Raj Mani - Compression and Chronic Wound Management

Some decades ago, when the four-layer elasticated bandage (then called the Charing Cross bandage) was developed for treating venous leg ulcers, it seemed the answer to a maidens prayer. It was possible to deliver better pressures, it seemed like the bandages would hold up better and we expected improved healing rates. Of course, our nurses needed specific training, and then there was the matter of finding additional costs associated with the bandages. Good data were gathered reliably. We understood healing rates in our own areas, learnt that bulky bandages interfere with wearing shoes and, perhaps the most important of all, that replicating a perfect bandage is an art form. During this period, there was much innovation of bandaging systems: developments of bandages with more tension, with imprinted figures to guide the hand that wrapped the bandage around legs, the short-stretch bandage and so on. The knowledge that pressure beneath the bandage varies with position and ambulation and pressure-measuring sensors also appeared. A lot of this was grist to the mill for our admired friend and colleague Hugo Partsch who has emphasised the importance of measuring calf circumference and the level (B1 point) on the calf where it should be done. With all this, it continues to be reasonable to expect that compression bandaging will benefit some 50% of the population with chronic wounds. So, what becomes of the remainder? What about patients who are wheelchair bound? And others who live in the upper floors of apartments with no liftshow would they get to a clinic to be treated with compression dressings? And above all what about those with venous disease or lymphoedema? How could we reasonably advise them to wear bandages/garments over their legs in environments where the mercury rarely drops below 30 C during the day? These were arguments had by the four of us when we met in some meeting or other. And so, the idea was born to write this book.

During all this period, devices have been innovated and tried and the findings are clear. Mechanical compression does improve venous return. But will wounds heal? Do you select a wound for a device? When is its use optimally indicated?

Surgery is a vital albeit another track. Based on the latest developments and evidence, surgical management of superficial vein incompetence in Asian societies (with younger demographics), with expectations of wound healing and low recurrence, may have a great deal to offer to such patients.

Going back to the whole picture, devices are recent on the scene. There is a need for a new paradigm that brings together surgery with devices and compression bandaging. The legend of Cinderella was interesting to hear as a child: in a real world, one shoe will not fit all. If you are wondering about costs, what is the true value of device or drug? Surely it must depend on getting it to the number who need it. This book reinforces the importance of compression to treat venous disease and lymphoedema. It discusses new devices and their associated benefits. The book also offers glimpses into the use of traditional medicine systems (Ayurvedic and Chinese) to treat lymphoedema and chronic wounds.