1. Allama Iqbal Medical College, Lahore, Pakistan; maira_younas@aimu.edu.pk
2. Allama Iqbal Medical College, Lahore, Pakistan; mehreenyounas@aimu.edu.pk

*             Correspondence: maira_younas@aimu.edu.pk

Keywords: venous, ulcer, healing, trendelenburg procedure, stab avulsion, reduction in wound size

1. INTRODUCTION

Venous ulcers are a global issue that negatively affects patients’ quality of life, places a strain on healthcare systems, and has a significant socioeconomic impact [1]. About 80% of instances of leg ulcers are venous ulcers, which are the most prevalent kind [2]. Venous ulcers most frequently occur above the medial malleolus (gaiter area); they also occur above the lateral malleolus in 20% of cases, and circumferential ulcers occur seldom [3, 4]. Venous ulcers affect more women than men and have a 0.6-2 percent worldwide prevalence. There are two types of venous ulcers: acute and chronic [5]. When there is a recurrence or no healing of the wound after six weeks, a leg ulcer is classified as chronic [6]. Half of the ulcers cure in four to six months, one-fifth remain unhealed after two years, and eight percent do not heal for more than five years [7]. Old age (≥55 years), female sex, obesity, history of deep vein thrombosis (DVT) and pulmonary embolism (PE), lower limb skeletal or joint disease, multiple pregnancies, lack of physical activity, history of ulcers, severe lipodermatosclerosis, and jobs requiring extended standing are risk factors for the development of venous ulcers [8]. Because of valve failure and insufficient blood pumping from the lower leg during walking, the mechanism underlying lower leg venous ulcers is elevated venous pressure and associated edema, which is transmitted to the venous end of the microcirculation through superficial veins and perforators. This leads to blood stasis at the microcirculation level, which ultimately results in tissue hypoxia. This results in changes to the tissue, which eventually lead to tissue damage when the disease reaches its end [9]. Trendelenburg operation, stripping, laser, sclerotherapy, subfascial endoscopic perforator surgery, radiofrequency ablation (RFA), and minimally invasive surgery are some of the treatment modalities [10, 11]. Effective open surgery requires a hospital stay and is performed under spinal or general anaesthetic. It might be connected to issues related to wounds, the angiogenesis and recurrence phenomena, and other factors [12]. According to a study conducted in Bangladesh, venous ulcer healing occurs more quickly (3–4 weeks) following stab avulsion than following Trendelenburg alone (4-6 weeks). According to a research, ulcers recover following a Trendelenburg operation on average in nine weeks [13]. Another study revealed that it takes 12 weeks for an ulcer to fully heal following a stab avulsion operation [14]. According to a different Indian study, stab avulsion leads to 1-3 weeks faster healing of venous ulcers following Trendelenburg than conservative therapy [4]. The study’s justification is that venous ulcers are a prevalent, incapacitating ailment that cause both the patient and society to suffer large financial losses. About 2% of people have it, and frequently, there is a long healing period followed by several recurrences. Even if there is a lack of demographic information regarding venous ulcer patients in developing nations such as Pakistan, the number of patients is still very high. Thus, the purpose of the current study is to evaluate the healing success of venous ulcers in individuals who have had Trendelenburg with those who have undergone Trendelenburg with perforators stab avulsion.

2. LITERATURE REVIEW

Venous leg ulcers (VLUs) bear a significant financial, social, and clinical burden on the healthcare system. Up to 1% of the general population and more than 4% of senior citizens suffer from them, and they have detrimental effects on quality of life similar to those of congestive heart failure. They also cause chronic pain, discomfort, and social embarrassment. Although VLU has a clear clinical and financial impact, treatment has not advanced much over the years. In addition to pharmaceutical therapies like topical and systemic medicines and even surgery, there are a plethora of conservative and interventional solutions accessible, including compression therapy [16]. Anatomically, the lower limb’s venous system may be separated into two sections: the deep venous system, which is located beneath the leg’s deep fascia, and the superficial venous system, which is found within the surface tissues. Fascial perforating veins allow the superficial veins to empty into the deep veins. Important superficial veins are the great saphenous vein (GSV) and small saphenous vein (SSV). It is the dorsal venous arch that forms GSV. It rises up the thigh and medial side of the leg. At the saphenofemoral junction, GSV ends by draining into the femoral vein. It is the dorsal venous arch that forms SSV. At the saphenopopliteal junction, it travels up the back of the leg and empties into the popliteal vein.  85–90% of the venous blood in the legs is pumped by the contractions of the calf muscles. Venous blood in the lower limbs travels from the skin into the superficial veins and then empties into the deep veins. There are valves in the veins that stop blood from flowing backward from deep veins to superficial veins. The veins become dilated and convoluted as a result of this increased intraluminal pressure, which they are unable to tolerate. The term varicose veins refers to this problem. In healthy individuals, this is prevented by the valves in the perforating veins [17]. In resource-rich nations, venous illness accounts for around 85% of all chronic lower limb ulcers. Between 40% and 50% are thought to stay active for six to twelve months, and 10% for up to five years. among the general population, prevalence estimates for VLU range from 1.5% to 3%, whereas among the elderly, they range from 4% to 5%. Venous leg ulcers have a significant socioeconomic impact and significantly lower the quality of life associated with health for both patients and their families.  In terms of the profile of those affected, ulcers are twice to three times more common in women than in men. Additional risk factors include smoking, being pregnant, being black, being obese, undernourished, inactive, and having a family history of venous leg ulcers and deep vein thrombosis (DVT). All women, regardless of age or gender, are more vulnerable. While non-Hispanic whites are more likely to develop venous leg ulcers (2–4 times the risk), African and American patients tend to present at younger ages, with progressive illness, and higher rates of hospitalization and amputation [18, 19]. The majority of research suggests that being a woman and growing older are the main risk factors. Adults 60 to 80 years of age are the most common age group to develop venous ulcers, and this age group is predicted to represent a growing percentage of new cases in the future. When they initially present with an ulcer, 72% of patients are over 60, compared to 22% who are in their 40s and 13% who are under 30.  An increase in venous stiffness causes hypertension, and a decrease in endothelial relaxation exacerbates vascular problems. The subendothelial layer contains the majority of collagen and smooth muscle, giving the skin a thinner appearance and increasing its susceptibility to ulcers and poor tissue perfusion. Males are far more likely than females to develop venous ulcers, with a 1.42 percentage point difference in incidence. Hormones and concerns about beauty cause women to seek medical attention three times more frequently than men do. A venous ulcer may be more likely to occur if you have a history of physical trauma, are overweight, are non-Hispanic, have a family history of ulcers, or any combination of these factors. An additional risk factor for getting a venous ulcer is having a history of deep vein thrombosis, having persistent lower limb edema, or having congestive heart disease. Standing for extended periods of time at work, having more children, and being inactive all raise the risk of getting venous leg ulcers [20–23]. VLUs usually appear above the medial and lateral malleoli, between the ankle and the calf. They are an indication of either chronic venous disease (CVD) or chronic venous insufficiency (CVI), which are both caused by the same underlying cause as chronic venous hypertension. In patients with chronic venous disease, the risk of ulceration rises with increasing venous hypertension and reaches 100% at pressures higher than 90 mmHg. Dysfunction of the deep venous system affects both the superficial and deep venous systems. There are several factors that can contribute to the formation of varicose veins, including genetics, sex, pregnancy, age, obesity, prolonged standing, trauma, and deep vein thrombosis [24]. Venous hypertension is a major contributor to the pathogenesis of cardiovascular disease by allowing blood to seep from veins into the surrounding tissues, where it is subsequently broken down and deposits hemosiderin. This leads to alterations in the subcutaneous tissue surrounding the ankles, resulting in pigmentation and fibrosis, ultimately causing the skin in that region to become rigid. Because the afflicted skin and subcutaneous tissue are so delicate, ulcers can form easily. The evolution of CVD is described by the CEAP severity grading system and categorization. The public was first given access to the 1995 edition of CEAP. Venous leg ulcers are caused by disturbances in the body’s macro- and microcirculation. Because calf vein thrombosis (DVT) kills the venous system’s valves, the venous system becomes ineffective and unable to stop venous blood from flowing back into the legs, which results in persistent or ambulation hypertension in the calf veins, is a common cause of venous leg ulcers. Legs become dark, indurated, and leathery to the touch as a result of elevated venous pressure. The increased permeability, leakage, and hemosiderin deposition in the skin are caused by the high venous pressure that is being conveyed back to the capillaries and superficial veins. This disorder is known as lipodermatosclerosis. It has been related to microcirculatory dysfunction because of leukocyte entrapment, leukocyte accumulation in small vessels, release of inflammatory factors and reactive oxygen species (free radicals), and further contribution to the formation of chronic wounds. White blood cell accumulation in tiny vessels can also obstruct the vessels, causing ischemia and tissue hypoxia that increase the risk of cell death and ulceration [25–28]. Venous ulcers can arise from congenital aplasia, which results in malfunctioning of the venous valve, which in turn produces venous hypertension and the other sequela mentioned above. The etiology of venous ulcers are a topic of much controversy. A lot of patients come in with a history of trauma, like a scrape on dry skin that left a tiny hole or skin injury from knocking a grocery cart into their legs by accident. According to one woman, her venous ulcer started in the scar left behind when the great saphenous vein was excised. Foot vein pressures in patients with venous disease are usually substantially greater than the 115 mmHg found in healthy individuals. Venous leg ulcers (VLUs) frequently include bioburden, and on rare occasions, an infected VLU may appear (Fig. 5). Although there is a lack of data to substantiate the existence of biofilms on VLUs, clinical suspicions point to their prevalence. Because these chronic wounds have a propensity to leak, there is a considerable risk of maceration at their borders [29, 30]. A physical examination, the clinical history, and the presentation all aid in distinguishing venous ulcers from other ulcers of the lower extremities. It is important to determine the history of pulmonary embolism, deep or superficial vein thrombosis, and ulcer recurrence when dealing with coexisting illnesses.  Venous ulcers usually have a distinct border and an uneven form. symptoms that go worse during the day and get better with altitude, such as limb heaviness, pruritus, discomfort, and edema. Signs of venous illness, such as varicose veins, edema, or venous dermatitis, may be observed during a physical examination. The location of venous ulcers over bone prominences, such as the gaiter area, is another finding. It is important to evaluate patients with leg wounds that are healing poorly or not at all in order to rule out concurrent conditions that are impeding the wounds’ ability to heal fast. Conditions such as anemia, hypoalbuminemia, and renal insufficiency can all impede the healing process. Individuals with uncommon or unidentified reasons might potentially profit from more focused laboratory testing. For example, patients who are suspicious of malignancy, osteomyelitis, diabetes mellitus, or other diseases that may cause persistent leg ulcers should have a complete blood count, blood glucose, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and When cancer is suspected and cannot be explained by other causes, a biopsy should be performed [31]. When a patient with an ulcer is first examined, most surgeons will perform a duplex scan to evaluate the condition of the deep and superficial veins. Clear visualization of the leg veins is possible with a duplex ultrasound examination. Direct visual inspection can be used to determine venous blood flow and the presence of venous thromboembolism. Venous intervention may be beneficial for patients with chronic venous illness if an obstruction or incompetent valves are first discovered using duplex ultrasound assessment. Recent research has demonstrated that venous leg ulcers (VLUs) can heal more quickly when treated with venous intervention. Plethysmography is another common venous examination that can be used to measure the venous volume, venous filling index, ejection percent, and residual volume fraction. Severe sickness and venous reflux are associated with a high venous filling index. Phlebography, contrast venography, and ultrasonography are further feasible options for venous research [32, 33]. An imaging examination may tell clinicians a lot about a wound, including its depth, the amount of blood flowing to the surrounding tissue, and whether or not there is infection or inflammation. While the significance of ultrasound imaging in wound care has been previously discussed, other imaging modalities, such as radiography, computed tomography scans (CT), and magnetic resonance imaging (MRI), can also be beneficial. Although radiographic studies have low sensitivity and specificity, they can be utilized to diagnose bone infections such as osteomyelitis. In many treatment contexts, MRI is the most effective modality for diagnosing osteomyelitis; nevertheless, CT scans can be more intrusive than they otherwise would be due to the ionizing radiation they involve [34]. A leg ulcer is not a diagnostic; rather, it is a physical condition that may arise from several etiologies. Even though venous ulcers are the most prevalent type of chronic wounds in the lower extremities, other disorders such pyoderma gangrenosum, peripheral neuropathy, malignancy, arterial occlusive disease, and other inflammatory ulcers should also be taken into account. An autoimmune sickness, calciphylaxis, pyoderma gangrenosum, and sickle cell disease may be responsible for 20% to 23% of chronic ulcers that do not respond well to vascular intervention. An arterial pulse examination, an ankle-brachial index test, and comprehensive venous Doppler ultrasonography should be performed as part of the initial noninvasive imaging process for any patient suspected of having venous ulcers. It is advised to use color duplex ultrasonography to assess for both superficial and profound venous reflux and obstruction [35]. When the ankle-brachial index is abnormal or there are other concurrent illnesses, such as diabetes, chronic kidney disease, or other conditions that can cause vascular calcification, further Doppler ultrasonography screening is required to evaluate arterial blood flow. Leg elevation is also regarded as standard of care when combined with compression therapy. Raising the lower limbs above the level of the heart is known as leg elevation, and its benefits include lowering edema, enhancing microcirculation and oxygen supply, and accelerating the healing of ulcers. Despite the fact that leg elevation works best when done for thirty minutes, three or four times a day. Under compression bandages, dressings are frequently applied to encourage quicker healing and discourage the bandage from sticking to the ulcer. There are many different types of dressings available, such as hydrocolloids, foams, hydrogels, and basic nonadherent dressings. The choice of dressing for venous ulcers can be influenced by factors such as cost, convenience of application, and patient and physician preference in the absence of conclusive data to support one dressing over another [36–38]. Venoactive drugs, which lessen swelling and inflammation and raise venous tone, may help patients with symptoms related to varicose veins, ankle edema, or venous ulcers. By inhibiting platelet aggregation, pentoxifylline lowers blood viscosity and enhances microcirculation. When combined with compression therapy, pentoxifylline has been demonstrated to be a successful venous ulcer adjunctive treatment. Comparing compression therapy alone to aspirin-like pentoxifylline therapy has demonstrated improvements in ulcer healing and size reduction. The data for flavonoids’ potential benefit in treating venous ulcers should be carefully considered. According to a Cochrane meta-analysis, vasoactive medicines can reduce pain and edema caused by chronic venous insufficiency; however, the precise mode of action of these therapies remains unknown. Thorough research should be done on the long-term safety and efficacy of phlebotomists [39, 40]. By employing a stiff stripper, W. Babcock popularized endoluminal stripping in 1903 and it continued to be used for many years [41]. Surgical and endovenous methods are used to treat chronic venous sickness by removing or obliterating inadequate veins or by separating the reflux origin from the rest of the vascular system. When compared to conservative therapy, these surgeries dramatically improve patients’ quality of life and minimize symptoms. The aim of compression and sclerotherapy, as well as surgical and endovenous operations, is to reduce the risk of superficial thrombophlebitis and minimize consequences. For the majority of the 20th century, the surgical gold standard for managing chronic venous disease was classic saphenofemoral ligation with stripping [42]. The great saphenous vein is ligated and split from the femoral vein at the saphenofemoral junction after the tributaries are removed. After a wire has been threaded into the great saphenous vein, it is withdrawn. The ligation is usually done around the point where the popliteal vein and lesser saphenous vein meet after the popliteal vein has been separated from the latter. Since tumescent anesthesia causes less stress and bleeding, it has supplanted the “traditional” method of invagination stripping in recent years [43]. A proximal ligation without stripping is used when the saphenous vein needs to be preserved, however the risk of recurrence is significantly higher with this procedure than with a saphenofemoral ligation with stripping. The CHIVA procedure is a surgical procedure intended to improve the hydrodynamic conditions of the leg vascular system by excising specific, insufficient tributaries, thereby relieving volume-loaded vein segments [44]. Saphenous veins may occasionally persist when dilatations get smaller. We would like to draw your attention to the following survey articles because of the complexity of this approach. Certain authors assert that this method outperforms the conventional saphenofemoral ligation and stripping in terms of efficacy and patient acceptance. To make definite findings, more study is needed, especially on the efficacy and recurrence rates when compared to the standard treatment [45]. An additional surgical approach for treating incompetent perforators is direct epi- or subfascial closure. Stopping the blood supply to an ulcer has been shown in certain trials to hasten its healing and reduce the likelihood that it will recur. It is hard to draw definitive conclusions on this technique’s efficacy when used alone because it is frequently combined with other procedures, such saphenofemoral ligation. The surgical technique known as phlebectomy involves creating tiny incisions to remove malfunctioning branch veins. Saphenofemoral ligation and stripping, usually carried out as an outpatient procedure under local anesthesia, is a possibility, as is completing the procedure endoluminally [46, 47]. This treatment involves ligating the great saphenous vein where it meets the femoral vein at the saphenofemoral junction. Additionally, branches of the great saphenous vein surrounding the saphenofemoral junction are tied off (SFJ). When GSV stripping is not done, there is a notable recurrence rate following ligation [48]. One tried-and-true method of treatment is varicose vein stripping. Eliminating the problem’s origin by severing all GSV tributaries and perforators is the aim. Under general, regional, or tumescent anesthesia, an incision is made in the groin crease, and the SF junction is removed via dissection. Identification and ligation of all GSV tributaries near the SFJ with great care. A high ligation of the saphenofemoral junction (SFJ) and a great saphenous vein (GSV) transection immediately above the knee mark the beginning of vein stripping. After that, the vein stripper’s head is delivered into the SFJ and it is implanted into the GSV at the transection site. Following the invagination of the GSV tip, the vein is dissected and the stripper is tied to it. Incisional scars are sutured, and compression tights are used. Because stripping for below-knee GSV carries a substantial risk of injuring the saphenous nerve, foaming sclerotherapy or avulsion stab phlebectomy are advised as an alternative. Furthermore, the formation of a hematoma is highly likely [26, 49]. The hook, micro, and mini phlebectomy are other names for the stab phlebectomy. It is a common surgical removal approach that entails making incisions over the avulsion and noticeable varicosities. A minimally invasive treatment known as a “stab phlebectomy” is performed as an outpatient under local anaesthetic. Limb compression is then applied to reduce bleeding and the formation of hematomas. This surgery has been carried out with progressively smaller incisions throughout time, leading to its current technique, which uses fine instruments made specifically to remove varicosities through tiny incisions. Using this method has produced noticeably better cosmetic effects. but heavily rely on the surgeon’s particular training and expertise. And with the exception of the proximal great saphenous vein, we can remove the majority of varicosities using this method. It might be possible to retrieve a longer segment of undesired vein by applying a specific amount of saline around the target veins prior to making a stab. Usually, a stab phlebectomy is carried out in addition of another surgery. If the junctional reflux is left untreated, the recurrence rate may be substantial [50]. Instead of doing a straightforward stab phlebectomy, high ligation and stripping should be used to treat junctional reflux if it is present [21]. The patient can immediately walk following a stab phlebectomy. Compared to high ligation and stripping, the risks of stab phlebectomy are significantly lower. These risks include hemorrhage and localized thrombophlebitis. After stab phlebectomy, the use of wide compression cushions over the wounds significantly reduces postoperative problems [50].

3. CONCLUSION

Based on the study’s findings, it can be said that, in our clinical circumstances, the Trendelenburg approach in combination with stab avulsion promotes early wound healing for the treatment of venous ulcers more effectively than the Trendelenburg process alone.

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