Journal of Wound Management

Background A major lower limb amputation profoundly affects patients´ lives. Shared decision-making (SDM) can play a crucial role when a sensitive decision such as determining the appropriate level of amputation has to be made. Despite clinicians aiming for SDM and patients wanting active participation, barriers persist for implementation.

Aim To explore facilitators and barriers to SDM among orthopaedic and vascular surgeons when deciding amputation levels.

Methods An electronic survey was distributed November 2023 at 21 hospitals in Denmark, yielding responses from 28 vascular and 24 orthopaedic surgeons. The questionnaire covered four domains known to influence SDM and assessed respondents’ viewpoints on the potential use and implementation of an SDM tool. Descriptive statistics and inter-specialty comparisons were performed.

Results More vascular surgeons than orthopaedic surgeons believed an SDM support tool would enhance patients’ decision-making experience (77% vs 48%); benefit their praxis (62% vs 35%); and that they would use such a tool (65% vs 48%). While both groups agreed on patients´ desire to participate in SDM (75%), 35% thought patients would find it difficult to understand the advantages and disadvantages of amputation at different levels. Vascular surgeons described being left out of the decision of amputation level and 63% of the orthopaedic surgeons reported a lack of a genuine choice of amputation level.

Conclusions The study identified facilitators and barriers to SDM in amputation level decisions, emphasising the need for enhanced interdisciplinary collaboration between vascular and orthopaedic surgeons. Implementing a decision support tool could facilitate collaboration between surgeons in favour of patient treatment satisfaction.

The study explored an under-researched but critical element of patient empowerment in chronic wound care, namely degrees of freedom. This refers to the personalisation of everyday wound care based on patients’ individual needs. To identify degrees of freedom in clinical practice, semi-structured interviews were conducted with patients (n = 23) and healthcare professionals (n = 16) and analysed using qualitative content analysis. The analysis yielded nine degrees of freedom with 42 concrete behaviours of primary control (shaping the actual treatment situation) and six degrees of freedom with 22 concrete behaviours of secondary control (shaping the patient’s inner experience). These could be assigned to four main degrees of freedom, namely patients’ self-action, cooperation between patients and health professionals, adaptation of treatment to patients’ needs, and the use of emotional coping strategies. Furthermore, two types of patients could be distinguished: those who are active and take responsibility for their wound, and those who remain passive and tend to endure. The implementation of degrees of freedom offers several positive effects, such as patients experiencing outcome efficacy and becoming experts on their wound. However, there are several implementation issues, such as patient reluctance or time constraints, that need to be overcome first.

Diabetic foot ulcers are a severe complication of diabetes mellitus and are commonly associated with peripheral artery disease and/or neuropathy. An inadequate treatment or the presence of concomitant infection may result in a delay in wound healing. However, in some circumstances, non-healing wounds may hide other underlying diseases, which in some cases may be malignant. A biopsy can be a useful tool to investigate chronic wounds to achieve early diagnosis with the aim of establishing an adequate treatment and to improve the prognosis. We present two clinical cases in which biopsy revealed the presence of malignancy in non-healing chronic ulcers.

Background Wounds continue to be of global concern, amid a lack of widespread adoption of evidence-based practice (EBP). Negative Pressure Wound Therapy (NPWT) is supported by a wealth of evidence and has been widely adopted to manage a broad range of wound indications. This case series demonstrates the safe and effective use of single use NPWT (sNPWT) in the management of non-healing surgical wounds, alongside optimised wound care strategies and interventions.

Aim To present how adopting sNPWT to manage non-healing surgical wounds, alongside a holistic approach to patient care can improve the clinical outcomes.

Management and outcomes Five case studies are presented from hospital and community healthcare settings. All patients had non-healing surgical wounds, and all received treatment with sNPWT; length of therapy days varied between 19 and 91 days. Following treatment with NPWT, three wounds healed, one reached near full approximation of wound edges, and one was managed palliatively with marked improvement in quality-of-life outcomes.

Conclusion In all five cases, the non-healing surgical wounds, either healed or improved substantially when treated with an evidence-based approach incorporating sNPWT alongside optimised wound care strategies and interventions.

Implications for clinical practice Holistic patient-centered care in conjunction with sNPWT may improve outcomes for patients experiencing non-healing surgical wounds.

In a recently published EWMA document on the holistic management of wound-related pain, the only recommendation regarding systemic drug therapy was to follow the WHO analgesic ladder. Since that ladder was developed to specifically address cancer pain, its application in the field of painful chronic wounds represents another case of misappropriation, as there was no evidence to support such a decision. There is still no evidence.

Misappropriation carries risks. The first step of the ladder recommends nonsteroidal anti-inflammatory drugs, which act by inhibiting cyclooxygenase in the inflammatory focus. Therefore, the drug must reach the inflammatory focus. But most chronic wounds are ischemic in nature, and ischemia should at least partially prevent drugs from reaching the wound bed. Consequently, the risk-benefit would to be inadequate in ischemic wounds, but there is no evidence, since this topic has not been the subject of research either.

Wound-related pain has been largely forgotten and, as a direct consequence, there is an unacceptable paucity of studies. It is time for a change.