Standard, Appropriate, and Advanced Care and Medical-Legal Considerations: Part Two—Venous Ulcerations (B)

William J. Ennis, DO, MBA,FACOS; Patricio Meneses, PhD

This is part B of "Standard, appropriate, and advanced care and medical-legal considerations: Part two—Venous Ulcerations.


There are numerous references concerning surgical options for the treatment of venous ulcers. The surgical interventions are divided into those that address the underlying venous hemodynamics and those that are specific to the wound bed. Surgical procedures have focused on the treatment of varicose veins and the correction of reflux or obstruction. Despite advances, such venous valve transplantation, cross-over bypass, banding techniques, and valvuloplasty, there are few agreements in the literature as to the long-term benefits for any of these procedures.[139–142] As noted in the compression therapy literature, one major problem is the use of a consistent classification system to describe patient populations. Inconsistencies in the performance of surgical procedures also complicates the issue. In one prospective audit for surgery on varicose veins, inadequate surgical elimination of incompetent veins was noted in 13 of 15 cases.[143] Inadequate success rates and patient morbidity led to the development of subfascial endoscopic perforator ligation surgery.[144–147] This modern day “Linton procedure” allows the surgeon to visualize the perforator veins with video equipment and minimizes morbidity through the use of small endoscopic trocar incisions. Another interesting approach has been the removal of periwound lipodermatosclerotic tissue as well as the ulcer with the use of a dermatome.[148]

The other focus of surgical treatments for venous ulcers addresses the wound bed itself. Many clinicians employ local wound debridement to prepare the wound for grafting, which may jump start the wound by converting a chronic wound into an acute wound. Another benefit of surgery is to remove debris and lower the wound bioburden. There are numerous methods of debridement, including autolytic, enzymatic, mechanical, and surgical. The surgical approach is the most expeditious, but good results can be obtained with the use of occlusive dressings and autolytic debridement. Again, the literature offers us little in the way of randomized, controlled trials to select the best method for any given clinical scenario. One highly cited paper offers insight into improved clinical outcomes through the use of debridement as part of the standard wound healing protocol.[149]

Skin grafting. The ultimate goal for all chronic wounds is total closure. Skin grafting is, therefore, an attractive option because with one procedure a patient can potentially be healed. Skin grafting is defined as the transfer of free, unattached donor skin to a noncontiguous recipient area.[150] Skin grafts can be partial or full thickness, and the donor can be human (allograft) or animal (xenograft). Initially, it was thought that skin grafts functioned as tissue replacement therapy, with the graft surviving in the recipient wound bed. Recent work with cultured tissues and bioengineered products has led to the observation that donor tissues may not be visually rejected but may be slowly replaced after providing a stimulus for the wound to go on towards healing (silent rejection). Allografts are thought to behave this way, and autografts may follow a similar process.[150] There is a negative perception in the medical community about the clinical success of skin grafting for venous ulcers.



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