Prediction of Wound Healing Outcome Using Skin Perfusion Pressure & Transcutaneous Oximetry
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Abstract: Chronic lower extremity wounds are challenging and typically occur in patients with complicating conditions such as diabetes and peripheral vascular disease. Noninvasive modalities developed to assess wound healing potential, such as transcutaneous oximetry (TcPO2), present problems including lengthy test time, variable results, and anatomical limitations. Skin perfusion pressure (SPP) testing appears to be a timely, objective, and reliable alternative. This prospective, single center, comparative study evaluated TcPO2 and SPP test results in 100 patients with chronic extremity wounds to determine their accuracy and usefulness in predicting wound healing potential. Concomitant baseline SPP and TcPO2 were measured and used as predictors of successful wound healing. A threshold of < 30 mmHg was selected as the cutoff below which the test was considered significantly abnormal and indicative of a wound that was unlikely to heal. Follow-up evaluations were conducted for 12 months or until healing, whichever occurred first. The study was evenly balanced for gender distribution and the mean age of the population was 63.4 years (range 19–94). Wounds were secondary to underlying diabetic, arterial, or venous conditions. SPP alone successfully predicted wound outcome in 87% of the cohort compared to TcPO2 at a rate of 64% (P < 0.0002). Furthermore, skin perfusion pressure was more sensitive in its ability to predict wound healing relative to TcPO2 (90% versus 66%; P < 0.0001). SPP with values ≥ 30 mmHg is a useful positive independent predictor of wound healing potential. The continued use and investigation of SPP as a reliable and objective measurement tool in wound assessment protocols and other microperfusion assessments are recommended.
Address correspondence to:
Takkin Lo, MD, MPH, CWS
Wound Treatment Center & Hyperbaric Medicine Service
Loma Linda University Medical Center
11234 Anderson St.
Loma Linda, CA 92354
Phone: 909-558-8097
E-mail: TLo@llu.edu
Chronic lower extremity wounds present a medical challenge because they fail to respond to established medical and surgical management in a timely manner. Often, these patients present with multiple local and systemic factors that may impact wound healing including diabetes mellitus, chronic venous insufficiency, hypertension, and peripheral vascular disease. Beyond the 20.8 million Americans with known diabetes,1 another 6.2 million remain undiagnosed and are unaware they have the disease.2
A frequently seen complication of diabetes mellitus is lower extremity ulceration (LEU). Patients with diabetes admitted to a hospital with a LEU are hospitalized longer on average than those who do not have ulcers,3,4 and while the majority of foot ulcers are managed in an outpatient setting, hospitalization accounts for approximately three quarters of the total expenditures on medical care related to diabetic foot ulcers.5 Impacting this population even further is that half of all lower extremity amputations occur in diabetic patients.3,4 Those undergoing a lower extremity amputation experience a diminished quality of life in addition to increased healthcare costs-the latter was confirmed by a health maintenance organization cost analysis utilizing data from 1993-1995.
1. Centers for Disease Control and Prevention. National Diabetes Fact Sheet: General Information and National Estimates on Diabetes in the United States, 2005. Atlanta, GA: US Department of Health and Human Services; 2005.
2. Centers for Disease Control and Prevention. Diabetes at a Glance: Disabling Disease to Double by 2050. Atlanta, GA: US Department of Health and Human Services; April 2007.
3. National Diabetes Data Group. Diabetes in America. Vol. 2. Bethesda, MD: National Institutes of Health; 1995. NIH publication 95-1468.
4. Reiber GE. The epidemiology of diabetic foot problems. Diabet Med. 1996;13(Suppl 1):S6–S11.
5. Ramsey SD, Newton K, Blough D, et al. Incidence, outcomes, and cost of foot ulcers in patients with diabetes. Diabetes Care. 1999;22(3):382–387.
6. Brod M. Quality of life issues in patients with diabetes and lower extremity ulcers: patients and care givers. Qual Life Res. 1998;7(4):365–372.
7. Ashry HR, Lavery LA, Armstrong DG, Lavery DC, van Houtum WH. Cost of diabetes related amputations in minorities. J Foot Ankle Surg. 1998;37(3):186–190.
8. Holstein P, Lassen NA. Healing of ulcers on the feet correlated with distal blood pressure measurements in occlusive arterial disease. Acta Orthop Scand. 1980;51(6):995–1006.
9. Adera HM, James K, Castronuovo JJ Jr, Byrne M, Deshmukh R, Lohr J. Prediction of amputation wound healing with skin perfusion pressure. J Vasc Surg. 1995;21(5):823–829.
10. Castronuovo JJ Jr, Adera HM, Smiell JM, Price RM. Skin perfusion pressure measurement is valuable in the diagnosis of critical limb ischemia. J Vasc Surg. 1997;26(4):629–637.
11. Castronuovo JJ Jr. Diagnosis of critical limb ischemia with skin perfusion pressure measurements. J Vasc Technol. 1997;21(3):175–179.
12. Castronuovo JJ Jr. The role of skin perfusion pressure and transcutaneous partial pressure oxygen measurements in chronic critical limb ischemia. In: Mansour MA, Labropoulos N, eds. Vascular Diagnosis. New York, NY: WB Saunders; 2005:247–255.
13. Shefield PJ. Tissue Oxygen Measurements. In: Davis J, Hunt T, eds. Problem Wounds: The Role of Oxygen. New York, NY: Elsevier; 1988:17–51.
14. Callam MJ, Harper DR, Dale JJ, Ruckley CV. Chronic ulcer of the leg: clinical history. Br Med J. 1987;294(6584):1389–1391.
15. Frykberg RG, Zgonis T, Armstrong DG, et al. Diabetic foot disorders. A clinical practice guideline. J Foot Ankle Surg. 2006;45(5 Suppl): S1–S66.
16. Kalani M, Brismar K, Fagrell B, Ostergren J, Jörneskog G. Transcutaneous oxygen tension and toe blood pressure as predictors for outcome of diabetic foot ulcers. Diabetes Care. 1999;22(1):147–151.
17. Jörneskog G, Brismar K, Fagrell B. Skin capillary circulation is more impaired in the toes of diabetic than non-diabetic patients with peripheral vascular disease. Diabet Med. 1995;12(1):36–41.
18. Fife CE, Buyukcakir C, Otto GH, et al. The predictive value of transcutaneous oxygen tension measurement in diabetic lower extremity ulcers treated with hyperbaric oxygen therapy: a retrospective analysis of 1,144 patients. Wound Repair Regen. 2002;10(4):198–207.
19. Centers for Medicare and Medicaid Services. Decision Memorandum: Hyperbaric Oxygen Therapy (HBO) for Hypoxic Wounds and Diabetic Wounds of the Lower Extremities. August 30, 2002. Publication CAG-00060N.
20. Tsai FW, Tulsyan N, Jones DN, Abdel-Al N, Castronuovo JJ Jr, Carter SA. Skin perfusion pressure of the foot is a good substitute for toe pressure in the assessment of limb ischemia. J Vasc Surg. 2000;32(1):32–36.
21. Okamoto K, Oka M, Maesato K, et al. Peripheral arterial occlusive disease is more prevalent in patients with hemodialysis: comparison with the findings of multidetector-row computed tomography. Am J Kidney Dis. 2006;48(2):269–276.
22. Akahori H, Uematsu M, Morozumi T, et al. Magnitude of the improvement in skin perfusion pressure is as important as skin perfusion pressure immediately following intervention for predicting limb salvage in critical limb ischemia. Presented at: 56th Annual Scientific Session of the American College of Cardiology; March 2007; New Orleans, LA.
23. Shimazaki M, Matsuki T, Yamauchi K, et al. Assessment of lower limb ischemia with measurement of skin perfusion pressure in patients on hemodialysis. Ther Apher Dial. 2007;11(3):196–201.
24. Iida O, Nanto S, Uematsu M, Morozumi T, Akahori H, Nagata S. Endovascular therapy for limb salvage in a case of critical lower limb ischemia resulting form fibromuscular dysplasia. J Vasc Surg. 2007;46(4):803–807.
