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Bilateral Amputation for Intractable Venous Ulceration
EJVES Extra 3, 45–46 (2002) doi:10.1053/ejvx.2002.0133, available online at http://www.idealibrary.com on
SHORT REPORT
Bilateral Amputation for Intractable Venous Ulceration S. Mercer∗ and P. Barker Royal Navy, Defence Medical Services Professor of Clinical Surgery, Surgical Directorate, Royal Hospital Haslar, Gosport, Hampshire PO12 2AA, U.K. Key Words: Venous ulcer; Amputation.
Introduction Leg ulcers affect some 15% of the population over the age of 70.1 Although a proportion of leg ulcers are associated with arterial insufficiency, about 54% are deemed to be purely due to venous disease.2 The vast majority of these will heal with conservative management,3 although some 10% will require surgical intervention to promote healing. In a small number of cases, where all efforts to achieve healing have failed, amputation may be the final means of controlling patients’ pain and suffering. We describe a case of bilateral leg amputation for venous disease.
Case Report An 80-year-old man was reviewed in the out-patient clinic with bilateral venous ulcers. He had a long history of venous insufficiency and leg ulcers, and had previously undergone split-skin grafting to his right leg in 1998. Four-layer bandaging was commenced, and tests were carried out which ruled out diabetes and vasculitides. He was admitted to hospital for treatment for pain and bleeding from the ulcers on the right foot, which appeared necrotic down to the periosteum; there were ulcers on the left ankle that were at least as advanced. Hand-held Doppler studies at the time showed an ABPI of one on each side, ∗ Please address all correspondence to: S. Mercer, Royal Navy, Defence Medical Services Professor of Clinical Surgery, Surgical Directorate, Royal Hospital Hasler, Gosport, Hampshire PO12 2AA, U.K. 1533–3167/02/ $35.00/0 2002 Published by Elsevier Science Ltd.
with all Doppler waveforms within normal limits. He underwent debridement and dressings and his pain was controlled with opiate analgesia. Despite maximal conservative management his ulcers showed no improvement, his pain increased and his depression deepened. He was offered bilateral amputation as a means of ridding him of his pain, avoiding the need for continuous dressings and hospital attendances, and achieving wheelchair independence. After long discussions he was certain that this offered him the best way forward, and agreed that it could considerably improve his quality of life. Accordingly he underwent bilateral through-knee amputations with no peri-operative complications. When he was discharged 11 days post-operatively for rehabilitation, he was painfree and his stumps were healing well. Unfortunately he died of congestive failure 3 weeks later.
Discussion The prevalence of venous ulceration in the community is around 0.16%2 and a significant proportion of the health care budget is spent in lengthy treatment of varicose ulcers.4 After 4 months of treatment, only around 75% of ulcers have healed, although 96% of ulcers will eventually heal with conservative measures alone.3 Once an ulcer has healed, then elective surgical procedures may be carried out to correct the underlying venous hypertension; ligation and stripping of the long saphenous vein, perforator surgery and subfascial endoscopic perforator surgery may all reduce ulcer recurrence if used appropriately. If an ulcer
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S. Mercer and P. Barker
remains static or enlarges despite maximal conservative measures, then operative management is indicated; the ulcer base can be excised back to healthy tissue and pinch grafts may be applied to the ulcer base. The last resort is amputation; in the U.K. some 5000 major limb amputations are carried out each year, but less than 2% of these are purely for venous disease.5 Amputation is a radical but definitive treatment for what can be a disabling and painful condition. We believe that this is the first reported case of a bilateral amputation for ulceration that was purely venous in aetiology, and would recommend its consideration in cases of intractable pain and suffering due to non-healing venous ulcers.
EJVES Extra, 2002
References 1 Callam MJ, Ruckley CV, Harper DR, Dale JJ. Chronic ulceration of the leg: extent of the problem and provision of care. Br Med J 1985; 290: 1855–1856. 2 Nelzen O, Bergqyist D, Lindhagen A. Venous and non-venous leg ulcers: clinical history and appearance in a population study. Br J Surg 1994; 81: 182–187. 3 Marston WA, Carlin RE, Passman MA et al. Healing rates and cost efficacy of out-patient compression treatment for leg ulcers associated with venous insufficiency. J Vasc Surg 1999; 30: 491–498. 4 Carr L, Philips Z, Posnett J. Comparative cost-effectiveness of four-layer bandaging in the treatment of venous leg ulceration. J Wound Care 1999; 8: 243–248. 5 Statistics and Research Division, Department of Social Security/Department of Health. Amputation Statistics for England, Wales, Northern Ireland, 1986. London: DSS, 1989.
SHORT REPORT
Bilateral Amputation for Intractable Venous Ulceration S. Mercer∗ and P. Barker Royal Navy, Defence Medical Services Professor of Clinical Surgery, Surgical Directorate, Royal Hospital Haslar, Gosport, Hampshire PO12 2AA, U.K. Key Words: Venous ulcer; Amputation.
Introduction Leg ulcers affect some 15% of the population over the age of 70.1 Although a proportion of leg ulcers are associated with arterial insufficiency, about 54% are deemed to be purely due to venous disease.2 The vast majority of these will heal with conservative management,3 although some 10% will require surgical intervention to promote healing. In a small number of cases, where all efforts to achieve healing have failed, amputation may be the final means of controlling patients’ pain and suffering. We describe a case of bilateral leg amputation for venous disease.
Case Report An 80-year-old man was reviewed in the out-patient clinic with bilateral venous ulcers. He had a long history of venous insufficiency and leg ulcers, and had previously undergone split-skin grafting to his right leg in 1998. Four-layer bandaging was commenced, and tests were carried out which ruled out diabetes and vasculitides. He was admitted to hospital for treatment for pain and bleeding from the ulcers on the right foot, which appeared necrotic down to the periosteum; there were ulcers on the left ankle that were at least as advanced. Hand-held Doppler studies at the time showed an ABPI of one on each side, ∗ Please address all correspondence to: S. Mercer, Royal Navy, Defence Medical Services Professor of Clinical Surgery, Surgical Directorate, Royal Hospital Hasler, Gosport, Hampshire PO12 2AA, U.K. 1533–3167/02/ $35.00/0 2002 Published by Elsevier Science Ltd.
with all Doppler waveforms within normal limits. He underwent debridement and dressings and his pain was controlled with opiate analgesia. Despite maximal conservative management his ulcers showed no improvement, his pain increased and his depression deepened. He was offered bilateral amputation as a means of ridding him of his pain, avoiding the need for continuous dressings and hospital attendances, and achieving wheelchair independence. After long discussions he was certain that this offered him the best way forward, and agreed that it could considerably improve his quality of life. Accordingly he underwent bilateral through-knee amputations with no peri-operative complications. When he was discharged 11 days post-operatively for rehabilitation, he was painfree and his stumps were healing well. Unfortunately he died of congestive failure 3 weeks later.
Discussion The prevalence of venous ulceration in the community is around 0.16%2 and a significant proportion of the health care budget is spent in lengthy treatment of varicose ulcers.4 After 4 months of treatment, only around 75% of ulcers have healed, although 96% of ulcers will eventually heal with conservative measures alone.3 Once an ulcer has healed, then elective surgical procedures may be carried out to correct the underlying venous hypertension; ligation and stripping of the long saphenous vein, perforator surgery and subfascial endoscopic perforator surgery may all reduce ulcer recurrence if used appropriately. If an ulcer
46
S. Mercer and P. Barker
remains static or enlarges despite maximal conservative measures, then operative management is indicated; the ulcer base can be excised back to healthy tissue and pinch grafts may be applied to the ulcer base. The last resort is amputation; in the U.K. some 5000 major limb amputations are carried out each year, but less than 2% of these are purely for venous disease.5 Amputation is a radical but definitive treatment for what can be a disabling and painful condition. We believe that this is the first reported case of a bilateral amputation for ulceration that was purely venous in aetiology, and would recommend its consideration in cases of intractable pain and suffering due to non-healing venous ulcers.
EJVES Extra, 2002
References 1 Callam MJ, Ruckley CV, Harper DR, Dale JJ. Chronic ulceration of the leg: extent of the problem and provision of care. Br Med J 1985; 290: 1855–1856. 2 Nelzen O, Bergqyist D, Lindhagen A. Venous and non-venous leg ulcers: clinical history and appearance in a population study. Br J Surg 1994; 81: 182–187. 3 Marston WA, Carlin RE, Passman MA et al. Healing rates and cost efficacy of out-patient compression treatment for leg ulcers associated with venous insufficiency. J Vasc Surg 1999; 30: 491–498. 4 Carr L, Philips Z, Posnett J. Comparative cost-effectiveness of four-layer bandaging in the treatment of venous leg ulceration. J Wound Care 1999; 8: 243–248. 5 Statistics and Research Division, Department of Social Security/Department of Health. Amputation Statistics for England, Wales, Northern Ireland, 1986. London: DSS, 1989.