Management of leg ulcers

Management of leg ulcers requires attention to a checklist of causes of delay in healing, the commonest cause of which is venous disease. Arterial disease must be excluded before fully effective management of venous disease is possible. Lymphatic failure is also worthy of attention. 'Keep moving' is an important management theme for the whole team, including the patient.

Common causes of leg ulceration

Good treatment of any leg ulcer depends upon an accurate diagnosis of the underlying cause. Most leg ulcers occur secondary to venous or arterial disease but other rarer causes sometimes need to be considered. The treatment of the underlying condition is far more important than the choice of dressing.

Calciphylaxis: a favorable outcome with hyperbaric oxygen

A 66-year-old female with diabetes mellitus and end-stage renal disease presented with painful bilateral lower extremity livedo reticularis and necrotic ulcerations. Her distal lower extremity pulses were intact and plethysmographic studies confirmed relatively normal large vessel arterial perfusion. Extensive laboratory analysis was remarkable for an elevated calcium x phosphorous product and parathyroid hormone level. An ulcer biopsy revealed small vessel medial calcinosis, and calciphylaxis was subsequently diagnosed. Despite aggressive wound debridements, antibiotics and subtotal parathyroidectomy, her ulcers failed to improve significantly prompting a trial of hyperbaric oxygen therapy. After 7 weeks of hyperbaric treatments, her ulcers had essentially healed.

[Magnetic therapy in treatment of patients with leg ulcers]

Various magnetic (continuous current, alternating current and "running" impulse) fields were applied in 74 patients with trophic ulcers of lower limbs. 10-12 days after the beginning of the magnetic therapy wound surface has completely cleaned from necrotic tissues, surrounding inflammatory changes eliminated, epithelization of the wounds began. The most pronounced clinical effect was observed after the use of "running" impulse of magnetic field.

Treatment of leg edema and wounds in a patient with severe musculoskeletal injuries

This case report describes the application of a technique for the treatment of leg edema and wounds resulting from a severe distal tibiofibular fracture. Following injury and numerous fracture- and wound-related surgeries in the first year postinjury, this patient developed leg edema, required daily treatment of 2 leg wounds, and was unable to wear a shoe due to foot swelling. He was referred to the physical therapy clinic 1 year postinjury for ankle rehabilitation and to diminish the leg edema. Therapy consisting of manual lymph drainage, compressive bandaging, exercise, and skin care was provided for 7 weeks. A compression stocking was issued near the end of treatment, which the patient continued to wear daily thereafter. At the time of discharge from therapy, the leg edema had decreased 74% and the wound area of both wounds had decreased 89%. Improvements continued following discharge. By 10 weeks after the start of treatment, edema had decreased 80.9%, one wound had healed, and the second wound was 93% improved. The patient was able to wear a shoe and resume recreational activities. This case report provides insight into a treatment that may shorten rehabilitation and control the cost of caring for injuries complicated by prolonged edema.

[Medico-economic study of the management of leg ulcers of venous origin. Initial results]

PURPOSE

There is little data on the different techniques used in France to treat venous leg ulcers. Due to the lack of a well-accepted standard, it is most likely that therapeutic attitudes vary greatly. An assessment of the respective cost/benefit ratios would be most useful, but requires prior knowledge of the techniques used. We therefore conducted a survey of the main management schemes applied in France.

PATIENTS AND METHODS

A cross-sectional survey involved 800 investigators (85% general practitioners. 15% specialists: angiologists and dermatologists) throughout France. Each investigator was invited to include 2 patients with venous ulcerations of the leg. One patient was to have a long-standing ulceration (at least 6 weeks duration) and the other a new ulceration (less than 2 weeks duration). Patients were followed to cure or to study end-point six months after diagnosis. The clinical observations at inclusion are presented here for 247 patients with venous ulcerations.

RESULTS

The patient population showed a clear predominance and advanced age (mean 72 years). In half of the cases, the diagnosis was made at a home visit and in 20% of the cases at an office visit for a reason other than leg ulceration. History taking revealed a high frequency of varicose veins, osteoarthritis of the lower limbs and high blood pressure as well as a high rate of recurrence (60% for long-standing ulcerations). Treatments prescribed at the first visit were divided into 10 groups. The most frequently used methods were: cleansing, contention and general therapy (antibiotics, anticoagulants, antiaggregates, analgesics). General practitioners focused primary treatment on general therapies and local care while specialists used contention more often (more than 90%) and different skin treatments. These different treatment combinations were then grouped into 7 main types of therapeutic attitudes, differentiating between general practitioners and specialists. There were however three common elements found in the treatments applied by more than 50% of the physicians: cleansing (99%), combined with contention (64%) or a general therapy (56%).

CONCLUSION

The main observation was that contention is used at a relatively high percentage (77%). This survey must be continued with a larger number of inclusion visits and an analysis of follow-up visits in order to identify possible changes in therapeutic attitudes and the associated costs as a function of treatment duration and rate of cure within the 6 month period.

Leg ulceration in the sickle cell patient

BACKGROUND

The purpose of this study was to determine cost of care for leg ulcers in sickle cell patients and suggest an improved modality in ulcer care.

STUDY DESIGN

We performed a retrospective study of a group of sickle cell disease patients with leg ulcers.

RESULTS

Eighteen patients with a leg ulcer (duration: mean, 53.7 months), sickle cell disease, and a mean of 20.7 years of age had various modalities of treatment with the only consistency in healing being a commercial moist-wound dressing.

CONCLUSIONS

There is no consistency in the treatment of the sickle cell patient with a leg ulcer. Treatment with a moist dressing had the best results.

A leg ulcer clinic: audit of the first three years

This study documents the establishment in 1994 of a leg ulcer clinic in Hobart, Tasmania. Information relating to patient demographics, results of treatment and costs required to successfully operate the clinic were studied prospectively. Over a 40-month period, 345 patients attended the clinic on 1154 occasions. Ulcers were classified as venous (59%), arterial (19%), mixed venous and arterial disease (13%), pressure injury (3%), traumatic injury (2%) or rheumatoid disease (1%). A wide range of dressings and bandages were used during treatment. The clinic cost an average of A$42,683 per annum to run. This information has the potential to be of use as a guide for any organisation planning to open a similar clinic.

[Treatment of post-phlebitic syndrome]

The Authors report their experience in the treatment of the post phlebitic syndrome at ulceration stage. The therapy is based on three important points: a first medical treatment and later saphenous striping with a specific tying of the insufficient perforant veins to consolidate the results of scarification in the future; finally ther removal of plugs of fascia for the therapy of hypodermitis with a personal technique.

The noninvasive vascular laboratory

The noninvasive vascular laboratory is an important resource in the management of patients with peripheral vascular disease. The commonly accepted uses of the vascular laboratory, including both indirect testing (segmental limb pressures, waveform analysis, digital pressures, exercise testing, reactive hyperemia) and direct vascular testing with CDI, have been reviewed. These techniques have changed how these patients are diagnosed, with less need for invasive diagnostic techniques. Patient management and intervention have also been altered by these advances. The use of noninvasive techniques and continue progress in this area should continue to advance patient care.

A novel treatment for venous leg ulcers

Venous ulceration, a relatively common manifestation of venous hypertension, is often difficult to treat. This article reports the authors' experience with a new wound-healing technology using a bilayered, culture-derived human skin equivalent (HSE, Apligraf) for treatment of venous ulcers. In the patients studied, HSE appeared to promote wound healing in three ways: 1) apparent graft "take"; 2) temporary wound closure (persistence of HSE with subsequent wound re-epithelialization from wound margins); and 3) stimulation of host healing without temporary persistence by acting as a biologic dressing. The demonstrated efficacy of HSE suggests that it will prove useful for promoting the healing of venous ulcers.

The chronic non-healing wound: how to make it better

Chronic wounds are a commonly encountered problem. An understanding of their aetiology, combined with a systematic approach to their management, is fundamental to achieving an optimal environment for healing to take place.

[Combined therapy of trophic ulcers with protracted healing]

The results of treatment of 126 patients with trophic ulcers of the low extremities were analyzed. Trophic ulcers in 74 patients (58.7%) appeared due to postthrombophlebitic disease, in 25 patients (19.8%) due to primary varicose veins of lower limbs, in 15 (11.9%) patients due to obliterative diseases of peripheral vessels and in 12 (9.5%)--other diseases. The duration of the illness made up from 1 to 50 years. In 26 patients (group 1) low-intensity laser irradiation (LLI) was used together with combined conservative therapy; in 32 patients (group 2) hyperbaric oxygenation (HBO), in 21 (3 group)--combined application of LLI and HBO was used. The examination of regional macrohemodynamics and microcirculation in 39 patients showed decrease of rheographic index (RI) in the shin, increase of the arterioles tone and venous outflow disturbance. The use of LLI and HBO resulted in undoubtful increase of RI and improvement of microcirculatory indexes. As a result of combined application of LLI and HBO microflora of the ulcers lowered from 10 and 10 per 1 gr in patients of group 1 and 2, respectively, in patients of group 3 there was no growth of pathogenic microflora. The investigation of humoral and cellular immunity after the application of LLI and HBO demonstrated strong immunocorrective action.

[Management of infected wounds and trophic ulcers by low frequency ultrasound]

The article is devoted to the investigation of the use of low frequency ultrasound surgical instrument in treatment of trophic ulcers and infected wounds in surgical patients. The method of treatment of these wounds and ulcers by cavitation influence through an intermediate medium was established, an ultrasound surgical apparatus "SUSA-2lf.02", being used, which has been developed and manufactured by AOZT "Medilen"--(St Petersburg). On the base of the experience in treatment of 76 patients intensification of diffusion of the medical preparations into the tissues was shown, among them--into the deep layers of the wound channel. The application of ultrasound provides favourable metabolic changes (normalization of pH of the medium), ensures deep diffusion of medicamentous preparations into the tissues surrounding the ulcers, and enhances therapeutic activity of the preparation.

Rheumatoid vasculitis in a patient with seronegative rheumatoid arthritis

We report on a 47-year-old woman with a 10-year history of seronegative rheumatoid arthritis (RA) who had experienced an episode of bilateral aseptic pleuritis, and in whom livedo reticularis and ulcers had developed on both lower extremities. Histological examination revealed rheumatoid vasculitis. In rheumatoid vasculitis, high titers of rheumatoid factors are commonly observed. In our case, however, there have been no characteristic laboratory findings throughout the course of the disease so far, despite the active RA. This report describes a rare case of seronegative RA with systemic rheumatoid vasculitis.