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Veins and Lymphatics 2013; volume 2:e13

[Veins and Lymphatics 2013; 2:e13] [page 39]

Comparison of knee-high
Mediven ulcer kit and Mediven
Plus compression stockings:
measurement of leg volume,
interface pressure and static
stiffness index changes
Gy�őző�Szolnoky, Georgina Molnár, Dóra
Nemes-Szabó, Enikő Varga, Mónika
Varga, Lajos Kemény
Department of Dermatology and
Allergology, University of Szeged,
Szeged, Hungary

Abstract

Ulcer stockings are produced to have higher
interface pressure and easier application com-
pared to those of classic medical compression
stockings. We aimed to compare volume
decrease, pressure loss and stiffness index of a
classical medical compression stocking and an
ulcer stocking of the same interface pressure
range in 10 patients with bilateral venous and
10 persons with lymphatic insufficiency.
Interface pressure measurement in supine
and standing positions and optoelectronic vol-
umetry served for primary outcome variables.
Both stockings were capable of inducing
remarkable gradual volume reductions in dif-
ferent time points except classic stocking at 2
h in phleboedema care. Ulcer stocking pres-
sures in lymph- and phleboedema were highly
superior. In lymphedema a gradual interface
pressure loss was attributed to both stockings
regardless of body positions. Static stiffness
indices did not differ statistically except classic
stocking at baseline (P=0.0312) and 2 h
(P=0.0082) comprising venous edema patie -
nts. Both stockings acted similarly but ulcer
stocking had considerably higher interface
pressures in each measurement and raised
stiffness indices initially and the two-layer sys-
tem facilitates donning therefore ulcer stock-
ing could serve an alternative of classic med-
ical compression stocking even in the treat-
ment of leg edema. 

Introduction

The intensive treatment of the two prevalent
causes of chronic leg edema [chronic venous
insufficiency (CVI) and lymphedema] is com-
monly based on various bandage systems.1

Inelastic bandages, especially when two or
more are applied in an overlapping fashion,
have high stiffness, a significant pressure loss

is observed within the first hours of applica-
tion due to the rapid volume reduction.2

Medical compression stockings (MCSs) are
elastic devices with relatively low stiffness
index (<10).3 Unlike bandages, MCSs are
observed to loose original interface pressure to
a lesser degree.2 There is an emerging body of
evidence that MCSs are also capable of effi-
cient volume reduction even in the intensive
therapeutical phase.1 Taken the previous data
together, MCSs are presumed to possess some
important features of efficient compression,
however the achievable high interface pres-
sures may associate low patient compliance as
both donning and removal of the garment
cause difficulties and require outstandingly
high forces.4 The pressure of the two superim-
posed stockings was shown to roughly corre-
spond to the direct addition of the interface
pressure exerted by the single layer due to
interface friction.5 Overlapping stockings effi-
ciently raise interface pressure and alleviate
application. Classic MCSs are recommended
for daily use but depending on interface pres-
sure in supine position, patients are some-
times asked to wear their stockings overnight.
The nocturnal wear of understocking of ulcer
garments is preferred.5 The new generation of
stockings with double-layers is preferably rec-
ommended for leg ulcer healing but its poten-
tial advances over traditional MCSs give rise to
a comparative study in view of stiffness.    

This was the background for a clinical study
in which we compared interface pressures of
an ulcer stocking with that of a traditional
MCS belonging to the identical pressure range. 

Materials and Methods

A total of 20 legs from ten out-patients with
bilateral CVI [three males, seven females; age
52-75, median 61; mean body mass index
(BMI) (kg/m2): 30.57 (21.52-45.84); mean dis-
ease duration (years): 5 (1-20); clinical
Clinical-Etiology-Anatomy-Pathophysiology
classification (CEAP)-classes C3-6] and anoth-
er 20 legs of ten secondary lymphedema out-
patients with bilateral lower limb affections
(three males, seven females; age 55-81, medi-
an 70; mean BMI (kg/m2): 36 (24-41); mean
disease duration (years): 8 (4-14) were
recruited. Each of the bilateral secondary lym-
phedema cases was stage II comprising 5 per-
sons with gynecological cancer treatment-
related moderate lymphedema and another 5
patients where repeated erysipelas affecting
both legs at different time caused lymphede-
ma. CVI was diagnosed using color-coded
duplex ultrasonography. Patients did not wear
any form of compression garment 48 h before
the beginning of the trial (wash-out period)
and lymphedematous legs did not receive sup-

plementary treatment (e.g. manual lymph
drainage, intermittent pneumatic compres-
sion). Inclusion criteria were in accordance
with the recommendations of the International
Compression Club.1 Informed consent was
obtained from each patient and the study pro-
tocol conformed to the regular ethical guide-
lines, as reflected in a prior approval by the
University of Szeged human research commit-
tee. According to limb girths standard below-
knee stockings (Mediven ulcer kit and
Mediven Plus compression class 3) were pro-
vided by the Medi Company (Bayreuth,
Germany). Interface pressure was measured
by Kikuhime (Medi Trade, Soro, Denmark)
device6 using small pressure probe placed to
point B1 at baseline, 2, 4 and 24 h in standing
and supine positions, as well. Pressure probe
was not held continuously under the stocking
but was placed immediately after pulling down
the compression material then stocking was
redone and finally the measurement was com-
pleted. According to our standards, Mediven
ulcer kit was assigned to right, while Mediven
Plus to the left leg. Stockings were worn for 24
h with a surprisingly sufficient tolerability. The
static stiffness index (SSI) was calculated as
the difference between standing and supine
pressures.7 Leg volumes were assessed with
infrared optoelectronic measurement using
Perometer (Perimed, Wuppertal, Germany)8 at
baseline and immediately after pulling down
the stockings taking only 2-4 min in each case.

Correspondence: Győző Szolnoky, Department of
Dermatology and Allergology, University of
Szeged, 6720 Szeged, Korányi fasor 6., Hungary.
E-mail: szolnoky@dermall.hu

Key words: volumetry, static stiffness index, med-
ical compression stocking, ulcer stocking.

Conference presentation: part of this paper was
presented at the International Compression Club
(ICC) Meeting on Stiffness of Compression
Devices, 2012 May 25, Vienna, Austria (http://
www.icc-compressionclub.com/).

Acknowledgments: Medi (Bayreuth, Germany)
Company supported the clinical study with stan-
dard Mediven Plus ccl 3 AD and Mediven ulcer kit
stockings.  

Received for publication: 17 January 2013.
Revision received: 8 March 2013.
Accepted for publication: 4 April 2013.

This work is licensed under a Creative Commons
Attribution 3.0 License (by-nc 3.0).

©Copyright G. Szolnoky et al., 2013
Licensee PAGEPress, Italy
Veins and Lymphatics 2013; 2:e13
doi:10.4081/vl.2013.e13

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Conference Presentation

[page 40] [Veins and Lymphatics 2013; 2:e13]

Feet and calves were subjected to volumetry. To
compare SSI of the two products (right side vs
left side), the non-parametric Mann-Whitney
test was used. Comparisons between the pres-
sure and volume values at different time points
using the same type of stocking were made by
Wilcoxon signed rank test as a nonparametric
measure. P values lower than 0.05 were con-
sidered as statistically significant.

Results

Volume change 
Both Mediven ulcer kit and Mediven Plus

stockings were capable of inducing remarkable
gradual volume reductions in different time
points. Each of the measured volume decreas-
es appeared to be significant except Mediven
Plus at 2 h among patients with phleboedema.

Interface pressure
The pressure exerted by ulcer stocking in

lymph- and phleboedema was highly superior
to that of Mediven Plus at each measurement
in lying and standing positions except a single
assessment at 2 h in upright position (P=
0.0707) of the patients with lymphedema.  

Pressure alteration
In lymphedema a gradual interface pressure

loss was attributed to both compression stock-
ings regardless of body position positions
(Figure 1). Mediven Plus failed to cause a
pressure decrease 2 h after the beginning of
application in supine (P=0.1016) and standing
(P=0.509) positions, as well. Venous edema
treatment with Mediven Plus associated sig-
nificant pressure losses in supine positions
but did not provoke any significant changes of
interface pressures (P=0.0762 at 2 h,
P=0.1602 at 4 h and finally P=0.0547 at 24 h)
in standing posture (Figure 2). 

Static stiffness index
The calculated static stiffness indices did

not differ statistically regardless of compres-
sion material in lymphedema (Figure 3A),
however this parameter of Mediven Plus
(median: 2.00) was significantly inferior to
that of ulcer stocking (median: 4.00) at the
first two measurements (baseline: P=0.0312
and 2 h: P=0.0082) comprising venous edema
patients (Figure 3B).

Discussion

According to experiments in the field of
compression therapy two factors play a pivotal
role in setting an efficient therapy. Interface

Figure 1. Interface pressures of Mediven Ulcer kit and Mediven Plus AD ccl 3 stockings
in supine (A,B) and standing (C,D) positions in lymphedema.

Figure 2. Interface pressures of Mediven Ulcer kit and Mediven Plus AD ccl 3 stockings
in supine (A,B) and standing (C,D) positions in venous edema.

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[Veins and Lymphatics 2013; 2:e13] [page 41]

pressure measured under the compression
material is able to restore venous and lymphat-
ic insufficiency along narrowing veins and
ameliorating interstitial pressure. Clinical
studies demonstrated that the application of
higher external pressure lead to a faster
venous leg ulcer healing by efficiently counter-
acting the high ambulatory venous pressure
thus providing an enhanced venous flow.
Lower extremity edema sometimes presents in
a combined form including impaired venous
function, lymphatic insufficiency and
increased capillary permeability,1 thus the rel-
atively high edema volume warrants fairly high
external pressure. Evacuation of edema and
the most advanced form of venous insufficien-
cy are preferably directed to inelastic compres-
sion bandaging in a multilayer and multicom-
ponent fashion where interface pressure is
strongly correlated with the tensile forces.9,10

MCSs are usually used in the maintenance
phase where achieved results (volume
decrease, healed ulcer) should be preserved.1

The higher success rate in leg affection is
attributed to the applied pressure. If the exter-
nal pressure meets the ordinary range of
ambulatory venous pressure in impaired func-
tion it might minimize the risk of recurrence.
Medical compression stockings are manufac-
tured from elastic material so as to facilitate
donning and positioning over bony promi-
nences but the elastic properties possess at
least two disadvantages: stockings less effi-
ciently assist muscle pump11 and keep nearly
the same pressure regardless of position hav-
ing low SSIs. A major burden of increasing
compression pressure is the tolerability.
Classic medical compression stockings of
higher pressures cause difficulties in donning
and keeping them on legs in lying position. A
new generation of stockings tends to alleviate
these problems comprising an under- and an

overstocking with relatively low pressures.
These two superimposed garments set the
final pressure.5 These overlapping stockings
were designed especially to treat leg ulcers but
their other advantages made them interesting
for other objectives like the use in chronic leg
edema (e.g. phleb- or lymphedema) however
remained relatively poorly characterized and
compared to other compression materials.
Beyond their relatively easy application we
were able to experience that ulcer stockings
also exerted significant leg volume reduction
and brought up significantly higher interface
pressure compared to classical MCSs. The dif-
ference between lying and standing positions
results SSI that is an accurate indicator of
appropriate stocking selection for patients.12

Low pressure at supine position and a substan-
tial rise after standing up provides a comfort-
able wear and an efficient prevention against
edema formation and venous dilation. We were
able to show that the SSI of the given ulcer
stocking was able to exceed that of compres-
sion class 3 medical stocking in venous edema
during the initial phase of treatment however
it remained still relatively low. Stockings with
higher stiffness have a higher anti-edematous
efficacy.13 A previous clinical trial disclosed
that the superposition of two stockings did not
only increase the interface pressure, but had a
further additive effect to the stiffness of the
final stocking combination.3

To our knowledge this is the first compara-
tive study examining two types of stockings
from the aspect of stiffness index as one of the
most emphasized primary outcome variable.
From the practical point of view we recom-
mend the use of ulcer stockings instead of
classic MCS with identical interface pressure
when the final pressure should be adjusted
along easier doffingand in case of distinct leg
edema forms. 

References

1. Stout N, Partsch H, Szolnoky G, et al.
Chronic edema of the lower extremities:
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2. Larsen AM, Futtrup I. Watch the pressure -
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3. Partsch H, Partsch B, Braun W. Interface
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4. Willenberg T, Lun B, Amsler F, Baumgar -
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7. Partsch H. The static stiffness index. A
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Under the auspices of the IUP. Int Angiol
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10. Partsch H, Clark M, Mosti G, et al.
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11. Mosti G, Partsch H. Measuring venous
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12. Van der Wegen-Franken K, Tank B,
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Dermatol Surg 2008;34:1477-85.

13. Van Geest AJ, Veraart JC, Nelemans P,
Neumann HA. The effect of medical elastic
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Figure 3. Comparison of static stiffness indices of Mediven Ulcer kit and Mediven Plus
AD ccl 3 stockings in lymphedema (A) and venous edema (B). 

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