Journal of Vascular Surgery
Volume 29, Issue 4 , Pages 752-755, April 1999

Chronic leg ulcers: The impact of venous disease☆☆☆

Department of Surgery and Centre of Caring Sciences, Uppsala University Hospital. Uppsala, Sweden

Article Outline

Abstract 

J Vasc Surg 1999;29:752-5.

 

Chronic leg ulceration of various causes has been a health care problem throughout history. The problematic consequences of the disease and the difficulties in the promotion of healing conditions once created the need for a special saint for chronic leg ulcers, St Peregrinus. At one of the oldest hospitals in Sweden, patients with leg ulcers comprised a large proportion of all in-hospital patients during the years 1767 to 1771.1 Both internal (laxatives) and external (turpentine, honey) treatment options were used, and, after a couple of months, at least some of the ulcers healed. Bandaging therapy was mentioned already in the Old Testament of the Bible (Isaiah 1:6). In 1916, John Homans2 classified ulcers as varicose and postphlebitic: the first was curable with varicose vein surgery, and the latter was practically not curable with surgical methods. To correctly treat chronic leg ulcers, it is a prerequisite to have a detailed knowledge of the cause and the distribution within the population. The aim of this report is to review the epidemiologic situation on the basis of data primarily from Sweden, with special emphasis on the impact of venous disease. A chronic leg ulcer is defined as any wound below the knee, the foot included, that does not heal within a 6-week period. One important problem is the multifactorial etiology of leg ulcers, and there are many contributing factors (eg, venous thrombosis, arteriosclerosis, diabetes, tumors, arthrosis, collagenosis, varicose veins). Another problem is that approximately 30% to 40% of ulcers may have more than one cause, which will influence how to treat the patient and the ulcer.3, 4, 5

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Prevalence of leg ulcers 

Differences in leg ulcer prevalence between various studies may have several causes, such as the use of overall or point prevalence, the inclusion or exclusion of foot ulcers, the age and sex distribution in the patient series, and the methodology of identifying patients. With a combination of questionnaires to the health care system (eg, wards, outpatient clinics, nurses) and questionnaires to randomly selected individuals within the population and a thorough investigation of the random samples of responders, it would seem as if an optimal estimate is obtained. We have been especially interested in an investigation of the ulcer situation in three Swedish regions—the city of Malmö (urban population), the county of Skaraborg (rural population), and the county of Uppsala (mixed population). The populations in the three regions are fairly similar (250,000 to 300,000 inhabitants).

One obvious problem is the large number of patients, especially younger male patients, who are not known to the health care system.6, 7 These patients take care of the ulcers themselves, and among them, there are, without doubt, patients with curable diseases, such as superficial venous insufficiency. The overall or lifetime prevalence is roughly three times higher than the point prevalence, and there is a clear increase with age (Table I).

Table I. Overall prevalence of leg ulcer in Skaraborg county (%)
Known to health care systemSelf care included
All causesVenousAll causesVenous
Total population0.900.491.901.03
>15 years old1.200.652.401.30
>64 years old4.202.275.603.02
The life time prevalence includes all the people who have ever had a leg ulcer, whereas the point prevalence measures the people with open ulcers during a limited period of time. The point prevalence gives the actual size of the problem and thereby an estimate of the workload of the health care professionals at any point of time. With a combination of the results from three comparable studies in Skaraborg county and the city of Malmö, 2.4% of the adult population older than 15 years had ever had leg ulcers and 5.6% of people 65 years or older had open or healed lower limb ulceration.610 The yearly incidence rate can be estimated to be between 0.03% and 0.06%.5

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Causes and characteristics of leg ulcers 

There are many causes of leg ulcers. The problem is even greater in that one patient may have several causes and that this may vary with time. So, a patient with a long-standing, pure venous ulcer may have arterial insufficiency develop with increasing age, which adds to the problem and makes treatment more difficult. One etiological classification is exemplified in Table II, where there is a combination of clinical and physiologic findings and the clinician decides on the most probable cause.

Table II. Etiologic classification of chronic leg ulcers with examples from the Skaraborg study3 (%)
Etiologic classificationNo. of ulcers above the foot (n = 353)No. of isolated foot ulcers (n = 110)
Venous522
Mixed venous/arterial*181
Mixed arterial/venous†45
Arterial419
Arterial and diabetes234
Diabetes114
Traumatic21
Pressure<113
Multifactorial (arterial, venous,33
diabetes)
Multifactorial (others)84
Other single causes64

The classification was made by one surgeon who combined clinical and physiologic findings. *Venous cause dominating. †Arterial cause dominating.

A random sample of the patients in the Skaraborg prevalence study was investigated by a clinician. In Table III, the main causes of chronic leg ulcers in the three Swedish regions previously mentioned are summarized.
Table III. Causes of chronic leg ulcers (%)
Skaraborg countyUppsala countyMalmö city
(n = 463)(n = 406)(n = 257)
Venous402934
Mixed181411
Arterial/diabetes21821
Traumatic2182
Others193132

All ulcers, including foot ulcers, are included.

One important methodologic difference should, however, be noticed. In the Skaraborg study, the diagnosis was established on the basis of one physician's combined clinical and physiologic investigation. In the two other counties, the diagnosis was made on the basis of a questionnaire, mostly the clinical investigation by a large number of nurses. Venous and nonvenous ulcers have a difference in distribution, with nonvenous being more peripherally located. So, only 9% of the foot ulcers are venous and 55% are nonvenous.

The distribution of venous insufficiency in 463 legs with current ulcers3 can be seen in Table IV.

Table IV. Distribution of venous insufficiency in 463 legs with current ulcers (%)
Ulcer above the footFoot ulcer
Femoral vein274
Popliteal vein4515
Long saphenous vein319
Short saphenous vein4416
Calf perforators5613

As understood from summarizing the columns, there are various types of combinations.

This classification was made with a combination of clinical and hand-held Doppler scan examinations (before the era of duplex scanning). Of those cases with venous insufficiency, 47% were purely superficial and 53% were deep, in 42% with a superficial component as well. This is important because ulcers that are caused by superficial insufficiency are potentially curable with surgical treatment.3, 11, 12 The influence of previous deep venous thrombosis is difficult to evaluate, but the frequency is high in older studies without anticoagulant treatment.13, 14, 15 In a recent series with adequate treatment, the frequency has decreased, but between 5% and 10% of the patients still have ulcers develop with time.16, 17 If patients with current ulcers are analyzed retrospectively, approximately 25% have a history of deep vein thrombosis.3 Of 287 patients without popliteal reflux, 29 (10%) had a history of deep vein thrombosis; of 176 with popliteal reflux, 86 (49%) had such a history; and, moreover, 65 (37%) had a history of major surgery or fracture, in which we know that the risk of deep vein thrombosis is high. Among patients with venous ulcers, 37% had a history of previous thrombosis.11 A positive history of thrombosis was significantly more common in patients with deep vein insufficiency (54%) as compared with patients with ulcers from isolated superficial vein insufficiency (14%).

There are several important differences between venous and nonvenous ulcers, some of which are shown in Table V.

Table V. Comparison between venous and nonvenous chronic leg ulcers
VenousNonvenousP value
Median patient age (years; range)77 (39 to 97)77 (13 to 91)
Diabetes (%)847<.001
History of thrombosis (%)3711<.0001
Median age at first ulcer (years; range)59 (14 to 92)73 (12 to 94)<.001
Median duration of ulcer history (years)13.42.5<.001
Recurrent ulcer (%)7245<.001
Because the median age of the patients is high, there is also a high frequency of associated diseases. Those patients with arterial ulcers have a higher frequency of diabetes, myocardial infarction, and intermittent claudication than do those patients with venous ulcers, who, on the other hand, have more deep vein thrombosis and varicose veins.5 The various ulcer groups do not differ in smoking habits.

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Socioeconomic factors 

To analyze the socioeconomic factors, 78 patients with leg ulcers were compared with 271 control patients without ulcers, all of whom were identified in a population survey in Malmö and Skaraborg.5 Except for a significantly lower income in the ulcer group, there was a surprising lack of differences in socioeconomic factors. So, 74% of the patients with ulcers earned less than $12,500 per year as compared with 50% of the patients without ulcers. One important factor is the high frequency of immobile patients with leg ulcers. In the Skaraborg study, only 40% walked without some sort of support and 18% used a wheelchair regularly.

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Present treatment 

Leg ulcer treatment by tradition has been considered of secondary interest by most health care workers. This is reflected in the large number of various local treatments found in a recent survey in Uppsala county in which 113 types of local wound treatments were identified. Dressing changes were made by district nurses in 52% of the cases, by other health care workers in 40%, by relatives in 2%, and by the patients themselves in 6%. In 6% of the patients with venous ulcers, the dressings were changed 2 to 3 times daily; in 36%, once daily; in 37%, 2 to 3 times a week; and in 21%, once a week.11 In the Skaraborg study, 74% of the patients with venous ulcers used daily compression as compared with 22% of the patients with nonvenous ulcers.11 Pain is a major problem in both venous and nonvenous leg ulcerations.18, 19 In an interview study in the Uppsala county, 89% of all the patients with leg ulcers reported pain. The annual cost of venous leg ulcer treatment in Sweden has been calculated to 250 Swedish Kroner per day, which would be a yearly cost in Sweden of 2 billion SEK.5 This figure excludes the people in selfcare, who induce a substantial indirect cost for the society. Another way to express the cost is that, in a county of Uppsala's size (290,000 inhabitants), 57 nurses were occupied full time with leg dressing changes, which means a cost for salary of approximately 15 million SEK per year.

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Prognosis 

In the Skaraborg study, at a mean follow-up period of 54 months, 54% of the venous ulcers were healed, 43% were open, and 3% of the legs were amputated.20 In Uppsala, 40% of the leg ulcers were healed within 3 months. The recurrence of healed venous ulcers is common. In patients with current venous ulcers, as many as 33% have their fourth episode of ulceration and 60% to 70% are already recurrent.11, 21 The long-term outcome for patients with ulcers caused by deep venous insufficiency appears to be worse than for patients with ulcers caused by superficial venous insufficiency or perforating vein incompetence alone.11, 20 To prevent recurrence, adequate compression is extremely important.19, 22, 23 Leg ulcer clinics with dedicated health care personnel, a multidisciplinary approach, and systematic care programs can at least improve the short-term healing of ulcers in the community.24, 25 Treatment in leg ulcer clinics also seems to give a better quality of life.26 Patients with leg ulcers, as a group, have a significantly decreased 5-year survival rate as compared with a matched control population (67%).20 However, with the analysis of patients with ulcers on the basis of cause, patients with venous ulcer have a normal expected survival rate, whereas those with arterial ulcers and ulcers of other causes have a significantly decreased survival rate. Thus, patients with venous leg ulcers are likely to live with their ulcers for a long period of their life unless a curative treatment is offered.

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Concluding remarks 

The problem of leg ulcers seems to remain. The enormous costs to the society of leg ulcers have been realized. An often complex etiology makes diagnosis and proper classification of ulcers essential to provide optimal treatment. There is enough basic information to organize effective treatment pathways. A multidisciplinary approach seems to be a prerequisite for improvements in leg ulcer care. A substantial proportion of so-called “chronic” leg ulcers are not chronic provided that adequate treatment is given. Today there should be knowledge enough to substantially decrease the size of the leg ulcer problem.

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Acknowledgements 

We thank the Swedish Medical Research Council 00759.

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References 

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☆ Reprint requests: Dr David Bergqvist, Professor of Vascular Surgery, Department of Surgery, University Hospital, S-751 85 Uppsala, Sweden.

☆☆ 24/9/96438

PII: S0741-5214(99)70330-7

Journal of Vascular Surgery
Volume 29, Issue 4 , Pages 752-755, April 1999

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