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Year : 2015 | Volume : 3 | Issue : 2 | Page : 130 - 133  


Original Articles
Analytical study of leg ulcers and surgical management

Lakshmi Narayana1, Shiv Rama Krishna Rao M2

1Professor of Surgery, Malla Reddy Medical College for Women, Hyderabad

2Associate Professor of Surgery, Malla Reddy Medical College for Women, Hyderabad

Corresponding Author:

Dr. G. Lakshmi Narayana

Email: gorityalaln@yahoo.com

Abstract:

Due to recent advances in diagnostic studies such as Doppler, Plethysmography there has been considerable gain in the knowledge about anatomy, pathophysiology of chronic leg ulcers. Even though there are various techniques and procedures in the management of chronic leg ulcers since the recent past, but the management of leg ulcers still remains a study. The objective was to study leg ulcers and their surgical management. All Patients visiting the surgical outpatient department with lower limb ulcers were included in this study. These cases were examined in detail and investigated thoroughly. This study included patients with venous ulcers, arterial ulcers, diabetic ulcers, non-healing ulcers and other rare types. In our study of 81 patients with leg ulcers, diabetic ulcers were the most common accounting for 38.27% of the cases, whereas venous ulcers accounted for 24.69% and arterial accounted for 13.58% cases. In our study amputations were mostly done in diabetic patients accounting for 57.89% cases. The risk of lower extremity amputation is 15 to 46 times higher in diabetics than in persons who do not have diabetes mellitus. Early detection and appropriate treatment of these ulcers may prevent up to 85 percent of amputations.

Key words: Doppler, chronic leg ulcers, venous ulcers

INTRODUCTION:

 

Ulceration of the lower leg and foot may be associated with a number of medical, surgical and dermatological conditions. Etiology of Leg Ulcers being venous disease which leads to local venous Hypertension (e. g. varicose veins), Arterial disease either large vessel (atherosclerosis), or small vessel (diabetes), Arteries associated with Autoimmune disease (Rheumatoid arthritis, lupus, etc.,), Trauma (could be self-inflicted), Chronic infection (Tuberculosis/Syphilis), Neoplastic (squamous/ basal cell carcinoma/ sarcoma). 1 They are distinct with regards to their location, appearance, bleeding, associated pain and findings. Ulcer healing is delayed by a variety of mechanisms like site, structures involved, mechanism of wounding, contamination, loss of tissue, local factors like infections, mechanical irritation, associated diseases and ischemia, systemic factors like malnutrition, diseases like diabetes, medications like steroids, immunodeficiency like HIV, and smoking. 2

Management of patients with leg ulcers has improved due to research based approaches, compression therapy for venous, 3 revascularization for arterial and a multidisciplinary approach for diabetic and decubitus ulcers being the important aspect. With more elderly in population this problem is likely to increase unless effective measures are taken to treat the various diseases that cause the leg ulceration. Due to recent advances in diagnostic studies such as Doppler, Plethysmography there has been considerable gain in the knowledge about anatomy, pathophysiology of chronic leg ulcers. Even though there are various techniques and procedures in the management of chronic leg ulcers since the recent past, but the management of leg ulcers still remains a study.

 

MATERIAL AND METHODS

 

This descriptive study was conducted in our CAIMS hospital, Karimnagar over a period from August 2011 to September 2013. All Patients visiting the surgical outpatient department with lower limb ulcers were included in this study. These cases were examined in detail and investigated thoroughly. This study included patients with venous ulcers, arterial ulcers, diabetic ulcers, non-healing ulcers and other rare types.

Inclusion Criteria:

All patients of lower limb ulcers attending OPD and admitted atIPD.

ExclusionCriteria:

  1. Neurogenic ulcers. 2. Traumatic ulcers.

A thorough systemic and local examination was carried out. The morphological features of ulcers i.e., number, distribution of ulcer on leg or foot, edges, floor, induration, discharge and associated diseases like varicose veins, eczema or patches were noted.

Basic as well as specific investigations like pus cultures, wedge biopsy, lipid profile, X-rays and Doppler examination were done according to the cases and clinical findings. The lower limb ulcers were managed with various treatment modalities like debridement, skin grafting, ligation and stripping, amputation, lumbar sympathectomy and sub-fascial ligation according to the underlying etiological factors responsible for the causation of the ulcer.

 

RESULTS & DISCUSSION

 

Table 1 – Distribution of Diabetic ulcer in Lower Limb

 

Limb

Number

%

Right

19

61.29

Left

10

32.26

Bilateral

02

6.45

Total

31

100

 

In this study out of the total 31 cases of diabetic ulcers 19(61.29%) cases had ulcer in the right lower limb, 10(32.26%) cases had ulcer in the left lower limb and the remaining 2(6.45%) cases had bilateral leg ulcers.

 

Table 2 – Distribution of Various types of Leg Ulcers

 

Etiological type

Number

%

Diabetic

31

38.27

Venous

20

24.69

Non healing

17

20.99

Arterial

11

13.58

Malignant

01

1.23

Others

01

1.23

Total

81

100

 

Among the 81 study subjects the commonest was found to be diabetic ulcer accounting for 31 cases(38.27%) followed by venous ulcers accounting for 20 cases(24.69%), followed by non-healing ulcers accounting for 17 cases(20.99%). Arterial ulcers were seen in 11 cases (13.58%) followed by malignant and rest of the ulcer accounting for 1 case each (1.23%).

 

Table 3 – Sex distribution of diabetic ulcers and venous ulcers

 

Sex

Number of diabetic ulcer (%)

Number of venous ulcer (%)

Male

26 (83.87)

19 (95)

Female

05 (16.13)

01 (05)

Total

31 (100)

20 (100)

 

In this study out of the total 31 cases of diabetic leg ulcers 26(83.87%) cases were male and remaining 5 (16.13%) cases were females. Of the total 20 venous ulcer cases, males were affected in 19(95%) cases and female was affected in 1(5%) case.

Table 4 – Age distribution of diabetic, venous and arterial ulcers

 

Age (years)

Diabetic ulcer

Number (%)

Venous ulcer

Number (%)

Arterial ulcer

Number (%)

31-40

01 (3.23)

01 (05)

03 (27.27)

41-50

11 (35.48)

09 (45)

05 (45)

51-60

08 (25.81)

06 (30)

03 (27.27)

61-70

09 (29.03)

01 (05)

00

71-80

01 (3.23)

03 (15)

00

> 80

01 (3.23)

00

00

Total

31 (100)

20 (100)

11 (100)

Out of the total 31 diabetic ulcers cases, 11(35.48%) cases were from 41-50 years age group, 9(29.03%) cases were from 61-70 years age group. Out of the 20 venous ulcer cases, 9(45%) cases were from 31-40 years age group, 6(30%) cases were from 41-50 years age group. Out of the total 11 arterial ulcer cases in the lower limbs, 5(45.45%) cases were from 41-50 years age group and 3(27.27%) cases were from 31-40 and above 50 years age group.

 

Table 5 – System affected in venous ulcers

 

System affected

Number

Percentage

Long saphenous system

10

50

Short saphenous system

03

15

Both

05

25

Deep veins

02

10

Total

20

100

 

In this study out of the total 20 venous ulcers, long saphenous system was affected in 10(50%) cases, short saphenous system was affected in 3(15%) cases, and both systems were affected in 5(25%) cases whereas deep venous system was affected in 2(10%) cases.

 

Table 6: Venous ulcer distribution n lower limb

 

Limb affected

Number

Percentage

Left

13

65

Right

05

25

Both

02

10

Total

20

100

 

In this study out of the 20 venous ulcers cases, left limb affected in 13(65%) cases, right limb affected in 5(25%) cases, and both limbs were affected in 2(10%) cases.

 

Table 7 – Arterial ulcers distribution according to pathology

 

Pathology

Number

Percentage

TAO

09

81.82

Atherosclerosis

02

18.18

Total

11

100

 

In this study out of the 11 cases of arterial ulcers in the lower limbs, 9 cases (81.82%) were of TAO (Thrombo Angitis Obliterans) and 2 cases (18.18%) were of atherosclerosis.

 

Table 8 – Various Treatment Modalities used

 

Treatment modality

Number

Percentage

Debridement

26

32.09

Skin grafting

20

24.69

Ligation and stripping

17

20.98

Toe amputation

05

6.17

Below knee amputation

09

11.11

Lumbar sympathectomy

03

3.70

Sub fascial ligation

01

1.23

Total

81

100

 

In our study most of the patients were treated with debridement 26(32.09%) cases, and skin grafting 20(24.69%) cases. This is followed by ligation and stripping 17(20.98%) cases, Toe amputation 5(6.17%) Below Knee amputation 9(11.11%) cases, cases, lumbar sympathectomy 3(3.70%) cases, and sub fascial ligation 1(1.23%) case.

 

DISCUSSION:

In our study of 81 patients with leg ulcers, diabetic ulcers were the most common accounting for 38.27% of the cases, whereas venous ulcers accounted for 24.69% and arterial accounted for 13.58% cases.

Diabetic ulcers are mostly caused due to the atherosclerotic lesions in large leg arteries or neuropathy resulting in decreased sensation. Peripheral arterial occlusive disease is four times more prevalent in diabetics than in non-diabetics. Neuropathy, a major etiologic component of most diabetic ulcerations is present in more than 82% of diabetic patients with foot wounds. If the diabetic ulcers in this study were considered vascular rather than metabolic then the percentage of vascular ulcers in our study is about 76.54% which is somewhat comparable to the above studies. In our study the diabetic ulcers were most commonly seen to be present in the right limb accounting for 61.29% as compared to the left limb, 32.26% cases. In a study by Ryath S. et. al. diabetic ulcers were mostly seen in the right foot

(80%) as compared to the left foot (20%) which are closer to our study results. 4

In our study the venous ulcers were found to be more common in 31-50 years of age group, accounting for 75% cases. According to a study by David J. et. al venous ulcer is a significant problem in those aged 65 years and older. 5 This can be explained as most of the patients in our study group belonged to the farmers, businessmen, daily wage workers that involved long hours of standing, and the ulcers they suffered from hampered their working capacity making them seek early medical advice. Males were affected more, 95% as compared to female population, accounting for 5%. Chronic venous insufficiency and mild varicose veins are more common in men than women, this probably explains the huge number of males affected with varicose ulcers as compared to females because of their house hold activities preventing them to exposure to heavy strain.

In our study the arterial ulcers were found to be more common in 31-50 years of age group, accounting for 72.72%. According to a study by Hannson Carita, the prevalence of peripheral vascular disease increases with age and it is 7 times more common in a 60 year old as compared to a 20 year old individual, This can be explained as most of the patients in our study group had TAO, which is common in young adults as compared to the elderly.

In our study most of the venous ulcers were located in the gaiter zone, 90% whereas diabetic, arterial and nonhealing were located in the foot. According to a study by Hansson Carita 6 ulcers at the ankles in the gaiter zone and venous ulcers are mostly caused by venous insufficiency.

In our study chronic non healing ulcer accounted for 20.99% cases. Malignant ulcer due to squamous cell carcinoma and ulcer associated with pyoderma gangrenosum accounted for 1.23% of the cases each.

According to Yound J. R. and Boyd A. M.et.al. 7 the distribution of different type of ulcer in different studies varies - 70% to 90% for venous ulcer, 5% to 15% for arterial ulcers and 1 % to 5% for other ulcers.

In our study amputations were mostly done in diabetic patients accounting for 57.89% cases. The risk of lower extremity amputation is 15 to 46 times higher in diabetics than in persons who do not have diabetes mellitus. Early detection and appropriate treatment of these ulcers may prevent up to 85 percent of amputations. The need for Lower Extremity Amputation (LEA) may vary geographically in Diabetic and Non Diabetic Patients. 8

 

REFERENCES:

 

  1. Norman S. Williams, Christopher J.K. Bulstrode, Wounds, Tissue Repair and Scars, Aetiology of Leg Ulcers, Bailey and Love’s Short Practice of Surgery, 25th Edition, page: 28
  2. Norman S. Williams, Christopher J. K. Bulstrode, Bailey and Love’s Short Practice of Surgery, 25th Edition, Wounds, Tissue Repair and Scars, Factors influencing healing of a wound, page: 24
  3. Simon DA, Dix FP, McCollum ChN, Management of Venous Leg Ulcers, BMJ, 3rd June, 2004, 328:1358-62.
  4. Ryath S.AL-Hemedawi,Suhaila M AL-Salloum,Saad S.AL-Azawi, A Study of Diabetic Foot Ulcers in Relation to Depth , Location of the Ulcer and Patients, Age and Sex. The Iraqi Postgraduate Medical Journal Vol.5,No.4,2006
  5. David J. Margolisa, Warren Bilkerb, Jill Santannab, Mona Baumpartenc, Venous Ulcers: Incidence and Prevalence in the elderly, Journal of the American Academy of Dermatology, Vol.46, Issue 3, March-2003, pages: 381-386.
  6. Hansson Carita, Studies on Leg and Foot Ulcers, Stockholm, ActaDermVenereol, 1988:45.
  7. Boyd AM et al., The Logical Management of Chronic Ulcers of the Leg. Angiology, 1952: 3: 207-215.
  8. Wrobel JS, Mayfield JA, Reiber GE., Geographic variation of lower-extremity major amputation in individuals with and without diabetes in the Medicare population Diabetes Care. 2001 May;24(5):860-4.




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