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Meta-Analysis
. 2012 Nov 14;11(11):CD000265.
doi: 10.1002/14651858.CD000265.pub3.

Compression for venous leg ulcers

Susan O'Meara  1 , Nicky Cullum, E Andrea Nelson, Jo C Dumville
Affiliations
Meta-Analysis

Compression for venous leg ulcers

Susan O'Meara et al. Cochrane Database Syst Rev. .

Abstract

Background: Up to one percent of people in industrialised countries will suffer from a leg ulcer at some time. The majority of these leg ulcers are due to problems in the veins, resulting in an accumulation of blood in the legs. Leg ulcers arising from venous problems are called venous (or varicose or stasis) ulcers. The main treatment is the application of a firm compression garment (bandage or stocking) in order to aid venous return. There is a large number of compression garments available and it was unclear whether they are effective in treating venous ulcers and, if so, which method of compression is the most effective.

Objectives: To undertake a systematic review of all randomised controlled trials (RCTs) evaluating the effects on venous ulcer healing of compression bandages and stockings.Specific questions addressed by the review are:1. Does the application of compression bandages or stockings aid venous ulcer healing? 2. Which compression bandage or stocking system is the most effective?

Search methods: For this second update we searched: the Cochrane Wounds Group Specialised Register (31 May 2012); the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 5, 2012); Ovid MEDLINE (1950 to May Week 4 2012); Ovid MEDLINE (In-Process & Other Non-Indexed Citations 30 May 2012); Ovid EMBASE (1980 to 2012 Week 21); and EBSCO CINAHL (1982 to 30 May 2012). No date or language restrictions were applied.

Selection criteria: RCTs recruiting people with venous leg ulceration that evaluated any type of compression bandage system or compression stockings were eligible for inclusion. Eligible comparators included no compression (e.g. primary dressing alone, non-compressive bandage) or an alternative type of compression. RCTs had to report an objective measure of ulcer healing in order to be included (primary outcome for the review). SECONDARY OUTCOMES of the review included ulcer recurrence, costs, quality of life, pain, adverse events and withdrawals. There was no restriction on date, language or publication status of RCTs.

Data collection and analysis: Details of eligible studies were extracted and summarised using a data extraction table. Data extraction was performed by one review author and verified independently by a second review author.

Main results: Forty-eight RCTs reporting 59 comparisons were included (4321 participants in total). Most RCTs were small, and most were at unclear or high risk of bias. Duration of follow-up varied across RCTs. Risk ratio (RR) and other estimates are shown below where RCTs were pooled; otherwise findings refer to a single RCT.There was evidence from eight RCTs (unpooled) that healing outcomes (including time to healing) are better when patients receive compression compared with no compression.Single-component compression bandage systems are less effective than multi-component compression for complete healing at six months (one large RCT).A two-component system containing an elastic bandage healed more ulcers at one year than one without an elastic component (one small RCT).Three-component systems containing an elastic component healed more ulcers than those without elastic at three to four months (two RCTs pooled), RR 1.83 (95% CI 1.26 to 2.67), but another RCT showed no difference between groups at six months.An individual patient data meta-analysis of five RCTs suggested significantly faster healing with the four-layer bandage (4LB) than the short stretch bandage (SSB): median days to healing estimated at 90 and 99 respectively; hazard ratio 1.31 (95% CI 1.09 to 1.58).High-compression stockings are associated with better healing outcomes than SSB at two to four months: RR 1.62 (95% CI 1.26 to 2.10), estimate from four pooled RCTs.One RCT suggested better healing outcomes at 16 months with the addition of a tubular device plus single elastic bandage to a base system of gauze and crepe bandages when compared with two added elastic bandages. Another RCT had three arms; when one or two elastic bandages were added to a base three-component system that included an outer tubular layer, healing outcomes were better at six months for the two groups receiving elastic bandages.There is currently no evidence of a statistically significant difference for the following comparisons:⋅alternative single-component compression bandages (two RCTs, unpooled);⋅two-component bandages compared with the 4LB at three months (three RCTs pooled);⋅alternative versions of the 4LB for complete healing at times up to and including six months (three RCTs, unpooled);⋅4LB compared with paste bandage for complete healing at three months (two RCTs, pooled), six months or one year (one RCT for each time point);⋅adjustable compression boots compared with paste bandages for the outcome of change in ulcer area at three months (one small RCT);⋅adjustable compression boots compared with the 4LB with respect to complete healing at three months (one small RCT);⋅single-layer compression stocking compared with paste bandages for outcome of complete healing at four months (one small RCT) and 18 months (another small RCT);⋅low compression stocking compared with SSB for complete healing at three and six months (one small RCT);⋅compression stockings compared with a two-component bandage system and the 4LB for the outcome of complete healing at three months (one small, three-armed RCT); and,⋅tubular compression compared with SSB (one small RCT) for complete healing at three months.

Secondary outcomes: 4LB was more cost-effective than SSB. It was not possible to draw firm conclusions regarding other secondary outcomes including recurrence, adverse events and health-related quality of life.

Authors' conclusions: Compression increases ulcer healing rates compared with no compression. Multi-component systems are more effective than single-component systems. Multi-component systems containing an elastic bandage appear to be more effective than those composed mainly of inelastic constituents. Two-component bandage systems appear to perform as well as the 4LB. Patients receiving the 4LB heal faster than those allocated the SSB. More patients heal on high-compression stocking systems than with the SSB. Further data are required before the difference between high-compression stockings and the 4LB can be established.

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Conflict of interest statement

Nicky Cullum, Susan O'Meara and Jo Dumville receive funding from the National Institute for Health Research (NIHR) under its Programme Grants for Applied Research funding scheme. This study presents independent research funded by the National Institute for Health Research (NIHR) under its Programme Grants for Applied Research funding scheme (RP‐PG‐0407‐10428). The views expressed in this review are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health.

Nicky Cullum is an NIHR Senior Investigator.

Nicky Cullum was Principal Investigator for one of the trials included in this review (Iglesias 2004); this trial was commissioned after the first version of this review was completed. Nicky Cullum is currently Co‐Investigator on the UK NIHR HTA Programme VenUS IV trial which will be eligible for a future update of this review.

Andrea Nelson was co‐applicant and trial co‐ordinator for one of the trials included in this review (Iglesias 2004); this trial was commissioned after the first version of this review was completed. Andrea Nelson was trial co‐ordinator and author of the main publication for one of the trials included in this review (Nelson 2007a).

Figures

1
1
This figure shows all the comparisons included in the review, and the number of evaluations for each comparison. The green shaded areas represent comparisons between similar compression systems. The numbers shown refer to numbers of comparisons, not numbers of RCTs. Key: 4LB = four‐layer bandage The abbreviations A‐N at the head of each column refer to the corresponding types of compression shown at the start of each row.
2
2
Methodological quality summary: review authors' judgements about each methodological quality item for each included study.
3
3
Methodological quality graph: review authors' judgements about each methodological quality item presented as percentages across all included studies.
4
4
Methodological quality summary with trials presented in chronological order Methodological quality summary with trials presented in chronological order Risk of bias summary figure with RCTs presented in chronological order.
5
5
Forest plot of comparison: 8 Two‐component system vs four‐layer bandage (4LB), outcome: 8.2 Patients with complete healing at 3 months.
6
6
Forest plot of comparison: 9 3 components including elastic bandage vs 3 components including inelastic bandage, outcome: 9.1 Patients/limbs with complete healing during trial.
7
7
Forest plot of comparison: 12 4LB vs multi‐layer short‐stretch bandage (SSB), outcome: 12.1 Patients with complete healing during trial period based on IPD.
8
8
4LB versus SSB: Kaplan‐Meier survival curves (unstratified analysis) based on IPD
9
9
Forest plot of comparison: 12 4LB vs multi‐layer short‐stretch bandage (SSB), outcome: 12.3 Hazard ratio estimates for time to healing based on IPD (fixed‐effect).
10
10
Forest plot of comparison: 17 Higher compression stockings versus SSB, outcome: 17.1 Patients with complete healing at 2‐4 months (fixed‐effect).
1.1
1.1. Analysis
Comparison 1 Compression vs no compression (primary dressing only), Outcome 1 Ulcers completely healed at 6 months.
2.1
2.1. Analysis
Comparison 2 Compression vs no compression (non‐compressive bandage), Outcome 1 Patients with complete healing at 1 year.
3.1
3.1. Analysis
Comparison 3 Compression vs no compression (usual treatment), Outcome 1 Patients with complete healing at 3 months.
3.2
3.2. Analysis
Comparison 3 Compression vs no compression (usual treatment), Outcome 2 Patients with complete healing at 1 year.
3.3
3.3. Analysis
Comparison 3 Compression vs no compression (usual treatment), Outcome 3 Patients with recurrence during 1 year follow‐up.
4.1
4.1. Analysis
Comparison 4 Single‐component compression (elastic bandage) vs single‐component compression (paste bandage), Outcome 1 Patients with complete healing at 3 months.
4.2
4.2. Analysis
Comparison 4 Single‐component compression (elastic bandage) vs single‐component compression (paste bandage), Outcome 2 Percentage change during trial relative to baseline ulcer area.
4.3
4.3. Analysis
Comparison 4 Single‐component compression (elastic bandage) vs single‐component compression (paste bandage), Outcome 3 Healing rate (cm squared per week adjusted for baseline ulcer perimeter).
5.1
5.1. Analysis
Comparison 5 Single‐component compression vs multi‐component compression (excluding paste bandages), Outcome 1 Complete healing during the trial period.
5.2
5.2. Analysis
Comparison 5 Single‐component compression vs multi‐component compression (excluding paste bandages), Outcome 2 Percentage change during trial relative to baseline ulcer area.
5.3
5.3. Analysis
Comparison 5 Single‐component compression vs multi‐component compression (excluding paste bandages), Outcome 3 Complete healing during the trial period (participants with simple VLU only).
6.1
6.1. Analysis
Comparison 6 Single‐component compression vs multi‐component compression (paste bandage), Outcome 1 Complete healing during the trial period.
7.1
7.1. Analysis
Comparison 7 Two‐component (outer elastic) vs two‐component (outer inelastic), Outcome 1 Patients with complete healing at 3‐6 months.
7.2
7.2. Analysis
Comparison 7 Two‐component (outer elastic) vs two‐component (outer inelastic), Outcome 2 Patients with complete healing at 1 month.
7.3
7.3. Analysis
Comparison 7 Two‐component (outer elastic) vs two‐component (outer inelastic), Outcome 3 Patients with complete healing at 1 year.
8.1
8.1. Analysis
Comparison 8 Two‐component system vs four‐layer bandage (4LB), Outcome 1 Patients with complete healing at 1 month.
8.2
8.2. Analysis
Comparison 8 Two‐component system vs four‐layer bandage (4LB), Outcome 2 Patients with complete healing at 3 months.
8.3
8.3. Analysis
Comparison 8 Two‐component system vs four‐layer bandage (4LB), Outcome 3 Patients with complete healing at 6 months up to point of withdrawal from randomised treatment.
8.4
8.4. Analysis
Comparison 8 Two‐component system vs four‐layer bandage (4LB), Outcome 4 Patients with complete healing at 6 months including withdrawals from randomised treatment.
9.1
9.1. Analysis
Comparison 9 3 components including elastic bandage vs 3 components including inelastic bandage, Outcome 1 Patients/limbs with complete healing during trial.
10.1
10.1. Analysis
Comparison 10 3 components including paste bandage vs 3 components including inelastic (short‐stretch) bandage, Outcome 1 Limbs with complete healing at 3 months.
11.1
11.1. Analysis
Comparison 11 Charing Cross 4LB vs other 4LB, Outcome 1 Patients/limbs with complete healing during trial.
12.1
12.1. Analysis
Comparison 12 4LB vs multi‐layer short‐stretch bandage (SSB), Outcome 1 Patients with complete healing during trial period based on IPD.
12.2
12.2. Analysis
Comparison 12 4LB vs multi‐layer short‐stretch bandage (SSB), Outcome 2 Limbs completely healed at 3 months (Duby 1993, IPD unavailable).
12.3
12.3. Analysis
Comparison 12 4LB vs multi‐layer short‐stretch bandage (SSB), Outcome 3 Hazard ratio estimates for time to healing based on IPD (fixed‐effect).
12.4
12.4. Analysis
Comparison 12 4LB vs multi‐layer short‐stretch bandage (SSB), Outcome 4 Hazard ratio estimates for time to healing based on IPD (random‐effects).
12.5
12.5. Analysis
Comparison 12 4LB vs multi‐layer short‐stretch bandage (SSB), Outcome 5 Hazard ratio estimates for time to healing based on IPD (fixed‐effect, Partsch 2001 removed).
12.6
12.6. Analysis
Comparison 12 4LB vs multi‐layer short‐stretch bandage (SSB), Outcome 6 Hazard ratio estimates for time to healing based on IPD (random‐effects, Partsch 2001 removed).
12.7
12.7. Analysis
Comparison 12 4LB vs multi‐layer short‐stretch bandage (SSB), Outcome 7 Incidence of any type of adverse event based on IPD (fixed‐effect).
12.8
12.8. Analysis
Comparison 12 4LB vs multi‐layer short‐stretch bandage (SSB), Outcome 8 Incidence of any type of adverse event based on IPD (random effects).
12.9
12.9. Analysis
Comparison 12 4LB vs multi‐layer short‐stretch bandage (SSB), Outcome 9 Incidence of bandage‐related adverse events based on IPD.
12.10
12.10. Analysis
Comparison 12 4LB vs multi‐layer short‐stretch bandage (SSB), Outcome 10 Number of adverse events (any type) based on IPD (fixed‐effect).
12.11
12.11. Analysis
Comparison 12 4LB vs multi‐layer short‐stretch bandage (SSB), Outcome 11 Number of adverse events (any type) based on IPD (random‐effects).
12.12
12.12. Analysis
Comparison 12 4LB vs multi‐layer short‐stretch bandage (SSB), Outcome 12 Number of adverse events (bandage‐related) based on IPD.
13.1
13.1. Analysis
Comparison 13 Four‐layer bandage (4LB) vs compression system with paste bandage as the base, Outcome 1 Patients/limbs with complete healing during trial.
13.2
13.2. Analysis
Comparison 13 Four‐layer bandage (4LB) vs compression system with paste bandage as the base, Outcome 2 Patients/limbs with complete healing at 3 months (random‐effects).
13.3
13.3. Analysis
Comparison 13 Four‐layer bandage (4LB) vs compression system with paste bandage as the base, Outcome 3 Percentage reduction of baseline ulcer area at 6 months.
13.4
13.4. Analysis
Comparison 13 Four‐layer bandage (4LB) vs compression system with paste bandage as the base, Outcome 4 Healing rate (pooled).
14.1
14.1. Analysis
Comparison 14 Adjustable inelastic compression boot vs other compression system, Outcome 1 Healing rate.
15.1
15.1. Analysis
Comparison 15 Single‐layer compression stocking vs paste bandage system, Outcome 1 Complete healing in trial period (varying lengths).
15.2
15.2. Analysis
Comparison 15 Single‐layer compression stocking vs paste bandage system, Outcome 2 Healing rate (cm2 per week).
16.1
16.1. Analysis
Comparison 16 Low‐compression stocking vs short‐stretch bandage (SSB), Outcome 1 Patients with complete healing at 3 months.
16.2
16.2. Analysis
Comparison 16 Low‐compression stocking vs short‐stretch bandage (SSB), Outcome 2 Patients with complete healing at 6 months.
17.1
17.1. Analysis
Comparison 17 High‐compression stockings vs short‐stretch bandage (SSB), Outcome 1 Patients with complete healing at 2‐4 months (fixed‐effect).
17.2
17.2. Analysis
Comparison 17 High‐compression stockings vs short‐stretch bandage (SSB), Outcome 2 Patients with complete healing at 2‐4 months (random‐effects).
17.3
17.3. Analysis
Comparison 17 High‐compression stockings vs short‐stretch bandage (SSB), Outcome 3 Percentage reduction of baseline ulcer area at 3 months.
18.1
18.1. Analysis
Comparison 18 Compression stocking vs two‐component bandage system, Outcome 1 Patients with complete healing at 3 months.
19.1
19.1. Analysis
Comparison 19 Compression stocking vs 4LB, Outcome 1 Patients with complete healing at 3 months.
20.1
20.1. Analysis
Comparison 20 Tubular compression vs short‐stretch bandage (SSB), Outcome 1 Patients with complete healing at 3 months.
21.1
21.1. Analysis
Comparison 21 Tubular compression vs tubular plus 1 elastic bandage, Outcome 1 Patients with complete healing at six months.
22.1
22.1. Analysis
Comparison 22 Tubular compression vs tubular plus 2 elastic bandages, Outcome 1 Patients with complete healing at six months.
23.1
23.1. Analysis
Comparison 23 Tubular plus 1 elastic bandage vs tubular plus 2 elastic bandages, Outcome 1 Patients with complete healing at six months.
See this image and copyright information in PMC

Update of

Comment in

References

References to studies included in this review

Blecken 2005 {published data only}
    1. Blecken SR, Villavicencio JL, Kao TC. Comparison of elastic versus nonelastic compression in bilateral venous ulcers: a randomized trial. Journal of Vascular Surgery 2005;42(6):1150‐5. - PubMed
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Duby 1993 {published data only}
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Gould 1998 {published data only}
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Harley 2004 {published data only}
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Iglesias 2004 {published and unpublished data}
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Kikta 1988 {published data only}
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Knight 1996 {published and unpublished data}
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Koksal 2003 {published data only}
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Kralj 1996 {published and unpublished data}
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    1. Mariani E, Mattaliano V, Mosti G, Gasbarro V, Bucalossi M, Blättler W, et al. The treatment of venous leg ulcers with a specifically designed compression stocking kit: comparison with bandaging. Phlebologie 2008;37:191‐7.
Meyer 2002 {published data only}
    1. Meyer FJ, Burnand KG, Lagattolla NRF, Eastham D. Randomized clinical trial comparing the efficacy of two bandaging regimens in the treatment of venous leg ulcers. British Journal of Surgery 2002;89(Pt 1):40‐4. - PubMed
    1. Ruckley CV, Callam MJ, Harper DR, Dale JJ, Gibson B, Prescott RJ. Randomized clinical trial comparing the efficacy of two bandaging regimens in the treatment of venous leg ulcers (Br J Surg 2002; 89: 40‐4). Letter 1. British Journal of Surgery 2002;89(6):810. - PubMed
Meyer 2003 {published data only}
    1. Meyer FJ, Burnand KG, Lagatolla NRF, Eastham D. More venous leg ulcers are healed by three‐layer paste than by 4LBs: a randomised, controlled, prospective study. Proceedings of the First World Wound Healing Congress; 10‐13 September, 2000. Melbourne, Australia, 2000:74‐5.
    1. Meyer FJ, McGuinness CL, Lagattolla NRF, Eastham D, Burnand KG. Randomized clinical trial of three‐layer paste and 4LBs for venous leg ulcers. British Journal of Surgery 2003;90(8):934‐40. - PubMed
    1. Nelson EA. 3‐layer paste bandages were more effective than 4 layer bandages for healing venous leg ulcers. Evidence Based Nursing 2004;7:21. - PubMed
Milic 2007 {published data only}
    1. Milic DJ, Zivic SS, Bogdanovic DC, Perisic ZD, Milosevic ZD, Jankovic RJ, et al. A randomized trial of the Tubulcus multilayer bandaging system in the treatment of extensive venous ulcers. Journal of Vascular Surgery 2007;46(4):750‐5. - PubMed
Milic 2010 {published data only}
    1. Milic DJ, Zivic SS, Bogdanovic DC, Jovanovic MM, Jankovic RJ, Milosevic ZD, et al. The influence of different sub‐bandage pressure values on venous leg ulcers healing when treated with compression therapy. Journal of Vascular Surgery 2010;51(3):655‐61. - PubMed
Moffatt 1999 {published data only}
    1. Franks PJ, Moffatt CJ, Ellison DA, Connolly M, Fielden S, Groarke L, et al. Quality of life in venous ulceration: a randomized trial of two bandage systems. Phlebology 1999;14:95‐9.
    1. McCollum CN, Ellison DA, Groarke L, Fielden S, Connolly M, Franks PJ, et al. Randomised trial comparing Profore and the original 4LB in the treatment of venous leg ulceration. European Wound Management Association Conference; 1997, 27‐29 April; Milan, Italy. London: Macmillan Magazines, 1997:30.
    1. Moffatt CJ, Simon DA, Franks PJ, Connolly M, Fielden S, Groarke L, at al. Randomised trial comparing two 4LB systems in the management of chronic leg ulceration. Phlebology 1999;14:139‐42.
Moffatt 2003a {published and unpublished data}
    1. Franks PJ, Stevens J, Hourican C, Doherty D, O'Connor T, McCullagh L, et al. Quality of life in venous ulceration: use of the SF‐36 in a randomised trial of two bandage systems. 11th Conference of the European Wound Management Association; 17‐19 May 2001; Dublin, Ireland. 2001.
    1. Franks PJ, Stevens J, Hourican C, Doherty DC, O'Connor T, McCullagh L, et al. Quality of life in venous ulceration: use of the SF‐36 in a randomized trial of two bandage systems (abstract only). Ostomy/Wound Management 2002;48(4):73.
    1. Moffatt CJ, McCullagh L, O'Connor T, Doherty DC, Hourican C, Lewis C, et al. Randomised trial comparing four layer with two layer high compression bandaging in the management of chronic leg ulceration. 11th Conference of the European Wound Management Association; 2001, 17‐19 May; Dublin, Ireland. 2002.
    1. Moffatt CJ, McCullagh L, O'Connor T, Doherty DC, Hourican C, Stevens J, et al. Randomized trial of four‐layer and two‐layer bandage systems in the management of chronic venous ulceration. Wound Repair and Regeneration 2003;11(3):166‐71. - PubMed
Moffatt 2008 {published data only}
    1. Moffatt C, Edwards L, Harding K, Collier M, Treadwell T, Miller M, et al. A randomized, crossover clinical trial of a two‐layer and four‐layer compression bandage system in the treatment of venous leg ulcers. 3rd Congress of the World Union of Wound Healing Societies Meeting; 2008, 4‐8 June; Toronto, Canada. 2008.
    1. Moffatt CJ, Edwards L, Collier M, Treadwell T, Miller M, Shafer L, et al. A randomised controlled 8‐week crossover clinical evaluation of the 3MTM CobanTM 2 layer compression system versus ProforeTM to evaluate the product performance in patients with venous leg ulcers. International Wound Journal 2008;5(2):267‐79. - PMC - PubMed
    1. Price P, Harding K, Moffatt C. Randomized, cross‐over, clinical trial to compare the impact of two‐layer versus a four‐layer compression bandage system in the treatment of venous leg ulcer. 18th Conference of the European Wound Management Association; 14‐16 May 2008; Lisbon, Portugal. 2008.
    1. Tucker JA. A prospective, multi‐site, randomized, cross‐over, clinical trial of a two‐layer and a four‐layer compression bandage system in the treatment of venous leg ulcers. Scientific and clinical abstracts from the 40th Annual Wound, Ostomy and Continence Nurses Annual Conference. Journal of Wound, Ostomy and Continence Nursing. 2008; Vol. 35:S71.
Moody 1999 {published data only}
    1. Moody M. Comparison of Rosidal K and Surepress in the treatment of venous leg ulcers. British Journal of Nursing 1999;8(6):345‐55. - PubMed
Morrell 1998 {published and unpublished data}
    1. Morrell CJ. Randomised controlled trial of four‐layer compression bandaging. Unpublished report 1996.
    1. Morrell CJ, King B, Brereton L. Community‐based leg ulcer clinics: organisation and cost‐effectiveness. Nursing Times 1998;94(9):51‐4. - PubMed
    1. Morrell CJ, Walters SJ, Dixon S, Collins KA, Brereton LML, Peters J, et al. Cost effectiveness of community leg ulcer clinics: randomised controlled trial. BMJ 1998;316(7143):1487‐91. - PMC - PubMed
Nelson 2007a {published data only}
    1. Dale JJ, Ruckley CV, Harper DR, Gibson B, Nelson EA, Prescott RJ. A factorial trial of drugs, dressings and bandages in the treatment of leg ulcers. Proceedings of the 5th European Conference on Advances in Wound Management; 1995, 21‐24 November; Harrogate, UK. 1996:193‐4.
    1. Franks PJ, Bosanquet N, Brown D, Straub J, Harper DR, Ruckley CV. Perceived health in a randomised trial of treatment for chronic venous ulceration. European Journal of Vascular and Endovascular Surgery 1999;17(2):155‐9. - PubMed
    1. Nelson EA, Harper DR, Ruckley CV, Prescott RJ, Gibson B, Dale JJ. A randomised trial of single layer and multi‐layer bandages in the treatment of chronic venous ulceration. Phlebology 1995;Suppl 1:915‐6.
    1. Nelson EA, Prescott RJ, Harper DR, Gibson B, Brown D, Ruckley CV. A factorial, randomized trial of pentoxifylline or placebo, four‐layer or single‐layer compression, and knitted viscose or hydrocolloid dressings for venous ulcers. Journal of Vascular Surgery 2007;45(1):134‐41. - PubMed
O'Brien 2003 {published data only}
    1. Clarke‐Moloney M, O'Brien JF, Grace PA, Burke PE. Health‐related quality of life during four‐layer compression bandaging for venous leg ulcer disease: a randomised controlled trial. Irish Journal of Medical Science 2005;174(2):21‐5. - PubMed
    1. O'Brien JF, Grace PA, Perry IJ, Burke PE. Randomised controlled trial: cost‐effectiveness of four‐layer compression bandaging in venous leg ulcer care. 11th Conference of the European Wound Management Association; 2001 17‐19 May; Dublin, Ireland. 2001.
    1. O'Brien JF, Grace PA, Perry IJ, Hannigan A, Clarke‐Moloney M, Burke PE. Randomized clinical trial and economic analysis of four‐layer compression bandaging for venous ulcers. British Journal of Surgery 2003;90(7):794‐8. - PubMed
Partsch 2001 {published and unpublished data}
    1. Partsch H, Damstra RJ, Tazelaar DJ, Schuller‐Petrovic S, Velders AJ, Rooij MJM, et al. Multicentre, randomised controlled trial of four‐layer bandaging versus short‐stretch bandaging in the treatment of venous leg ulcers. VASA 2001;30(2):108‐113. - PubMed
Polignano 2004a {published and unpublished data}
    1. Allegra C, Cariotti R, Bonadeo P, Gasbarro S, Cataldi R, Polignano R, et al. Four‐layer compared with Unna's Boot in venous leg ulcer management. 11th Conference of the European Wound Management Association. Dublin, Ireland. 2001.
    1. Allegra C, Cariotti R, Bonadeo P, Gasbarro S, Cataldi R, Polignano R, et al. Four‐layer compared with Unna's Boot in venous leg ulcer management. 11th Annual Meeting of the European Tissue Repair Society. Cardiff, UK. Wound Repair and Regeneration. 2001; Vol. 9, issue 5:393.
    1. Polignano R, Bonadeo P, Gasbarro S, Allegra C. A randomised controlled study of four‐layer compression versus Unna's Boot for venous ulcers. Journal of Wound Care 2004;13(1):21‐4. - PubMed
Polignano 2004b {published data only}
    1. Polignano R, Guarnera G, Bonadeo P. Evaluation of SurePress Comfort: a new compression system for the management of venous leg ulcers. Journal of Wound Care 2004;13(9):387‐91. - PubMed
Rubin 1990 {published data only}
    1. Rubin JR, Alexander J, Plecha EJ, Marman C. Unna's boot vs polyurethane foam dressings for the treatment of venous ulceration. A randomized prospective study. Archives of Surgery 1990;125(4):489‐90. - PubMed
Scriven 1998 {published and unpublished data}
    1. Scriven JM, Taylor LE, Wood AJ, Bell PRF, Naylor AR, London NJM. A prospective randomised trial of four‐layer versus short stretch compression bandages for the treatment of venous leg ulcers. Annals of the Royal College of Surgeons 1998;80(3):215‐20. - PMC - PubMed
Szewczyk 2010 {published data only}
    1. Szewczyk MT, Jawień A, Cierzniakowska K, Cwajda‐Białasik J, Mościcka P. Comparison of the effectiveness of compression stockings and layer compression systems in venous ulceration treatment. Archives of Medical Science 2010;6(5):793‐9. - PMC - PubMed
Taradaj 2007 {published data only}
    1. Taradaj J, Franek A, Dolibog P, Cierpka L, Blaszczak E. The impact of the sonography and compression therapy on enhancement of healing venous leg ulcers after surgical treatment [Wplyw sono‐i kompresoterapil na wspomaganie gojenia owrzodzen zylnych goleni po leczeniu chirurgicznym]. Polski Merkuriusz Lekarski 2007;23(138):426‐9. - PubMed
Taradaj 2009 {published data only}
    1. Taradaj J, Franek A, Brzezinska‐Wcislo L, Blaszczak E, Polak A. Randomized trial of medical compression stockings versus two‐layer short‐stretch bandaging in the management of venous leg ulcers. Phlebologie 2009;38(4):157‐63.
Taylor 1998 {published data only}
    1. Taylor A. A prospective study to compare healing rates and associated treatment costs for current management of venous leg ulcers in the community and a four‐layer compression bandage regime. Proceedings of the 4th European Conference on Advances in Wound Management. London: Macmillan Magazines, 1995:199‐200.
    1. Taylor A, Taylor R, Marcuson R. Comparative healing rates and cost of conventional and four‐layer treatment of venous ulcers.. Phlebology 1995;10:85.
    1. Taylor AD, Taylor RJ, Marcuson RW. Prospective comparison of healing rates and therapy costs for conventional and four layer high compression bandaging treatments of venous leg ulcers. Phlebology 1998;13:20‐4.
    1. Taylor AD, Taylor RJ, Marcusson RW. Prospective comparison of healing rates and therapy costs for conventional and four layer compression bandaging treatments of venous leg ulcers. Surgical Directorate, Central Manchester Healthcare NHS Trust.
Travers 1992 {published data only}
    1. Travers JP, Dalziel KL, Makin GS. Assessment of a new one‐layer adhesive bandaging method in maintaining prolonged limb compression and effects on venous ulcer healing. Phlebology 1992;7:59‐63.
Ukat 2003 {published and unpublished data}
    1. Ukat A, Konig M, Vanscheidt W, Münter K‐C. Short‐stretch versus multilayer compression for venous leg ulcers: a comparison of healing rates. Journal of Wound Care 2003;12(4):139‐43. - PubMed
Vowden 2000 {published and unpublished data}
    1. Vowden K. A randomized study comparing compliance, healing and complications from three alternative 4LB regimens in the treatment of venous leg ulcers. 9th European Conference on Advances in Wound Management; 9‐11 November, 1999; Harrogate, UK. 1999.
    1. Vowden KR, Mason A, Wilkinson D, Vowden P. Comparison of the healing rates and complications of three 4LB regimens. Journal of Wound Care 2000;9(6):269‐72. - PubMed
Wilkinson 1997 {published and unpublished data}
    1. Wilkinson E, Buttfield S, Cooper S, Young E. Randomised controlled trial of two systems of compression bandaging for chronic venous leg ulcers. Unpublished report 1996.
    1. Wilkinson E, Buttfield S, Cooper S, Young E. Trial of two bandaging systems for chronic venous leg ulcers. Journal of Wound Care 1997;6(7):339‐40. - PubMed
Zuccarelli 1997 {published and unpublished data}
    1. Zuccarelli F, Allaert FA. Effectivity of support in the treatment of leg ulcers. A comparative multicentre study of elastic bandage (BIFLEX®) versus extensive bandage [Efficacité de la contention dans le traitement des ulcères de jambe. Etude multicentrique comparant une bande élastique (BIFLEX®) et une bande extensible]. Angéiologie 1997;49(5):15‐8.

References to studies excluded from this review

Alvarez 2005 {published data only}
    1. Alvarez O, Markowitz L, Booker J, Rogers R, Waltrous L, Patel M. A randomized clinical trial to evaluate healing of chronic venous ulcers in ambulatory patients treated with modified unna's boot and four layer compression bandage. European Wound Management Association Conference; 2005, 15‐17 September; Stuttgart, Germany. 2005.
Baccaglini 1998 {published data only}
    1. Baccaglini U, Giraldi E, Spreafico G, Sorrentino P, Castoro C, Penzo S, et al. Evaluation of the Jobst UlcerCare system for the treatment of venous ulcers. Phlebology 1998;13(4):163‐5.
Blair 1988 {published data only}
    1. Blair SD, Wright DDI, Backhouse CM, Riddle E, McCollum CN. Sustained compression and healing of chronic venous ulcers. BMJ 1988;297:1159‐61. - PMC - PubMed
Brizzio 2006 {published data only}
    1. Brizzio EO, Blttler W, Rossi G, Chirinos A, Cantero I, Idiazabal G, et al. Healing venous leg ulcers with different modalities of leg compression. Phlebologie 2006;35:349‐55.
Cameron 1996 {published data only}
    1. Cameron J, Hofman D, Poore S, Duby T, Cherry G, Ryan T. A comparative study of two bandage systems. Proceedings of the 3rd European Conference on Advances in Wound Management. London: Macmillan Magazines, 1994:168.
    1. Cameron J, Hofman D, Poore S, Duby T, Cherry G, Ryan T. A retrospective trial in the treatment of venous leg ulcers. Wounds 1996;8(3):95‐100.
Cherry 1990 {published data only}
    1. Cherry G. Clinical comparison of a new compression bandage. Nursing Standard 1990;8 (Suppl):8‐11. - PubMed
Falanga 1998 {published data only}
    1. Falanga V, Margolis D, Alvarez O, Auletta M, Maggiacomo F, Altman M, et al. Rapid healing of venous ulcers and lack of clinical rejection with an allogenic cultured human skin equivalent. Archives of Dermatology 1998;134:293‐300. - PubMed
    1. Falanga V, Saap LJ, Ozonoff A. Wound bed score and its correlation with healing of chronic wounds. Dermatologic Therapy 2006;19:383‐90. - PubMed
Fuessl 2009 {published data only}
    1. Fuessl HS. Which bandage for venous leg ulcer? [Welcher verband beim ulcus cruris?]. MMW‐Fortschritte Der Medizin 2009;151(34‐3):28.
Hamel‐Desnos 2010 {published data only}
    1. Hamel‐Desnos CM, Guias BJ, Desnos PR, Mesgard A. Foam sclerotherapy of the saphenous veins: randomised controlled trial with or without compression. European Journal of Vascular and Endovascular Surgery 2010;39:500‐7. - PubMed
Heinen 2010 {published data only}
    1. Heinen M, Borm G, Achterberg T. 'Lively Legs': increased physical activity and fewer wound days in venous leg ulcer patients (abstract). Fourth European Nursing Congress. Journal of Clinical Nursing 2010;19(Supplement):42.
Hjerppe 2010 {published data only}
    1. Hjerppe A, Saarinen JP, Venermo MA, Huhtala HS, Vaalasti A. Prolonged healing of venous leg ulcers: the role of venous reflux, ulcer characteristics and mobility. Journal of Wound Care 2010;19(11):474‐84. - PubMed
Horakova 1994 {published data only}
    1. Horakova M, Partsch H. Venous leg ulcers: are compression bandages indicated?. Phlébologie 1994;47:53‐7.
    1. Partsch H, Horakova MA. Compression stockings for the treatment of venous leg ulcers [Kompressionstrumpfe zur Behandlung venoser Unterschenkelgeschwure]. Wiener Medizine Wochenschrift 1994;144:242‐9. - PubMed
Ivanovic 2011 {published data only}
    1. Ivanovic N, Panfil E‐M. Compression in varicose ulcer. What is the effect of this measure? [Kompression bei Ulcus cruris venosum. Welchen effekt hat die Maßnahme?]. Pflegewissenschaft 2011;64(7):412. - PubMed
Jull 2009 {published data only}
    1. Jull A, Walker N, Parag V, Molan P, Rodgers A, on behalf of the Honey as Adjuvant Leg Ulcer Therapy (HALT) trial collaborators. Venous ulcer management in New Zealand: usual care versus guideline recommendations. Journal of the New Zealand Medical Association 2009;122(1295):9‐18. - PubMed
Jünger 2006 {published data only}
    1. Jünger M, Riebe H. A world's novelty: Venotrain micro balance combining compression therapy with effective skin care ‐ a randomised, controlled, prospective, explorative study. European Venous Forum. London, UK. 29 June‐1 July 2006.
Kucharzewski 2003 {published data only}
    1. Kucharzewski M, Ślezak A, Franek A. Topical treatment of non‐healing venous leg ulcers by cellulose membrane. Phlebologie 2003;32:147‐51.
Kuznetsov 2009 {published data only}
    1. Kuznetsov NA, Rodoman GV, Nikitin VG, Karev MA, Shalayeva TI. The use of current bandages in the treatment of patients with venous trophic ulcers of the shin: clinical and economic aspects. Khirugiia Moskva 2009;11:63‐9. - PubMed
Lee 2009 {published data only}
    1. Lee G, Rajendran S, Anand S. New single‐layer compression bandage system for chronic venous leg ulcers. British Journal of Nursing (Tissue Viability Supplement) 2009;18(15):S4‐S18. - PubMed
Luo 2009 {published data only}
    1. Luo Y‐W, Yang Y, Xin S‐J. Graduated compression stockings in the therapy of chronic venous insufficiency (482 reports). Journal of Dalian Medical University 2009;31(6):692‐4.
Marston 1999 {published data only}
    1. Marston WA, Carlin RE, Passman MA, Farber MA, Keagy BA. Healing rates and cost efficacy of outpatient compression treatment for leg ulcers associated with venous insufficiency. Journal of Vascular Surgery 1999;30:491‐8. - PubMed
Nissinen‐Paatsamala 1995 {published data only}
    1. Nissinen‐Paatsamala K, Jansén C. Low elastic long‐time bandaging ‐ intensive care of varicose ulcer with diminished personnel. Suomen Lääkärilehti 1995;50:717‐9.
Northeast 1990 {published and unpublished data}
    1. Northeast ADR, Layer GT, Wilson NM, Browse NL, Burnand KG. Increased compression expedites venous ulcer healing. Royal Society of Medicine Venous Forum, 1990 October Meeting. 1990.
Olofsson 1996 {published data only}
    1. Olofsson B, Ljunghall K, Nordin‐Bjorklund K, Sorensen S, Leppert J. Two therapeutic models in venous leg ulcers are compared: better results with optimized compression [Optimerad kompression ger battre resultat]. Lakartidningen 1996;93(51‐52):4752‐4. - PubMed
Partsch 2008a {published data only}
    1. Partsch H, Vanscheidt W, Ukat A. Dose‐response relationship in randomized clinical studies of compression therapy for venous insufficiency oedema. Phlebology 2008;23:233‐4.
Robson 2004 {published data only}
    1. Brennan M, Serena TE, Hanft J, Snyder R. Patients with venous leg ulcerations have diminished quality of life: analysis of a multi‐centre randomized clinical trial. The Symposium on Advanced Wound Care and the Wound Healing Society. 2010, April 17‐20.
    1. Robson MC, Hanft J, Garner W, Jenson J, Serena T, Payne WG, et al. Healing of chronic venous ulcers is not enhanced by the addition of topical repifermin (KGF‐2) to standardized care. The Journal of Applied Research 2004;4(2):302‐11.
Russo 1999 {published data only}
    1. Russo A, Roberta C. Multi‐layer versus two‐layer bandage system in the treatment of venous leg ulcers. A comparative study. 9th European Conference on Advances in Wound Management; 1999, 9‐11 November; Harrogate UK. 1999.
Sabolinski 1995 {published data only}
    1. Sabolinski M, Borchard G, Mulder G. Cost benefit analysis of living skin equivalent versus graduated, multi‐layered compression therapy for the treatment of venous skin ulcers. Diabetes 1995;44(Suppl 1):107.
    1. Sabolinski M, Borchard G, Mulder G. Cost‐benefit analysis of Living Skin Equivalent versus graduated, multi‐layered compression therapy for the treatment of venous skin ulcers. Proceedings of the 5th European Conference on Advances in Wound Management; 1995, 21‐24 November; Harrogate, UK. London: Macmillan Magazines, 1996:107‐9.
Scriven 2000 {published data only}
    1. Scriven JM, Bello M, Taylor LE, Wood AJ, London NJM. Studies of a new multi‐layer compression bandage for the treatment of venous ulceration. Journal of Wound Care 2000;9(3):143‐7. - PubMed
Serra 2010 {published data only}
    1. Serra N, Palomar F, Fornes B, Capillas R, Berenguer M, Aranda J, et al. Effectiveness of the association of multilayer compression therapy and periwound protection with Cavilon® (no sting barrier film) in the treatment of venous leg ulcers [Efectividad del tratamiento de las úlceras venosas con vendaje compresivo multicapa asociado a protección de la piel perilesional con Cavilon® (película barrera no irritante)]. Gerokomos 2010;21(3):124‐30.
Sikes 1985 {published data only}
    1. Sikes E. Evaluation of a transparent dressing in the treatment of stasis ulcers of the lower limb. Journal of Enterostomal Therapy 1985;12:116‐20. - PubMed
Sironi 1994 {published data only}
    1. Sironi G, Losa S, Luca G, Pezzoni F. Patients with venous leg ulcers in vascular surgery treatment with Intrasite gel, Opsite Flexigrid, Allevyn and Flexobande Legere/Forte: a randomised comparative clinical evaluation ‐ an interim report (poster presentation). 13th Conference of the European Wound Management Association; 2003, 22‐24 May; Pisa, Italy. 2003.
    1. Sironi G, Losa S, DiLuca G, Pezzoni F. Treatment of venous leg ulcers with Intrasite gel, Opsite Flexigrid, Allevyn hydrocellular dressing and Flexobande (elastic compression bandage) in vascular surgery. A protocol for clinical evaluation. 3rd European Conference on Advances in Wound Management; 1993, 19‐22 October; Harrogate, UK. London: Macmillan Magazines, 1994:164.
Smith Strom 2006 {published data only}
    1. Smith Strom H. Comparison of healing and costs with two different treatments. A randomized controlled study of patients with leg ulcers, treated in primary health care [Norwegian]. Vard I Norden, Nursing Science and Research in the Nordic Countries 2006;26(2):4‐9.
Szewczyk 2009 {published data only}
    1. Jawien A, Szewczky MT, Banaszkiewicz Z, Moscicka P, Hancke E. Pain associated with venous ulcers and its relation to dynamics of wound healing. EWMA Journal 2010;10(2):42.
    1. Jawien A, Szewczyk MT, Mościcka P, Cierzniakowska K, Cwajda J. Evaluation of clinical effectiveness of two‐ and four‐layer compression in venous leg ulcer treatment: randomized study. European Venous Forum abstracts. Phlebology 2008;23:234‐5.
    1. Szewczyk MT, Jawień A, Migdalski A, Piotrowicz R, Grzela T, Brazis P. Predicting time to healing by anatomical assessment of venous pathology. Medical Science Monitor 2009;15(2):CR74‐CR81. - PubMed
Torra i Bou 2003 {published data only}
    1. Torra i Bou JE, Rueda Lopez J, Blanco Blanco J, Torres Ballester J, Toda Lloret L. Venous ulcers. Multilayer compression system or crepe bandage? Comparative study on effectiveness, cost and impact on quality of life [Spanish]. Revista de Enfermeria 2003;26(9):59‐66. - PubMed
Van Laere 2010 {published data only}
    1. Laere M. Comparative study between 2 short stretch compression systems. EWMA Conference, 26‐28 May 2010, Geneva, Switzerland. EWMA Journal 2010;10(2):149, Abstract 173.
Vowden 2001 {published data only}
    1. Vowden KR, Wilkinson D, Vowden P. The K‐Four bandage system: evaluating its effectiveness on recalcitrant venous leg ulcers. Journal of Wound Care 2001;10(5):182‐4. - PubMed
Walker 1996 {published data only}
    1. Walker P, Faria DT. Evaluation of a three layer bandage system versus a 4LB system in venous leg ulcers. Symposium on Advanced Wound Care and Medical Research Forum on Wound Repair. Wayne: Health Management Publications, 1996:121.
Zamboni 2004 {published data only}
    1. Zamboni P, Cisno C, Marchetti F, Mazza P, Fogato L, Carandina S, et al. Haemodynamic CHIVA correction surgery versus compression for primary venous ulcers: first year results. Phlebology 2004;19(1):28‐34.
    1. Zamboni P, Cisno C, Marchetti F, Mazza P, Fogato L, Carandina S, et al. Minimally invasive surgical management of primary venous ulcers vs. compression treatment: a randomized clinical trial. European Journal of Vascular and Endovascular Surgery 2003;25(4):313‐8. - PubMed

References to studies awaiting assessment

Bertaux 2010 {published data only}
    1. Bertaux E, Ettner N. A new approach to treat venous leg ulcers by compression therapy. EWMA Conference, 26‐28 May 2010, Geneva, Switzerland. EWMA Journal. 2010; Vol. 10, issue 2:40, Abstract 39.
Harrison 2011 {published data only}
    1. Harrison MB. The Canadian bandaging trial: A multi‐site RCT of bandaging technologies for venous leg ulcers. The 2011 International Nursing Research Conference; 16‐18 May, 2011; Harrogate, UK. 2011.
    1. Harrison MB, VanDenKerkhof EG, Hopman WM, Graham ID, Carley ME, EA Nelson for the Canadian Bandaging Group. The Canadian Bandaging Trial: evidence‐informed leg ulcer care and the effectiveness of two compression technologies. BMC Nursing 2011;10(20):available from http://www.biomedcentral.com/1472‐6955/10/20 (accessed June 2012). - PMC - PubMed
    1. Smith LJ, Harrison MB, Graham ID, Lamb M. Community leg ulcer bandaging study: lessons learned in a pilot, randomized controlled trial. Ostomy Wound Management 2010;56(9):32‐42. - PubMed
Moffatt 2003b {published data only}
    1. Moffatt CJ. A multi‐centre randomised study comparing a new innovative vari‐stretch compression bandaging system with a traditional multi‐layer compression bandage system for the management of venous leg ulcers [Abstract]. 13th Conference of the European Wound Management Association; 2003, 22‐24 May; Pisa, Italy. 2003:111.
Mosti 2010 {published data only}
    1. Mosti G, Mattaliano V, Conte R, Abel M. Promotion of healing, pain relief, tolerability and quality of life: results of a prospective, controlled, randomized comparison study with two wound dressings in out‐patients with non‐infected leg ulcers. EWMA Conference, 26‐28 May 2010, Geneva, Switzerland. EWMA Journal. 2010; Vol. 10, issue 2:59, Abstract 77.
Mosti 2011 {published data only}
    1. Mosti G, Crespi A, Mattaliano V. Comparison between a new, two‐component compression system with zinc paste bandages for leg ulcer healing: a prospective, multicenter, randomized, controlled trial monitoring sub‐bandage pressures. Wounds: A Compendium of Clinical Research & Practice 2011;23(5):126‐34. - PubMed
Taradaj 2011 {published data only}
    1. Taradaj J, Franek A, Cierpka L, Brzezinska‐Wcislo L, Blaszczak E, Polak A, et al. Early and long‐term results of physical methods in the treatment of venous leg ulcers: randomized controlled trial. Phlebology 2011;26(6):237‐45. - PubMed
Wong 2012 {published data only}
    1. Andriessen A, Wong IKY, Lee DTF, Wong LY, Chao DVK, Heung NF, et al. RCT comparing treatment outcome and quality of life of two compression bandaging systems and standard care without compression in venous leg ulcer patients (abstract). EWMA Journal 2011;11(2 Suppl):61.
    1. Wong IKY, Andriessen A, Charles HE, Thompson D, Lee DTF, So WKW, et al. Randomized controlled trial comparing treatment outcome of two compression bandaging systems and standard care without compression in patients with venous leg ulcers. Journal of the European Academy of Dermatology and Venereology 2012;26:102‐10. - PubMed
    1. Wong IKY, Andriessen A, Lee DTF, Thompson D, Wong LY, Chao DVK, et al. Randomized controlled trial comparing treatment outcome of two compression bandaging systems and standard care without compression in patients with venous leg ulcers. Journal of Vascular Surgery 2012;55(5):1376‐85. - PubMed

References to ongoing studies

Dumville 2009 {published data only}
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Weller 2010 {published data only}
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References to other published versions of this review

Cullum 1997
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EHCB 1997
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O'Meara 2009
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