas P, Scurr JH, Dormandy JA. Causes of venous ulceration: a new hypothesis. Br Med J (Clin Res Ed) 1988; Jun 18; 296: 1726-1727.
  • 7 Falanga V, Eaglstein WH. The “trap” hypothesis of venous ulceration. Lancet 1993; Apr 17; 341 (8851): 1006-1008.
  • 8 O’Donnell TF, Passman MA, Marston WA, Ennis WJ, Dalsing M, Kistner RL. et al. Management of venous leg ulcers: Clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum. JVS 2014; 60: 3S-59S.
  • 9 Mosti G, De Maeseneer M, Cavezzi A, Parsi K, Morrison N, Nelzen O. et al. Society for Vascular Surgery and American Venous Forum Guidelines on the management of venous leg ulcers: the point of view of the International Union of Phlebology. Int. Angiol 2015; 34 (03) 212-218.
  • 10 Franks PJ, Barker J, Collier M, Gethin G, Haesler E, Jawien A, Laeuchli S, Mosti G, Probst S, Weller C. Management of Patients With Venous Leg Ulcers: Challenges and Current Best Practice. J Wound Care 2016; Jun; 25 (Suppl. 06) S1-S67.
  • 11 Mosti G, Partsch H. Duplex scanning to evaluate the effect of compression on venous reflux. Int Angiol 2010; Oct; 29 (05) 416-420.
  • 12 Mosti G, Mattaliano V, Partsch H. Inelastic compression increases venous ejection fraction more than elastic bandages in patients with superficial venous reflux. Phlebology 2008; 23 (06) 287-294.
  • 13 Mosti G, Partsch H. Measuring venous pumping function by strain-gauge plethysmography. Int Angiol 2010; Oct; 29 (05) 421-425.
  • 14 Partsch B, Mayer W, Partsch H. Improvement of ambulatory venous hypertension by narrowing of the femoral vein in congenital absence of venous valves. Phlebology 1992; 07: 101-104.
  • 15 Milic DJ, Zivic SS, Bogdanovic DC, Jovanovic MM, Jankovic RJ, Milosevic ZD, Stamenkovic DM, Trenkic MS. The influence of different sub-bandage pressure values on venous leg ulcers healing when treated with compression therapy. J Vasc Surg 2010; Mar; 51 (03) 655-661.
  • 16 Brizzio E, Amsler F, Lun B, Blättler W. Comparison of low-strength compression stockings with bandages for the treatment of recalcitrant venous ulcers. J Vasc Surg 2010; 51: 410-416.
  • 17 Cullum N, Nelson EA, Fletcher AW, Sheldon TA. Compression for venous leg ulcers. Cochrane Database Syst Rev 2001; (02) CD000265.
  • 18 Franks PJ, Moody M, Moffatt CJ. et al. Randomised trial of cohesive short-stretch versus four-layer bandaging in the management of venous ulceration. Wound Rep Reg 2004; 12: 157-162.
  • 19 Moffatt CJ, McCullagh L. O’Connor et al. Randomized trial of four-layer bandage systems in the management of chronic venous ulceration. Wound Rep Reg 2003; 11: 166-171.
  • 20 Fletcher A, Cullum N, Sheldon TA. A systematic review of compression treatment for venous leg ulcers. BMJ 1997; 315: 576-580.
  • 21 Callam MJ, Harper DR, Dale JJ. et al. Lothian Forth Valley leg ulcer healing trial—part 1: elastic versus non-elastic bandaging in the treatment of chronic leg ulceration. Phlebology 1992; 07: 136-141.
  • 22 Duby T, Hofman D, Cameron J. et al. 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; 05: 276-279.
  • 23 Ukat A, Konig M, Vanscheid W. et al. Short stretch versus multilayer compression for venous leg ulcers: a comparison of healing rates. JWC 2003; 12: 139-143.
  • 24 Scriven JM, Taylor LE, Wood AJ. et al. A prospective randomised trial of four-layer versus short stretch compression bandages for the treatment of venous leg ulcers. Ann R Coll Surg Engl 1998; 80: 215-220.
  • 25 Nelson EA, Iglesias CP, Cullum N. et al. Randomized clinical trial of four-layer and short-stretch compression bandages for venous leg ulcers. Br J Surg 2004; 91: 1292-1299.
  • 26 Mariani F, Mattaliano V, Mosti G, Gasbarro V, Bucalossi M, Blättler W. The treatment of venous leg ulcers with a specifically designed compression stocking kit. Phlebologie 2008; 37: 191-197.
  • 27 Junger M, Partsch H, Ramelet AA, Zuccarelli F. Efficacy of a ready-made tubular compression device versus short stretch bandages in the treatment of venous leg ulcers. Wounds 2004; 16: 313-320.
  • 28 Jünger M, Wollina U, Kohnen R, Rabe E. Efficacy and tolerability of an ulcer compression stocking for therapy of chronic venous ulcer compared with a below-knee compression bandage: results from a prospective, randomized, multicentre trial. Curr Med Res Opin 2004; Oct; 20 (10) 1613-1623.
  • 29 Horakova MA, Partsch H. Compression stockings in treatment of lower leg venous ulcer. Wien Med Wochenschr 1994; 144 (10–11): 242-249.
  • 30 Amsler F, Willenberg T, Blättler W. Management of venous ulcer: a meta analysis of randomized studies comparing bandages to specifically designed stockings. J Vasc Surg 2009; 50: 668-674.
  • 31 Mosti G. Elastic stockings vs inelastic bandages for ulcer healing: a fair comparison?. Phlebology 2012; Feb; 27 (01) 1-4.
  • 32 Arnoldi CC. Venous pressure in the leg of healthy human subjects at rest and during muscular exercise in the nearly erect position. Acta Chir Scand 1965; 130 (06) 570-583.
  • 33 Partsch B, Partsch H. Calf compression pressure required to achieve venous closure from supine to standing positions. J Vasc Surg 2005; 42: 734-738.
  • 34 Partsch H, Mosti G, Mosti F. Narrowing of leg veins under compression demonstrated by magnetic resonance imaging (MRI). Int Angiol 2010; 29 (05) 408-410.
  • 35 Partsch H, Clark M, Mosti G. et al. Classification of Compression Bandages: Practical Aspects. Derm Surg 2008; 34: 600-609.
  • 36 Pellicer J, Garcia-Morales V, Hernandez MJ. On the demonstration of the Young- Laplace equation in introductory physics courses. Phys Educ 2000; 35: 126-129.
  • 37 Partsch H. The static stiffness index: a simple method to assess the elastic property of compression material in vivo. Dermatol Surg 2005; 31: 625-630.
  • 38 Partsch H. The use of pressure change on standing as a surrogate measure of the stiffness of a compression bandage. Eur J Vasc Endovasc Surg 2005; 30: 415-421.
  • 39 Partsch H. Compression therapy in leg ulcers. Reviews in Vascular Medicine 2013; 01: 9-14.
  • 40 Partsch H. Compression therapy of venous ulcers. EWMA JOURNAL 2006; 02: 16-20.
  • 41 Reynolds S. The impact of a bandage training programme. JWC 1985; 08: 55-60.
  • 42 Nelson EA. et al. Improvements in bandaging technique following training. JWC 1995; 04: 181-184.
  • 43 Keller A, Müller ML, Calow T, Kern IK, Schumann H. Bandage pressure measurement and training: simple interventions to improve efficacy in compression bandaging. Int Wound J 2009; 06: 324-330.
  • 44 Zarchi K. et al. Delivery of Compression Therapy for Venous Leg Ulcers. JAMA Dermatol 2014; 150: 730-736.
  • 45 Protz K. et al. Compression therapy: scientific background and practical applications. JDDG 2014; 794-801.
  • 46 Mosti G, Partsch H. Is low compression pressure able to improve venous pumping function in patients with venous insufficiency?. Phlebology 2010; Jun; 25 (03) 145-150.
  • 47 Mosti G, Partsch H. Inelastic bandages maintain their hemodynamic effectiveness over time despite significant pressure loss. J Vasc Surg 2010; Oct; 52 (04) 925-931.
  • 48 Mosti G, Crespi A, Mattaliano V. Comparison Between a New, Two-component Compression System With Zinc Paste Bandages for Leg Ulcer Healing: A Prospective, Multicenter, Randomized, Controlled Trial Monitoring Sub-bandage Pressures. Wounds 2011; 23 (05) 126-134.
  • 49 Mosti G, Rossari S. L’importanza della misurazione della pressione sottobendaggio e presentazione di un nuovo strumento di misura. Acta Vulnol 2008; 06: 31-36.
  • 50 Partsch H, Mosti G. Comparison of three portable instruments to measure compression pressure. Int Ang 2010; Oct; 29 (05) 426-430.
  • 51 Mosti G, Mattaliano V, Partsch H. Influence of different materials in multicomponent bandages on pressure and stiffness of the final bandage. Dermatol Surg 2008; 34: 631-639.
  • 52 Partsch H. Variability of interface pressure exerted by compression bandages and standard size compression stockings. Proceedings of 20th Annual Meeting of American Venous Forum. Charleston. 20–23/February/2008
  • 53 Moffat C. Variability of pressure provided by sustained compression. Int Wound J 2008; Jun; 05 (02) 259-265.
  • 54 Milic DJ, Zivic SS, Bogdanovic DC, Jovanovic MM, Jankovic RJ, Milosevic ZD, Stamenkovic DM, Trenkic MS. The influence of different sub-bandage pressure values on venous leg ulcers healing when treated with compression therapy. J Vasc Surg 2010; Mar; 51 (03) 655-661.
  • 55 Harding K. et al. Simplifying Venous Leg Ulcer Management. Wound International. 2015
  • 56 Fife CE. et al. Why is it so hard to do the right thing in wound care?. Wound Rep Reg 2010; 18: 154-158.
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