Management of pure venous ulcers

The management is primarily aimed at treating the underlying venous hypertension. Much of it can be achieved successfully in specialist nurse led clinics, on a shared care basis with community nurses, with easy access to the vascular services.

Figure 15.21. Multilayer compression therapy.

Elevation

The patient must be encouraged to regularly spend periods during the day lying down with the leg elevated on pillows so that the foot is above the heart. They should avoid sitting or standing for long periods with their legs fully dependant.

Exercise

Too often patients are told to rest. Walking activates the venous muscle pumps as does regularly moving the ankles and toes. Ankle flexion is possible within multilayer compression and it should be encouraged. The degree of ankle mobility is directly proportional to the leg ulcer healing rate.

Graduated compression

For the treatment of open ulceration multilayer elastic systems are superior to single bandages and should allow a pressure of 40 mmHg or more at the ankle, reducing to about half that below the knee. The first layer should be a generous one of wool roll followed by a bandage to compress the wool such as a white crepe bandage. On this foundation the elastic compression bandages should be applied (Fig. 15.21).

Healing rates of 60% or more at 6 months should be possible, but 20% remain unhealed at 1 year.

Healed legs should be fitted with compression hosiery aiming for an ankle pressure of 18 mmHg (Fig. 15.22). These should be worn during the day indefinitely and be renewed once in 3 months.

Superficial venous surgery

This does not improve ulcer healing rates but there is now level one evidence that it is very important in reducing ulcer recurrence. In patients with isolated superficial reflux or mixed superficial and segmental deep reflux, representing 85% of patients with venous leg ulcers, simple varicose vein surgery reduces the ulcer recurrence rate at 3 years from 50% to 20%. In the elderly a sapheno-femoral or sapheno-popliteal junction ligation can be carried out under local anaesthetic.

Figure 15.22. Graduated compression hosiery.

Perforator surgery

There has been a recent resurgence in the popularity of perforator ligation due to the advantages of the endoscopic subfascial approach, without the difficulties relating to a large wound, by the development of endoscopic techniques through a more proximal, smaller incision ('SEPS'). In fact this technique is usually combined with open saphenous vein surgery and it is probably the latter that has the greater effect on venous hypertension.

Local treatment of the ulcer

Usually a simple non-adherent dressing is all that is required as a primary dressing under the compression. Chemical or larval debridement can be employed if there is excessive slough. Systemic antibiotics are only useful if there is frank cellulitus, only then should ulcers be swabbed for bacteriology as they will always share the patient's normal skin flora. Split or pinch skin grafts are often used on large ulcers and can be placed under compression bandages; there is no level one evidence regarding their effect on healing rate.

Nutrition

Obese patients should be advised that weight loss will help their ulceration and undernourished patients will have slow healing. Any underlying anaemia should be addressed.

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