ABSTRACT
The incidence of hard‐to‐heal wounds is rising globally with adverse effects on quality of life. Yet, there is no reliable data available on hard‐to‐heal wound prevalence, aetiology, and outcomes in a low‐to‐middle income country without improper care being a confounding factor. In this retrospective study of 460 individuals (876 wounds) that received appropriate standard of care at a specialised wound care clinic in the Kwazulu‐Natal province of South Africa, acute/traumatic wounds were most prevalent (230/460, 50%) followed by ulcers (173/460, 38%) (DFUs 13%, VLUs 12%, PIs 11%, MLUs < 1%, ALUs < 1%) and atypical wounds (55/460, 12%) (atypical wounds 8%, vectors 4%). Definitions for wound aetiologies are provided. Delayed referral for specialised wound care was evident for individuals with ulcers. 103/460 (22%) individuals did not respond to the standard of care and were classified as hard‐to‐heal (< 40% wound closure after 4 weeks and/or > 12 weeks of the standard of care). Diabetes mellitus (45/103, 44%) and wound infection (44/103, 43%) accounted for poor healing trajectories in the hard‐to‐heal cohort, whereas 14/103 (13%) individuals had other comorbidities. High prevalence rates of hard‐to‐heal wounds in the heterogenous South African population necessitate recognition of wound management as a specialty in South Africa.
Keywords: chronic wounds, diabetes, hard‐to‐heal wounds, healing rates, infection, wound healing
Summary.
Reliable data are needed on the prevalence, aetiology and healing outcomes of hard‐to‐heal wounds in South Africa.
Retrospective data analysis was performed on 460 individuals (876 wounds) receiving appropriate standard of care over a 5‐year period based on available guidelines.
High prevalence rates of hard‐to‐heal wounds and delayed referral in the heterogenous South African population necessitate recognition of wound management as a specialty.
1. Introduction
Wound healing is a complex physiological process that is susceptible to various intrinsic and extrinsic factors that influence the individual (whole body) and/or the localised wound environment resulting in disruptions to the healing process [1]. Failure to progress through the phases of healing in a timely manner leads to the development of chronic wounds [2, 3]. Based on previous studies, the current consensus is that a wound failing to progress towards healing within 4 weeks of receiving the appropriate standard of care (SoC), should be defined as chronic [2, 4, 5], and one study suggests that due to all the variables, there is no acceptable scientific definition [6, 7]. SoC is a legal term described as the level of care a sensible and reasonable person would apply within the situation [8]. There is very little data available on the true prevalence and global burden of chronic wounds due to disparities in study designs, lack of clear definitions, measurement methods and access to proper wound care, however, estimated to be 2.21 per 1000 population [9]. This is associated with a significant financial burden on healthcare systems and individuals due to the high costs related to wound management [6, 10].
The quality of life (QoL) for individuals suffering from chronic wounds is furthermore significantly reduced [6, 10, 11]. These individuals experience not only disruptions of daily life and work attendance, but increased risk of mortality, reduced mobility, wound malodour, increased pain, financial pressure, social isolation, depression, loss of sexual performance and sexuality, and distrust and dissatisfaction in healthcare providers who have provided them with advice and care [12, 13, 14]. In addition to the clinical status (deterioration) of the wound, prominent predictors of QoL include the patient's age and socioeconomic circumstances [13]. Initial wound management is often performed by community‐based primary healthcare providers with no specialised wound education. Latrogenic factors due to a lack of competency exacerbates delayed healing and result in unnecessary financial and psychosocial costs [15, 16]. Early referral to specialist wound care is thus essential to improve treatment efficiency and QoL and to reduce health care costs [15], with consensus from expert panels even suggesting that the involvement of a wound specialist in short‐term in‐patient hospital care can have a significant effect on healing trajectories [17]. After the application of SoC for 4 weeks wounds that fail to heal by 40%–50% are considered hard‐to‐heal (HTH) and require prolonged treatment (> 12 weeks) [5, 18]. Many confounding factors make it difficult to distinguish scientifically between chronic wounds that will respond to treatment and those that will become HTH [7]. There is no reliable data available on HTH prevalence, aetiology and outcomes in a low‐to‐middle‐income country without improper care being a confounding factor.
2. Materials and Methods
2.1. Study Population and Ethics
A descriptive study based on retrospective data analysis was performed. Individuals who attended a specialised wound care clinic in the Kwazulu‐Natal province of South Africa between January 2018 and December 2022 were considered for inclusion in this study. Refer to supporting information for more information on the overall demographic and socio‐cultural environment within South Africa. Inclusion criteria: Above 18 years of age, received appropriate SoC based on wound aetiology and prior consent. Exclusion criteria: Minor (< 18 years of age), malignant wounds, stoma, individuals diagnosed with cancer, and individuals who did not have an open wound. The study was conducted according to the Declaration of Helsinki and was approved by the Human Research Ethics Committee (N23/03/021, project ID 27333) at Stellenbosch University.
2.2. Data Collection
The clinical patient files were assigned a folder number, and the data were de‐identified by assigning each patient a unique study number. Strict confidentiality was maintained with restricted access to the data. Data were collected and captured onto RedCap (Research Electronic data capture) database and on a spreadsheet (Microsoft Excel) by qualified and trained researchers with quality control checks performed. Information on the demographic data pertaining to age (years), sex, co‐morbidities, metabolic status, wound history, number of wounds per individual, anatomical location of wounds, wound aetiologies, wound infection, wound measurement and healing parameters was collected and captured. Metabolic status was recorded as a confirmed diabetes mellitus diagnosis based on HbA1c (≥ 6.5%; 48 mmol/mol) and/or an oral glucose tolerance test (fasting blood glucose > 7.8 mmol/L; 2‐h blood glucose > 11 mmol/L) [19, 20]. Wound infection was recorded as either confirmed by microbiology analysis of wound swabs by commercial pathology laboratories accredited for diagnostics and/or clinical signs and symptoms of the wound infection continuum documented in the patient file as part of the Wound bed preparation: TIME (Tissue, Inflammation/infection, Moisture imbalance, Epithelial edge advancement) for an update (for the year 2018) and TIMERS (Tissue management, Inflammation and Infection, Moisture balance, Epithelial edge, Repair and Regeneration, Social factors) holistic wound assessment and management (for the years 2019–2022) [18, 21, 22, 23].
2.3. SoC
The clinic offers specialised wound care based on primary or secondary referrals or individuals referred by themselves in the private medical sector. SoC is provided unaffected by resource constraints (except for advanced regenerative modalities) by nurse practitioners with wound management education qualifications, within an interdisciplinary healthcare team. Appropriate holistic SoC based on wound aetiology was provided according to the relevant and most recently updated international and national consensus guidelines (when available). (Table 1) [18, 24]. Individuals attended the clinic once or twice weekly for the duration of the treatment period with some individuals infrequently performing self‐care and visiting the clinic every 2 weeks.
TABLE 1.
Wound descriptions and best practice national/international guideline references for specific wound types utilised throughout the study period, as updated.
| Wound aetiology | Description | Best practice national/international guidelines and/or references for specific wound types. | Reference |
|---|---|---|---|
| Traumatic | Sudden, unplanned injury that occurs after accidents, acts of violence or other extrinsic factors. Includes abrasions, lacerations, skin tears, burns, gunshots, amputations, dog bites, punctures, avulsions/degloving and excoriations. | Guidelines used for specific traumatic wound types for example, skin tears and burns. | |
| Dog bite wounds | |||
| World Health Organisation. WHO expert consultation on rabies: third report. Volume 1012. World Health Organisation. | |||
| NICD. Department of Health South Africa. Prevention of Rabies in Humans. | |||
| Degloving wound: | |||
| Degloving soft tissue injuries of the extremity: characterisation, categorization, outcomes, and management. | |||
| Gunshot wound: | |||
| Gunshot wounds: Ballistics, pathology, and treatment recommendations, with a focus on retained bullets. | |||
| Skin tears | A traumatic wound caused by mechanical forces, including adhesive removal skin injury. Varies by depth but does not extend through the subcutaneous layer. | Best practice recommendations for the prevention and management of skin tears in aged skin. | [25] |
| Burns | A traumatic wound caused by thermal, electrical, chemical or electromagnetic energy. | WHASA consensus document on the management of acute burns. | [26, 27] |
| Primary management of burn injuries: Balancing best practice with pragmatism. | |||
| Surgical Wound surgical wound dehiscence | An incision through the skin is made during surgery. | WUWHS Consensus Document. Surgical wound dehiscence: Improving prevention and outcomes. | [28, 29] |
| Surgical wound dehiscence (SWD) is a partial or total separation of previous approximated wound edges. | International best practice recommendations for the early identification and prevention of surgical wound complications. | ||
| Atypical Wound | A wound not within a typical wound category. | Atypical wounds. Best clinical practice and challenges. | [30] |
| Vector wound | A wound caused by any living agent or insect that potentially carries and transmits infectious pathogens, microbes, or toxins. | Spider bites in SA identification. | [31] |
| Diabetic foot ulcers (DFUs) | Open wound that occurs as a complication of the multifactorial pathogenesis of diabetes mellitus. | WHASA consensus document on the management of the diabetic foot. | [32, 33] |
| IWGDF Guidelines on the prevention and management of diabetic foot disease. | |||
| Venous leg ulcers (VLUs) | Open wound of the lower leg or foot affected by chronic venous insufficiency and venous hypertension. | WHASA consensus document on the management of lower limb ulcers. | [34, 35] |
| Best practice recommendations for the prevention and management of venous leg ulcers. | |||
| Mixed leg ulcers (MLUs) | Open wound caused by a combination of chronic venous insufficiency and peripheral arterial occlusive disease. | WHASA consensus document on the management of lower limb ulcers. | [34] |
| Arterial leg ulcer (ALUs) | Open wounds caused by peripheral arterial disease and damage to arteries | WHASA consensus document on the management of lower limb ulcers. | [34, 36] |
| Best practice recommendations for the prevention and management of peripheral arterial ulcers. | |||
| Pressure injury (PIs) | Damage to the skin and/or underlying soft tissue, usually occurring over a bony prominence due to prolonged pressure or pressure combined with shear. | WHASA consensus document on the management of pressure ulcers. | [37, 38, 39] |
| Best practice recommendations for the prevention and management of pressure injuries. | |||
| EPUAP/NPIAP/PPPIA prevention and treatment of pressure ulcers/injuries: Clinical practice guideline. |
Note: Shaded grey area in column 1 refers to the specific wound type (aetiology).
Abbreviations: EPUAP/NPIAP/PPPIA, European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance; IWGDF, International Working Group on the Diabetic Foot; WHASA, Wound Healing Association Southern Africa; WUWHS, World Union of Wound Healing Societies.
2.4. Wound Aetiology and Healing Outcomes
The criteria for the differential diagnosis of wounds are described in Table 1. In addition to the wound aetiology, wounds were further classified into either acute, chronic or HTH according to time to heal measured in weeks and reduction in surface area, defined as (a) Acute wound: a wound completely healed within 4–5 weeks (weeks) of treatment [4, 7]. (b) Chronic wound: a wound that was either open > 12 weeks prior to the first clinic visit and then responded to subsequent SoC and/or a wound that required > 4 weeks but < 12 weeks of SoC [2, 4, 5]. (c) HTH wounds: a wound that did not respond to SoC resulting in < 40% wound closure after 4 weeks and/or a wound that required more than 12 weeks of SoC [5, 18].
Wound surface area (cm2) (greatest length × greatest width) measurements using the ruler method were documented at each clinic visit for the duration of treatment and used to calculate the percentage (%) wound closure over time using the following formula: [((wound size first visit) – (wound size n visit)/(wound size first visit))] * 100.
Healing outcomes were defined as either:
completely healed (100% wound closure),
>95% closed at a final clinic visit,
ongoing or still open after 24 weeks of treatment,
healed after amputation or
unknown (lost‐to‐follow‐up).
2.5. Statistical Analysis
All statistical analysis was performed using GraphPad Prism (version 10). The Kolmogorov–Smirnov (K‐S) normality test with Lilliefors correction and the Shapiro–Wilk test were used to assess the normal distribution of data. Descriptive data is reported as either /N (%), means (SD) (normally distributed) and/or median (interquartile range) (non‐parametric data). Multivariate analysis (ANOVA) with the Kruskal–Wallis multiple comparisons test was done to determine differences between groups. Fisher's Exact test was performed to determine any relationships between variables and wound classification. The threshold for significance was accepted at p < 0.05.
3. Results
3.1. Overview of the Study Population and Wound Aetiology
Five hundred and fifty‐eight (N = 558) individuals attended the wound clinic between 2018 and 2022, of which 138 did not meet the inclusion criteria and were thus excluded from the analysis (Figure 1A). A total of 460 individuals were included in the study with data reported for a total number of 876 wounds over the 5‐year period. The average number of wounds per individual is reported in Table 2. Half of the individuals incurred acute/traumatic wounds (230/460, 50%) (n/N) which included:
surgical wounds (22%).
other traumatic wounds (18%) caused by (incidents and falls 66/85, motor vehicle accidents 11/85, dog bites 5/85, assaults 2/85, gunshot wounds 1/85).
skin tears (7%).
burn wounds (3%).
FIGURE 1.
Overview of study population and prevalence based on aetiology. (A) Flow diagram giving an overview of the number of individuals and number of wounds included in the study. (B) Pie chart illustrating the prevalence of different wound types based on aetiology.
TABLE 2.
Overview of wound patient demographics and healing outcomes.
| Acute/traumatic wounds | Atypical wounds | Ulcers | |||||||
|---|---|---|---|---|---|---|---|---|---|
| Aetiology | Traumatic: Other | Skin tear | Surgical | Burns | Vectors | Atypical | DFUs | VLUs | PIs |
| (Number of individuals) | (N = 85) | (N = 31) | (N = 100) | (N = 16) | (N = 19) | (N = 36) | (N = 59) | (N = 56) | (N = 52) |
| Age (years) a | 62 (42–73) | 84 (78–87)*** | 62 (47–70) | 47 (36–65) | 58 (48–70) | 52 (40–68) | 66 (54–71) | 73 (59–79)** | 71 (58–82)* |
| Sex b | |||||||||
| Male | 46 (54%) | 12 (38%) | 46 (46%) | 8 (50%) | 8 (42%) | 18 (50%) | 43 (73%) | 16 (29%) | 27 (52%) |
| Female | 39 (46%) | 19 (61%) | 54 (54%) | 8 (50%) | 11 (58%) | 18 (50%) | 16 (27%) | 40 (71%) | 25 (48%) |
| Confirmed diabetes b | 8 (9%) | 0 (0%) | 12 (12%) | 2 (12%) | 3 (16%) | 10 (28%) | 59 (100%) | 9 (16%) | 31 (60%) |
| Number of open wounds per individual c | 1.8 ± 1.3 | 2.6 ± 2.4 | 1.8 ± 1.2 | 2 ± 1.7 | 1.2 ± 0.5 | 2 ± 1.6 | 2 ± 1.9 | 2 ± 1.3 | 2.5 ± 2.1 |
| Duration of wounds (prior to first clinic visit) | |||||||||
| (weeks) c | 3.3 ± 4.3 | 2.5 ± 4.8 | 3.4 ± 3.9 | 3.0 ± 5.3 | 4.9 ± 8 | 4.8 ± 6.2 | 9.0 ± 9.9 | 48 ± 110 | 23 ± 60 |
| (range in weeks) | (0.1–24) | (0.1–24) | (0.1–24) | (0.4–20) | (0.1–28) | (0.1–28) | (0.35–52) | (0.7–572) | (0.4–312) |
| > 12 weeks b | 5 (6%) | 1 (3%) | 5 (5%) | 1 (6%) | 5 (26%) | 5 (14%) | 17 (29%) | 16 (29%) | 10 (19%) |
| Treatment time (days) c | 36 ± 45 | 41 ± 38 | 38 ± 40 | 26 ± 22 | 50 ± 59 | 44 ± 46 | 92 ± 128 | 85 ± 117 | 61 ± 103 |
| Single visit b | 29 (34%) | 4 (13%) | 21 (21%) | 2 (13%) | 1 (5%) | 5 (14%) | 11 (18%) | 3 (5%) | 15 (29%) |
| < 4 weeks b | 34 (40%) | 12 (39%) | 40 (40%) | 9 (56%) | 7 (37%) | 17 (47%) | 14 (24%) | 20 (36%) | 18 (34%) |
| 4‐12 weeks b | 27 (32%) | 13 (42%) | 34 (34%) | 5 (31%) | 9 (47%) | 11 (31%) | 17 (29%) | 17 (31%) | 13 (25%) |
| > 12weeks b | 5 (6%) | 3 (10%) | 5 (5%) | 0 (0%) | 2 (11%) | 3 (8%) | 17 (29%) | 16 (27%) | 6 (12%) |
| Chronic (> 4 weeks) b | 22 (26%) | 15 (48%) | 39 (39%) | 5 (31%) | 11 (58%) | 14 (39%) | 34 (58%) | 33 (59%) | 19 (37%) |
| HTH b | 9 (11%) | 4 (13%) | 12 (12%) | 2 (12%) | 5 (26%) | 6 (17%) | 28 (47%) | 24 (43%) | 13 (25%) |
| Diabetes only d | 2/9 | 0/4 | 1/12 | 0/2 | 1/5 | 0/6 | 3/28 | 1/24 | 0/13 |
| Infection only d | 4/9 | 0/4 | 9/12 | 2/2 | 2/5 | 5/6 | 0/28 | 16/24 | 7/13 |
| Diabetes + Infection d | 1/9 | 0/4 | 1/12 | 0/2 | 0/5 | 1/6 | 25/28 | 2/24 | 6/13 |
| Other d | 2/9 | 4/4 | 1/12 | 0/2 | 2/5 | 0/6 | 0/28 | 5/20 | 0/13 |
| Healing outcomes | |||||||||
| Lost‐to‐follow‐up b | 57 (67%) | 13 (42%) | 57 (57%) | 10 (63%) | 10 (53%) | 23 (64%) | 30 (51%) | 26 (46%) | 40 (77%) |
| Positive healing outcome d | 27/28 | 18/18 | 42/43 | 6/6 | 8/9 | 12/13 | 18/29 | 26/30 | 8/12 |
| Ongoing wounds d | 0/28 | 0/18 | 1/43 | 0/6 | 1/9 | 0/13 | 2/29 | 4/30 | 4/12 |
| Amputation d | 1/28 | 0/18 | 0/43 | 0/6 | 0/9 | 1/13 | 9/29 | 0/30 | 0/12 |
Note: Statistical analysis: One‐Way ANOVA with Kruskal–Wallis multiple comparisons test. ALUs and MVLUs were not included in data analysis, the number of cases within this table is thus n = 454.
Median (IQR).
n/N (%).
Mean ± SD.
n/N. (n/N refers to the number of cases).
p < 0.05 indicates significant difference in patient age between PI cases and surgical, atypical cases.
p < 0.05 indicates significant difference in patient age between VLU cases and surgical, atypical cases.
p < 0.01 indicates significant difference in patient age between skin tear cases and all other wound types.
This was followed by ulcer cases (173/460, 38%) (n/N) including:
DFUs (13%).
VLUs (12%).
PIs (11%).
MLUs (< 1%).
ALUs (< 1%).
Wounds that were not within a typical wound category accounted for 55/460 (n/N) (12%) and included atypical wounds (36/460, 8%) and vectors (19/460, 4%) (Figure 1B). There was an overall equal distribution of male and female cases in most wound types, except for skin tears (61% female), VLUs (71% female) and DFUs (73% male) (Table 2). The anatomical location of wounds per aetiology is presented in Figure 2A–J. The majority of acute traumatic wounds were located on the upper and lower limbs and skin tears were on the lower limbs (Figure 2B,C). Surgical wounds were mainly located in the abdominal midline or navel area (Figure 2D), burn wounds on the hands and lower limbs (Figure 2E), vectors on the lower limbs (Figure 2F) and atypical wounds occurred randomly throughout the body (Figure 2G). Typically, DFUs and VLUs were located on the lower limbs, (Figure 2H,I) and pressure injuries (PIs) were mostly on the buttocks, heel and sacral locations (Figure 2J). Given the small number of cases presenting with MLUs (3 cases) and ALUs (3 cases), they were not included in subsequent statistical analysis.
FIGURE 2.
Anatomical location of wounds. (A) Wound location diagram as reference for the mapping of the anatomical location of wounds. (B–J) The frequency distribution of wound sites at each of the anatomical locations is presented for (B) other traumatic wounds (n = 85), (C) skin tears (n = 31), (D) surgical wounds (n = 100), (E) burn wounds (n = 16), (F) vector wounds (n = 19), (G) atypical wounds (n = 36), (H) diabetic ulcers (DFUs) (n = 59), (I) venous leg ulcers (VLUs) (n = 56) and (J) PIs (n = 52).
3.2. Patient Demographics and Age
The patient population included in this study is representative of the Kwazulu‐Natal region within South Africa. The age of the study population ranged between 18 and 93 years, with the individuals presenting with skin tears (84 (78–87)) being significantly older than the individuals with all the other wound aetiologies (p < 0.01). Although younger than the skin tear cohort, individuals presenting with VLUs (73(59–79)) and PIs (71(58–82)) were also significantly older than the individuals in the other wound aetiologies (p < 0.01) (Table 2). A significant association between the age of the individuals and the treatment period required to heal was however only evident in the surgical wound cohort (R = 0.2793, p = 0.0127), suggesting that age was not the major determining factor in the healing trajectory of individuals within the respective wound types.
3.3. Wound Duration, Treatment Time and Healing Trajectories
The self‐reported duration of the wound before the patient's first visit to the clinic was documented. The average wound duration before seeking specialist wound care for the acute/traumatic wounds was on average 2–3 weeks (skin tears, surgical, burns, other traumatic wounds) and 4–5 weeks for atypical wounds and vectors. Whereas a significant delay in referral to a specialised wound clinic was evident in individuals with ulcers (p < 0.01), with the average wound duration before the individual's first visit to the clinic being 9 weeks for DFUs, 23 weeks for PIs and 48 weeks for VLUs (Figure 3A, Table 2). Similarly, a significant difference was evident in the duration of treatment (SoC), especially in those individuals with DFUs requiring prolonged intervention times (Figure 3B, Table 2).
FIGURE 3.
Description of wound healing rates. The distribution of data for the (A) duration of wounds (weeks) prior to the first clinic visit and (B) the standard of care treatment time frame (days) is presented in violin plots indicating the median (solid line) and interquartile ranges (dotted line). Statistical analysis: One‐way ANOVA with Kruskal–Wallis multiple comparisons test. Statistical significance for each graph is presented in the compact letter display format (a,b,c)—if two groups (wound aetiologies) do not share a letter, it indicates p < 0.05. (C) Percentage of wounds (%) classified as either chronic (black bars) or hard‐to‐heal (red bars) per aetiology. (D–L) Wound healing trajectories based on the percentage wound closure (%) over a 12‐week period are presented for acute wounds, chronic wounds and HTH wounds within each aetiology. The sample size for MLUs and ALUs (< 1%) was too small to include in the analysis.
Chronic wounds requiring > 4 weeks of treatment were evident in 192/460 (n/N) (42%) individuals. Of these chronic wounds a subset of individuals (103/192) (n/N) did not respond to SoC and failed to heal by 40% within the first 4 weeks of treatment or required > 12 weeks of SoC and was thus classified as HTH. The overall prevalence of HTH wounds in the entire cohort was 22% (103/460). The prevalence of individuals suffering from chronic and HTH wounds for each aetiology is reported in Figure 3C and Table 2. A clear distinction was evident in the healing trajectory of acute, chronic and HTH wounds (% wound closure over time). Acute wounds healed within 4–5 weeks of receiving appropriate treatment, chronic wounds required 4–12 weeks of treatment to achieve 100% wound closure and HTH wounds failed to close within 12 weeks. Refer to Figure 3D–L for wound closure rates over a 12‐week period based on aetiology and wound type. In addition to a delayed healing response evident in HTH wounds, an increase in wound surface area was often evident in these wounds, especially in the HTH burn wounds, the DFUs and the iatrogenic atypical wound (Figure 3G,I,J).
3.4. Healing Outcomes and Amputation Rates
A large portion of individuals (266/460, 58%) only attended the wound clinic once or were lost‐to‐follow‐up with healing outcomes unknown (Table 2). The overall number of individuals who had single clinic visits or who were lost to follow‐up during the treatment period is reported in Figure 4A–I together with the outcomes for all individuals per wound aetiology over time. Upon exclusion of the cases that were lost to follow‐up, positive healing outcomes defined as either complete healing or > 95% wound closure at the final clinic visit were achieved in 96% of acute/traumatic other wounds, 100% of skin tears, 98% of surgical wounds, 100% of burn wounds, 89% of vector wounds, 92% of atypical wounds, 62% of DFUs, 87% of VLUs and 67% of PIs (Table 2). Wounds that failed to completely close and were not healed at 24 weeks of treatment were observed in one surgical case (74‐year‐old with type 2 diabetes), 2 DFU cases (non‐compliance) and 4 VLU cases (> 70 years of age) with treatment continued beyond 24 weeks.
FIGURE 4.
Healing outcomes. The frequency distribution (% of cases) of healing outcomes over time per aetiology is presented for (A) traumatic wound cases (n = 85), (B) skin tear cases (n = 31), (C) surgical wound cases (n = 100), (D) burn wound cases (n = 16), (E) vector wound cases (n = 19), (F) atypical wound cases (n = 36), (G) diabetic ulcer cases (n = 59), (H) venous leg ulcer cases (n = 56) and (I) pressure injury cases (n = 52). Single visits refer to cases in which the patient only visited the clinic once. ALL refer to all other cases except for the single visits. These cases (ALL) are further stratified based on treatment duration and the outcomes presented for cases that received either < 4 weeks of treatment, 4–12 weeks of treatment or > 12 weeks of treatment. Ongoing wounds were classified as wounds that remained open after a prolonged treatment period of 24 weeks.
The overall amputation rate in the entire cohort was 2% (11/460). Most of the amputations were evident in DFU individuals 9/59 (15%) (Figure 4G). Of these 9 DFUs, 7 individuals had amputations before visiting the clinic and received amputation postoperative care with a treatment time at the clinic ranging from 1 to 24 weeks. Two individuals with DFUs were non‐compliant and presented with gangrene and a history of multiple amputations over a 2‐year period. Two amputations occurred in individuals without diabetes mellitus. One was a traumatic wound amputation (forearm) following a motor vehicle accident (treatment time to heal: 100% closure at 14 weeks) and the other was an iatrogenic atypical wound causing penile autoamputation (treatment time to heal: 100% closure at 29 weeks).
3.5. Infection Rates and Metabolic Status of Individuals With HTH Wounds
Over the 5‐year study period, a total of 103/460 individuals (22%) had HTH wounds. A confirmed diagnosis of diabetes mellitus was present in 45/103 (44%) of the HTH cases, with signs of infection present in 36/45 (80%) of these diabetic HTH wounds. Clinical signs of infection (with or without microbiology confirmation) were furthermore reported in 44/103 (43%) HTH cases without diabetes. There was however a portion of individuals 14/103 (13%) with HTH wounds in which neither infection nor diabetes could account for the poor healing responses. The individual characteristics of these 14 cases are presented in Table 3.
TABLE 3.
Comorbidities of HTH cases in which neither diabetes nor wound infection accounted for poor healing outcomes.
| Wound aetiology | Age (years) | Sex (M/F) | Comorbidities |
|---|---|---|---|
| Traumatic (N = 2) | 46 | M | Occasional smoking/drinking |
| 70 | M | Hypertension | |
| Skin tears (N = 4) | 79 | F | RA, hypertension |
| 87 | M | Osteoarthritis, hypertension | |
| 83 | M | RA, hypertension | |
| 78 | F | Arterial fibrillation, hypothyroidism, PAD | |
| Surgical (N = 1) | 58 | F | Smoking history of 28 years |
| Vectors (N = 2) | 83 | F | RA |
| 49 | F | Depression | |
| VLUs (N = 5) | 54 | F | RA, hypertension |
| 66 | M | Cardiac arrhythmia, hypertension | |
| 66 | F | DVT, fibromyalgia, hyperthyroidism, RA, anticoagulant medication | |
| 72 | F | Hypertension | |
| 87 | F | DVT |
Abbreviations: DVT, deep vein thrombosis; F, female; M, male; PAD, peripheral arterial disease; RA, rheumatoid arthritis.
4. Discussion
The incidence of chronic wounds is worsening globally due to an increased prevalence of multi‐morbidities associated with non‐communicable diseases, antimicrobial resistance, and the aging population [1, 18, 40, 41]. This has necessitated the implementation of international guidelines for advanced wound management that focuses on an holistic individualised‐centred approach in addition to the management of the wound aetiology and wound environment to ensure optimal conditions for repair [18, 24]. Despite this, practical and current wound management guidelines are often not available in primary and secondary healthcare facilities, especially in low‐to‐middle‐income countries. A survey of wound care knowledge conducted in South Africa in 2010 indicated that only 32% of registrars and 18% of general practitioners (GPs) attained scores of 70% or more, whilst an audit analysis of malpractice litigation cases in nursing practice in South Africa in 2018 highlighted that 91% of adverse events were due to clinicians not following guidelines, followed by 75% due to a lack of knowledge, 69% poor monitoring and 63% due to clinical manifestations not responded to, emphasising the need for wound education amongst healthcare providers at the primary and secondary level [14, 42, 43]. Data from a resource‐constraint hospital in South Africa suggested a wound burden of up to 34.6% in individuals admitted on a single day [44]. There is, however, very little to no long‐term data available on the chronic wound burden in South Africa.
The lack of data on the prevalence and aetiology of chronic and HTH wounds underestimates the problem which represents a significant barrier to addressing this public health challenge effectively. This impedes the effective allocation of resources, management and advancement of wound care [9] and has directly impacted patient outcomes by delaying diagnosis and appropriate referral to advanced wound care facilities [15, 45]. The purpose of this study was therefore to report on the prevalence, aetiology and healing trajectories of HTH wounds within a private clinic in a low‐to‐middle income country without improper care being a confounding factor.
This study illustrates delayed referral in ulcer individuals from primary and secondary health care facilities and/or self‐referral to the specialised wound clinic, with DFU, VLU and PI individuals suffering from non‐healing ulcers for periods up to 9, 23 and 48 weeks respectively before referral. Referral to a qualified wound care provider for advanced assessment and diagnosis if a wound has not healed or reduced in size by 40%–50% within 4 weeks is essential [15, 45]. Studies have illustrated that certain key sources of uncertainty exist in primary health care when evaluating wounds. These include heterogeneity in aetiology, patient populations and treatment choices as well as challenges in capturing healing outcomes [46]. Education is therefore required on a primary and secondary level that will enable knowledgeable, skilled nurses, GPs and registrars to make clinical judgement calls during the initial treatment phase. This is crucial since suboptimal treatment during this initial phase can lead to wound deterioration leading to a status of HTH [47].
Not all individuals with wounds respond to conventional SoC. In the current study, 42% of cases were chronic of which 22% became HTH. Previous population‐based reports suggest that 1%–2% of the global population suffers from chronic wounds, with 2019 data from the USA indicating that up to 16% of Medicare beneficiaries are impacted by chronic wounds [9, 48, 49]. The high prevalence rate reported here is based on individuals seeking medical treatment and is thus not representative of the entire population. Nonetheless, consistent with other reports [50, 51], the data emphasises the effectiveness of best practice wound care with positive healing outcomes evident in almost all the individuals with acute/traumatic wounds; skin tears, surgical wounds, minor burn wounds, vectors, atypical wounds, other traumatic wounds and VLUs who completed their treatment within 12 weeks and were not lost to follow‐up. Whereas positive outcomes were only evident in two‐thirds of DFUs and PIs within 24 weeks of treatment.
There are numerous risk factors associated with poor healing outcomes which include lifestyle and demographic factors (genetics, smoking, socioeconomic status, psychosocial factors), metabolic disorders (obesity, diabetes, poor nutrition), vascular disease (arterial disease, venous disease, lymphatic insufficiency, oedema, hypertension), auto‐immunity, neuropathy, immune suppression, microbial infection, systemic medication, cancer therapy and patient adherence amongst others [2, 14, 52, 53, 54, 55, 56, 57]. Consistent with previous reports, the non‐diabetic individuals that developed HTH wounds in this study suffered from various co‐morbidities, the most prevalent of which was hypertension and rheumatoid arthritis. The more risk factors an individual has, the more likely the wound will become HTH, there are however currently no biomarkers available to predict healing outcomes in high‐risk individuals. In the current study, diabetes‐associated co‐morbidities, infection and/or old age did account for most of the HTH wounds, with the amputation rate amongst DFU cases (15%) being consistent with global reports [58]. The majority of these amputations in DFU cases (7/9) did, however, occur before the individual's first visit to the clinic, with individuals receiving amputation postoperative care. Despite the small sample size, a strength of this study was reporting on the wound trajectories over time between acute, chronic, and HTH wounds with diverse aetiologies over a period of 12 weeks, after initiating best practice SoC. Although large variability was observed in healing trajectories, a clear distinction was evident with HTH wounds showing an increase in the surface area during the very early stages (2–4 weeks) which was not evident in acute or chronic wounds that responded to treatment. This is consistent with a previous study illustrating that the percentage change in wound area over a 4 week period is a robust predictor of healing outcomes in DFUs [5]. Given the absence of validated biomarkers, the wound trajectory could thus be used to identify individuals in need of advanced regenerative modalities within the first 2–4 weeks of SoC and warrants further investigation. Early identification of individuals at peril is pivotal to ensure timely intervention and an appropriate therapeutic plan, especially since the 5 year mortality rate is 30% for individuals with a DFU and after non‐traumatic amputation in individuals with co‐morbidities is 50% within 3 years [14, 55]. This is supported by a scoping review of original research studies over the previous 5 years which illustrated that wound duration and surface area are amongst the most frequent prognostic factors in complex wounds [59]. Numerous clinical and preclinical studies have also shown that early intervention is key to optimising healing outcomes [60, 61, 62] and reiterates that specialist wound care by an interdisciplinary team is not only essential to improving the QoL for individuals but is also cost‐effective [15, 17, 63].
5. Conclusion
This study is the first to generate a comprehensive dataset on the prevalence and aetiology of HTH wounds in South Africa, albeit from a single private clinic. The retrospective nature of the study and the practical use of the ruler method for measuring the surface area of wounds although with intended clinical accuracy were limitations. It is recommended that further prevalence and healing trajectory studies in other regions of South Africa are conducted prospectively to expand on this work with the inclusion of skin tone data and paediatric populations. A further limitation of the study is not reporting on the severity of wounds, which was beyond the scope of this study. Nonetheless, the high prevalence rates of chronic and HTH wounds reported in the heterogenous South African population necessitate the recognition of wound management as a specialty in South Africa and prompt referral to specialised wound clinics.
Conflicts of Interest
PJ Idensohn is the owner and director of the wound care clinic where the study was conducted.
Supporting information
Data S1. Supporting Information.
Acknowledgements
We would like to extend our deepest gratitude to the nursing and support staff at the clinic for their invaluable contributions to this research. Their expertise, dedication, and compassionate care have been instrumental in the successful execution of this study. The meticulous attention to detail and commitment to patient well‐being demonstrated by the nursing team greatly enhanced the quality of our work and facilitated the collection of data.
Funding: This study was supported by the Faculty of Medicine & Health Sciences, Stellenbosch University.
Suggested Reviewers: Leanne Atkin, University of Huddersfield, UK. leanne.atkin1@nhs.net, Dimitri Beeckman, Orebro University, Belgium. dimitri.beeckman@oru.se, Geoff Sussman, Monash University, Australia. geoff.sussman@monash.edu, Nicola Waters, Thompson Rivers University, Canada. nwaters@tru.ca.
Data Availability Statement
Data available upon request from authors.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data S1. Supporting Information.
Data Availability Statement
Data available upon request from authors.