Current Concepts In Diagnosing Chronic Diabetic Foot Ulcerations

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What About Chronic Venous Stasis Ulcerations?

When patients report their history in a particular way, one can suspect chronic venous stasis ulceration. Often, this description will include discomfort that patients report as a deep aching sensation within their legs.

• “I had to stop wearing my compression stockings because they were making my legs swell.”
• “I just began noticing drainage on my stockings.”
• “I noticed water blisters on my legs but did not know what to do about them. Now I have sores on my legs that just will not heal.”

Fluid retention within the legs, ankles or feet is a hallmark of this condition. The pathomechanics for venous ulcer development includes inflammation that stimulates leukocyte activation, endothelial damage, platelet aggregation and intracellular edema. That sounds an awful lot like the mechanism for blood clot formation. Among the risk factors for venous ulcer development are older age, obesity, previous leg injuries, deep venous thrombosis and phlebitis.

In this instance, the chronic condition is venous stasis, not necessarily the ulceration. Often occurring on the medial ankle and associated with chronic pain, venous stasis ulcerations require therapy to address the wound as well as mechanisms to address fluid retention in the limb to reverse the process successfully. At times, the medical team employs medications to encourage diuresis when appropriate.

The use of compression hose is the mainstay in long-term management of venous stasis ulcers. Often, these modalities range from 20 mmHg compression to 30 mmHg compression. While elevation, the use of compression hose and local wound care can be effective, the risk and rate of recurrent ulceration is a reality. Researchers have demonstrated that surgical correction of superficial venous reflux reduces 12-month ulcer recurrence.46 In that study, the authors concluded that most patients with chronic venous stasis ulcerations will benefit from simple venous surgery. This conclusion was evident in the fact that 12-month ulcer recurrence rates were significantly reduced in the compression hose and surgery group in comparison to compression therapy alone (12 versus 28 percent).

With this in mind, I cannot overstate the importance of getting a vascular surgery consultation in the case of chronic venous stasis complicated by ulceration. Considering the data that 1 to 2 percent of the population will suffer from chronic venous ulceration, delayed healing times and increased incidence of recurrence are predictable.47,48 Recurrence rates are reportedly as high as 26 to 28 percent and one study reported a 68 percent recurrence rate.46,48-51 As many as 10 percent of the U.S. population may suffer from valvular incompetence in the venous system and 0.2 percent of those patients may develop an ulceration.52 It is understood that recurrent ulceration may occur in as many as 70 percent of those at risk.52

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Author(s): 
Molly Judge, DPM, FACFAS

2. Be sure to classify the wound type for documentation purposes as this will directly correlate with the treatment plan you select. In the event that the conservative wound care plan is not successful, then it is important to question the working diagnosis and wound classification. In fact, this may well be the time to consider a second opinion.

3. Determining whether there is an organism interfering with wound healing is important as bacterial colonization and infection commonly interfere with wound healing, and at times can be indolent with subtle outward signs of change. There are numerous methods to reduce bacterial load in a wound bed and when this is a problem, modifying the debridement method and/or the wound care plan are in order.

4. Understand the nature of the most common diabetic dermatopathology as this is often a coexisting and confounding factor when dealing with the chronic ulceration in patients with diabetes.

   Dr. Judge is a Fellow of the American College of Foot and Ankle Surgeons. She is in private practice at North West Ohio Foot and Ankle Institute, serving Ohio and Michigan. Dr. Judge is an adjunct faculty member at Ohio University and the Kent State University College of Podiatric Medicine. She is also on the faculty for graduate medical education at Mercy Health Partners in Toledo, Ohio.

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