Recurrent Leg Ulcers Research Articles

Correlation between Leg Ulceration and Perforator Venous Insufficiency (PVI) in Patients (Pts) with Sickle Cell Disease (SSD).

Chronic or recurrent leg ulceration occurs in 25% of adult SSD pts, but as many as 75% never develop leg ulcers. PVI correlates with leg ulceration in non-SSD pts. We studied 46 SSD pts: 40 with hemoglobin (Hb) SS, 3 with sickle-b thalassemia, 2 with Hb SC and 1 with Hb SD. Chronic and/or recurrent leg ulceration was present on at least 1 leg of 25/46 (ulcer+) and absent in 21/46 (ulcer-) SSD pts. Their ages ranged from 19–67 years, with a median of 31. Using color-flow venous duplex (7–5 mega-Herz probe; Advanced Technology Laboratory 5000), the status of perforator veins in both legs of each pt was determined (only one of a single pt's two ulcerated legs was studied). Perforator veins were considered incompetent (PVI) if their diameter was >3 mm, and their reflux times were >0.35 seconds. For the 36/91 ulcer+ and 55/91 ulcer- legs, there was a significant association between PVI and ulceration in the same leg (generalized mixed linear model, p=0.002). Estimated probability of ulceration in a non-PVI leg was 0.20 (95% confidence interval [0.10, 0.36]); estimated probability of ulceration in a PVI leg was 0.61 (95% CI [0.41, 0.79]). Odds ratio was 6.2 (95% CI [2.0, 19]). The prevalence of ulceration in either leg, among 22 pts with PVI in at least 1 leg, was compared with that among 23 pts with PVI in neither leg (omitting the pt with one unstudied leg). There was significant association between ulceration in either leg and PVI in either leg (Fisher's exact test p<0.001). Estimated probability of ulceration in either leg when neither leg had PVI was 0.22 (95% confidence interval [0.07, 0.44]); estimated probability of ulceration in either leg when either leg had PVI was 0.86 (95% CI [0.65, 0.97]). Odds ratio was 23 (95% CI [4.7, 110]). PVI may be involved in the pathogenesis of leg ulceration in pts with SSD.

Leg Ulcers among Patients with Sickle Cell Disease on Hydroxyurea Therapy.

Leg ulcers remain a debilitating complication of Sickle Cell Disease (SCD): significant pain, tendency to polymicrobial infection, difficult to heal, and tendency to recur in ~ 50% of patients. According to CSSCD data, 2.5% of 2075 patients had leg ulcers at study entry; overall incidence was 9.97 per 100-person years in patients without concomitant alpha thalassemia (thal), and 5.73 per 100 person years in those with alpha thal.Hydroxyurea (HU) is an approved therapeutic agent for adults with SCD; it has been shown to decrease frequency of pain crises and acute chest syndrome and decrease transfusion requirements. Recently, HU was associated with a 40% reduction in mortality. There have been reports of an association between HU therapy and leg ulcers in patients with myeloproliferative disorders (MPD) and more recently with SCD. A retrospective study from the Mayo Clinic (Best et al, Ann. Intern. Med. , 128:29, 1998) found that among 115 patients with various forms of MPD, 14 developed leg ulcers after an average HU exposure of 6 years; all ulcers healed after stopping HU, and 2 patients had recurrences of their ulcers after resuming HU. Chaine et al (Arch. Dermatol , 137: 467, 2001) reported that 5/17 (29%) patients with SCD on HU developed leg ulcers. If HU, the most effective available therapeutic agent for SCD is indeed causative of leg ulcers, this should raise serious concerns. In an effort to further clarify this problem, we performed a retrospective analysis. 421 adult SCD patients (age 16–60) formed the subject of this study. 152 were treated with HU for a minimum of 6 months. 269 patients were not exposed to HU. A total of 25 patients (5.9%) had leg ulcers; 17 were treated with HU, 8 were not. Thus, the frequency of leg ulcers was 11.2% among HU treated patients, as opposed to 2.9% among those who did not receive HU therapy (p<0.001). However, of the 17 patients with ulcers, 16(94%) had a history of ulcers prior to HU exposure. Only one patient developed ulcers for the first time after starting HU therapy. 6/17 patients experienced healing of their ulcers despite continuing HU. Among the patients treated with HU, those who had ulcers were more anemic (pre-treatment Hb 7.4 vs 8.2 g/dl, p=0.01) and were older (mean age 40.5 vs 33.0, p<0.001), confirming previous observations. Logistic regression analyses showed that only age and prior history of leg ulcers were significant risk factors for the development of ulcers in patients with SCD under HU therapy.Our data on a large number of patients does not suggest that HU therapy alone is causative of leg ulcers in SCD patients. The supporting evidence for this conclusion comes from our observations that 1) a vast majority of patients (16/17; 94%) who developed leg ulcers after starting HU had a previous history of ulcers. This is also true of the report by Chaine et al, where 4/5 patients with leg ulcers had a prior history; 2) in 6/17 patients (35.3%) ulcers healed with conventional therapy despite continuation of HU. Furthermore, it should be noted that patients with leg ulcers represent a more severe group and are thus more likely candidates for HU therapy. We conclude that HU therapy alone is not causative of leg ulcers in patients with SCD. In addition, HU does not appear to prevent recurrence of leg ulcers in patients with a prior history; nor does it expedite ulcer healing. Other as yet unknown factors, some of which are likely genetic, play an important role in determining the risk for developing leg ulcers.

Risk Factors for Delayed Healing and Recurrence of Chronic Venous Leg Ulcers—An Analysis of 1324 Legs

Objective Despite similar disease patterns and treatment, there is great variation in clinical outcome between venous ulcer patients. The aim of this study was to identify independent risk factors for venous ulcer healing and recurrence. Methods Consecutive patients assessed by a specialist nurse-led leg ulcer service between January 1998 and July 2003 with an ABPI>0.85 were included in this study. Independent risk factors for healing and recurrence were identified from routinely assessed variables using a Cox regression proportional hazards model. Results A total of 1324 legs in 1186 patients were studied. The 24-week healing rate was 76% and 1 year recurrence rate was 17% (Kaplan–Meier life table analysis). Patient age ( p<0.001, HR per year 0.989, 95% CI 0.984–0.995) and ulcer chronicity ( p=0.019, HR per month 0.996, 95% CI 0.993–0.999) were independent risk factors for delayed ulcer healing. Ulcer healing time ( p<0.001, HR per week 1.016, 95% CI 1.007–1.026) and superficial venous reflux not treated with surgery ( p=0.015, HR 2.218, 95% CI 1.166–4.218) were independent risk factors for ulcer recurrence. Conclusions Elderly patients with longstanding ulcers should be targeted for further research and may benefit from adjunctive treatments to improve clinical outcomes. Patients not treated with superficial venous surgery were at increased risk of leg ulcer recurrence.

Ulcer clubs need government leg up.

Leg ulcer recurrence rates could be cut and the massive annual bill for wound care reduced dramatically if the benefit of 'Leg Clubs' was more widely understood, a nurse expert said last month.

Compression therapy and pressure in the deep venous system

Objectives: To evaluate the effect of five different elastic compression stockings on the venous pressure in the deep venous system in the supine and standing positions. Methods: Setting: Departments of Dermatology and Radiology, University Hospital Maastricht, The Netherlands. Patients: A total of eight limbs of seven subjects (five patients and two healthy volunteers) with a mean age of 53 years (range 33-79) were measured. The patients were known to have severe venous insufficiency and recurrent leg ulceration. A catheter connected to an external pressure transducer was placed in one of the deep veins of the lower leg after puncturing the popliteal vein. The position of the catheter was established with contrast medium. Venous pressure recordings were made in the supine and standing positions while wearing an anti-embolism stocking and while wearing four different compression stockings (class II and III). Results: All stockings worn in the supine position caused a significant increase in pressure when compared with no compression at all ( P &lt;0.05; Wilcoxon rank test). Only the strong compression class III stockings caused a significant and clinically relevant pressure increase, compared with the other four elastic compression stockings ( P &lt;0.05; Wilcoxon rank test). In the standing position no differences in pressure were found between the elastic stockings, or when any stocking was compared with the use of no stocking at all. Conclusions: The results demonstrate that only strong compression class III stockings (&gt;40 mmHg at the ankle) increase the pressure in the deep venous system in the supine position. Because of this, these elastic stockings may be the only stockings that have a positive influence on the pathologic deep venous system in patients with deep venous insufficiency, such as after deep venous thrombosis. The study confirms earlier clinical observations that in the treatment of patients with post-thrombotic symptoms and deep venous insufficiency only strong elastic compression stockings are effective.

Organotypic cultures of autologous hair follicle keratinocytes for the treatment of recurrent leg ulcers

Our purpose was to evaluate, in an open study, the efficacy of epidermal equivalents (EEs), a tissue-engineered epidermis prepared from autologous hair follicle keratinocytes, for the treatment of recurrent leg ulcers ( n = 50). To generate EEs, keratinocytes expanded from the outer root sheaths of plucked anagen hair follicles were seeded on cell culture inserts at air-liquid interface. The total culture time was 5 to 6 weeks. Three days after the procedure, 95% of EEs adhered to the wound bed. After 8 weeks, 70% of the total wound surface was re-epithelialized and 32% of the ulcers were healed. After applying the EEs, a major relief of wound pain was noticed by the patients. EEs were applied in ambulatory patients without surgical facilities. Because 92% of the cases included in this study presented a recurrence of their ulcers after a split-thickness skin graft, we consider these ulcers as difficult to treat and propose the EEs as an alternative effective treatment of recurrent leg ulcers. (J Am Acad Dermatol 2003;48:207-14.)

Leg ulcer in Klinefelter's syndrome.

Hypostatic ulceration of the legs is relatively uncommon in men. Recently, the hypothesis that recurrent ulceration in men may be associated with chromosomal abnormalities such as Klinefelter's syndrome is gradually being accepted. Herein, we describe a patient with Klinefelter's syndrome complicated by recurrent leg ulcers, in whom immunological disorders such as positive antinuclear factor, antiphospholipid antibodies and cryoglobulins without venous insufficiencies were demonstrated. Interestingly, these abnormalities of immune functions were normalized after the androgen replacement therapy for Klinefelter's syndrome, and his leg ulcers immediately recovered.

Preventing Venous Ulcer Recurrence: The Impact of the Well Leg Clinic

Background: The aim of this prospective study was to evaluate the effectiveness of a nursing-led clinic within a District Hospital setting in detecting early skin break-down in healed venous ulcers. Patients and Methods: A total of 76 patients (45 women, 31 men; age range 24-91 years, mean 74 years) with healed venous ulcers were included in the study between July 1999 and April 2001. Patients were counselled about managemant of ulcers at their initial visit and followed up at 3 and 6 months. Results: We received 79 referrals and of those 76 (96%) accepted our invitation. Fifty-six patients did attend the first clinic appointment, 39 (67%) attended their second clinic visit at 3 months and 38 (68%) were followed up by a telephone call at 6 months. During this period 9 recurrent leg ulcers were noted which were referred for further intervention. Conclusion: It is important to provide follow-up for patients with healed ulcers in order to minimise the recurrence rate and to re-institute treatment soon, as recurrence can occur early following healing.

65-Year-Old Woman With Painful Leg Ulcers

65-Year-Old Woman With Painful Leg Ulcers

Predilection of hemolytic anemia-associated leg ulcers for the medial malleolus.

Ischemic ulcers are usually found above the lateral, and venous stasis ulcers at the medial malleoli. Leg ulcers occur in at least 25% of sickle cell disease (SSD) patients in clinic populations, usually in the malleolar region. The function of the large leg veins in most SSD patients is unimpaired. We determined leg ulcer location in 41 sickle cell anemia (SS), and 4 sickle-beta 0 thalassemic patients with longstanding chronic and/or recurrent leg ulceration, and reviewed published reports of leg ulcers in hereditary spherocytosis and thalassemias. Of the 57 legs of the 45 SSD patients with only 1 ulcer, 42 (74%) were medial and 15 lateral. The difference was significant (p < 0.001). Of patients with only a single ulcer, 22 were medial and 4 lateral. Of 15 reported patients with leg ulcers related to spherocytosis or thalassemia, 20/24 (83%) ulcers were medial. The medial malleoli are the most common site of leg ulceration in SSD and in other chronic hemolytic anemias. This suggests that stasis may play a role in the leg ulceration associated with chronic hemolytic anemia.

Venous leg ulcer recurrence: prevention and healing.

After a leg ulcer has healed, well-fitting compression stockings, patient education and regular check-ups are the basis for preventing recurrence. This article examines patterns in recurrence and subsequent healing among patients at an ulcer clinic.

Impaired venous hemodynamics in a minority of patients with chronic leg ulcers due to sickle cell anemia.

Chronic or recurrent leg ulceration occurs in 25% of sickle cell anemia patients, but not in the remaining 75%. Doppler studies of venous function were normal in 16 sickle cell anemia patients with leg ulcers. Venous Duplex Ultrasound was used to study 33 sickle cell anemia patients with chronic leg ulcers. Six of the 33 patients had venous reflux in at least one leg. Venous insufficiency may contribute to the development of leg ulcers in a minority of sickle cell anemia patients. A minority of sickle cell anemia patients with chronic leg ulcers can be shown to have leg venous reflux by duplex ultrasound imaging.

Community nurses', home carers' and patients' perceptions of factors affecting venous leg ulcer recurrence and management of services.

The two elements reported in this paper are taken from a larger study of issues related to venous leg ulcers and their prevention. The first of these concerns is the provision of an aftercare service for older people whose leg ulcers have healed. Focus group methodology was employed to elucidate the views of community nurses and social service home carers. The former group believed that health promotion was largely ineffective in reducing leg ulcer recurrence. The application and removal of compression stockings was regarded as an appropriate task for home carers, while the district nurses indicated that they regarded the management of active lesions as a better use of their skills. The carers from social services, by contrast, felt that skin care should be the responsibility of health service staff. The second element of the study involved a semi-structured questionnaire administered to 12 patients. They tended to regard skin care as a health problem. 31 references .

Community nurses', home carers' and patients' perceptions of factors affecting venous leg ulcer recurrence and management of services.

This study examines the feasibility of utilizing social service home carers (SSHC) to provide a collaborative approach with community nurses for the provision of leg ulcer aftercare in four National Health Service (NHS) Trusts. The purpose of this study was to gain insight into what community nurses and people with healed venous leg ulcers felt influenced leg ulcer recurrence. Studies have demonstrated that provision of community-based leg ulcer clinics has improved healing rates of venous leg ulcers, yet recurrence remains a problem. The reasons for this are far from clear, and further research is required before unequivocal support can be given to one approach to the provision of care for this client group. Collaborative approaches to the provision of leg ulcer aftercare are beginning to receive more attention. It has been recognized that social service health carers could be co-opted to provide essential aftercare once healing has occurred, although the logistics of this approach have not been fully explored. This study was conducted in four NHS Trusts. Stage one used focus groups to explore the perceptions of district nurses (n = 15) and social service health carers (n = 15) of a leg ulcer shared care project and to gain insight into factors that they felt influenced recurrence. The second stage used semistructured interviews (n = 12) to explore the perceptions that people with healed leg ulcers have about factors influencing ulcer recurrence. Key themes emerging from this study were: health promotion is perceived by community nurses and patients to be ineffective and leg ulcer aftercare services are fragmented. Organizational factors such as time constraints and limited resources were cited by community nurses and home carers as being responsible for high leg ulcer recurrence rates. Community nurses expressed a desire to delegate preventative aspects of leg ulcer care to home carers rather than participate in health promotion strategies to support healing behaviours. A strategy aimed at supporting healing behaviour in elderly people has the potential to reduce the recurrence of leg ulceration and improve quality of life. The findings suggest that such a strategy needs to rationalize delivery of leg ulcer aftercare to provide seamless care. It needs to improve carers' and patients' understanding of factors influencing leg ulcer recurrence and facilitate development of a more balanced professional--patient relationship.

Preventing unnecessary suffering: an audit of a leg ulcer clinic.

Unnecessary patient suffering and increased costs in leg ulcer care were reported in an Effective Health Care bulletin (NHS Centre for Reviews and Dissemination (NHSCRD), 1997). Follow-up assessment of patients with a history of venous ulceration has beneficial effects for patients' quality of life, and for effective and efficient management of resources for community nurses. This article describes the process of implementing evidence-based practice in a leg ulcer clinic in South London within existing resources, which resulted in the successful prevention of leg ulcer recurrence.

Risk Factors for Healing and Recurrence of Chronic Venous Leg Ulcers

Risk Factors for Healing and Recurrence of Chronic Venous Leg Ulcers

Influences on patient adherence with compression hosiery.

Compression hosiery plays a vital role in preventing leg ulcer recurrence, but many patients choose not to wear it. This review identifies the factors that may be responsible for this and suggests how the problem can be overcome.

Influences on patient adherence with compression hosiery

Compression hosiery plays a vital role in preventing leg ulcer recurrence, but many patients choose not to wear it. This review identifies the factors that may be responsible for this and suggests how the problem can be overcome.

Risk Factors for Healing and Recurrence of Chronic Venous Leg Ulcers

Objective: To identify independent risk factors for delayed healing and increased recurrence of chronic venous leg ulcers. Design: Prospective study. Setting: Community-based leg ulcer service. Patients: Six hundred and thirty-three limbs in 587 consecutive patients with an ankle-brachial pressure index (ABPI) ≥0.85. Method: Potential risk factors were initially assessed in a one-stop clinic incorporating clinical evaluation, ABPI and venous duplex imaging. Limbs were treated within a defined protocol. Twenty-four-week healing and 3-year ulcer recurrence rates were determined. Results: Of 12 potential risk factors age ( p&lt; 0.001), ulcer chronicity ( p&lt; 0.001) and popliteal vein reflux ( p&lt; 0.005) were independent risks for delayed healing. Of 13 potential risk factors rheumatoid arthritis ( p&lt;0.005) and healing time ( p &lt; 0.05) were independent risks for ulcer recurrence. Isolated superficial venous reflux treated by saphenous vein surgery predicted reduced ulcer recurrence ( p&lt; 0.005). Conclusion: Targeting in primary care of ulcer patients with specific characteristics might encourage earlier referral and appropriate resource management. Leg ulcer patients with superficial venous reflux might benefit from surgical correction.

Risk factors for delayed healing and long-term recurrence in chronic venous leg ulcers

Abstract Background This study aimed to identify risk factors for delayed healing and increased recurrence of chronic venous leg ulcers. Methods Some 669 patients with chronic leg ulcers were assessed at a one-stop clinic over the 4 years to July 1999. Possible risk factors and venous reflux patterns, assessed with colour duplex, were recorded prospectively for each patient. Some 633 legs with an ankle: brachial pressure index greater than 0·85 were treated with weekly four-layer bandaging until healed, followed by class 2 compression stockings and regular follow-up. Patients with isolated superficial venous reflux were offered surgery. Results Cox regression analyses of possible risk factors are summarized in the Table below. Conclusion Age, ulcer chronicity and reflux in the popliteal vein are independent risk factors for delayed ulcer healing. Delayed ulcer healing and rheumatoid arthritis are independent risk factors for ulcer recurrence. Legs with surgically corrected superficial venous reflux are relatively protected from ulcer recurrence.