Management of leg ulcers

Editor,—I congratulate Sarkar and Ballantyne for their excellent review on the management of leg ulcers.¹ Additional comments regarding investigative methods of peripheral arteriopathy and the management of venous leg ulcers are, however, necessary.

In the United States, more than 1200 amputations are performed each week for a diabetic foot ulcer.² One of the main cause of non-healing ulcer in diabetics is peripheral arteriopathy, which is often underestimated. In these patients, the ankle/brachial pressure index (ABI) is not sensitive enough. Falsely raised values are frequent in the case of incompressible arteries (mediocalcinosis), especially in diabetics, but they are also found in elderly patients or in those with chronic renal failure. An ABI in the normal range is also observed in hypertensive or diabetic subcutaneous microangiopathy. Therefore, an arterial duplex ultrasound is recommended as well as recording the toe blood pressure or the skin perfusion pressure by plethysmography or laser Doppler.

Almost all venous leg ulcers can heal with adequate compression therapy. However, 30% to 40% of patients with venous leg ulcers have an isolated superficial venous incompetence that can be treated with surgery alone, avoiding long term use of compression bandages and reducing recurrence rate.^{3  4} Some degree of superficial reflux in the ulcer area is also found in patients with deep venous incompetence. Treatment of these local haemodynamic abnormalities may be an important factor in the healing of the ulcers and in prevention of their recurrence. Consequently, venous surgery is a good alternative for many patients, especially the elderly who have difficulties putting on compression stockings and those with peripheral arteriopathy, which may be aggravated with it. Phlebectomies of saphenous veins and their branches with ligation of incompetent perforating veins can be done under local anaesthetic and are therefore particularly suitable for elderly patients.⁵ Preoperative duplex ultrasound is, however, necessary to localise precisely the incompetent venous segments.