A study of venous leg ulcers

Arun, V (2008) A study of venous leg ulcers. Masters thesis, Stanley Medical College, Chennai.

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Abstract

INTRODUCTION: “Venous ulceration” is defined as ulceration of the malleolar skin in the presence of perforating vein incompetence with or without deep vein incompetence. Ulceration of the lower leg is a common symptom that will affect 2% of people in their life time. Its prevalence increases with age from 0.5% among patients over 40 to 2 % among those who are 80.As the proportion of elderly people ion the population increases, we can expect a rise in the present estimated number of leg ulcers unless a more educated approach to its management is taken. Though important advances have been made in the management of leg ulcers, India lags far behind the standards set by the European countries. Treatment is fragmented, poorly taught and inadequately researched. The average time taken to heal an ulcer is about 6months and some persist for years. Good management depends on accurate diagnosis, simple and appropriate care of the wound and treatment of underlying cause. AIM OF THE STUDY: The objective of this study is to analyze the incidence of Venous leg ulcers in different age groups and sex, to know the relationship between socio economic status and venous ulcers, to compare duration of ulcer and symptoms, to analyze underlying pathology, the side of ulcer, to evaluate the causes, the recurrences and complications and finally to find out the best suited procedure. PATIENTS AND METHODS: Patients with clinical diagnosis of venous ulcer between 2005 June to 2007 April (only inpatients) were included in this study. Among 116 patients who had venous ulcerations 111were due to varicose veins and 5 patients had DVT. A detailed history including symptoms, duration of ulcer, mode of development, occupation, previous surgery, claudication were taken. The patients were examined in both standing and recumbent postures. The location, size, floor of the ulcer and secondary changes in the leg including pigmentation, periostitis of underlying bone, mobility of ankle joint were noted. Regional lymph nodes were examined. Legs were examined individually for varicosities. Saphenofemoral / Saphenopopliteal and perforator incompetences were made out by Trendelenburg, multiple tourniquet test and Schwartz test. Deep vein assessed by Perthe’s test. Perforator incompetences were localized by palpating the deep fascia for defects. Arterial pulses of both feet examined to rule out arterial components. Abdominal and pelvic examination were done to rule out tumors, dilated suprapubic veins and ascitis. Doppler and Duplex imaging was used to rule out DVT and localize perforator incompetence in all cases. Routine investigations of blood and urine were done. Swab taken from the wound and antibiotics prescribed according to culture and sensitivity. Patients were treated with initial Hydrogen Peroxide and Povidone Iodide until wound became healthy and then normal saline dressing was done daily. Elastocrepe bandage was applied from the level of head of metatarsal up to the knee. The limb was kept elevated by raising the foot end of the bed. 110 patients underwent surgery. The choice of surgery was determined by the extent of disease and patients general condition. The procedures done included Trendelenburg operation, complete stripping of long saphenous vein, multiple avulsion, sub-fascial ligation and extra-fascial ligation of perforators. After performing the surgery a layer of pad and cotton bandage was applied, over which elastocrepe bandage was also applied. The dressings were changed on the 3rd POD. Patient was allowed to walk after 12 hours. The sutures were removed after 10 days. They were advised to avoid prolonged standing and to wear elastocrepe bandage for 6 months. CONCLUSION: From the study 116 cases of venous leg ulcers I was able to arrive at some conclusions. 1) Though venous ulceration is described as a disease of elderly, it is found equally common among young adults as per my study. This could be due to more prolonged standing occupations and perhaps young adults are more prone to traumatise themselves while working. 2) Male : Female incidence is 24 :1 i.e. Females in Chennai are more resistant to venous ulceration when compared to males. Females here are more homebound and they can relax more in between their working hours. 3) DVT as a cause of venous ulcer as per my study is 5/116 (approx. 4%). This is pretty less when compared to Western Statistics. 4) Our Indian patients have excellent tolerance. Even with leg ulcers they continue to work. This is evidenced by a history of upto 7 years duration of leg ulcer. This may be due to indifference and ignorance. 5) Leg ulceration is common in poor people below poverty line. (Perhaps we can not compare with the available data alone because many middle class and most high class people never come to Govt. Hospital). This may also be related to their nutritional status. 6) The common associations of ulcer are hyper pigmentation followed by pruritis and pain, especially on prolonged standing which is relieved by keeping legs elevated. Pain is most often felt at the ulcer site and some times also felt involving entire leg. 7) Left sided venous ulcers are more common than (R) side ulcers. This may be due to loaded sigmoid colon compressing veins draining the (L) lower limb. 8) Wound haematoma though described as a common post operative complication, it is rare where absolute meticulous haemostasis is achieved during surgery. 9) Failure to ligate the incompetent medial ankle perforator is the most common cause of recurrent venous ulcer. At the same time even when all the perforators are ligated meticulously the ulcer recurs after some time. This shows that our understanding is not yet complete. 10) We have to spend more time in teaching the patients regarding Acompression bandages, and to demonstrate them how to wear it. 11) Arterial component contributing towards venous ulcer were excluded by clinical palpation of pedal pulses. In few cases difficulty encountered in palpating which was overcome with the help of Doppler. 12) Stripping of great saphenous vein was performed upto just above ankle in almost all cases. This stripping should be limited to upper calf, since distal to this Part most long saphenous vein is normal in diameter and can be used for Bypass Surgeries. 14) Though the patients were advised to come for follow-up only half of the patients responded (55 out of 110). One month post surgery most were found to heal except in five patients who did not wear elastocrepe as advised.

Item Type: Thesis (Masters)
Uncontrolled Keywords: venous leg ulcers
Subjects: MEDICAL > General Surgery
Depositing User: Subramani R
Date Deposited: 18 Nov 2019 11:31
Last Modified: 18 Nov 2019 11:31
URI: http://repository-tnmgrmu.ac.in/id/eprint/11744

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