Recalcitrant Venous Ulcers Research Articles

Outcomes of Free Flap Reconstruction for Chronic Venous Ulceration in the Lower Limb: A Systematic Review.

The mainstay of treatment for venous ulceration is conservative wound management and lifelong compression therapy. For patients with recalcitrant ulcers, free flap reconstruction has been proposed as a treatment option to reconstruct the diseased soft tissues as well as the underlying insufficient venous system. This review systematically evaluates the outcomes of free flap reconstruction for chronic venous ulcers in the lower limb. A protocol was developed a priori and registered on the PROSPERO database. A systematic search of literature was performed in MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), clinical trials registries, and OpenGrey from inception to April 2020 according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Studies of patients undergoing free tissue transfer reconstruction for chronic venous ulcers in the lower limb were included. A total of 5 noncomparative cohort studies featuring 56 patients with 62 recalcitrant venous ulcers treated with 64 free flaps who had a mean age of 50 years (range, 17-76 years) were included, and a narrative analysis undertaken. Mean defect size following ulcer debridement was 153.3 cm 2 (range, 24-600 cm 2 ). Defects were reconstructed with muscle (n = 39 [60.9%]), fasciocutaneous (n = 23 [35.9%]), and visceral (n = 2 [3.1%]) free flaps, with latissimus dorsi (n = 16, 25%) and rectus abdominis flaps (n = 16, 25%) being the most frequently used. Mean follow-up ranged from 24 to 125 months. Pooled flap survival rate was 95%. No recurrence within the territory of the flap was reported, but there were 20 instances (35.7%) of new ulcers outside of the flap boundaries. There is currently an absence of evidence to support the use of free flap reconstruction for recalcitrant venous ulcers compared with conventional management. Although evidence suggests that it is technically feasible, there is no evidence to suggest it prevents ulceration outside the reconstructed region. Further studies are necessary to evaluate its effectiveness for venous ulcers in the lower limb.

Deep Venous Stenting Improves Healing of Lower Extremity Venous Ulcers

Long standing, recalcitrant venous ulcers fail to heal despite standard compression therapy and wound care. Stenting of central veins has been reported to assist in venous ulcer healing. This study reports outcomes of deep venous stenting for central venous obstruction in patients with recalcitrant venous ulcers at a single comprehensive wound care center. A single center retrospective analysis was conducted of patients with CEAP (Clinical, Etiology, Anatomy, and Pathophysiology) 6 disease that had undergone deep venous stenting in addition to wound care and compression therapy. Intra-operative details, wound healing, and stent patency rates were recorded. Stent patency and intra-operative details were compared between the healed and unhealed groups. Between 2010 and 2019, 15 patients met inclusion criteria (mean age: 63 years old, 12 males). Pre-operative mean wound area was 14.1 cm2 with mean wound duration of 30 months. 93% of patients healed the ulcers at mean healing time of 10.6 months. Wound recurrence rate was 57% with mean recurrence time of 14.8 months. Ten patients presented with an inferior vena cava (IVC) filter, 4 in the healed group and 6 in the unhealed group. The common iliac vein was stented in all patients. Extension into the IVC was required in 4, the common femoral vein in 11, and femoral vein in 2 patients. The average stent length was 190cm. During the follow-up period, primary patency rates in healed patients (mean follow-up time: 19.2 months) was 83% and 59% in the unhealed group (mean follow-up time: 36.6 months); secondary patency rates were 83% and 89%, respectively. In patients with recalcitrant venous ulcers with central venous obstruction, deep venous stenting resulted in a high rate of healing. However, a prolonged 10 month healing time was observed and despite high stent patency, wound recurrence rate was high.

The Recalcitrant Venous Leg Ulcer Unhealed After 1 Year Despite Wound Center Care: Influential Risk Factors for Nonhealing

Venous leg ulcers (VLUs) are associated with a high cost of care, loss of productivity, and reduced quality of life. Despite regular treatment of VLUs, some fail to heal. Several risk factors have previously been identified to be associated with the failure of a VLU to heal, but for the majority of publications, the definition was limited to less than a 24-week period. Furthermore, the currently available literature is sparse and often contradictory. A retrospective cohort study was performed at an academic vascular and wound center. A total of 66 VLUs were included. These patients underwent a variety of treatments based on the Society for Vascular Surgery/American Venous Forum guidelines; these included compression, débridement, skin grafting, endovenous radiofrequency ablation, ligation and stripping, sclerotherapy, perforator surgery, and iliac vein stenting. We examined risk factors in patients who failed to heal their VLU after a 52-week period of treatment in our center. Risk factors were chosen on the basis of clinical opinion and available literature. All of the following were considered: treatment disparity factors—age, sex, and race (white vs nonwhite); condition-centric factors—size of ulcer, superficial venous involvement, deep venous involvement, presence of an incompetent perforator, history of superficial venous procedure in the affected limb, and history of deep venous thrombosis in the affected limb; and potential systemic factors—hypertension, obesity, diabetes mellitus, congestive heart failure, depression, history of smoking, and presence of an inflammatory or autoimmune condition predisposing to chronic steroid use. Both univariate (unadjusted) and multivariate (adjusted) logistic regression were used to assess the magnitude of effect that a given risk factor had on healing. After 52 weeks of treatment in our center, 20 of 66 VLUs (30%) remained unhealed. Further results are shown in the Table. Several risk factors are shown to be associated with the failure to heal a VLU; some are already commonly accepted in practice, such as deep venous involvement and post-thrombotic etiology, and others are novel. The large presence of deep venous involvement in the unhealed vs healed cohort (80% vs 48%) highlights the need for a viable treatment option for deep venous disease. In regard to race, there is no significant difference in the number of visits or appropriate interventions to the superficial or deep system performed on whites vs nonwhites, implying that there is no issue with discrimination in regard to access of care at our wound center. This suggests that an alternative, possibly biologic factor is placing nonwhites at risk for not healing their VLU—a topic that would clearly benefit from future studies. In addition, the influence of depression on poor outcomes, although not significant at the multivariate level in our study, is becoming increasingly prevalent in vascular patients. Overall, it is important to consider all risk factors when evaluating a patient for VLU to coordinate an effective treatment plan.TableUnadjusted (single variable) and adjusted (multivariable) odds ratios (ORs) for risk factorsRisk factorUnadjusted OR (95% CI)PAdjusted OR (95% CI)PAge, years0.99 (0.96-1.03).781.01 (0.94-1.09).78Male0.72 (0.25-2.08).5411.80 (0.43-321.35).14Nonwhite1.38 (0.46-4.08).56189.92 (2.30-1.56 × 104).02Size of ulcer, cm21.02 (0.99-1.04).150.99 (0.95-1.03).71Superficial venous involvement0.39 (0.12-1.29).120.16 (4.9 × l0−3-5.30).31Deep venous involvement4.36 (1.26-15.06).0283.28 (1.74-4.0 × 103).025Incompetent perforator0.47 (0.16-1.37).170.004 (4.7 × l0−5-0.42).02Superficial venous surgery1.76 (0.53-5.86).360.60 (0.04-9.55).72Deep venous thrombosis12.30 (3.39-44.65)<.001492.12 (3.34-7.3 × 104).015Hypertension0.80 (0.27-2.36).691.35 (0.13-14.02).80Obesity1.71 (0.59-4.93).321.63 (0.14-18.84).69Diabetes mellitus1.03 (0.28-3.83).970.11 (2.9 × l0–3-4.23).24Congestive heart failure0.25 (0.03-2.15).210.005 (2.9 × l0–6-10.05).17Depression4.44 (1.29-15.35).01815.72 (0.82-301.96).07Smoking history1.38 (0.46-4.08).563.39 (0.14-82.56).45Inflammatory condition2.44 (0.32-18.71).39145.52 (0.77-2.7 × 104).36CI, Confidence interval. Open table in a new tab

PC182 The Impact of Different Treatment Modalities on Recalcitrant Venous Ulcer Healing

PC182 The Impact of Different Treatment Modalities on Recalcitrant Venous Ulcer Healing

Combined treatment with endovenous laser ablation and compression therapy of incompetent perforating veins for treatment of recalcitrant venous ulcers.

Objective Patients with healed venous ulcers often experience recurrence of ulceration, despite the use of long-term compression therapy. This study examines the effect of closing incompetent perforating veins (IPVs) on ulcer recurrence rates in patients with progressive lipodermatosclerosis and impending ulceration. Methods Patients with nonhealing venous ulcers of >2 months' duration underwent duplex ultrasound to assess their lower extremity venous system for incompetence of superficial, perforating, and deep veins. Endovenous laser ablation (EVLA) of perforating veins was performed on patients with CEAP 6 disease with increasing hyperpigmentation, lipodermatosclerosis, and/or progressive malleolar pain. A minimum of 2 months of compressive therapy was attempted before endovenous ablation of IPVs. Demographic data, risk factors, CEAP classification, procedural details, and postoperative status were all recorded. Results Forty ulcers with 46 associated IPVs were treated with EVLA in 36 patients with CEAP 6 recalcitrant venous ulcers. Treated incompetent perforator veins were located in the medial ankle (85.7%), calf (10.7%), and lateral ankle (3.5%). Endovenous laser ablation was successful in 76% (35/46) with the first laser treatment of incompetent perforator veins and 15.2% (7/46) additional ablation procedures were performed. Of the 46 treated IPVs, 42 (91.3%) were occluded on the duplex examination at 12 months. The average energy administrated per perforating vein treated was 162 joule. Two patients reported localized paresthesia, which subsided spontaneously, but no deep venous thrombosis or skin burn was observed. Conclusion Especially in the case of liposclerotic or ulcerated skin in the affected region, PAP of IPVs is highly effective, safe, and appears to be feasible. Patients with active venous ulcers appear to benefit from EVLA of incompetent perforators in order to reduce the risk of ulcer recurrence.

Commentary on “The Effect of Deep Venous Stenting on Healing of Lower Limb Venous Ulcers”

It is now well accepted that placement of venous stents is the “method of choice” for treatment of pelvic venous outflow obstruction. George et al.1George R. Verma H. Ram B.L. Tripathi R.K. The effect of deep venous stenting on healing of lower limb venous ulcers.Eur J Vasc Endovasc Surg. 2014; x (xx–xx)Google Scholar performed computed tomography (CT) venography in patients with persistent venous leg ulcers after failed conservative treatment and superficial venous interventions. The authors proceeded with transfemoral/ascending phlebography when CT-venography findings suggested obstruction. Obstruction was found in 38 patients (44 limbs) and stents were placed. The actual number of patients tested to find these patients is not given. The endpoint was healing of the ulcer. The cumulative freedom from ulcer after stenting was at 2 years approximately 60%. This was achieved despite the presence of perforator insufficiency, deep reflux, and significant saphenous incompetence in 90%, 26%, and 10%, respectively, of patients with pre-intervention duplex scanning. Patients with healed ulcers continued to stay healed at a cumulative rate of approximately 83% at 2 years. This findings are line with the results of others as referred to in the study and point to the importance of iliofemoral venous outflow obstruction in the pathophysiology of venous ulcer formation. The prevalence of outflow obstruction in patients with recalcitrant venous ulcers is still unknown. It may be hard to decide since non-thrombotic iliac vein lesions are ubiquitous and we still don't know at what degree a venous stenosis is hemodynamically significant. I agree with the authors that it certainly appears to be worthwhile to search for an iliofemoral outflow obstruction in patients with leg ulcers, which are difficult to heal or recur with other treatment. The authors don't inform us what they considered a significant obstruction. In absence of lack of hemodynamic information, most would consider to treat an obstruction with a minimal diameter stenosis of >50% based on acceptable clinical outcome in patients stented with this criterion. Although very helpful in diagnosis and accurate placing of stents, intravascular ultrasound is unfortunately often too expensive to use. The authors used a so-called “trial angioplasty” or “diagnostic ballooning” when no obvious obstruction was seen. However, there is no information in the study what degree of “waisting” resulted in an intervention. The method has not been validated. I would caution those that use this technique. Large diameter balloons (especially if high pressure balloons are used) placed in the angle at the iliac confluence or at the internal iliac venous inflow may produce a false waist with the unfolding of the balloon. An accurate hemodynamic test for outflow obstruction, preferably non-invasive, needs to be developed to establish a defined indication for stenting. Until then awareness of the importance of obstruction, clinical signs and symptoms, and morphological criteria will have to do. A reduction of the ulcer size is not in itself an accepted endpoint, but could be used within a Venous Clinical Severity Score. A proper CEAP classification of the study patients was not given. It is difficult to analyze the reasons for lack of healing and recurrence of ulcers in this small amount of material. None was found. The presence of axial deep reflux, development of “new” reflux, occlusion of the stent system, recurrence of deep vein thrombosis, incompliance with concomitant compression therapy, etc., have certainly been pointed out in larger studies by others. The Effect of Deep Venous Stenting on Healing of Lower Limb Venous UlcersEuropean Journal of Vascular and Endovascular SurgeryVol. 48Issue 3PreviewTo report the outcomes of endovascular interventions on deep veins in patients with venous ulcers (C6). Full-Text PDF Open ArchiveRe. “The Effect of Deep Venous Stenting on Healing of Lower Limb Venous Ulcers”European Journal of Vascular and Endovascular SurgeryVol. 48Issue 6PreviewWe read with interest Peter Neglen's commentary on our paper.1,2 Full-Text PDF Open Archive

The recalcitrant venous leg ulcer – a never ending story?

SummaryIntroduction: In general, four particular causes of recalcitrant venous leg ulcers may be distinguished. These are foot pump insufficiency, chronic venous compartment syndrome and non-re-canalized popliteal vein thrombosis. The fourth cause of recalcitrant venous leg ulcers is lipodermatosclerosis as a symptom of severe chronic venous insufficiency.Methods: We reviewed the literature and based on this we describe four main causes of recalcitrant venous leg ulcers and their specific treatment.Results: Foot pump insufficiency arises when the plantar foot veins are not able to empty. Treatment should consist of physical therapy, a mechanical foot pump device and an insole. Lipodermatosclerosis may be treated by excision and split-thickness skin grafting (Vigoni procedure). Chronic venous compartment syndrome is usually caused by post-thrombotic syndrome and treatment consists of a fasciectomy, but is rarely used nowadays. Patients with non-re-canalized popliteal vein thrombosis may be supported by intermittent pneumatic compression, walking exercises, alternate standing and walking with lying down. All patients with recalcitrant venous leg ulcers must wear medical elastic compression stockings with high stiffness and high compression lifelong.Conclusions: Patients with recalcitrant venous leg ulceration are challenging. More specific treatment will heal more of these ulcers.

Muscle Flaps and their Role in Limb Salvage

Muscle flaps have proved to be a valuable and versatile tool in the surgical treatment of the severely compromised lower extremity. Utilized as both local pedicle flaps and free tissue transfers, muscles have been successfully employed to cover complex wounds, manage osteomyelitis, salvage infected vascular grafts, treat recalcitrant venous stasis ulcers, preserve amputation levels, and restore motion following compartment syndrome. Free flap pedicles have also been used in a flow-through fashion to create a distal arterial bypass. This article explores the multipurpose role of muscle flaps in limb salvage surgery and their beneficial physiologic characteristics in hostile wound environments.

Endovenous ablation of incompetent perforating veins is effective treatment for recalcitrant venous ulcers

Endovenous closure of incompetent saphenous veins has been reported to facilitate venous ulcer healing; however, there is little information about the effectiveness of perforator ablation (PA) in healing recalcitrant venous ulcers. We report our experience with PA with venous ulcers unresponsive to prolonged compression therapy. Patients with nonhealing venous ulcers of >3 months' duration underwent duplex ultrasound to assess their lower extremity venous system for incompetence of superficial, perforating, and deep veins. Patients who had either no saphenous incompetence or persistent ulcers after saphenous ablation underwent PA of incompetent perforating veins >3 mm that demonstrated reflux; initial treatment was performed on the perforator vein adjacent to the ulcer with additional incompetent veins treated if ulcer healing failed. Seventy-five ulcers with 86 associated incompetent perforating veins were treated with PA in 45 patients with CEAP 6 recalcitrant venous ulcers. Treated incompetent perforator veins were located in the medial ankle (61%), calf (37%), and lateral ankle (2%). Initial success of PA, assessed by postprocedure duplex ultrasound, was 58%; repeat ablation was 90% successful and 71% had eventual successful perforator closure. No complications (skin necrosis, infection, or nerve injury) occurred. Failure of ulcer healing with successful perforator closure occurred in 10% and was due to intercurrent illness, patient noncompliance, and patient death due to unrelated causes. Of patients who healed their ulcers, the healing occurred at a mean of 138 days; an average PA of 1.5 incompetent veins per ulcer was required for healing. Ninety percent of ulcers healed when at least one perforator was closed; no ulcer healed without at least one perforator being closed. This experience demonstrates both the feasibility and effectiveness of PA for a selected group of patients with venous ulcers who fail conventional therapy with compression.

Endovenous Ablation of Incompetent Perforator Veins Is Effective Treatment for Recalcitrant Venous Ulcers

Objectives: Endovenous closure of incompetent saphenous veins has been reported to facilitate venous ulcer healing; however, there is little information about the effectiveness of perforator ablation (PA) in healing recalcitrant venous ulcers. We report our experience with PA with venous ulcers unresponsive to prolonged compression therapy. Methods: Patients with nonhealing venous ulcers of >3 months' duration underwent duplex ultrasound imaging to assess their lower extremity venous system for incompetence of superficial, perforating, and deep veins. Patients who had either no saphenous incompetence or persistent ulcers after saphenous ablation underwent PA of incompetent perforating veins >3 mm that demonstrated reflux; initial treatment was performed on the perforator vein adjacent to the ulcer, with additional incompetent veins treated if ulcer healing failed. Results: Fifty-six ulcers with 74 associated incompetent perforating veins were treated with PA in 44 patients with CEAP 4 (9%), 5 (6%), and 6 (85%) recalcitrant venous ulcers. Treated incompetent perforator veins were located in the medial ankle (67 %) and calf (33%). Initial success of PA, assessed by postprocedure duplex ultrasound imaging, was 55 %; reported complications of catheter site skin necrosis (0%), infection (0%), and nerve injury (0%) did not occur. In 18% of patients, more than one procedure was required for perforator closure; 73% had eventual successful perforator closure. Failure of perforator closure occurred in 27% and was associated with intercurrent illness, patient noncompliance, and patient death from unrelated causes. Of patients whose ulcers healed, the healing occurred at a mean of 2.3 months; an average PA of 1.5 incompetent veins per ulcer were required for healing. Conclusions: This experience demonstrates both the feasibility and effectiveness of PA for a selected group of patients with venous ulcers who fail conventional therapy with compression.

Comparison of low-strength compression stockings with bandages for the treatment of recalcitrant venous ulcers

To compare the proportion and rate of healing, pain, and quality of life of low-strength medical compression stockings (MCS) with traditional bandages applied for the treatment of recalcitrant venous leg ulcers. A single-center, randomized, open-label study was performed with consecutive patients. Sigvaris prototype MCS providing 15 mm Hg-25 mm Hg at the ankle were compared with multi-layer short-stretch bandages. In both groups, pads were placed above incompetent perforating veins in the ulcer area. The initial static pressure between the dressing-covered ulcer and the pad was 29 mm Hg and 49 mm Hg with MCS and bandages, respectively. Dynamic pressure measurements showed no difference. Compression was maintained day and night and changed every week. The primary endpoint was healing within 90 days. Secondary endpoints were healing within 180 days, time to healing, pain (weekly Likert scales), and monthly quality of life (ChronIc Venous Insufficiency Quality of Life [CIVIQ] questionnaire). Of 74 patients screened, 60 fulfilled the selection criteria and 55 completed the study; 28 in the MCS and 27 in the bandage group. Ulcers were recurrent (48%), long lasting (mean, 27 months), and large (mean, 13 cm2). All but one patient had deep venous reflux and/or incompetent perforating veins in addition to trunk varices. Characteristics of patients and ulcers were evenly distributed (exception: more edema in the MCS group; P = .019). Healing within 90 days was observed in 36% with MCS and in 48% with bandages (P = .350). Healing within 180 days was documented in 50% with MCS and in 67% with bandages (P = .210). Time to healing was identical. Pain scored 44 and 46 initially (on a scale in which 100 referred to maximum and 0 to no pain) and decreased within the first week to 20 and 28 in the MCS and bandage groups, respectively (P < .001 vs .010). Quality of life showed no difference between the treatment groups. In both groups, pain at 90 days had decreased by half, independent of completion of healing. Physical, social, and psychic impairment improved significantly in patients with healed ulcers only. Our study illustrates the difficulty of bringing large and long-standing venous ulcers to heal. The effect of compression with MCS was not different from that of compression with bandages. Both treatments alleviated pain promptly. Quality of life was improved only in patients whose ulcers had healed.

Silver-Impregnated Vacuum-Assisted Closure in the Treatment of Recalcitrant Venous Stasis Ulcers

Vacuum-assisted closure (VAC) has made a significant contribution to the treatment of acute and chronic wounds. Microdeformational forces from the VAC device accelerate granulation tissue formation when compared with moist saline dressing changes. We present 2 patients with multiple comorbid conditions and complex venous stasis ulcers that had persistent purulent drainage after conventional treatment modalities. Only after utilizing silver-impregnated VAC therapy (GranuFoam Silver), combining the antimicrobial benefits of silver with the advantages of VAC technology, were the wound beds adequately prepared for substantial split-thickness skin grafts. Based on these cases, the silver-impregnated VAC device may be a useful adjunct in wound bed preparation when standard therapies have failed to clear infected wounds. This may lead to improved healing rates and overall decreased wound burden in these complex patients.

118 Dermagraft as an Adjunct in the Treatment of Venous Leg Ulcers

Aim: To document successful healing of a recalcitrant venous ulcer with adjunctive use of Dermagraft Materials and Methods: A 74‐year‐old Hispanic male presented with a chronic venous ulcer at the medial aspect of his right ankle. Biopsy failed to reveal malignancy and confirmed stasis changes. Treatment was ongoing including compression therapy, local debridements, and moist wound healing, off‐loading, and nutritional support. The wound remained free of infection. Due to the continued recalcitrant nature of the lesion multiple applications of Dermagraft were utilized to augment healing. Results: The researcher observed dramatic improvement in wound dimensions, wound contracture, and granulation tissue. Conclusions: Dermagraft appears to augment healing in patients with venous ulcers and may be useful as adjunctive therapy. Acknowledgements: Smith &amp; Nephew Wound Management, Largo, Fl.

Management of leg ulcers.

Introduction - management of leg ulcers. Part I Wound healing: molecular biology of chronic wounds cytokines in progressing stages of chronic venous insufficiency bacteriology of leg ulcers synthetic dressings therapy with growth factors cultured keratinocyte grafts. Part II Venous leg ulcers: epidemiology of leg ulcers postthrombbtic syndrome classification of chronic venous insufficiency venous mapping with Doppler and duplex sonography duplex ultrasound for the assessment of venous reflux phlebography magnetic resonance imaging and computed tomography in advanced chronic venous insufficiency plethysmography micoangiopathy in the pathogenesis of chronci venous insufficiency compression therapy of venous ulcers physical therapy of the ankle joint in patients with chronic venous imcompetence and arthrogenic congestive syndrome manual lymph drainage adjuvant systemic drug therapy in venous leg ulcers chronic leg ulcers and eczema complications in the treatment of leg ulcers surgical management of varicose veins in advanced chronic venous insufficiency paratibial fasciootomy and crural fasciectomy subfascial and edcoscopic perforator surgery shave therapy for recalcitrant venous ulcers. Part III Arterial leg ulcers: assessment of peripheral arterial occulsive disease management of arterial leg ulcers and of combined (mixed) venous-arterial leg ulcers percutaneous transulminal angioplasty in the mangement of arterial leg ulcers reconstructive arterial surgery. Part IV Conservative therapy of diabetic foot: orthopaedic aspects in diabetic neuropathic osteoarthropathy diabetic foot infection. Part V Leg ulcers of different origins: differential diagnosis of leg ulcers management of leg ulcers in rheumatoid arthritis and in systemic sclerosis management of vasculitic leg ulcers and pyoderma gangrenosum conclusions.

Shave therapy for recalcitrant venous ulcers.

Shave therapy for recalcitrant venous ulcers.

Free tissue transfer in treatment of the recalcitrant chronic venous ulcer.

We propose that a long-term cure for the recalcitrant chronic venous ulcer must involve a dual surgical approach including (1) wide excision of the ulcer and surrounding liposclerotic tissue bed, and (2) replacement by a free flap containing multiple, competent microvenous valves with a normal microcirculation. Advantages of free flaps over skin grafting include improvement of the underlying pathophysiology; increase in blood supply to the area; ability to cover exposed bone, joint, or tendon; and a lower incidence of recurrence. During the past 8 years, 20 consecutive muscle free flaps were performed in 18 patients for 19 recalcitrant venous ulcers (two "sequential" flaps to the ipsilateral leg in 1 patient and a repeat flap after initial failure in 1 patient). Twelve males and 6 females ranged in age from 17 to 76 years (mean, 44 years). Nontraumatic, nonosteomyelitic venous ulcers had been present for an average of 3.5 years (range, 1-10 years) and failed an average of 2.4 skin grafts (range, 0-6 grafts). Defects ranged from 100 to 600 cm2 (mean, 238 cm2). Donor tissues included rectus abdominis (N = 13), latissimus dorsi (N = 5), gracilis (N = 1), and serratus (N = 1) muscles. Recipient vessels included posterior tibial (N = 12), anterior tibial (N = 6), and peroneal (N = 2). In all instances except one, only one vein, usually one of the venae comitantes, was anastomosed in end-to-end fashion. Successful free tissue transfer was accomplished in 18 of 20 flaps (90%). Complications included infection with partial flap and/or skin graft loss (three flaps), and partial skin graft loss (two flaps). There were no recurrences within the flaps; however, breakdown occurred at the junction between the flap and residual adjacent liposclerotic skin in 1 patient. Follow-up average 32.7 months (range, 8-65 months); 3 patients were lost to follow-up. Free muscle transfer can provide a long-term cure for the recalcitrant venous ulcer by replacing the diseased tissue bed with healthy tissue containing multiple, competent microvenous valves and a normal microcirculation. This can be accomplished in one reconstructive procedure with excellent long-term results.

Pharmacologic treatment of venous leg ulcers.

In terms of prevalence, total cost and morbidity, venous leg ulcers are probably by far the most important type of ulcerations in the leg. The macrocirculatory defect leading to a raised ambulatory venous pressure is now accepted as a common initial pathologic pathway. Most current treatment modalities, such as surgery or external compression, are designed to control the macrovascular defect. However, it is the microcirculatory consequences of the venous hypertension that give rise to the trophic skin changes and ultimately to ulceration. At this microcirculatory level, pharmacotherapy may be a useful adjunct in the treatment of venous leg ulcers. The microcirculatory pathophysiologic changes include decreased fibrinolytic activity, elevated plasma fibrinogen, microcirculatory thrombi, and inappropriate activation of the white blood cells. The oxidative burst from the activated white cells probably plays a key role by releasing locally leukocyte-derived free radicals, proteolytic enzymes, cytokines, platelet-activating factor, and a number of other noxious mediators. An important additional component in recalcitrant venous ulcers is co-existing arterial disease, which is probably present in 15-20% of cases. Decreased arterial perfusion pressure will further aggravate the ischemic changes caused by the venous hypertension. Pentoxifylline downregulates leukocyte activation, reduces leukocyte adhesion, and also has fibrinolytic effects. A number of clinical studies have therefore been carried out to examine the clinical efficacy of pentoxifylline in treatment of venous leg ulcers. Probably the largest published placebo-controlled, double-blind randomized study was reported in 1990. In this study, 80 patients received either pentoxifylline 400 mg three times a day orally or matching placebo for 6 months or until their reference ulcer healed if this occurred sooner. Complete healing of the reference ulcer occurred in 23 of the 38 patients treated with pentoxifylline compared to 12 of the 42 patients treated with placebo. The odds ratio in favor of pentoxifylline was 1.81 (95 confidence intervals 1.20-2.71).