Chronic venous insufficiency in persons with a history of injection drug use

Persons with a history of injection drug use have many risk factors for the development of chronic venous insufficiency (CVI), yet this phenomenon has not been studied systematically in this population. Persons (N = 204) with a history of injection drug use who were in enrolled in a treatment center were examined for clinical manifestations of CVI. The CVI clinical classification was graded on a 7-point scale for each leg. Most participants (n = 179, 87.7%) exhibited clinical evidence of CVI. Significant predictors of CVI clinical manifestations were leg infections/cellulitis (rho =.53); years injection in the veins of the groin, legs, and feet (rho =.47); deep vein thrombosis (rho =.37); and total years injection heroin (rho =.27). There was a linear functional relationship between years of injection drug use and the CVI clinical classification, but only when the injections were in the veins of the groin, legs, or feet; otherwise, the specific mechanisms of this relationship were not evident. The findings indicate that CVI is a common occurrence in persons who have injected drugs.

Prevalence and risk factors of chronic venous insufficiency

Venous disease in the legs occurs very commonly in the general population in Western countries. Around one third of women have trunk varices. A lower prevalence has been observed in men but some recent surveys have suggested that the occurrence in men may be comparable to that in women. The prevalence increases with age but the incidence of new cases appears to be constant throughout adult life. Open venous ulcers occur in about 0.3% of the adult population and a history of open or healed ulceration occurs in around 1%. The etiology of chronic venous disease in the legs is unknown. A genetic predisposition may be present but evidence for this and for a mode of inheritance is lacking. There is some suggestion that prolonged standing may be a risk factor but studies are open to considerable bias. In women, obesity and previous pregnancy has been associated with the presence of varicose veins but the evidence is inconsistent. There have been few well-conducted studies examining diet and bowel habit as a risk factor. The risk of ulceration is related to the severity of varicosities and venous insufficiency, and is increased following deep vein thrombosis. Much further research is required to investigate the cause of this common condition in the general population.

Management of venous thromboembolism in pregnancy

Pulmonary thromboembolism (PTE) is the major cause of maternal death in the UK, with recent trends showing an increase in the numbers of deaths. Underlying PTE is the problem of deep venous thrombosis (DVT). An appreciation of risk factors, particularly, thrombophilia, and signs or symptoms suggestive of thromboembolism, coupled with objective diagnosis and treatment should reduce mortality and morbidity. There are particular considerations with regard to the management of thrombosis in pregnancy, especially the use of anticoagulants. Low-molecular-weight heparins are now replacing unfractionated heparin for the treatment of DVT and PTE in pregnancy.

The effect of head rotation on the diameter of the internal jugular vein: implications for free tissue transfer

PURPOSE

To determine the effects of medial (inwards) and lateral (outwards) rotation of the head on the transverse diameter of the internal jugular vein.

MATERIAL

The original study sample included 26 patients. Duplex ultrasound was used to measure the transverse diameter of the internal jugular vein at a fixed point on either side of the neck. Measurements were taken with the head central (neutral position), rotated laterally and medially.

RESULTS

Using Student's t-test we found that lateral rotation of the head produced a reduction in the mean of the transverse diameters of the left and right ipsilateral vein from 6.9 mm to 5.4 mm (p < 0.03) and 5.9 mm to 5.0 mm (p = 0.2173) respectively. One patient excluded from the study because of previous neck surgery showed complete occlusion of the ipsilateral internal jugular vein on lateral rotation of the head.

CONCLUSION

There is a possibility that patency of the vein could be compromised if the head is turned laterally. This situation may arise immediately after surgery in the ventilated and paralysed patient when the head may be unsupported. It could be of particular importance if the vein has been used as a recipient vein for free tissue transfer.

[Differential diagnosis of leg ulcers]

Over the last years the treatment of chronic leg ulcers has developed from a merely symptomatic to a differentiated therapy. Although more than 90% of the ulcers are of vascular origin, many other causes are possible. A survey of the various triggers of chronic ulcers of the lower limb is given. Vascular, hematological, neuropathic, infectious, malignant and chemico-physical causes are discussed. New findings regarding hemostatic defects as the basis of thrombophilia and ulcers are presented.

Clinical classification of free-flap perfusion complications

Free-tissue transfer is a standard procedure in hand and other plastic and reconstructive surgery. The aim of the present article was to present a new clinical classification of disturbances of the circulation, and to assess the results of treating the specific complication at each of the stages described. Within a period of 29 months, 194 free microvascular flaps were prepared and evaluated in a prospective study. Postoperative monitoring was carried out from a purely clinical point of view. A distinction was made between arterial and venous circulatory disturbances and, in both cases, four stages were characterized, according to the time required for recapillarization, the color of the transfer, and bleeding on puncture. Complications occurred in 69 cases (36 percent), including intraoperative revisions during a first operation. The ratio of arterial to venous insufficiency was 33:35. In the presence of arterial disturbances of the circulation, the proportion of losses increased in progressive stages to 41 percent. With venous disturbances, losses which occurred in stages 1 and 2 were predominantly partial. In 164 cases (85 percent), the flaps remained undamaged. In 15 cases (8 percent), there was partial loss of the transfer and, in a further 13 cases (6 percent), there was complete loss. The authors' results confirmed that the presented clinical classification is, indeed, a measurement of the severity of circulatory impairment. Despite the relatively high complication rate, the use of various methods of treatment finally led, in the overwhelming majority of cases, to a positive result.

[Reconstructive venous valve surgery]

The indication for venous valves surgery has to consider morphological and functional aspects. 36 reconstructive valve repair procedures and the long-term results are reported. The procedures need surgical skill and a meticulous operation technique. Primary idiopathic valvular incompetence can be treated with a direct valvuloplasty (Kistner). The leaflets of the floppy valve become shortened either by an open repair or with a closed procedure. Patients suffering from post-thrombotic syndrome showing intact valves in the deep femoral vein may undergo a transposition operation. In this case the superficial femoral vein is implanted end to side into the deep femoral vein distally to a proximal valve. The best results in post-thrombotic syndrome are achieved with a free transplantation of a venous valve from the axillary vein into the superficial femoral or into the popliteal vein (Taheri). Postoperatively the patients are anticoagulated and have to wear a compressing stocking (Grade III). The results of direct valvuloplasty (Kistner) and valve transplant (Taheri) are satisfactory, whereas the results of transposition seem to be disappointing. Good results are depending mostly on a correct indication for the operation and on avoiding the contraindications.

[Veno-occlusive liver disease after total infradiaphragmatic lymphoid irradiation. A rare complication]

BACKGROUND

Radiotherapy is potentially curative in early stages of follicle center lymphoma. Frequent side effects are pancytopenia, nausea and abdominal discomfort. A radiation-induced liver injury with serious clinical symptoms and changes in liver function is a rare complication.

CASE REPORT

Whole abdomen was irradiated in a 49-year-old patient with a centrocytic-centroblastic lymphoma, stage IA (localization: left inguinal region). A total dose of 30 Gy was delivered in a weekly fractionation of five times 1.5 Gy. Kidneys were protected by shielding after a dose of 13.5 Gy, liver blocks were positioned after 25 Gy. During the last 2 days of therapy the patient presented with weight gain, ascites, dyspnoea and elevated liver enzymes. Diagnostics revealed hepatosplenomegaly, ascites and an increased portosystemic pressure gradient. Liver biopsy specimen showed a veno-occlusive disease. Complete relief of symptomatology was achieved within 7 days following placement of a transjugular intrahepatic portosystemic stent-shunt (TIPSS), heparinization and diuretics. Liver enzymes are in the normal range.

CONCLUSION

Veno-occlusive disease of the liver (VOD) is a very rare side effect of primary abdominal irradiation of follicle center lymphoma. This complication should be taken into consideration if a patient presents with upper right quadrant pain, ascites and elevation of liver enzymes especially within 4 months following radiotherapy. Genesis of veno-occlusive disease, diagnostics, therapy and a review of the literature are presented.

A Colour Doppler Ultrasound Study of Venous Reflux in Patients with Chronic Leg Ulcers

OBJECTIVES

to evaluate the distribution of superficial and deep venous reflux in patients with chronic leg ulcers.

MATERIALS

retrospective study of 186 patients with chronic leg ulcers (212 lower limbs).

RESULTS

in 127 legs without arterial disease and a history of deep venous thrombosis (DVT), 62 (49%) had superficial, 45 (35%) had superficial and deep, and 14 (11%) had isolated deep venous reflux. In legs with a previous DVT, isolated deep venous reflux was more common (21/55, 38%) but superficial reflux, often in combination with deep reflux, still predominated (56%).

CONCLUSIONS

a large part of the venous insufficiency causing venous leg ulcers is superficial and suitable for varicose vein surgery. In patients with chronic leg ulcers most reflux affects the superficial system and is potentially suitable for surgical correction.

Sequelae after limb-sparing surgery with major vascular resection for tumor of the lower extremity

PURPOSE

Limb-sparing procedures have recently replaced amputations as the treatment for tumors invading major vessels of the lower extremity. Major arteries must be reconstructed for limb salvage. The veins are not usually reconstructed. This study was undertaken to investigate the sequelae such as chronic venous disease after venous resection for tumors.

METHODS

Ten patients who underwent limb-sparing surgery for a tumor of the lower extremity or retroperitoneum that required major vascular resection were studied. The median follow-up period was 48 months. After combined resection of a major artery and vein, arterial reconstruction was performed. The veins were not reconstructed. The resected veins included the inferior vena cava (n = 2), the external iliac and common femoral veins (n = 3), the superficial femoral vein (n = 3), and the popliteal vein (n = 2). The main outcome measures were clinical classification of chronic venous disease in 10 patients and air plethysmography in seven patients.

RESULTS

Clinical classification was C(0A) in 6 patients, C(3A) in 1 patient, C(3S) in 2 patients, and C(4S) in 1 patient. Venous claudication with uncontrollable edema was observed in two patients with C(3S) disease. Pain and itching with inflammatory skin changes were observed in one patient with C(4S) disease. These three patients had undergone resection of the femoral vein, including the deep femoral vein along with proximal adductor muscles. Air plethysmography revealed that the ejection fraction was significantly lower and the residual volume fraction was significantly higher in the three patients with symptoms than in symptom-free patients.

CONCLUSIONS

Significant chronic venous disease was observed in the patients who underwent combined resection of the femoral vein, the deep femoral vein, and the adductor muscles for a tumor.

Causes of re-recurrence after polytetrafluoroethylene patch saphenoplasty for recurrent varicose veins

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The 1999 French Venous Disease Survey: epidemiology, management, and patient profiles

A recent (1999) Sofres survey of representative samples of the adult French population aged 15 and over showed that almost half this population suffered from lower limb venous complaints and that 43% of them were untreated. Of those treated, 24.2% received venotropics, including 21.5% by prescription, while 6.0% practiced self-medication. Venous disease sufferers form a relatively underprivileged sector of the population in terms not only of age, income, work and living conditions, but also of general health and medical history. Despite its clinical efficacy and potential social utility, venotropic treatment is possible only if backed by adequate state health insurance coverage supplemented by mutual and private insurance schemes. Any restriction to such coverage will only decrease access to prescription venotropics.

Could gut-liver function derangements cause chronic venous insufficiency?

Upregulation of adhesion molecules and neutrophil infiltration of venous valve cusps may be risk factors for chronic venous insufficiency. But studies that focus on the target organ (vein) fail to consider the influence of systemic inflammation on WBC behavior in the microcirculation. This study probes the gut-liver axis as a potential source of gut-derived oxidative stress and free radical production leading to white blood cell activation in chronic venous insufficiency. Venous hemodynamics (ambulatory venous pressure, air plethysmography, duplex) and gut-derived oxidative stress markers were studied in nine patients with chronic venous insufficiency (group I) and nine age- and sex-matched control subjects with no venous disease (group II). Group I had healed venous ulcers (class 5, CEAP) but near-normal ambulatory venous pressure, to eliminate high ambulatory venous pressure as a chronic venous insufficiency risk factor. Markers of gut-derived oxidative stress included: stool analysis; intestinal permeability; hepatic detoxification challenges with caffeine, salicylate, and acetaminophen; and urine lipid peroxides. Ambulatory venous pressure did not significantly differ (group I, 42.5 +/- 5.3 mm Hg; group II, 35.5 +/- 5.5 mm Hg; p = NS). Candida overgrowth in stool distinguished group I from group II (7/9 pts vs 1/9 pts, respectively; p = 0.015). Increased intestinal permeability (lactulose/mannitol ratio) was prevalent in both groups (group I 0.07 +/- 0.02, group II 0.17 +/- 0.08, p = NS; normal range, 0.01-0.03). Both groups showed similar incidence of elevated urine lipid peroxides (5/9 pts vs 6/9 pts, respectively; p = NS), yet group I exhibited underfunction of both sulfation (group I 16.8 +/- 2.9%, group II 43.3 +/- 11%, p<0.03; normal acetaminophen recovery 16-36%) and glucuronidation (group I 30.4 +/- 4.1%, group II 64.1 +/- 14.4%, p<0.04; normal acetaminophen recovery 27%-56%) relative to oxidative stress, perhaps an indicator of diminished antioxidant capacity in patients with chronic venous insufficiency. Gut dysbiosis (as indicated by stool yeast) and hepatic detoxification challenge pathway exhaustion may lead to subclinical, systemic inflammation and peripheral white blood cell adhesion in chronic venous insufficiency. Further exploration of the relationship between oxidative stress and venous disease is needed.

Causes and effects of the chronic inflammation in venous leg ulcers

The pathogenesis of venous leg ulcers is multifactorial. In this review article new physiological, molecular and cellular abnormalities in venous ulcers related to the chronic inflammation are presented and discussed. Venous hypertension causes disturbed microcirculation and pathological changes of the capillaries, which eventually locks the condition in a self-amplifying, detrimental cascade with persistent elevated levels and activities of pro-inflammatory cytokines and proteases preventing progress into a healing phase. As a consequence fibroblasts senescence and become less responsive to growth factors the older the ulcers become. Current data imply there is no deficiency but rather an unfavorable distribution of growth factors in venous ulcers. An imbalance in proteolytic enzymes and their endogenous inhibitors is a common finding in chronic venous leg ulcers. Variation in disease severity and concomitant ailments in this heterogeneous patient group may explain the contradictory results in the literature. Thus, to advance the areas of research further, longitudinal studies involving larger number of patients are required to identify the major pathogenic factors.

Endovascular venous stenting in May-Thurner syndrome

BACKGROUND

Chronic pulsatile compression of the left common iliac vein between the crossing right common iliac artery and the lowest lumbar vertebral body may induce focal intimal proliferation of the vein (May-Thurner syndrome), resulting in impaired venous return and left iliofemoral thrombosis. Corrective surgical treatment requires extensive dissection. In this report, we describe our experience with endovascular venous stenting in May-Thurner syndrome.

METHODS

Six patients with symptomatic May-Thurner syndrome were treated with percutaneous transluminal angioplasty and implantation of self-expanding stents. RESULTS Postprocedure phlebography revealed patent iliofemoral veins with unimpeded venous outflow and disappearance of collaterals in all patients. No procedure-related complications occurred. At follow-up (median, 12 months), 5 of 6 patients were free of symptoms. In one patient lower extremity edema was aggravated despite a patent stented segment of the left iliac vein. The patient continues to wear support stockings to compensate for continuing venous insufficiency. Color coded duplex scanning revealed patency at regular intervals in 5 patients. In one patient, occlusion of the stented venous segment with return of symptoms was detected at one month. Patency could not be restored despite catheter-directed thrombolytic therapy. After angioplasty, however, adequate collateral circulation was restored and symptoms resolved completely.

CONCLUSIONS

Endovascular venous stenting in May-Thurner syndrome is technically feasible, and leads to reduction of symptoms in the majority of patients with high patency rates in the medium-term. This approach may prove to be a percutaneous alternative to surgical treatment.

Compression of femoral vein by the strap of a urine-collecting device in a spinal cord injury patient

OBJECTIVE

To report an unusual cause of femoral vein compression in a spinal cord injury (SCI) patient.

DESIGN

A case report of a SCI patient in whom the strap of a urinal produced compression of femoral vein. Setting Regional Spinal Injuries Centre, Southport, England.

SUBJECT

A 65-year old male, who had sustained paraplegia at T-10 level 33 years ago, attended the spinal unit for a routine follow-up intravenous urography (IVU). He was wearing a urinal, which was held tightly over the penis by means of two straps coursing over the inguinal regions.

MAIN OUTCOME MEASURES

IVU was performed by injecting 50 ml of Ultravist-300 via a 23-gauge butterfly needle inserted in a vein over the dorsum of the left foot. After completion of the injection, an X-ray of the pelvis was taken to evaluate the right hip. This showed contrast in the vena profunda femoris, circumflex femoral veins and inter-muscular veins with evidence of compression of proximal femoral vein.

RESULTS

It was suspected that the strap holding the urinal was causing compression of the femoral vein. Therefore, a venogram was performed 5 days later, when the patient had discarded the urinal and the straps. This showed free flow of contrast through the left femoral and iliac veins.

CONCLUSION

Compression of femoral vein by a strap holding the urinal was discovered serendipitously in this patient during a routine follow-up. Physicians and health professionals should bear in mind this rare complication when examining spinal cord injury patients who use this type of urine collecting device, and discuss with them alternative methods for urinary drainage.

The venous stasis syndrome after deep venous thrombosis or pulmonary embolism: a population-based study

OBJECTIVES

To estimate the incidence and determine predictors of venous stasis syndrome and venous ulcers after deep venous thrombosis and pulmonary embolism.

PATIENTS AND METHODS

This population-based retrospective cohort study reviewed medical records of 1527 patients with incident deep venous thrombosis or pulmonary embolism between 1966 and 1990. We recorded baseline characteristics, event type (deep venous thrombosis with or without pulmonary embolism or pulmonary embolism alone), leg side and site of deep venous thrombosis (proximal with or without distal deep venous thrombosis vs distal deep venous thrombosis alone), and venous stasis syndrome and venous ulcer.

RESULTS

Two hundred forty-five patients developed venous stasis syndrome. One-year, 5-year, 10-year, and 20-year cumulative incidence rates were 7.3%, 14.3%, 19.7%, and 26.8%, respectively. By 20 years the cumulative incidence of venous ulcers was 3.7%. Patients with deep venous thrombosis with or without pulmonary embolism were 2.4-fold (95% confidence interval, 1.7-fold-3.2-fold) more likely to develop venous stasis syndrome than patients with pulmonary embolism and no diagnosed deep venous thrombosis. In patients aged 40 years or younger with proximal compared with distal-only deep venous thrombosis, venous stasis syndrome was 3.0-fold more likely (95% confidence interval, 1.6-fold-4.7-fold). In patients with unilateral leg deep venous thrombosis, venous stasis syndrome usually developed in the concordant leg (P < .001). There was a 30% (95% confidence interval, 2%-62%) increased risk for venous ulcer per decade of age at the incident venous thromboembolism.

CONCLUSIONS

The cumulative incidence of venous stasis syndrome continues to increase for 20 years after venous thromboembolism. Pulmonary embolism alone is less likely to cause venous stasis syndrome.

Investigation of chronic venous insufficiency: A consensus statement (France, March 5-9, 1997)

This consensus document provides an up-to-date account of the various methods available for the investigation of chronic venous insufficiency of the lower limbs (CVI), with an outline of their history, usefulness, and limitations. CVI is characterized by symptoms or signs produced by venous hypertension as a result of structural or functional abnormalities of veins. The most frequent causes of CVI are primary abnormalities of the venous wall and the valves and secondary changes due to previous venous thrombosis that can lead to reflux, obstruction, or both. Because the history and clinical examination will not always indicate the nature and extent of the underlying abnormality (anatomic extent, pathology, and cause), a number of diagnostic investigations have been developed that can elucidate whether there is calf muscle pump dysfunction and determine the anatomic extent and severity of obstruction or reflux. The difficulty in deciding which investigations to use and how to interpret the results has stimulated the development of this consensus document. The aim of this document was to provide an account of these tests, with an outline of their usefulness and limitations and indications of which patients should be subjected to the tests and when and of what clinical decisions can be made. This document was written primarily for the clinician who would like to learn the latest approaches to the investigation of patients with CVI and the new applications that have emerged from recent research, as well as for the novice who is embarking on venous research. Care has been taken to indicate which methods have entered the clinical arena and which are mainly used for research. The foundation for this consensus document was laid by the faculty at a meeting held under the auspices of the American Venous Forum, the Cardiovascular Disease Educational and Research Trust, the European Society of Vascular Surgery, the International Angiology Scientific Activity Congress Organization, the International Union of Angiology, and the Union Internationale de Phlebologie at the Abbaye des Vaux de Cernay, France, on March 5 to 9, 1997. Subsequent input by co-opted faculty members and revisions in 1998 and 1999 have ensured a document that provides an up-to-date account of the various methods available for the investigation of CVI.

Venous congestion and blood flow in free transverse rectus abdominis myocutaneous and deep inferior epigastric perforator flaps

A series of 240 deep inferior epigastric perforator (DIEP) flaps and 271 free transverse rectus abdominis myocutaneous (TRAM) flaps from two institutions was reviewed to determine the incidence of diffuse venous insufficiency that threatened flap survival and required a microvascular anastomosis to drain the superficial inferior epigastric vein. This problem occurred in five DIEP flaps and did not occur in any of the free TRAM flaps. In each of these cases, the presence of a superficial inferior epigastric vein that was larger than usual was noted. It is therefore suggested that if an unusually large superficial inferior epigastric vein is noted when a DIEP flap is elevated, the vein should be preserved for possible use in flap salvage. Anatomical studies with Microfil injections of the superficial venous system of the DIEP or TRAM flap were also performed in 15 cadaver and 3 abdominoplasty specimens to help determine why venous circulation (and flap survival) in zone IV of the flaps is so variable. Large lateral branches crossing the midline were found in only 18 percent of cases, whereas 45 percent had indirect connections through a deeper network of smaller veins and 36 percent had no demonstrable crossing branches at all. This absence of crossing branches in many patients may explain why survival of the zone IV portion of such flaps is so variable and unpredictable.

Vascular medicine and osteopathic medicine: treating the whole patient

Education and instruction in the care of the patient with peripheral vascular diseases is, at best, fragmented during the first years of medical training. Attention to the issues of peripheral arterial, venous, and lymphatic disorders deserves a more formal approach with respect to physician education, patient evaluation and treatment, knowledge and application of various diagnostic modalities, and involvement of our physician colleagues in complementary disciplines. The vascular medicine internist is an invaluable resource in these areas. The aging of our general population will lead to an increase in manifest peripheral vascular disease within our patient population. Having received additional comprehensive training in the management of the complex patient with peripheral vascular disease, the vascular medicine internist may serve as a complete resource for their care.

Influence of pneumoperitoneum on the deep venous system during laparoscopy

BACKGROUND

There is widespread concern that laparoscopic procedures that are usually performed under general anesthesia, using muscle relaxation, in a reverse Trendelenberg position and with pneumoperitoneum, may lead to venous stasis in lower limbs.

OBJECTIVE

To evaluate perioperative changes in the venous system and determine the frequency of deep venous thrombosis associated with minimally invasive surgery.

DESIGN

Prospective consecutive series.

SUBJECTS

Sixty-five patients undergoing elective minimally invasive surgery.

INTERVENTION

Laparoscopic procedures with no thromboprophylaxis.

RESULTS

Sixty-one patients completed the investigations (coagulation profile and lower limb venous duplex scan) on admission and on the first postoperative day. The median duration of pneumoperitoneum was 45 minutes (range: 18-90 minutes). None of postoperative scans revealed thrombosis. No significant changes in the postoperative coagulation profile were identified. Perioperative scans of the left femoral vein revealed an increase in cross-sectional area (P<0.05) and a decrease in peak blood velocity (P<0.05).

CONCLUSION

In this study of low-risk patients for thromboembolism, laparoscopy with pneumoperitoneum at pressures below 12 mm Hg per se did not increase the prevalence of deep venous thrombosis. This implies that venous hemodynamic changes observed during pneumoperitoneum did not cause deleterious venous stasis. Still, caution needs to exercised with regard to the view that no special precautions to prevent deep venous thrombosis are warranted in patients undergoing laparoscopy.

[Chronic venous insufficiency after open tibial fracture. An underestimated problem]

There is a wide range of alternatives for primary bone reconstruction in the treatment of open lower leg fractures with soft tissue damage of the type Gustillo II and III. The primary objective should always be the protection of soft tissue damage whether one uses the fixateur externe, or an unreamed nail or primary bone shortening with secondary callus distraction. In recent years, this approach has produced better results and a reduction in the rate of major amputations. The overall effects of the initial treatment can only be analysed after a number of years. Research results indicate long-term soft tissue complications of the lower leg, varying from harmless swelling to venous ulcer. We conducted a clinical investigation which compared 80 patients, who were treated between 1985 and 1994 using the venous-occlusion plethysmography, to 50 healthy individuals. Clinically significant damage of the deep venous system was found in over 50% of cases. There was a direct correlation between the number of years since the initial treatment and the degree of damage found. Based on these findings, we recommend that the initial treatment of this condition and the preventative treatment of the secondary trauma diseases should follow regulated surgical guidelines and be recognised for insurance purposes.

Free vascularized osteocutaneous fibular graft to the tibia

We reviewed the clinical results of reconstruction performed for extensive tibial bone and soft tissue defect with a free vascularized osteocutaneous fibular graft in 46 patients (43 male and 3 female). The mean duration of follow-up was 30 months (range 13-76 months). The mean age at the time of reconstruction was 41 years (range 15-66 years). In the 46 consecutive procedures of free vascularized osteocutaneous fibular grafts, bony union was achieved in 43 grafted fibulae at an average of 3.75 months after operation. There were two delayed unions and one non-union. Forty-four cutaneous flaps survived, and two cutaneous flaps failed due to deep infection and venous insufficiency. One necrotized cutaneous flap was replaced with a latissimus dorsi free flap and the other with a soleus muscle rotational flap without replacing the grafted fibulae; unions were obtained without significance complications. All grafted fibulae hypertrophied during the follow-up periods. The most common complication was fracture of the grafted fibulae in 15 patients, and it occurred at an average of 9.7 months after the reconstruction. The fractured fibulae were treated with long leg above-the-knee cast immobilization or internal fixation with conventional cancellous bone graft. Free vascularized osteocutaneous fibular graft is a good treatment modality for the reconstruction of extensive bone and soft tissue defect in the leg. Fracture of the grafted fibula, one of the most common complications after this operation, can easily be treated with cast immobilization or internal fixation with conventional cancellous bone graft.