Clinicopathological Analysis and Management of Lower Limb Ulcers

Illampreti, V; Santhosh, K

doi:10.65188/nurexus.1041

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ORIGINAL ARTICLE

Journal of MedVerse Research & Practice

ISSN: 3107-4278

Clinicopathological Analysis and Management of Lower Limb Ulcers

Dr.V Illampreti

1

, Dr. K santhosh

2

Postgraduate, Associate Professor

Department of General Surgery, SRM Medical College, Trichy

Email: illampreti0606@gmail.com

Submission Date: 25.08.2025

Accepted Date: 21.09.2025

Published Date: 30.09.2025

article distributed under the terms of the Creative Commons Attribution License (CC BY 4.0), which permits

unrestricted use, distribution, and reproduction in any medium, provided the original author(s) and source are credited.

Abstract

Background: Lower limb ulcers represent a significant clinical challenge due to their chronicity, diverse etiology,

and high morbidity. Despite advances in diagnostic and therapeutic modalities, management outcomes remain

variable across patient populations.

Objectives: To study the clinicopathological profile of lower limb ulcers and evaluate their management outcomes in

a tertiary care setting.

Methods: A prospective interventional study was conducted in the Department of General Surgery, SRM Medical

College, Trichy, from July 2024 to June 2025. A total of 100 patients aged 18–65 years with lower limb ulcers were

enrolled using convenience sampling. Detailed history, clinical examination, and relevant investigations were

performed. Patients were assessed for associations with comorbidities (hypertension, diabetes, smoking), peripheral

vascular status, neuropathy, and history of trauma. Management included surgical debridement, lumbar

sympathectomy, or amputation as indicated. Data were analyzed and compared with existing literature.

Results: Venous ulcers were the most common etiology (40%), followed by diabetic ulcers (34%), arterial ulcers

(17%), and traumatic ulcers (9%). Venous ulcers showed strong association with varicose veins (30%), while arterial

ulcers were significantly associated with Raynaud’s phenomenon (47%) and absent peripheral pulses (47%).

Neuropathy-related sensory loss was most frequent in diabetic ulcers (35%). Hypertension was prevalent in arterial

(71%) and venous (30%) ulcers, while smoking was common in arterial (88%) and diabetic ulcers (76%). Surgical

debridement was most often required for diabetic (76%) and venous ulcers (38%). Lumbar sympathectomy was

performed in 18% of arterial ulcer cases. Amputation was necessary in 44% of patients, particularly those with

arterial (65%) and venous ulcers (78%).

Conclusions: Venous and diabetic ulcers constitute the majority of lower limb ulcers, with significant contributions

from vascular and neuropathic mechanisms. Risk factors such as hypertension, diabetes, and smoking strongly

influence disease course and outcomes. Surgical debridement and timely vascular interventions play a crucial role in

management, while amputation remains a last resort in advanced cases. Early diagnosis, multidisciplinary care, and

risk-factor modification are essential for improving limb salvage and reducing morbidity.

Keywords: Lower limb ulcer, venous ulcer, diabetic ulcer, arterial ulcer, neuropathy, amputation, debridement,

sympathectomy

Introduction

An ulcer is a discontinuity in the epithelial surface associated with destruction of the underlying tissues,

which may extend to involve subcutaneous fat, muscle, or even bone [1]. A chronic ulcer is generally

defined as a full-thickness skin defect that does not heal or re-epithelialize within four weeks [2]. Such

wounds display impaired healing not merely due to their depth or size, but because of underlying

pathological processes that must be identified and corrected to achieve recovery [3].Lower limb and foot

ulcers are common clinical problems with significant morbidity. They are frequently encountered in

surgical wards and outpatient clinics, causing pain, disability, and financial burden [4]. Their etiology is

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diverse, spanning medical, surgical, and dermatological domains. The leading causes include chronic

venous insufficiency, peripheral arterial disease, and diabetes mellitus [5]. Less frequent causes are

infections, vasculitis’s, skin cancers, and inflammatory dermatoses such as pyoderma gangrenosum [6].

Rare associations, such as combined hypercoagulability and vasculitis syndromes, have also been described

[7].

The incidence of leg ulcers is higher in the elderly, largely due to comorbidities such as atherosclerosis,

diabetes, obesity, and smoking [8]. Despite extensive research in the last few decades on the anatomy,

pathology, and treatment of chronic ulcers, management continues to evolve, and innovative strategies

remain essential [9]. Vascular ulcers account for over 90% of chronic leg ulcers. Of these, venous

hypertension contributes to approximately 70% of cases, mixed venous-arterial disease to 15%, and pure

arterial insufficiency to about 5% [10]. The CEAP classification (Clinical, Etiological, Anatomical,

Pathophysiological) provides a standardized framework for assessment and treatment of venous ulcers [11].

Arterial ulcers arise from impaired perfusion due to mechanisms such as vessel wall thickening,

intraluminal obstruction, or external compression [12]. Diabetic foot ulcers constitute another major group,

with nearly 15% of individuals with diabetes developing one during their lifetime [13]. They are

multifactorial, with peripheral neuropathy being the most important cause. Loss of protective sensation

leads to repetitive, unnoticed trauma, abnormal pressure distribution, and eventual skin breakdown. These

ulcers are further complicated by infection and delayed healing [14].

Materials & Methods

Study Design

This prospective interventional study was conducted to evaluate the clinical profile, management strategies,

and treatment outcomes of patients presenting with lower limb ulcers.

Study Setting and Duration

The study was carried out in the Department of General Surgery, SRM Medical College, Trichy, over a

period of one year, from July 2024 to June 2025. Patients were recruited from both the General Surgery

Outpatient Department (OPD) and the surgical inpatient wards.

Study Population

The study population comprised adult patients presenting with lower limb ulcers who attended the

Department of General Surgery during the study period. Participants were selected using a convenience

sampling technique after confirming eligibility according to the predefined inclusion and exclusion criteria.

Sample Size

A total of 100 patients with lower limb ulcers were enrolled in the study.

Inclusion Criteria

Patients aged 18 to 65 years with any type of lower limb ulcer who were willing to provide written

informed consent were included in the study.

Exclusion Criteria

Patients who declined participation, individuals younger than 18 years or older than 65 years,

immunocompromised patients including those with HIV infection, those receiving long-term corticosteroid

therapy, individuals with other known immunodeficiency disorders, and patients with clinically suspected

or histopathologically confirmed malignant ulcers were excluded from the study.

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Data Collection Tool

Following approval from the Institutional Ethics Committee, eligible participants were enrolled after

obtaining written informed consent. Baseline demographic characteristics and detailed clinical history were

recorded using a structured case record proforma. Each patient underwent a comprehensive general

physical examination and a detailed local examination of the ulcer. Ulcer characteristics including site, size,

depth, duration, number of ulcers, wound bed characteristics, edge, floor, surrounding skin changes,

discharge, presence of infection, vascular status, neurological assessment, and underlying etiology were

documented systematically. Associated comorbid conditions such as diabetes mellitus, peripheral vascular

disease, hypertension, chronic venous insufficiency, smoking history, and other relevant risk factors were

also recorded. Appropriate laboratory investigations, including complete blood count, blood glucose

estimation, renal function tests, wound culture and sensitivity, Doppler studies, radiological investigations,

and other relevant diagnostic tests, were performed whenever clinically indicated. Patients subsequently

received appropriate treatment according to the study protocol based on the etiology and severity of the

ulcer. Treatment modalities included wound debridement, appropriate dressings, antibiotic therapy,

glycemic control, compression therapy, vascular interventions, skin grafting, or other surgical procedures as

required. Participants were followed at regular intervals, and treatment outcomes including ulcer healing,

reduction in ulcer size, infection control, need for additional surgical intervention, complications, duration

of hospital stay, and overall clinical outcome were documented systematically throughout the follow-up

period.

Ethical Considerations

The study protocol was approved by the Institutional Ethics Committee before commencement of the study.

Written informed consent was obtained from all participants after explaining the objectives and procedures

of the study. Confidentiality of patient information was maintained throughout data collection, analysis, and

reporting. Participation was voluntary, and all study procedures were conducted in accordance with the

ethical principles of the Declaration of Helsinki and the Indian Council of Medical Research (ICMR)

guidelines.

Statistical Analysis

Data were entered into Microsoft Excel 2019 and analyzed using IBM SPSS software version 26.0 (IBM

Corp., Armonk, NY, USA). Continuous variables were expressed as mean ± standard deviation (SD) or

median with interquartile range (IQR) depending on data distribution, while categorical variables were

presented as frequencies and percentages. Comparisons between groups were performed using the Chi-

square test or Fisher's exact test for categorical variables and the Independent Student's t-test or Mann–

Whitney U test for continuous variables, as appropriate. Paired Student's t-test or Wilcoxon signed-rank test

was used to compare pre- and post-intervention parameters where applicable. Binary logistic regression

analysis was performed to identify independent predictors of ulcer healing and treatment outcomes. A p-

value <0.05 was considered statistically significant.

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Results

Table 1. Association of Varicose Veins with Causes of Ulcers (N = 100)

Venous ulcers showed the strongest association with varicose veins (30%), whereas arterial, diabetic, and

traumatic ulcers showed no direct association.

Table 1. Association of Raynaud’s Phenomenon with Causes of Ulcers

Cause of Ulcer

Absent

Present

Total

Arterial

9

8

17

Diabetes

34

0

34

Trauma

9

0

9

Venous

40

0

40

Total

92

8

100

Arterial ulcers were the only group significantly associated with Raynaud’s phenomenon (47%).

Table 2. Association of Loss of Sensation with Causes of Ulcers

Cause of Ulcer

Absent

Present

Total

Arterial

6

11

17

Diabetes

22

12

34

Trauma

9

0

9

Venous

31

9

40

Total

68

32

100

Neuropathy-related ulcers were most common in diabetes (35% with loss of sensation), followed by arterial

ulcers (65% with sensory loss).

Table 3. Association of Peripheral Pulses with Causes of Ulcers

Cause of Ulcer

Absent

Present

Total

Arterial

8

9

17

Diabetes

0

34

Trauma

0

9

Venous

2

38

40

Total

10

90

100

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Absence of peripheral pulses was strongly associated with arterial ulcers (47%). Pulses were generally

preserved in diabetic, venous, and traumatic ulcers.

Table 4. Association of Hypertension with Causes of Ulcers

Cause of Ulcer

Absent

Present

Total

Arterial

5

12

17

Diabetes

20

14

34

Trauma

6

3

9

Venous

28

12

40

Total

59

41

100

Hypertension was most commonly observed among arterial (71%) and venous (30%) ulcer patients.

Table 5. Association of Diabetes Mellitus with Causes of Ulcers

Cause of Ulcer

Absent

Present

Total

Arterial

9

8

17

Diabetes

0

34

Trauma

9

0

9

Venous

22

18

40

Total

40

60

100

As expected, all diabetic ulcers were present in patients with diabetes. Interestingly, 45% of venous ulcers

also co-existed with diabetes.

Table 6. Association of Smoking with Causes of Ulcers

Cause of Ulcer

Absent

Present

Total

Arterial

2

15

17

Diabetes

8

26

34

Trauma

3

6

9

Venous

20

40

Total

33

67

100

Smoking was a major risk factor, seen in 88% of arterial ulcers and 76% of diabetic ulcers.

Table 7. Surgical Debridement in Relation to Causes of Ulcers

Cause of Ulcer

Not Required

Required

Total

Arterial

14

3

17

Diabetes

8

26

34

Trauma

9

0

9

Venous

25

15

40

Total

56

44

100

Surgical debridement was most frequently required in diabetic (76%) and venous ulcers (38%).

Table 8. Lumbar Sympathectomy in Relation to Causes of Ulcers

Cause of Ulcer

Not Done

Done

Total

Arterial

14

3

17

Diabetes

34

0

34

Trauma

9

0

9

Venous

40

0

40

Total

97

3

100

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Lumbar sympathectomy was selectively performed in arterial ulcers (18%).

Table 9. Amputation in Relation to Causes of Ulcers

Cause of Ulcer

Not Required

Required

Total

Arterial

6

11

17

Diabetes

32

2

34

Trauma

9

0

9

Venous

9

31

40

Total

56

44

100

Amputation was most frequently required for arterial ulcers (65%) and venous ulcers (78%), while rare in

diabetic ulcers (6%).

Discussion

In this prospective interventional study of 100 patients with lower-limb ulcers, venous ulcers were the most

common cause (40%), followed by diabetic ulcers (34%), arterial ulcers (17%), and traumatic ulcers (9%).

Our findings both support and diverge from earlier reports. Abbade and Lastória reported that venous ulcers

account for nearly 70% of all lower limb ulcers in population-based studies, which is higher than the 40%

observed in our series [15]. Similarly, Vasudevan highlighted that venous pathology remains the

predominant cause of chronic lower limb ulcers in India [16]. The lower proportion of venous ulcers in our

cohort may be due to referral bias, as our hospital-based surgical department more often receives

complicated arterial and diabetic ulcers.

Armstrong and colleagues demonstrated that nearly one-third of diabetic patients will develop a foot ulcer

in their lifetime, with neuropathy being the most important risk factor [17]. Our study reflected a similar

pattern, as neuropathic loss of sensation was common among 34% of patients with diabetic ulcers. Dayya et

al. further emphasized that repeated sharp debridement plays a crucial role in diabetic ulcer management, a

finding consistent with our frequent use of surgical debridement in this group [18].

Population studies often cite arterial ulcers as comprising 5–10% of all chronic lower limb ulcers.

However, in our study, arterial ulcers accounted for 17%. Humphries and colleagues reported that ischemic

ulcers are frequently associated with absent peripheral pulses and a higher risk of amputation, findings

which were consistent with our observations [19].

Smoking and hypertension were strongly associated with arterial and diabetic ulcers in our cohort.

Humphries et al. also identified smoking as a significant predictor of peripheral arterial disease and ulcer-

related amputations [19]. This similarity underlines the need for early lifestyle modification in patients with

lower limb ulcers.

Debridement was commonly required in diabetic and venous ulcers in our study. Elraiyah and colleagues,

in their systematic review, demonstrated that regular sharp debridement accelerates healing of diabetic foot

ulcers [20]. Lumbar sympathectomy was selectively performed in patients with critical limb ischemia in

our cohort. Karanth et al. reported that sympathectomy may provide symptomatic relief in carefully

selected cases with non-reconstructable ischemia [21]. Amputation was required in 44% of our cohort,

mostly in arterial and diabetic ulcers. This proportion is higher than community-based studies but aligns

with tertiary surgical referral data. Humphries et al. observed that amputation rates remain high among

patients with combined diabetes and peripheral arterial disease, despite advances in revascularization [19].

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Limitations

The limitations of our study include its single-centre design, convenience sampling, and lack of long-term

follow-up for ulcer healing. Further multicentric studies with larger samples and standardized vascular

assessments are needed for better generalizability.

Conclusions

Our findings emphasize the importance of early detection of diabetes- and ischemia-related ulcers,

aggressive debridement, vascular assessment, and risk-factor modification. A multidisciplinary approach

involving surgeons, vascular specialists, and wound-care teams remains essential to improve limb salvage

and reduce amputation rates.

Conflict of Interest: Nil

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