Skin grafts to improve leg ulcer healing

Jones JE, Nelson EA

Published Online:

January 20, 2010

Approximately 1% of people in industrialised countries have a leg ulcer at some time, mainly caused by poor blood flow back from the legs towards the heart. Skin grafts, either using the patient's own skin, artificial skin or donor skin/cells, have been evaluated to see whether they improve the healing of ulcers. The review of trials found evidence that tissue-engineered skin composed of two layers increases the chance of healing. There was not enough evidence to recommend any other type of graft, and further research is required.

Abstract (click to read)

Background:

Venous leg ulceration is a recurrent, chronic, disabling condition. It affects up to one in 100 of people at some time in their lives. Standard treatments are simple dressings and compression bandages or stockings. Sometimes, despite treatment, ulcers remain open for months or years. Sometimes skin grafts are used to stimulate healing. These may be taken, or grown into a dressing, from the patient's own uninjured skin (autografts), or applied as a sheet of bioengineered skin grown from donor cells (allograft). Preserved skin from other animals, such as pigs, has also been used (xenografts).

Objectives:

To assess the effect of skin grafts for treating venous leg ulcers.

Search strategy:

For this update the search strategies were modified and we searched conducted in the Cochrane Wounds Group Specialised Register (May 2009); The Cochrane Central Register of Controlled Trials (CENTRAL) - The Cochrane Library Issue 2 2009; Ovid MEDLINE - 1950 to May Week 2 2009; Ovid EMBASE - 1980 to 2009 Week 20 and Ovid CINAHL - 1982 to May Week 3 2009. No date or language restrictions applied.

Selection criteria:

Randomised controlled trials (RCTs) of skin grafts in the treatment of venous leg ulcers.

Data collection and analysis:

Two review authors independently undertook data extraction and assessment of study quality.

Main results:

For this update of the review, we identified another 2 eligible trials bringing the total to 17 trials (931 participants) - all of which were generally at moderate or high risk of bias. In 12 trials, participants also received compression bandaging.

Eleven trials compared a graft with standard care in which no graft was used. Two of these trials (102 participants) compared a dressing with an autograft; three trials (80 participants) compared frozen allografts with dressings, and two trials (45 participants) compared fresh allografts with dressings. Two trials (345 participants) compared tissue-engineered skin (bilayer artificial skin) with a dressing. In two trials (97 participants) a single-layer dermal replacement was compared with standard care.

Six trials compared alternative skin grafting techniques. The first trial (92 participants) compared autografts with frozen allograft, a second (51 participants) compared a pinch graft (autograft) with porcine dermis (xenograft), the third (7 participants, twelve ulcers) compared tissue-engineered skin with a split-thickness graft, the fourth (10 participants) compared an autograft delivered on porcine pads with an autograft delivered on porcine gelatin microbeads, the fifth trial (92 participants) compared a meshed graft with a cultured keratinocyte autograft, and the sixth trial (50 participants) compared a frozen keratinocyte allograft with a lyophilised (freeze-dried) keratinocyte allografts.

Significantly more ulcers healed when treated with bilayer artificial skin than with dressings. There was insufficient evidence from the other trials to determine whether other types of skin grafting increased the healing of venous ulcers.

Authors' conclusions:

Bilayer artificial skin, used in conjunction with compression bandaging, increases venous ulcer healing compared with a simple dressing plus compression. Further research is needed to assess whether other forms of skin grafts increase ulcer healing.

This record should be cited as:

Jones JE, Nelson EA. Skin grafting for venous leg ulcers. Cochrane Database of Systematic Reviews 2007, Issue 2. Art. No.: CD001737. DOI: 10.1002/14651858.CD001737.pub3

Assessed as up to date:

November 5, 2009

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Primary Review Group:

Wounds Group

PEARLS - Practical Evidence About Real Life Situations (click to read)

Clinical question:

How effective is bilayer artificial skin grafting under compression in venous skin ulcers?

Bottom line:

Applying bilayer artificial skin in conjunction with compression bandaging increases the chance of healing a venous ulcer compared with compression and simple dressing (NNT = 5 for 6 months’ treatment).

Caveat:

There was not enough evidence to determine whether other types of skin grafting, such as xenografts (preserved skin from other animals such as pigs) increased the healing of venous ulcers.

Context:

Venous leg ulcers are a recurrent, chronic, disabling condition, affecting up to 1 in a 100 adults at some time. Prevalence increases with age, and is higher among women. Skin grafts may be taken, or grown into a dressing, from the patient’s own uninjured skin (autografts), or applied as a sheet of bio-engineered skin grown from donor cells (allograft).

Cochrane Systematic Review:

Jones JE et al. Skin grafting for venous leg ulcers. Cochrane Review 2007. Issue 1. This review contains 15 trials and 768 participants.

Authored by:

Brian R McAvoy

Cochrane Primary Health Care Field

Health topics:

Heart & circulation > Ulcers: venous > Surgery

Wounds > Ulcers: venous > Surgery

Cochrane Summaries^beta

Independent high-quality evidence for health care decision making

Skin grafts to improve leg ulcer healing

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