Venous Ulcer - Case Discussion for MBBS Surgery

MODEL CASE PRESENTATION

1. DEFINITION

• S Das Manual of Clinical Surgery, 13th Ed. - It is the "abnormal venous hypertension in the lower third of the leg" that forms the basic cause.

2. ETIOLOGY AND PREDISPOSING FACTORS

• Superficial venous incompetence - primary varicose veins (sapheno-femoral or sapheno-popliteal junction incompetence)
• Perforator vein incompetence - especially the Cockett perforators (ankle perforators connecting posterior tibial vein to posterior arch vein)
• Deep venous obstruction/incompetence - post-thrombotic destruction of deep vein valves (most important)

• Female sex (women > men markedly)
• Age 40-60 years
• Obesity
• Multiple pregnancies
• Prolonged standing
• Previous DVT / post-thrombotic syndrome
• Family history of varicose veins

3. PATHOPHYSIOLOGY

1. Normal mechanism: Calf muscle pump + competent valves lower venous pressure during walking
2. Valve failure: Damaged valves (from DVT, primary incompetence) cause reversal of flow through incompetent perforators
3. Venous hypertension in the gaiter region (ankle skin) results
4. Pericapillary fibrin cuffs form (from protein leakage), acting as barriers to O2 and nutrient diffusion
5. Leukocyte trapping - WBCs trapped in capillaries release proteolytic enzymes and reactive oxygen species
6. Fibroblast senescence, growth factor inhibition, mast cell degranulation - all impair healing
7. Haemosiderin deposition from RBC extravasation - key factor in ulcer development
8. Ultimately: skin necrosis and ulceration

4. CLINICAL FEATURES

Site

• Lower third of the medial leg (gaiter area) - between calf muscles and ankle
• Never above the junction of the middle and upper thirds of the leg
• Majority on the medial side at the site of Cockett perforators
• Extension to foot or upper calf is uncommon and should raise suspicion of another diagnosis

Appearance of Ulcer

Surrounding Skin (Signs of Chronic Venous Hypertension)

• Haemosiderosis / hyperpigmentation - from haemosiderin (iron) and melanin deposits
• Lipodermatosclerosis (LDS) - fibrosis, thickening, and induration of subcutaneous tissue; gives "inverted champagne bottle" appearance
• Venous eczema - itchy, scaly skin
• Varicose veins - may or may not be present proximally
• Atrophie blanche - white scarred patches with telangiectasia
• Scars of previous ulcers

Symptoms

• Painless when chronic (key feature!)
• Initially painful when acute; pain settles as it becomes chronic
• Surrounding skin may be tender
• Aching, heaviness, swelling - worse at end of day, better on elevation

Regional lymph nodes

• Inguinal nodes enlarged only if the ulcer is infected

Classic venous leg ulcer in the gaiter area - from Bailey & Love's Short Practice of Surgery, 28th Ed.

5. CEAP CLASSIFICATION

6. DIFFERENTIAL DIAGNOSIS

7. INVESTIGATIONS

Mandatory

1. ABPI (Ankle-Brachial Pressure Index) - Doppler measurement
   • ABPI >0.8: Pure venous ulcer - full compression safe
   • ABPI 0.5-0.8: Mixed arterial-venous ulcer - modified compression (30 mmHg)
   • ABPI <0.5 or ankle pressure <60 mmHg: Revascularization required BEFORE compression
   • 15-30% of venous ulcers have concurrent arterial disease (mixed ulcer)
2. Duplex ultrasonography - Assessment of deep and superficial venous system
   • Identifies reflux sites (saphenofemoral junction, saphenopopliteal junction, perforators)
   • Confirms or excludes DVT
   • Guides surgical planning

Ancillary (For Atypical/Non-Healing Ulcers)

• Full blood count (FBC) - anaemia (sickle cell), polycythaemia
• Blood glucose - diabetes
• ESR / CRP - inflammatory causes
• Sickle cell test (if appropriate ethnicity)
• Antibody screen - rheumatoid factor (rheumatoid ulcer)
• Biopsy - if edge is raised, everted, or ulcer is suspicious for malignancy (Marjolin's ulcer)

8. MANAGEMENT

Keystone Principle

Reduce ambulatory venous hypertension - through compression AND ablation of venous incompetence.

A. CONSERVATIVE (Non-operative)

• Clean the ulcer, remove slough
• Non-adherent primary dressing
• Manage exudate
• Antibiotics only if cellulitis is present (NOT routinely - they do NOT speed healing without infection)

• Elevate the foot of the bed
• Reduces venous hypertension and oedema

• Four-layer compression bandaging:
  • Layer 1: Orthopaedic wool (distributes pressure, absorbs exudate)
  • Layer 2: Cotton crepe (smooths wool)
  • Layer 3: Elastic bandage (1/3 of interface pressure)
  • Layer 4: Cohesive bandage (2/3 of interface pressure - stiffness)
  • Target interface pressure: 35-40 mmHg
• Two-layer compression hosiery - equally effective, used when ABPI is adequate

• Pentoxifylline - increases microvascular perfusion (reduces plasma viscosity + cytokine inhibition); useful adjunct to compression
• Horse chestnut seed extract (Aescin) - safe adjunct for venous hypertension; improves symptoms, reduces leg volume
• Aspirin (antiplatelet) - some evidence as adjunct

B. OPERATIVE / INTERVENTIONAL

1. Superficial Venous Ablation/Surgery

• Endovenous Laser Ablation (EVLA) or Radiofrequency Ablation (RFA) - preferred (minimally invasive)
• High ligation + stripping of incompetent saphenous vein
• The ESCHAR trial showed: compression + surgery reduced ulcer recurrence significantly vs. compression alone (but did NOT accelerate primary healing in isolation)
• Early endovenous ablation nearly halves time to healing and is cost-effective (Bailey & Love, p. 1063)

2. Perforator Surgery

• SEPS (Subfascial Endoscopic Perforator Surgery) - minimally invasive perforator ligation
  • Classical open Linton procedure (1938) abandoned due to high wound complications
  • SEPS technique: Patient supine, leg elevated 45-60°, Esmarch bandage + thigh tourniquet applied, two small proximal medial incisions, laparoscopic trocars, CO2 insufflation of subfascial space, perforators doubly clipped and divided, compression bandage for 5 days post-op
  • Ulcer healing in 88% at 1 year in North American registry (146 patients)
  • Ulcer recurrence: 16% at 1 year, 28% at 2 years
  • SEPS alone: controversial - no advantage over superficial venous surgery + compression alone in primary analysis
  • Often combined with saphenous ablation (72% of cases)

3. Skin Grafting (for Large/Non-Healing Ulcers)

• Pinch grafting - simple, outpatient procedure
• Split skin graft (SSG) / mesh graft - for larger ulcers after preparation of wound bed
• Results: Good early healing, moderate long-term results (50% healed at 5 years)
• Apligraf (bilayered living skin construct) - 63% healed at 6 months vs. 49% with compression alone; median healing 61 vs. 181 days; most benefit for large (>1000 mm²) or longstanding (>6 months) ulcers

4. Deep Venous Reconstruction

• For post-thrombotic disease with deep venous obstruction
• Options: venous bypass, valve reconstruction/transplantation
• Reserved for highly selected patients failing all other treatment

C. PREVENTION OF RECURRENCE

• Treat superficial venous incompetence if not already done
• Class 2 below-knee graduated compression stockings - worn for life
• Indicated for: residual reflux, deep venous occlusion, recurrent ulceration
• Even with successful ablation/stockings: 20-30% reulceration by 5 years
• Highest risk of reulceration: post-thrombotic limb

9. COMPLICATIONS OF VENOUS ULCER

1. Infection / Cellulitis - inguinal lymphadenopathy
2. Marjolin's Ulcer - squamous cell carcinoma arising from the edge of a long-standing venous ulcer
   • Key features: raised, everted edge; hard base; painless; radioresistant (due to fibrosis)
   • Lymphatic metastasis is unusual (lymphatics destroyed by chronic disease)
   • Biopsy is mandatory whenever the edge changes character
3. Contact dermatitis - from topical preparations
4. Osteomyelitis - rare, from deep penetration
5. Psychological morbidity and impaired quality of life

10. PROGNOSIS

• Nearly all venous ulcers can be healed with proper compression and venous treatment
• 20-30% recurrence rate by 5 years even in compliant patients
• Worst prognosis: post-thrombotic limbs
• Venous disease accounts for ~85% of all chronic lower limb ulcers in developed countries
• Community prevalence: 0.1-0.3% (2-4% in elderly)
• Dressings alone account for 1-3% of western healthcare expenditure

QUICK EXAM REVISION SUMMARY

• S Das - A Manual on Clinical Surgery, 13th Ed.
• Bailey and Love's Short Practice of Surgery, 28th Ed.
• Schwartz's Principles of Surgery, 11th Ed.
• Mulholland and Greenfield's Surgery, 7th Ed.