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. 2019 Dec 13;17(2):363–369. doi: 10.1111/iwj.13280

Evaluating complications in below‐knee skin cancer surgery after introduction of preoperative appointments: A 2‐year retrospective cohort study

Vivian M Lindholm 1,✉, Kirsi M Isoherranen 1, Marika T Schröder 1, Sari T Pitkänen 1
PMCID: PMC7948880  PMID: 31837117

Abstract

Below‐knee dermatological surgery has a high risk of complications such as wound infection, bleeding, and necrosis. In this study, we evaluated the impact of preoperative appointments on complication risks. We searched the medical records of the Helsinki University Central Hospital (HUS) Dermatosurgery unit for all below‐knee surgeries during 2016, when no preoperative nurse appointments were carried out, and compared it with 2018, when preoperative appointments for risk patients were introduced. The study included 187 patients in 2016 and 179 patients in 2018, of whom 68 (about one third) attended preoperative appointments. At the appointments, risk factors were evaluated, and compression therapy was introduced when possible. The results show complication rates of 13.4% in 2016 vs 10.1% in 2018 (P = .33), despite significantly higher risks in the 2018 patient group. The odds ratio for complications in appointment attendees vs non‐attendees was reduced after adjustments to 0.58; however, this was insignificant (P = .47). The odds of complications for skin grafts were considerably higher: 11.33 vs other surgery techniques (P = .00). In conclusion, the introduction of preoperative appointments appeared to reduce complications in below‐knee surgery. For graft reconstructions, complication risk is high, even with carefully planned pre‐ and postoperative care. Further studies are needed to evaluate preventable risk factors of below‐knee graft reconstructions.

Keywords: below‐knee, dermatological surgery, preoperative evaluation, prevention, wound healing

1. INTRODUCTION

Dermatological surgery is a relatively new expanding subspecialty within dermatology; it still needs further research regarding risk management, especially in the European setting.1 Below‐knee surgery has a high risk of complications,2, 3, 4, 5 and it has been previously stated that further studies on complication management of these common but risky interventions are needed.6 Guidelines for preoperative management in dermatology have been published,7, 8, 9, 10, 11 but to our knowledge, no previous studies have assessed their benefits. Based on previous medical studies, the advantages of preoperative evaluation are not easily proven scientifically.12

2. METHODS

We searched the medical records of the Helsinki University Central Hospital (HUS) Skin and Allergy Hospital's Dermatosurgery unit for all below‐knee surgeries during the years 2016 and 2018. The preoperative nurse appointments were introduced for at‐risk patients 2 to 4 weeks prior to surgery in 2018. Table 1 presents the appointment objectives.

Table 1.

Preoperative appointment objectives

Informing the patient: Planned intervention, pre‐ and postoperative care.
Collecting information about the patient: Medication (especially anticoagulative/thrombotic), allergies, and medical history (peripheral diseases, valve prosthesis, diabetes, etc.).
Determining surgery technique (consulting the surgeon).
Preparing treatment area: Initialising treatment of leg oedema (consulting the surgeon or a physiotherapist when needed), eczema, or infections.
Initialising treatment of malnutrition and supporting smoking cessation.
Planning postoperative care:
Length of immobilisation, compression treatment, and sick leave.
Need of departmental care, walking aid, or home care.
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The study included both benign and malignant tumours. It excluded punch biopsies (n = 8), as well as underlying diseases that disturb wound healing, such as pyoderma gangrenosum (n = 1). If the same patient had multiple interventions, only the chronologically first intervention was documented (excluding n = 59 interventions). Analyses included 366 patients after the exclusions. It included 187 patients in 2016 and 179 patients in 2018, of whom 68 patients, about one third, attended a preoperative appointment. Data about the patient or performed interventions were documented based only on HUS medical records (not, eg, information from health care centres). The patients were instructed to contact our hospital if any complications occurred. Surgery photographs were used to specify it if the localisation of the lesion was unclear based on medical records.

We assessed the benefit of preoperative appointments by comparing complication risk year 2016 vs 2018. We compared the odds ratio (OR) for complications with and without a preoperative appointment, adjusted for multiple covariates. We also compared the complication risk for different surgery techniques.

Complications were classified as infection, delayed wound healing, necrosis, bleeding, or scar issue. Wounds were documented as infected if they had purulent discharge, if antibiotics were prescribed, or if infection was mentioned. Prolonged wound healing without these signs was documented as delayed wound healing. This complication group also included wound dehiscence.

The covariates we documented were age, gender, body mass index (BMI) if known, smoking status, diabetes diagnosis, working status, immunosuppressive or anticoagulative/antithrombotic medication, walking aid use, diagnosed peripheral vascular or lymphatic disease, lower limb oedema, malnutrition, previous chronic ulcers, surgery diagnosis, technique, and localisation.

We recorded the use of pre‐/postoperative antibiotics, compression therapy or given immobilisation, or nutritional advice. We recorded surgery techniques as slack or strained primary closure; flap reconstructions; full‐thickness skin grafts (FTSGs) or secondary intention healing; and locations of the tumour such as toes, foot, malleoli, and lower 1/3 to 3/3 of leg below knee. We also documented postoperative departmental care and sick leaves, as well as additional postoperative appointments. The study protocol has been approved by the HUS Ethical Review Committee.

2.1. Statistical methods

Bivariate analysis, conducted using chi‐squared tests (Fisher exact), was used to assess complication risks for different patient groups, and independent samples were T‐tested to assess their statistical significance. We calculated adjusted ORs for complications by multinomial logistic regression. Area under the curve (ROC) was calculated to retrieve the cut‐off point for the age at which the complication risk significantly rose, maximising Youden's index. The results are presented as ORs and their 95% confidence intervals (CI). P < .05 was considered statistically significant.

3. RESULTS

The study material is presented in (Table 2)

Table 2.

Study material

Mean age 65 years
Mean BMI 26
62% women
36% working
87% walking without aid
7% smoking
15% diabetes diagnosis
30% anticoagulative/antithrombotic medication
9% immunosuppressive medication
30% peripheral vascular or lymphatic disease/lower limb oedema
3% previous chronic ulcer
Surgery diagnosis: 19% melanoma, 27% basal cell carcinoma, 12% squamous cell carcinoma, 43% others (skin cancer precursors: melanoma in situ, benign tumours, dysplastic nevi).
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3.1. Complications year 2016 vs 2018

The overall complication rate was 13.4% in 2016 and 10.1% in 2018, but the difference was statistically insignificant with P = .33 (95% CI −0.33‐0.99). The 2016 patient group vs 2018 had a statistically significant difference regarding their ability to walk without aid (P = .01) and regarding the number of patients with leg oedema (P = .03). Other covariates showed no significant difference. The patient mean age was 64.1 years in 2016 vs 66.3 years in 2018 (P = .24). The mean number of postoperative, additional nurse appointments reduced from 0.65 to 0.43 (P = .19 [−0.11‐0.56]) from 2016 to 2018. Figure 1 presents the incidence of different complications in 2016 and 2018 (Figure 1).

Figure 1.

Figure 1

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Incidence (%) and numbers (n) of different complications in 2016 and 2018. Overall complication rate, infection, and delayed healing rates decreased in 2018

3.2. Complications for preoperative appointment attendees vs non‐attendees

The OR for complications in patients attending the preoperative appointment vs those without a preoperative appointment was 2.11 (P = .04, 1.04‐4.31) without covariate adjustments. After full adjustments, the OR for complications was lower, 0.58 (P = .47, 0.14‐2.49), for patients attending the appointment. There were differences in these two groups of patients, which were statistically significant regarding their age (P = .00), working status (P = .00), ability to walk without aid (P = .04), leg oedema, vascular or lymphatic diseases (P = .00), or number of FTSGs (P = .00).

3.3. Complication rates for different surgery techniques

FTSGs had 12.2 higher odds for complications vs other surgery techniques (P = .00, 6.01‐24.59). After full adjustments, the ORs were 11.3 higher (P = .00, 2.98‐42.48). The complication rate for FTSGs was higher in 2016, with 44% vs 34% in 2018, but this difference was insignificant (P = .44), (Figure 2). We also saw no significant difference in complications for appointment attendees vs non‐attendees with FTSG reconstructions (50% vs 33%, P = .18), when including both 2016 and 2018 patients. Flap repairs had 8.0 higher odds for complications, but the small number of flap reconstructions (n = 8) limits the reliability of this result (Table 3).

Figure 2.

Figure 2

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Complication incidence (%) and numbers (n) for different surgery techniques in 2016 and 2018. Complication rates were high for flap and full‐thickness skin graft (FTSG) surgeries. Complication rates for FTSGs in 2018 decreased. For flap reconstructions, the result is limited by a small number of patients (n = 8)

Table 3.

OR for complications for different surgery techniques

Surgery technique OR, (P, 95% CI)
Slack primary closure 0.072 (0.00, 0.025‐0.21)
Full adjustment 0.046 (0.00, 0.01‐0.22)
Strained primary closure 0.69 (0.38, 0.31‐1.56)
Full adjustment 1.53 (0.45, 0.51‐4.63)
Flap 8.00 (0.013, 1.56‐41.0)
Full adjustment (n not enough)
Full‐thickness skin graft (FTSG) 12.16 (0.00, 6.01‐24.6)
Full adjustment 11.26 (0.00, 2.98‐42.5)
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Note: Significant results bolded.

3.4. Factors influencing complication risk

Regarding complication risk, these covariates were significant: age > 80 (P = .00), FTSG (P = .00), and flap reconstructions (P = .00). When also including P values .05 to .20, immunosuppressive medication (P = .08), gender (P = .09), leg oedema (P = .13), squamous cell carcinoma (P = .13), and ulcer history (P = .15) appeared to have an impact on complication risk. The age of 80 years was chosen as the cut‐off point for higher complication risk by calculating area under the curve. The maximised sensitivity (49%) and specificity (20%) was at age 79.5 years. The specific tumour location showed no significant effect on complication risk (P = .46).

3.5. Prophylactic measures

Figure 3 presents the percentage of patients receiving different prophylactic measures. Prescribed pre‐ or postoperative compression therapy, antibiotics, immobilisation instructions, or sick leaves are presented separately for each year, as well as the number of patients with pre‐ or postoperative departmental care. The use of both pre‐ and postoperative compression therapy increased significantly (P = .00), as well as the number of immobilisation instructions (P = .00), (Figure 3).

In addition, we calculated the OR for complications after postoperative compression vs without compression in a population with peripheral disease (leg oedema or vascular or lymphatic disease). Odds for complications in the crude model were 1.41 (P = .67, 0.29‐6.85), and after full adjustments, it was 0.67 (P = .74, 0.061‐7.19), showing a decline in complication, although this was insignificant.

4. DISCUSSION

Previous studies have reported that the risk for postoperative complications within dermatological surgery has been between 0.7% and 29%, with some studies separately focusing on, for example, below the knee, dermatology inpatients, or FTSGs, all factors significantly influencing complication risk.1, 6, 13, 14, 15, 16 The risk for infection has been between 1.3% and 8.7%5, 17 and exclusively for below‐knee operations up to 30%.2, 4, 6, 18 In addition, poor preoperative skin condition and tumour ulceration19 and patient characteristics such as diabetes,20 smoking,15, 21 and age3, 19 are considered risk factors for surgical site infections (SSIs). Flap and graft reconstruction are the types of surgeries associated with the highest risk for SSI.1, 18 Graft take in lower leg surgeries have been reported at rates of 64% to 90%, depending on the study.13, 22, 23 The risk of bleeding complications has previously been reported to be between 0.3% and 3%1, 5, 16 and for necrosis between 1.7% and 8.6%.1, 5

Honaker et al6 evaluated the complication risk of 69 patients in below‐knee Mohs surgery, with an overall complication rate of 17%, of which 50% were infections, 3.25% delayed wound healing, 2.17% hypergranulation, and 8% hypertrophic scars. The overall complication rate was lower in our study (13.4% and 10.1% in the different years); however, our study also included primary closure surgeries, which probably reduce the risks. To the best of our knowledge, other studies that exclusively evaluated below‐knee surgery complications assessed only infection risks, not risks for different complications. Overall, the complication rates in our study are quite well in line with previous studies. An infection rate of 4.9% is quite low, but we separately documented delayed wound healing without infectious signs (4.6%). The necrosis rate (1.6%), bleeding complications (0%), and documented scar issues (0.5%) were also low.

4.1. Complications in the year 2016 vs 2018

A general consensus exists that a careful preoperative evaluation reduces complication risks, especially in below‐knee surgery, which contains patient‐related risks for complications such as leg oedema and ischaemia. In our study, postoperative complications were reduced from 13.4% to 10.1% after introducing preoperative appointments, although the difference was not statistically significant. A previous study assessing the benefits of preoperative appointments also had difficulties showing significant results and discussed the possible reasons.12 Factors probably influencing the results of our study were differences in patient‐related risks during 2016 and 2018. There were significantly more patients in 2018 with leg oedema and without the ability to walk without aid, and the population was older. However, it is possible that leg oedema was documented more precisely that year. It is also possible that the differences in complication rates were not significant because of the relatively low number of patients in this study.

Our results could have been biased by the risk that patients were in touch with other health care units when suffering complications, reducing the documented number of complications. The additional focus on complications and complication management in 2018 may have caused more patients to contact us regarding their complications in 2018 than in 2016. This may have led to a higher complication rate in 2018 in comparison with 2016, negatively influencing the benefits of preoperative appointments.

We evaluated patient groups that would specifically benefit from preoperative appointments based on their complication risks, as given in Table 4. We probably would see the benefits of preoperative appointments even more clearly by applying this recommendation at our clinic.

Table 4.

Patient groups that benefit from a preoperative appointment based on higher complication risk (P < .2)

Age > 80 (P = .00)
Flap or full‐thickness skin graft (FTSG) reconstructions (P = .00)
Immunosuppressive medication (P = .08)
Male gender (P = .09)
Lower limb oedema (P = .13)
Squamous cell carcinoma (P = .13)
Previous chronic ulcer (P = .15)
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4.2. Complications for preoperative appointment attendees vs non‐attendees

The appointments did not significantly reduce the complication risk when we assessed complication risk for preoperative appointment attendees vs non‐attendees. In fact, when not taking confounding factors into account, the complication risk for appointment attendees was higher. This result is likely biased by the fact that at‐risk patients were particularly chosen for the preoperative appointments. We noted significant differences regarding patients' ages, working status, ability to walk without aid, leg oedema, vascular or lymphatic diseases, and the number of FTSGs for appointment attendees. The risk for this bias could be decreased using a randomised controlled trial (RCT) study design, although ethical issues may limit the possibilities in this regard.

4.3. Complication rates for different surgery techniques

The complication rate in FTSGs was high, with the OR for complications 11 times higher than for other reconstruction techniques, even with preoperative appointments and, thus, carefully planned care. Complications were even more frequent for flap reconstructions than for FTSGs (Figure 2), although the low number of flap constructions (n = 8) limits the reliability of these results. Further studies may be warranted to investigate the prevention of complications in FTSG surgery. Here, negative pressure wound therapy (NPWT) after FTSG would be a possible approach. NPWT is widely used to treat acute and chronic wounds.24 Some studies show a positive effect of NPWT on postoperative wound healing, but the evidence is still limited with a need for larger RCT studies.24, 25, 26

5. CONCLUSIONS

Although we could not observe a statistically significant effect of the preoperative appointments in below‐knee surgical complications, we still believe in the need to focus on pre‐ and postoperative care. We saw a significant rise in the number of immobilisation instructions given and in pre‐ and postoperative compression therapy (Figure 3). These factors are seen as important interventions to limit complications in lower limb surgery.27, 28 Pre‐ and postoperative interventions may have played a significant role in this study in reducing complications in 2018.

Figure 3.

Figure 3

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Prophylactic measures in %. In 2018, pre‐ and postoperative compression therapy became more common (P = .00 and P = .00), and immobilisation instructions were amplified (P = .00)

In conclusion, our study showed that there appears to be a benefit of preoperative nurse appointments in below‐knee surgery, especially for at‐risk patients. Leg oedema is a frequent finding in the elderly population, and the introduction of compression therapy before surgery may be cost‐effective in this regard. The cost of treating complications is usually significantly higher than those of preventive measures, which has been clearly demonstrated in pressure ulcer29 and wound care30 studies. Treating complications will cause multiple additional postoperative appointments, increasing treatment costs remarkably. Smoking cessation, which clearly reduces surgical complications,31 is another example of successful complication prevention. Dermatosurgery is a continuously expanding field, so there is a clear demand for further studies concerning the cost‐effectiveness of preoperative nurse appointments, patient education, and lifestyle advice before surgery.

ACKNOWLEDGEMENTS

This study was funded by Helsinki University Central Hospital's Inflammation Center, Finska Läkaresällskapet, and Stiftelsen Dorothea Olivia, Karl Walter och Jarl Walter Perkléns Minne. We thank Ritva Luukkonen from the University of Helsinki for her assistance with statistical analyses.

Lindholm VM, Isoherranen KM, Schröder MT, Pitkänen ST. Evaluating complications in below‐knee skin cancer surgery after introduction of preoperative appointments: A 2‐year retrospective cohort study. Int Wound J. 2020;17:363–369. 10.1111/iwj.13280

Funding information Finska Läkaresällskapet; Stiftelsen Dorothea Olivia, Karl Walter och Jarl Walter Perkléns Minne; Helsinki University Central Hospital's Inflammation Center

REFERENCES

  • 1. Amici JM, Rogues AM, Lasheras A, et al. A prospective study of the incidence of complications associated with dermatological surgery. Br J Dermatol. 2005;153(5):967‐971. [DOI] [PubMed] [Google Scholar]
  • 2. Delpachitra M, Heal C, Banks J, Divakaran P, Pawar M. Risk factors for surgical site infection in minor dermatological surgery: a systematic review. Adv Skin Wound Care. 2019;32(5):217‐226. [DOI] [PubMed] [Google Scholar]
  • 3. Heal CF, Buettner PG, Drobetz H. Risk factors for surgical site infection after dermatological surgery. Int J Dermatol. 2012;51(7):796‐803. [DOI] [PubMed] [Google Scholar]
  • 4. Dixon AJ, Dixon MP, Askew DA, Wilkinson D. Prospective study of wound infections in dermatologic surgery in the absence of prophylactic antibiotics. Dermatol Surg. 2006;32(6):819‐827. [DOI] [PubMed] [Google Scholar]
  • 5. Bordeaux JS, Martires KJ, Goldberg D, Pattee SF, Fu P, Maloney ME. Prospective evaluation of dermatologic surgery complications including patients on multiple antiplatelet and anticoagulant medications. J Am Acad Dermatol. 2011;65(3):576‐583. [DOI] [PubMed] [Google Scholar]
  • 6. Honaker JS, Bordeaux JS, Tuttle MS. Retrospective review of risk factors predictive of complications in patients after below the knee Mohs micrographic surgery. Dermatol Surg. 2016;42(4):568‐570. [DOI] [PubMed] [Google Scholar]
  • 7. Leshin B, Whitaker DC, Swanson NA. An approach to patient assessment and preparation in cutaneous oncology. J Am Acad Dermatol. 1988;19(6):1081‐1088. [DOI] [PubMed] [Google Scholar]
  • 8. Otley CC. Perioperative evaluation and management in dermatologic surgery. J Am Acad Dermatol. 2006;54(1):119‐127. [DOI] [PubMed] [Google Scholar]
  • 9. Duncan KO, Leffell DJ. Preoperative assessment of the elderly patient. Dermatol Clin. 1997;15(4):583‐592. [DOI] [PubMed] [Google Scholar]
  • 10. Alam M, Norman RA, Goldberg LH. Dermatologic surgery in geriatric patients: psychosocial considerations and perioperative decision‐making. Dermatol Surg. 2002;28(11):1043‐1050. [DOI] [PubMed] [Google Scholar]
  • 11. Saleh K, Schmidtchen A. Surgical site infections in dermatologic surgery: etiology, pathogenesis, and current preventative measures. Dermatol Surg. 2015;41(5):537‐549. [DOI] [PubMed] [Google Scholar]
  • 12. Wijeysundera DN, Austin PC, Beattie WS, Hux JE, Laupacis A. Outcomes and processes of care related to preoperative medical consultation. Arch Intern Med. 2010;170(15):1365‐1374. [DOI] [PubMed] [Google Scholar]
  • 13. Oganesyan G, Jarell AD, Srivastava M, Brian Jiang SI. Efficacy and complication rates of full‐thickness skin graft repair of lower extremity wounds after Mohs micrographic surgery. Dermatol Surg. 2013;39(9):1334‐1339. [DOI] [PubMed] [Google Scholar]
  • 14. Alam M, Ibrahim O, Nodzenski M, et al. Adverse events associated with Mohs micrographic surgery: multicenter prospective cohort study of 20 821 cases at 23 centers. JAMA Dermatol. 2013;149(12):1378‐1385. [DOI] [PubMed] [Google Scholar]
  • 15. Wahie S, Lawrence CM. Wound complications following diagnostic skin biopsies in dermatology inpatients. Arch Dermatol. 2007;143(10):1267‐1271. [DOI] [PubMed] [Google Scholar]
  • 16. O'Neill JL, Shutty B, Lee YS, et al. Comparing demographic characteristics and adverse event rates at two dermatologic surgery practices. J Cutan Med Surg. 2014;18(5):337‐340. [DOI] [PubMed] [Google Scholar]
  • 17. Rogers HD, Desciak EB, Marcus RP, Wang S, MacKay‐Wiggan J, Eliezri YD. Prospective study of wound infections in Mohs micrographic surgery using clean surgical technique in the absence of prophylactic antibiotics. J Am Acad Dermatol. 2010;63(5):842‐851. [DOI] [PubMed] [Google Scholar]
  • 18. Rosengren H, Heal CF, Buettner PG. Effect of a single preoperative dose of Oral antibiotic to reduce the incidence of surgical site infection following below‐knee dermatological flap and graft repair. Dermatol Pract Concept. 2019;9(1):28‐35. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 19. Kulichová D, Geimer T, Mühlstädt M, Ruzicka T, Kunte C. Surgical site infections in skin surgery: a single center experience. J Dermatol. 2013;40(10):779‐785. [DOI] [PubMed] [Google Scholar]
  • 20. Dixon A, Dixon M, Dixon J. Prospective study of skin surgery in patients with and without known diabetes. Dermatol Surg. 2009;35(7):1035‐1040. [DOI] [PubMed] [Google Scholar]
  • 21. Dixon AJ, Dixon MP, Dixon JB, Del Mar CB. Prospective study of skin surgery in smokers vs. nonsmokers. Br J Dermatol. 2009;160(2):365‐367. [DOI] [PubMed] [Google Scholar]
  • 22. Audrain H, Bray A, De Berker D. Full‐thickness skin grafts for lower leg defects: an effective repair option. Dermatol Surg. 2015;41(4):493‐498. [DOI] [PubMed] [Google Scholar]
  • 23. Struk S, Correia N, Guenane Y, Revol M, Cristofari S. Full‐thickness skin grafts for lower leg defects coverage: interest of postoperative immobilization. Ann Chir Plast Esthét. 2018;63(3):229‐233. [DOI] [PubMed] [Google Scholar]
  • 24. Dumville JC, Land L, Evans D, Peinemann F. Negative pressure wound therapy for treating leg ulcers. Cochrane Database Syst Rev. 2015;7:CD011354. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 25. Webster J, Liu Z, Norman G, et al. Negative pressure wound therapy for surgical wounds healing by primary closure. Cochrane Database Syst Rev. 2019;3:CD009261. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 26. Apelqvist J, Willy C, Fagerdahl A, et al. EWMA document: negative pressure wound therapy. J Wound Care. 2017;26(Suppl 3):S1‐S154. [DOI] [PubMed] [Google Scholar]
  • 27. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for prevention of surgical site infection, 1999. Am J Infect Control. 1999;27(2):97‐134. [PubMed] [Google Scholar]
  • 28. O'Meara S, Cullum N, Nelson EA, Dumville JC. Compression for venous leg ulcers. Cochrane Database Syst Rev. 2012;11:CD000265. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 29. Demarré L, Van Lancker A, Van Hecke A, et al. The cost of prevention and treatment of pressure ulcers: a systematic review. Int J Nurs Stud. 2015;52(11):1754‐1774. [DOI] [PubMed] [Google Scholar]
  • 30. Lindholm C, Cearle L. Wound management for the 21st century: combining effectiveness and efficiency. Int Wound J. 2016;13(Suppl 2):5‐15. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 31. Sörensen LT. Wound healing and infection in surgery. The clinical impact of smoking and smoking cessation: a systematic review and meta‐analysis. Arch Surg. 2012;147(4):373‐383. [DOI] [PubMed] [Google Scholar]

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