S. Hoskin

Aetiology of Chronic Leg Ulcers

This study was undertaken to determine the relative prevalence of the factors causing chronic ulceration of the leg in the general population. Two hundred and fifty-nine patients with chronic ulceration of the leg were found on screening a Western Australian population of 238,000. (The prevalence of chronic ulceration of the leg was 1.1 per 1000 population.) Two hundred and forty-two of these patients (93%) with 286 chronically ulcerated limbs were fully assessed to determine the factors contributing to ulceration. In 239 limbs (84%) ulceration involved the leg; in these limbs venous disease was the most prevalent cause of ulceration (160 limbs). Arterial disease was found in 66 limbs, with both venous and arterial disease present in 35 limbs. Rheumatoid arthritis was a causative factor in 27 limbs and diabetes was found with 29 limbs with ulceration involving the leg. In 47 limbs (16%) ulceration was confined to the foot; arterial disease (35 limbs) and diabetes (23 limbs) were the most prevalent causes of ulceration in these limbs. Venous disease was infrequent (three limbs). No disorder of the circulation was found in 48 limbs (20%) with ulceration involving the leg, and in 58 (20%) of all ulcerated limbs. More than one aetiological factor was present in 93 limbs (33%). A cause for ulceration was not found in 10 limbs (3.5%).

The influence of dressings on venous ulcer healing — A randomised trial

OBJECTIVE To assess the effect of different dressings on venous ulcer healing. DESIGN A randomised clinical trial. MATERIALS Patients were randomised to treatment with one of three dressings: a zinc oxide impregnated bandage, a zinc oxide impregnated stockingette, or an alginate dressing. All patients were treated as outpatients and had compression bandaging with two minimal stretch bandages (Elastocrepe) and a stockingette (Tubigrip) to keep the bandages in place. METHODS One hundred and thirteen patients (133 ulcerated limbs) with chronic ulceration of the leg due to venous disease alone, and attending Fremantle Hospital Leg Ulcer Clinic, Western Australia were entered into the study. Healing was measured as complete healing of the ulcerated limb or failure of the limb to heal within 9 months. RESULTS There was no significant difference between the three groups in ulcer size, duration, and other parameters compared. Healing was affected significantly by ulcer size and which leg was ulcerated. There was significantly faster healing with the paste bandage. CONCLUSION The use of a paste bandage significantly improved the healing of chronic venous ulcers when used in combination with compression bandaging, and compared to an alginate dressing and a zinc oxide impregnated stockingette.

OUTPATIENT TREATMENT OF CHRONIC VENOUS ULCERS IN A SPECIALIZED CLINIC

Chronic leg ulcers have many different causes and therefore need an accurate diagnosis in order to give the most effective treatment. A specialized clinic was set up in Fremantle Hospital in July 1988 with the aims of performing a thorough clinical and laboratory assessment to establish the cause of ulceration in every patient, and treating patients according to the cause of ulceration. Patients with arterial, neoplastic or dermatological conditions were treated as appropriate for their diagnosis and patients with other chronic ulcers were managed as outpatients where possible.

Influence of arterial disease, age and active ulceration on venous refilling time measured by photoplethysmography

This study investigated the influence of arterial disease, patient age and the presence of a venous ulcer on venous refilling time as measured by photoplethysmography. Refilling time was evaluated in 157 control limbs, in 133 limbs with venous disease, in 17 limbs with arterial disease and in 20 limbs with mixed disease (arterial and venous disease) as the cause of ulceration. Refilling time reduced progressively with age in control subjects and was significantly shorter over the age of 50 years. Limbs with venous disease alone had a significantly shorter refilling time when compared with controls (Mann-Whitney U test, P < 0.01); however, there was no alteration in refilling time with age. Limbs with arterial disease, without clinical evidence of venous insufficiency, had a shorter refilling time when compared with controls but a longer refilling time compared with those with venous disease (P < 0.01). The refilling time in patients with mixed ulcers did not differ from those with venous ulcers (P < 0.265). Refilling time measured when an ulcer was present was not significantly different to that measured after the ulcer had healed (P = 0.59). Venous refilling time normally reduces with age but is not affected by arterial disease or the presence of an ulcer.

THE EFFECT OF PROBE POSITION, CALF MUSCLE FUNCTION AND LIPODERMATOSCLEROSIS ON PHOTOPLETHYSMOGRAPHIC VENOUS REFILLING TIME

Objective: To assess the influence of probe position, lipodermatosclerosis and method of calf muscle emptying on the venous refilling time as measured by photoplethysmography in both normal limbs and limbs with chronic venous disease. Design: Prospective evaluation of age- and sex-matched control and study groups. Setting: University Department of Surgery, Vascular Research Laboratory, Fremantle Hospital, Western Australia. Patients: There were 38 controls and 31 patients with venous ulceration. Interventions: Venous refilling times were measured in six positions on the leg in all subjects: the foot, 5 cm below medial tibial condyle in the upper calf, and in the gaiter region on the medial, lateral, anterior and posterior positions at 7.5 cm above the medial malleolus. Measurements were undertaken on active exercise and after bimanual calf compression in the medial gaiter region. Measurements were also undertaken in areas of lipodermatosclerotic skin and in normal-appearing adjacent skin. Results: In normal legs, the lowest refilling times were in the anterior and lateral gaiter positions. Venous patients had a shorter refilling time in the dorsal foot, medial gaiter, posterior gaiter and medial below-knee positions, when compared with controls (Mann–Whitney U-test, p<0.01). The shortest refilling time in patients with venous disease was in the medial gaiter region. Refilling time was slightly prolonged over Hpodermatosclerotic skin compared with adjacent normal-looking skin. Refilling time measured after passive emptying of the calf muscle by external compression was significantly prolonged compared with calf emptying by active calf compression (p<0.01). This change was similar for both groups. Conclusions: When using venous refilling time on photoplethysmography to distinguish venous from normal limbs, the best separation is in the medial gaiter position. If other probe sites or methods of calf emptying are to be employed, it is imperative that individual laboratory normal ranges be established for the particular method being employed.