Keys To Treating Venous Leg Ulcerations

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Author(s): 
Kathya Zinszer, DPM, and Sabina Malhotra, DPM

Venous leg ulcers are a severe outcome of chronic venous insufficiency, making it crucial to have an appropriate treatment plan. These authors highlight their three-pronged approach to treating venous leg ulcerations, emphasizing assessment of the ulcer, compression techniques and educating patients.

Though the prevalence of venous leg ulcerations is still considered low, it is the refractory nature of this specific type of leg ulcer along with the inconsistency in treatment options that lead to the increased risk in the development and recurrence of venous leg ulcerations. Also referred to as stasis ulcers, venous leg ulcerations are the most severe and debilitating outcome of chronic venous insufficiency in the lower limb and account for 80 percent of lower limb ulcerations.1 We presume that the refractory nature of venous leg ulcers in particular could be closely related to the variable ways in which practitioners from diverse specialties, including podiatry, approach the assessment and therefore treatment of the venous leg ulcer.

   We will highlight our no-nonsense threefold approach to venous leg ulcerations: assess/address, compress, and educate. As podiatric physicians and lower extremity specialists, we play an integral role in the appropriate early assessment of venous leg ulcers, how best to treat ulcers at numerous stages of their development as well as the utilization of different methods of compression for short and long-term treatment. We hope to hone in on the practical aspects of addressing these ulcers within the scope of our specialty as well as the appropriate use of multidisciplinary consultation for best patient outcomes.

Assessing The Clinical Presentation And Using Ancillary Tests

A variety of underlying conditions play a role in the development of venous leg ulcerations but the most commonly accepted cause is the elevation of ambulatory venous pressure, also known as venous hypertension.1 In venous insufficiency, venous leg ulcerations typically present around the ankle. Even today, many practitioners may incorrectly diagnose an ulcer as “venous.” As treatment of the ulcer may vary depending on ulcer etiology, it is paramount to have an adequate understanding of the pathophysiology of venous leg ulcerations, and make a correct diagnosis before initiating treatment.

   Venous ulcers can exist in the presence of mixed arterial and venous pathology. It is important to differentiate between venous versus arterial origin as treatment of only the elevated venous pressure may not succeed if severe arterial disease is present.2 Regardless, moderate amounts of applied compression may be successful in healing venous leg ulcerations in patients with mild to moderate arterial insufficiency.3

   On physical exam, one should rule out gross arterial disease by establishing that pedal pulses are present. However, note that oftentimes pedal pulses may be difficult to assess secondary to significant lymphedema. The ankle brachial index (ABI) should optimally be greater than 0.8. This is particularly important as compression therapy is generally contraindicated with an ABI of less than 0.7, which suggests a degree of vascular disease.4 In patients with diabetes or with an ABI greater than 1.0, a toe brachial index (TBI) of > 0.6 or a transcutaneous partial pressure of oxygen (TcPO2) of > 40 mmHg in the area of the ulcer may suggest adequate microvascular flow.

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