Leg ulcers are a common problem but increasing co-morbidity makes them challenging to manage. Further research is needed to boost our understanding of complex wounds
In this article…
- Why leg ulcer management is becoming increasingly complex
- How age, obesity and multiple co-morbidities can impact on treatment
- Taking patients’ needs into account
Irene Anderson is senior lecturer, tissue viability, University of Hertfordshire; Susan Knight is Queen’s nurse and tissue viability specialist nurse, Milton Keynes Community Health.
Anderson I (2011) Managing venous leg ulcers. Nursing Times; 107: 35, early online publication.
Factors such as an ageing population, increasing rates of obesity and complex co-morbidities are complicating the management of venous leg ulcers. There is a need to improve leg ulcer care both through the skill of practitioners and overhaul of services. Best-practice guidelines must be followed while at the same time taking into account the needs of patients, who have much reduced quality of life due to their condition. Many aspects of leg ulceration which are not well understood and more research in areas such as surgical techniques and compression materials is needed to improve outcomes for patients.
Keywords: Venous leg ulcer, Obesity, Quality of life
- This article has been double-blind peer reviewed
- Figures and tables can be seen in the attached print-friendly PDF file of the complete article
5 key points
- Leg ulcers are complex wounds and should be managed by skilled practitioners
- Factors such as age, obesity and co-morbidity can affect the effectiveness of treatment
- A better understanding of the benefits of different compression materials is needed
- Surgery may be appropriate for some patients
- Quality of life is an important issue and patients’ needs should be taken into account
Leg ulcer management is becoming increasingly complex (Moffatt et al, 2007). Up to 3% of the population may experience leg ulceration and venous aetiology accounts for up to 80% of leg ulcers (Agren and Gottrup, 2007). However, factors such as age, obesity, and concurrent illness blur the divisions between standard classifications of venous, arterial and mixed aetiology ulcers and can complicate treatment.
Moffatt et al (2007) highlighted a study in Wandsworth where 34% of patients with leg ulcers were found to have complex aetiologies. This illustrates the importance of patient assessment being carried out by skilled practitioners who have the knowledge and experience to differentiate between aetiologies and are able to identify complicating factors such as arterial disease and co-morbidities before beginning treatment.
Injecting drug users are another group of patients who develop leg ulceration. These tend to be in the younger age groups, ranging from 15 to 44 years (Health Protection Agency, 2005). The actual prevalence of injected drug use in the UK is unknown, but in 2002, Lowe claimed that the actual number could be as high as 270,000. In 2007, Devey explained how prepared heroin is injected directly into a vein; the average addict will inject three times a day, every day. As surface veins become varicosed then deeper veins are used, for example the jugular vein or the femoral vein. The femoral vein can be used for years causing damage to the lumen and the formation of scar tissue, which leads to venous hypertension and hypertrophic skin changes (Devey, 2007).
The key management principles for venous leg ulcers are compression, leg elevation and exercise. However, many aspects of leg ulceration are not clearly understood and research is needed to ensure that patients have the best chance of healing and remaining healed for as long as possible.
Causes of venous ulcers
Venous ulcers are caused by chronic venous insufficiency. Venous blood reaches the heart from the lower leg largely through the action of the calf muscle pump, while valves in the superficial and deep veins prevent backflow. Any damage to the valves, for example from trauma, will render them unable to prevent backflow and venous blood will pool in the lower leg. This pooling leads to venous congestion and vasodilation, which in turn pushes fluid out of the blood vessel into the tissues as oedema.
Red blood cells also leak into tissues causing staining, known as haemosiderin staining, which is characteristic of chronic venous disease (Morison and Moffatt, 2004). Over a period of time, these events lead to skin changes and in many cases eventual ulceration of the leg (Anderson, 2006).
Venous disease affects lymphatic drainage, and oedema is often a result of a combination of problems in both the lymphatic and the venous system (Tiwari et al, 2003), and known as lympho-venous disease. Moffatt et al (2004) reported that more than a third of people with leg ulcers had concurrent lymphoedema.
Where there is significant lymphatic involvement, oedema may affect the thigh as well as the lower limb, requiring more complex treatment with compression bandaging, toe bandaging, lymphatic drainage and patient support (Williams and Mortimer, 2007).
Oedema can also be caused by cardiac or renal problems, so it is vital that the underlying problem is identified and the multidisciplinary team is involved in diagnosis and management (Moffatt et al, 2007). This could include the GP and a specialist leg ulcer or lymphoedema nurse or other suitably qualified and experienced practitioner.
A strong emphasis is being placed on the quality of leg ulcer management (Shorney, 2010), with the aim of making better use of resources and bringing greater focus on patients and carers. These changes will affect the way services are managed and funded, and quality metrics are being developed to guide standardisation and cohesiveness in services (DH, 2010).
Acronyms have begun to emerge from Department of Health documents that will affect the planning and provision of leg ulcer services. QUIPP or Quality, Innovation, Productivity and Prevention (DH, 2010) is a strategy that aims to improve quality of care while at the same time making efficiency savings. It is linked to CQUIN (Commissioning for Quality and Innovation) - a payment framework for achieving local quality improvements (NHS Institute for Innovation and Improvement, 2009). Underpinning these initiatives is a move for greater involvement of patients in shaping and assessing the quality of services through PROMs or Patient Reported Outcome Measures (NHS Information Centre, 2011).
The aim is that patients’ views on the impact of treatment on their quality of life will help to measure success and will also enable GPs and other health professionals to make more informed referrals (NHS Information Centre, 2011). Services need to be proactive in demonstrating improvements rather than retrospectively assessing care (Ousey and Cook, 2011; NHS The Information Centre, 2011).
Currently PROMS relate to specific procedures and do not encompass tissue viability in general. In order to establish the quality outcomes for the care of these patients there needs to be a set of standards against which services are measured; these should include patient safety, effectiveness, and experience (Shorney, 2010).
The key treatment for venous leg ulcers to aid healing and prevent recurrence is graduated compression therapy. The underlying theory for this relates to Laplace’s Law, which states that the pressure on the limb is determined by the bandage width (usually 10cm) and the application techniques of stretch (50%) and overlap (50%) - assuming the leg has a graduated profile with the ankle smaller than the calf (Moffatt et al, 2007).
In recent years there has much research on the way materials behave when applied as bandages or hosiery to the leg. Partsch (2005) and others (Mosti et al, 2008; Partsch et al, 2006) introduced the concepts of static stiffness and dynamic stiffness in an attempt to find a way of standardising the measurement of material performance. Using a pressure monitor the difference between the sub-bandage pressure is measured when the person is lying down and standing up (Partsch, 2005). This pressure is always measured is at the base of the calf muscle, where it joins the Achilles tendon (known as point B1) to ensure that measurements are consistent (Partsch et al, 2006).
One interesting point to come out of this ongoing research is that there is not necessarily a clear difference between the effects of long-stretch (elastic) bandages and short-stretch (inelastic) bandages. Multiple layers of elastic materials may act in a more inelastic way when layered with other elastic bandages.
For compression hosiery the materials used determine the stiffness of the garment and there are differences between manufacturers (Best Practice Statement, 2005). The clinical relevance of the behaviour of these materials relates to working and resting pressures, which will have an impact on patient comfort. For example, stiffer materials will give higher working pressures, which may have a greater impact on calf muscle function and oedema reduction (Partsch et al, 2006).
Surgical intervention has an important role in managing venous disease and reducing recurrence of leg ulceration. Barwell et al (2004) randomised 500 patients to have either compression therapy alone or superficial venous surgery and compression therapy. There was no advantage in having surgery with active ulceration but surgery after ulcers had healed reduced recurrence from 28% to 12% over a year.
Interestingly, when the team published results at four years the recurrence was 56% and 31%, although they were unable to ascertain if the patients in the follow-up had been wearing the class 2 compression hosiery as prescribed (Gohel et al, 2007). Unfortunately due to co-morbidities the researchers found that 46% of patients were unsuitable for surgery before the study began. The SIGN guidelines (2010) point out that there is a lack of good quality evidence on the impact of deep venous surgery.
Obesity is an increasingly important factor in venous ulcers. National guidance on obesity (National Institute for Health and Clinical Excellence, 2006) recommends diet and exercise for helping people to manage weight loss, with surgery generally recommended only for those with a BMI greater than 40.
Padberg et al (2003) did a study of 39 limbs in 20 obese patients who had clinical signs of severe venous disease. On investigation with Duplex ultrasound, they found 24 of the 39 limbs had little or no venous abnormalities. They concluded that the obesity itself caused venous deficits, probably due to the pressure put on the veins. They likened it to a type of ascites in the tissue (Padberg et al, 2003) compounded by excess fatty tissue compressing lymphatic vessels and veins (Stigant, 2009). There was also evidence of congestion and scarring in lymphatic tissue which would further reduce capacity.
The researchers did find that concordance with compression therapy was poor for active and healed ulcers, and this was partly due to physical factors such as patients being unable to reach (or see) their feet. The obesity was linked to varying degrees with heart failure, which further complicated patients’ ability to manage therapy and physical activity.
The study did not investigate healing rates, but the demographic data indicated that time to healing for patients was in excess of seven months and about 50% had ulcer recurrences within three years. The researchers’ overall conclusion was that morbid obesity itself contributes to venous disease.
Tobon et al (2008) carried out a literature review on obesity and venous disease and found that deficits in vitamins A and C, as well as zinc and protein levels, are common in such patients. They also established that a significant proportion of obese people included in studies are at risk of malnutrition, but it is unclear whether obesity adds specifically to the deficits and if the vitamin deficits in particular contribute to more prolonged ulceration in this patient group.
It should be noted that even surgical treatment of obesity can lead to vitamin and protein deficiencies (Wardle et al, 2011). NICE guidance (2006) stresses the importance of helping people to understand the health implications of obesity rather than focusing on how they look, which could reinforce low self-esteem. Stigant (2009) suggested that linking weight loss to specific effects such as reduced swelling can often be a useful motivating factor.
The National Bariatric Surgery Registry (NSBR,2010) concluded in its recent report that surgery was a cost effective way of improving health outcomes for this group of patients. The report indicated that bariatric surgery can induce sustainable weight loss in the morbidly obese patient compared with diet and pharmacotherapy. However, Wardle et al (2011) suggested the recommendations from this NSBR report on surgical interventions over diet and pharmacological treatment can leave many medical practitioners questioning the guidance in practical terms. Surgery can lead to some rare mechanical complications, infection, haemorrhage, strictures and nutritional complications. Without some form of intervention for example, how feasible is it to ask people with a BMI over 35 to follow diet and exercise alone when they have lower leg problems and low self-esteem? This highlights the potential importance of early intervention for the identification and management of lower leg oedema.
Other problems in treating this group of patients are highlighted by Booth et al (2011), who reviewed National Patient Safety Agency reports and found issues with inadequate provision of equipment, care pathways and obesity specific training. Generally equipment in clinics/surgeries is suitable for patients weighing up to 180–190kg, and couches/chairs are not wide or strong enough for patients exceeding this weight. This has implications for nurses managing this group and may indicate why some patients do not receive adequate management of their chronic oedema and associated venous disease/leg ulceration.
Quality of life
The impact of leg ulcer management on the way patients manage their activities of daily living needs to be assessed carefully and empathetically. Wearing bandages for up to a week will make it difficult to attend to personal hygiene, and while there are aids available to protect bandages from getting wet when showering bandages still make relatively simple procedures challenging.
Patients will probably be unable to wear their normal footwear while in active treatment with bandages, and alternatives may leave them vulnerable to falls, an inadequate range of ankle flexibility and social isolation if open-toed sandals or house slippers mean they cannot go outdoors in inclement weather (King et al, 2007).
In a systematic review of issues for patients living with venous and mixed aetiology ulcers, Herber et al (2007) found limitations on activities of daily living, concerns over body image, and psychological effects, all of which lead to anxiety and depression that is further compounded by increasing isolation.
A major issue – and one which patients often say is the worse part of having an ulcer - is the underestimation of the pain they experience (Hofman et al, 1997). The World Health Organization’s three-step ladder for managing pain provides a range of options from non-opioids to opioids (tinyurl.com/WHO-pain-ladder).
It is important that nurses really engage with their patients to understand the nature and triggers of the pain they experience. Too often things such as leg elevation, good skin management and choices in compression therapies are overlooked but can alleviate pain and discomfort.
Franks et al (2006) measured health-related quality of life in 95 patients with leg ulceration at 24 and 48 weeks. At 24 weeks all showed a significant improvement in pain regardless of whether the ulcer had healed. However, at 48 weeks both healed and unhealed patients had worse pain scores and lower energy levels. Unhealed patients also exhibited reduced mobility at 48 weeks. The deterioration was thought to be as a result of general ageing but it was interesting to see this effect regardless of healing.
The consequences of venous disease symptoms such as skin changes and itching, oedema and ulceration are clearly a heavy burden for patients, and concordance with treatment can be a major undertaking. This becomes more problematic in older people who also have dementia or other forms of cognitive impairment.
Managing symptoms such as pain and itching can be extremely difficult when the person affected cannot articulate discomfort or understand the reasons for treatment. Older people with complex conditions, especially those frail enough to need residential care, are already in a high-risk category and ulceration increases this risk further. Such patients have higher mortality rates than those without ulcers (Takahashi et al, 2008).
Ultimately, the relationship between the patient and nurse is crucial (Ebbeskog, 2001), especially in the management of a long-term condition such as leg ulcers preventing recurrence.
There is a need to improve leg ulcer care, especially among practitioners who are less engaged in developing skills and competencies (Knight, 2008; Anderson, 2003). There is a current focus on improving the quality of services and directly involving patients in the evaluation of outcomes.
Serious health issues such as obesity affect the way leg ulcer-related services are delivered, and a greater understanding of the needs of morbidly obese people is required so that lower limb breakdown can be prevented where possible and managed safely when problems occur. This needs to be combined with wider knowledge of how affected people can be supported to engage in healthier lifestyle choices.
A better understanding of the materials used in compression therapies would enable practitioners to select effective treatments while including the patients’ needs in the decision. Developments in surgical techniques for venous disease would enable more patients to benefit from surgical intervention, particularly to help prevent ulcer recurrence.
As some of our patients become older and both physically and mentally frailer, standard management techniques of compression, exercise and elevation become less applicable and we need to develop more effective strategies and management techniques to manage lower limb problems while minimising distress to people who have reduced and altered understanding of their condition and treatment.
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