Leg ulcer management in primary care with special reference to pinch grafting

Abstract: Wound management in primary and community care was investigated throughout a period of 12 years within a well-defined population in one county in Southern Sweden. The estimated prevalence of chronic leg and foot ulcers was 0.19% in 1998 and the mean prevalence was 0.20% during the years 1994-1998. Venous ulcers were the most common (38%) and 7% of the nurses’ workload was devoted to ulcer care. During the period 1986 to 1998 ulcers with missing or unknown aetiology decreased from 31% to 6%, while treatment time per ulcer decreased from 2.1 to 1.7 hours/week. Pinch grafting for treatment of chronic leg ulcers of different aetiologies, sizes and duration has been used in primary care by the author since 1987. The results from 199 operations of 126 ulcers on 85 patients treated at one health centre were specifically studied showing healing rate within three months to be 33%, and 60% within 12 months. Smaller ulcers and ulcers with shorter duration healed better than larger ulcers and ulcers of longer duration, both within three and 12 months. For patients with rheumatoid arthritis 50% of the ulcers were of multi-factorial aetiology with signs of venous insufficiency or vasculitis. Healing after pinch grafting was seen in ulcers with an area less than 15 cm2 and significant pain reduction postoperatively was also found. The costs of treating venous leg ulcers with pinch grafting were evaluated for 58 consecutive patients, 29 in hospital care and 29 in primary care. The healing rate within three months was the same (31%) but the costs were 3.3 to 5.9 times less for patients in primary care. Ulcer area was calculated using four different devices, digital and mechanical planimeter, grid tracing, and the diameter product. Digital planimetry appeared to be a quick and practical method and can be recommended for a dermatological department or a specialised larger health centre with extensive ulcer care. This investigation has shown that pinch grafting is suitable for treating chronic leg ulcers, particularly venous ulcers, in primary care. For patients with RA and leg ulcers pinch grafting was successful for minor ulcers, both regarding healing and pain relief. Monitoring standards for assessment of ulcer aetiology through repeated questionnaires and educating medical staff seemed to assure more accurate diagnoses, a prerequisite for effective leg ulcer treatment.