Surgical treatment of trophic ulcers of the leg and foot

185 TRANSACTIONSOF THE ROYAL SOCIETY OF TROPICAL

MEDICINE AND HYGIENE.

Vol. XXVII.

No. 2.

July, 1933.

SURGICAL TREATMENT

OF T R O P H I C AND F O O T .

ULCERS

OF T H E

LEG

SKIN AUTO-PLASTIC OPERATION BY THE ITALIAN METHOD, PERIARTERIAL SYMPATHECTOMY, LUMBAR SYMPATHETICGANGLIONECTOMYAND RAMI-SECTION. BY

CESARE ROMITI, M.D. (ITALY). Surgeon at the Mackenzie Hospital, Demerara Bauxite Company, Ltd.; Hon. Consulting Surgeon, Public Hospital, Georgetown, British Guiana.

The object of this note is to describe one of the types of ulcer met with on the lower limb, and its treatment by surgical methods. The ulcer in question is very common in British Guiana, as, I suppose, it is in other tropical countries, where it is usually designated " tropical ulcer." It should, however, be distinguished from " tropical sloughing phaged~ena ulcer," an entirely different condition from that here considered. " Trophic ulcer " is the name, I think, most suitable: it conveys both the idea of the pathogenesis and localisation of the disease. This term is used to denote a chronic adynamic ulceration, localised on the lower part of the leg, the ankle or dorsum of foot ; it spreads very slowly, and though there is no tendency to invade the deeper structures, extension is associated with an intense connective tissue infiltration at its margins and in the underlying tissues ; it is always preceded by well-marked dystrophic alterations of the affected regions. In regard to its etiology and pathogeny, the following points have been noted :--1. Micro-organisms. Specific micro-organisms have not been isolated

186

SURGICAL TREATMENT OF TROPHIC ULCERS OF THE LEG AND FOOT.

from the affected tissues. At an early stage of the disease, the common pyogenic organisms are found in smear preparations from the ulcers. Staphylococcus pyogenes aureus and a Streptococcus have been recovered from the same material by cultivation. In old standing cases, these organisms are still found but in very small numbers. Bacteriological investigations in twenty-five cases gave the following results : Pure cultures of a Streptococcus were obtained in four cases. Pure cultures of Staphylococcus pyogenes aureus were obtained in nine cases. In twelve cases both organisms were present. 2. Age and Sex.--Males are more often affected than females ; the disease is commoner among young adults, but is not observed in young children. 3. Race.--The disease is met with among Negroes and East Indians, very occasionally in other races. Race has no importance in itself, but the disease is prevalent among people who go barefooted and work in watery places, and, in those who are physically debilitated, owing to chronic malaria, intestinal helminthiasis (mainly ancylostomiasis), avitaminosis, etc. 4. Dystrophic affections are always well marked and are a regular factor in the production of this type of ulcer. These dystrophic conditions are very numerous and varied ; they will be described in the section dealing with the clinical features of this disease. Two main causes lead to these dystrophic conditions of the lower limb : the first is to be found in the recurring septic infections of the skin from childhood onwards, which, as a rule, are improperly treated and result in sores which take a very long time to heal and leave extensive scars. It is about the sites of these sores that the conditions now being considered arise. The second main cause lies in the constant exposure of the leg and foot to muddy water, which leads to sclerous atrophy of the skin of the exposed areas. Once the trophic alterations are established, any incidental lesion associated with sepsis will see the onset of an ulcer, which in old standing cases has all the typical characteristics of a callous ulcer. C L I N I C A L FEATURES.

The regions affected are exclusively the leg, ankle and dorsum of foot, most commonly the lower third of the leg and about the inner malleolus. The ulcer is, as a rule, single, but the presence of two or more ulcers may be observed. Scars from previously healed ulceration are generally present, and it is always in the centre of an area in which marked trophic alterations have occurred that the ulcer will be found. A history of some minor injury is most constantly obtained at the onset of the disease, in other cases a boil, a pustule, or an insect bite may be traced, starting as a small abrasion, or slight punctured wound,

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a small infected wound resulting, which shows no tendency to heal. Gradually it enlarges but without any phagedoenic process; its base instead of being covered with healthy granulations, remains atonic and greyish in colour, while the margins have a tendency to become thickened due to infiltration of the connective tissues without undermining. There is no sloughing though the secretion in some cases may be purulent. There are but very slight signs of local inflammatory reaction. These ulcers do not cause pain. There are no general symptoms and no fever. The margins are clean cut and there are no signs of proliferation of the epithelium to cover the solution of continuity. If in its initial stage the condition is properly treated, healthy granulation and epithelialisation will result in healing. It should be pointed out that the healing process, even if these sores are treated properly from the initial stage, takes a much longer time than usual. If instead at this stage the ulcer is neglected or improperly treated (as very often happens), infiltration of connective tissues around and in the underlying tissues ensues and a typical ulcer is formed. In the old standing case, the margins are raised, thick and hard in consistence ; the base is pale with but very slight secretion, and adherent to underlying tissues. The widespread connective tissue infiltration may lead to deformity due to cicatricial contraction, as well as to an elephantoid condition of the skin of the part. Other changes may be noted :--

1. Sclerous atrophy of the skin.--A change never observed above the middle third of the leg. The skin is shiny, smooth, hairless ; it cannot be pinched up in folds between the fingers. Whitish patches are often present. 2. Hyperpigmentation.--This may be noted around the ulcer. It presents the characteristics of the hyperpigmentation associated with chronic varicose conditions of the leg. The pigmentation may be localised in the malleolar region only, but in old standing cases it is very extensive and diffuse. It can be easily distinguished even in black or dark-skinned patients, so marked is the increase in the colour of the skin. 3. Eczema.--The most common feature is a dry eczema with furfuraceous scales or with large scales partially detached. 4. Alterations of nails.--Dystrophic changes in the nails have been very frequently observed. Sub-ungual hyperkeratosis, with atrophic changes, consisting in thinning of the nail-plate, transverse furrowing, unusual brittleness and the free edge of the nail fissured and broken, are constant findings in these patients ; in two cases a claw-like condition resulted. 5. Alterations of the sweat glands.--Anidrosis over the affected areas may be observed. More commonly hyperidrosis is present and the limb, then, is constantly cold and clammy. 6. Partial or complete loss of hair is the unavoidable consequence of the atrophic condition of the skin. 7. Sensibility of the affected areas is always markedly altered ; sensibility

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SURGICAL T R E A T M E N T OF T R O P H I C ULCERS OF T H E L E G A N D

FOOT.

to thermic, tactile and painful stimuli, is entirely abolished in the areas immediately surrounding the ulcer, with a gradual approach to the normal, increasing from the region of the ulcer toward the parts of the limb where the skin is normal and healthy. Patients complain of numbness of the lower limbs. 8. Superficial circulation is very poor and the affected limbs are always cold and pale. In conclusion, the principal cause of this type of ulcer lies in the dystrophic conditions of the lower limbs, and it cannot occur if these conditions are absent. Its localisation is always in the lower part of the leg and dorsum of foot. Similar ulcers have not been observed in the upper third of the leg. DIFFERENTIAL DIAGNOSIS. The diagnosis of " trophic ulcer " is by no means difficult, as the trophic alterations of the limb are always very evident. It may be easily differentiated from " ulcus tropicum " (phagedenic or sloughing tropical ulcer) on account of the absence of slough, the absence of phagedena and the absence of the fuso-spirillum organism in scrapings from the ulcer; and differs from it in the clinical course and characteristics. The " tropical ulcer " is very rapid in its onset and evolution ; it occurs in limbs in which the integuments are as a rule normal ; the ulcer is occupied by a thick slough forming an adherent pseudomembrane made up of necrotic tissues, putrid, dark greenish in colour. The secretion from the ulcer is very abundant. It is extremely painful and its base is soft and ~edematous. Its localisations are various, and, as a rule, different from those of the trophic ulcer. All these characteristics are absolutely the opposite of those observed in trophic ulcer, which is very slow in its onset and evolution. Ulcus tropicum heals very quickly with appropriate treatment. In the cases of tropical ulcer which I have observed, local application of " luatol " or of calomel powder effected a cure in a few days, while the same treatment does not alter in any way,the elir/ical course of trophic ulcer. In the differential diagnosis from syphilitic ulcers of the leg, the Wassermann test may be useful, but, as in this country, among the general population, the percentage of positive Wassermann reactions is rather high, the differential diagnosis will be more reliably based on the clinical features of the diseases. Gummatous ulcers are usually multiple ; they are scattered in all regions of the leg, mainly in the calf and upper third ; they are punchedout and regular in outline with a tendency to join together. The characters of the base and margins are typical, and there is never such an extensive infiltration of the surrounding connective tissues as in the trophic ulcer. In one of my cases of trophic ulcer of the leg, in which the Wassermann reaction was positive, specific treatment (N.A.B. intravenously) did not cause any change in the ulcer, though later it reacted to treatment by periarterial sympathectomy.

2

TROPflIC ULCER. Fig. l.--Distrophic alterations of leg, predisposing to the formation of trophic ulcer. Fig. 2.--Same alterations and a trophic ulcer forming from a small injury. Fig. 3 . - - A trophic ulcer of the ankle. "l'o face [~aA,e l S ~ .

6

DIFFERENTIAL DIAGNOSIS. Fig. 4 --Phagedenic ulcers from strepto-staphylococcal infection. Note the integrity of the skin and the undermining of the edges of the ulcers. The three ulcers, situated in the centre and united by narrow cutaneous bridges, were nearly fused together as the triangular flap of skin was completely undermined. Figs. 5 and 6.--'Fypical appearance of the trophic ulcer (tropical-sloughing phagedena) from association of spirilla and fusiform bacilli. Note the dome of the ulcer from sloughing, the intensive secretion and the integrity of the conditions of the skin of leg and foot.

CASE OPERATED ON BY PERIARTERIAL SYMPATHECTOMY. Figs. 9 and 10.--Before operation.

Figs. 11 and 12.--After operation.

CASE OPERATED BY LUMBAR ~YMI"ATHF.TIC GANGI_IONECTOMY AND RAMI-SECTION.

Fig. 13.

Before operation. Fig. 14. Twenty days after operation. Fig. 15. One year after operation. Figs. 7 and 8. Before and after operation. By Italian plastic.

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The differential diagnosis of varicose ulcer deserves careful consideration, as the clinical and pathological features in the two conditions are in many ways similar. There are, however, some fundamental features which lead to an easy differentation between the two diseases, and they might well be grouped together. The first point is the age at which trophic ulcer, occurs ; it is a condition of early adult life, at an age when varicose ulcer is exceptional. The second is the constant absence of varicosity of the venous system of the leg in patients suffering from trophic ulcers. The third is the absence in cases of trophic ulcer of cedema from venous stasis. The last point of difference is the localisation, trophic ulcer being frequently seen on the dorsum of the foot--a region in which varicose ulcers have never yet been described. The photographs of some cases of ulcers of the lower limb observed by the author in British Guiana, show better than any description the differential characters upon which diagnosis can be advanced. (Plates I to IV). TREATMENT.

General considerations : The treatments of trophic ulcers of the leg and foot are of various kinds. (a) Treatment may be applied directly to the ulcer, in an attempt to obtain healing without consideration of the causes and pathogenesis of the disease, or (b) treatment may aim exclusively at modifying the dystrophic conditions which constitute the underlying cause of the ulcer and its persistence as an otherwise chronic condition. The former methods, (a), are mainly represented by medical treatment, the latter, (b), by surgical treatment including treatment by wholesale excision and skin grafting.

(a) Medical Treatment. The success of any medical treatment, for this type of ulcer, depends entirely upon the stage of the dystrophic processes in the limb. If these are advanced and the ulcer is situated in the middle of a hard scar with a very extensive infiltration of all surrounding connective tissues, the limb cold, pale and clammy, very little may be expected from any medical treatment; and from my experience it would hardly be advisable to waste any time in attempting it. The same is true of cases in which elephantoid conditions, etc., are present. It is not proposed here to deal with the various medical treatments which have been used from time to time.

(b) Surgical Treatment. The indications for treatment by surgical measures have been discussed above.

190

SURGICAL TREATMENT OF TROPHIC ULCERS OF THE LEG AND FOOT.

It is the proper treatment for all old-standing cases with callous ulcers and for cases in which ulceration has recurred after partial or complete healing under medical trefitment. Three different surgical procedures have been adopted for the treatment of trophic ulcers :-1. 2. 3.

Excision and skin-grafting. Periarterial sympathectomy. Lumbar sympathetic ganglionectomy and rami-section.

Skin Auto-Plastic Operation according to the Italian Method. Thiersch skin-grafting has been tried in a few cases but the method gave unsatisfactory results. The ulcer cannot be brought into a suitable condition for such grafts, owing to persistence of sepsis and the associated dystophic conditions. It is, therefore, necessary to turn to the methods of the plastic surgeon. Here again it has been found that in practice it is generally impossible to obtain an auto-plastic skin-flap from a region sufficiently near the area of excision owing to the dystrophic condition of the skin of the limb. The impossibility of repairing the flap wound is another point against this method. The only satisfactory means in my experience is the adoption of the Italian method, the skin-flap being obtained from the other leg. The advantages are that healthy skin is used, torsion of the pediele can be avoided, the blood supply to the flap is never in jeopardy, the raw surface left after the flap is cut is more easily dealt with. Periarterial Sympathectomy. The nature of the pathological processes underlying trophic ulcer would appear to be an indication for this method of treatment. Trophic disturbances are the chief factor in the production of this type of ulcer and any method by which the nutrition of the part can be improved is one of great value. LE~ICHE, in 1911, introduced this operation into surgical practice, since when a large literature has accumulated. UFFREDUZZI (1924), makes the following points concerning the changes which follow periarterial sympathectomy : (a) Contraction of the artery with transitory isch~emia of the limb is the immediate consequence of the operation. This condition lasts about 6 hours and is followed by an intense vasodilation with increase of temperature of the limb, etc. This active hyper~emia persists for a period lasting from three weeks to three months. (b) The active hypermmia of the limb is followed by considerable modifications in the aspect of the ulcer and resolution and healing processes are markedly accelerated.

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(c) There is a rapid decrease in the number of bacteria present in the ulcer. While healing is thus promoted, something is also effected towards rendering the tissues permanently more healthy. It must be admitted, however, that when the vasodilatation due to the sympathectomy is over, any occasional cause may again disturb the trophic equilibrium and the ulcer will be liable to relapse.

Lumba~ Sympathetic Ganglionectomy and Trunk Resection. This type of operation, which has been very largely practised at the Section of Neurologic Surgery of the Mayo Clinic * for treatment of various vasospastic diseases, does not appear to have yet been used in the treatment of trophic ulcers such as those herein described. It represents a great advance on simple periarterial sympathectomy, with its temporary beneficial effects: by sympathetic ganglionectomy and trunk resection, an increased flow of blood leading to a permanent increase in surface temperature is obtained. ADSON and BROWN (1930), favour lumbar ganglionectomy including the second, third and fourth ganglia, as well as resection of the accompanying lumbar sympathetic trunk and rami. I have followed the technique described by AoSON (1929), in six cases on which I have operated by lumbar sympathetic ganglionectomy and ramisection (two cases of trophic ulcer, one of perforating ulcer of the foot, two cases of Raynaud's disease, and one case of chronic arthritis.) REPORT OF CASES. A total of 84 cases of trophic ulcers of leg and foot have been treated at the Mackenzie Hospital during a period of four years. During the same period, a total of twelve ulcers of the leg other than trophic were treated and they are classified as follows : Tropical phagedenic ulcers Strepto-staphylococcal phagedenic ulcer

5

Varicose ulcers Syphilitic ulcer

5 1

1

The tropical ulcers were all observed in young children of mixed and Negro race, the youngest was 3 years, the oldest 12 years of age. In all cases, Spirillum and fusiform bacilli were recovered from the ulcers. Cure was rapidly obtained in two cases by local application o f " luatol " and in three cases by local application of calomel powder. *I desire to thank Drs. ADSON,MACCP.AI¢and LEARMONTH(nOwProfessor of Surgery at Aberdeen University) of the Neurogic Section of the Mayo Clinic, for their kindness in showing me all details of the lumbar sympathetic ganglionectomy during my visit to Rochester, Minn., U.S.A., during 1930 and 1932.

192

SURGICALTREATMENT OF TROPHIC ULCERS OF THE LEG AND FOOT.

The phagedenic strepto-staphylococcaI ulcer was noted in a young man of 20 years and cured by Alibour's water application. The varicose ulcers were all observed in patients over 50 years of age and cured in an average time of twelve days by Schiassi's operation. The syphilitic ulcer was cured by specific treatment (N.A.B.). ANALYSIS OF THE EIGHTY-FOUR CASES OF TROPHIC

ULCERS OF THE

LEG AND FOOT.

Number of Ulcers:

Sex :

Male patients Female patients Age : 0 to 9 years 10 to 19 ,, 20 to 29 ,, 30 to 39 ,, 40 to 49 ,, 50 and over Race : Negro East Indian Aboriginal Indian Portuguese

74 10

Single ulcers noted in 71 cases Multiple . . . . 8 ,, Single ulcers bilaterally in 5 cases

0 11

Localization of Ulcers :

38 19 8 8

Middle and lower Case8 third of leg 35, right leg left Ankle 28, right inner outer left inner outer Dorsum of foot 21, right foot left ,,

48 26 5 5

16 19 10 8 7 3 11 10

RESULTS FROM MEDICAL TREATMENTS.

Sixty-five early cases were treated without surgical interference. About 50 per cent. of these cases were discharged with the ulcer completely healed. In the others, healing of the ulcer proceeded quickly until its size was reduced to a fraction of an inch in diameter, but then there was no further progress in the repair, in spite of any kind of treatment. If these cases were left without treatment and with only a simple protective dressing, in a very short time the ulcer entirely broke down again to its original size. Strapping or occlusive dressing by plaster (elastoplast, diaehylon, zopla, etc.), was adopted in some of these patients. The healing of the ulcer in every such ease took rather a long period, counted at least in weeks and not seldom in months. The greater number of cases, sooner or later, had a relapse of the ulcer. To conclude in regard to medical treatments, healing of trophic ulcers of the leg and foot may be obtained, but from my experience every form of medical treatment has in common the following disadvantages : 1. In all eases the cause of the disease is not removed. 2. Early or late relapse of the ulcer is the rule.

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3. Not every case is liable to improvement or cure by medical treatment only ; old-standing callous ulcers react very poorly to medical treatments. 4. Deformities complicating the ulcers--such as retracted scars impairing the function of the limb, from intensive connective infiltration of the region around the ankle, and varying from simple stiffness to total immobilisation with foot in flexed position--are not liable to improve under medical treatment. 5. The healing of the ulcer takes a long period of time. 6. The healing of the ulcer is obtained by the formation of a very thick scar which, in some instances amounts in itself to a deformity. RESULTS FROM SURGICAL TREATMENT.

Surgical treatment has been adopted in nineteen cases of trophic ulcer. Of these twelve cases were operated on by the skin auto-plastic operation according to the Italian method, five cases by periarterial sympathectomy, and two cases by lumbar sympathetic ganglionectomy and rami-section. All cases operated on exhibited very old standing ulcers which had relapsed repeatedly after complete healing by medical treatment. So far, no recurrence of the ulcer has occurred after operative treatment, but as far as the cases, in which peri-arterial sympathectomy was performed, are concerned, it would not be surprising if a recurrence of the ulcer took place for the reasons already given. All cases operated on by skin auto-plastic operation (Italian method) healed completely without trouble. Re-examined, after an interval of over three years, the skin grafts were found to have maintained their normal characteristics and the place where the graft was done could hardly be distinguished from the normal skin; retracted scars had to be excised in some cases to restore the movements of the ankle. Auto-plastic skin grafting is a method of wide application and the large size of the ulcer is not a contra-indication to this treatment. The advantages of this operation are :-1. It is efficacious in curing the ulcer, regardless of how long standing it may be, and even if the operation does not modify the dystrophic conditions of the limb. 2. It is the only method of treatment by which deformities such as those caused by retracted scars can be improved or cured. 3. It is the only method of treatment which provides a normal covering of healthy skin and avoids the inconvenience of a large scar. 4. The operation does not present risks and its performance is very simple. The operation on the sympathetic is more particularly indicated in cases in which owing to the position and extent of the ulceration an auto-plastic operation is impossible or when the dystrophic condition would appear to demand it.

194

SURGICAL TREATMENT OF TROPHIC ULCERS OF THE LEG AND FOOT.

Of the two operations upon the sympathetic, lumbar sympathetic ganglionectomy and rami-section represents the ideal, as it is the operation of choice to cure the dystrophic alterations of the limb permanently. The one objection to this method is that it entails a major operation demanding a skilled surgeon. REFERENCES. Aoso~, A. W. (1930). The surgical indications for sympathetic ganglionectomy and trunk resection, etCo Bull. New York Acad. Med. Sec. Ser., vi, 17. ADSON, A. W. & BROWN,G . E. (1929). The treatment of Raynaud's disease by resection of the upper thoracic and lumbar sympathetic ganglia and trunks. Surg. Gyn. & Obstet., 577-603. UFFREDUZZI,O. (1924). La chirurgia del simpatico perivasale. Arch. ed Atti Soc. Ital. Chit., IIa, 1.