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R E S E A R C H A R T I C L E Open Access
Experiences with Surgical treatment of chronic
lower limb ulcers at a Tertiary hospital in
northwestern Tanzania: A prospective review of
300 cases
Fidelis Mbunda
1†
, Mabula D Mchembe
2
, Phillipo L Chalya
1*
, Peter Rambau
3†
, Stephen E Mshana
4†
,
Benson R Kidenya
5
and Japhet M Gilyoma
1
Abstract
Background: Chronic lower limb ulcers constitute a major public health problem of great important all over the
world and contribute significantly to high morbidity and long-term disabilities. There is paucity of information
regarding chronic lower limb ulcers in our setting; therefore it was necessary to conduct this study to establish the
patterns and outcome of chronic lower limb ulcers and to identify predictors of outcome in our local setting.
Methods: This was a descriptive prospective study of patients with chronic lower limb ulcers conducted at
Bugando Medical Centre between November 2010 and April 2012. Ethical approval to conduct the study was
sought from relevant authorities. Statistical data analysis was done using SPSS version 17.0 and STATA version 11.0.
Results: A total of 300 patients were studied. Their ages ranged from 3 months to 85 years (median 32 years). The
male to female ratio was 2:1. The median duration of illness was 44 days. Traumatic ulcer was the most frequent
type of ulcer accounting for 60.3% of patients. The median duration of illness was 44 days. The leg was commonly
affected in 33.7% of cases and the right side (48.7%) was frequently involved. Out of 300 patients, 212 (70.7%) had
positive aerobic bacterial growth within 48 hours of incubation. Pseudomonas aeruginosa (25.5%) was the most
frequent gram negative bacteria isolated, whereas gram positive bacteria commonly isolated was Staphylococcus
aureus (13.7%). Twenty (6.7%) patients were HIV positive with a median CD4+ count of 350 cells/μl. Mycological
investigation was not performed. Bony involvement was radiologically reported in 83.0% of cases. Histopathological
examination performed in 56 patients revealed malignancy in 20 (35.7%) patients, of which malignant melanoma
(45.0%) was the most common histopathological type. The vast majority of patients, 270 (90.0%) were treated
surgically, and surgical debridement was the most common surgical procedure performed in 24.1% of cases. Limb
amputation rate was 8.7%. Postoperative complication rate was 58.3% of which surgical site infection (77.5%) was
the most common post-operative complications. The median length of hospital stay was 23 days. Mortality rate was
4.3%. Out of the two hundred and eighty-seven (95.7%) survivors, 253 (91.6%) were treated successfully and
discharged well (healed). After discharge, only 35.5% of cases were available for follow up at the end of study
period.
(Continued on next page)
* Correspondence: drphillipoleo@yahoo.com
†
Equal contributors
1
Department of Surgery, Catholic University of Health and Allied Sciences-
Bugando, Mwanza, Tanzania
Full list of author information is available at the end of the article
© 2012 Mbunda et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.
Mbunda et al. BMC Dermatology 2012, 12:17
http://www.biomedcentral.com/1471-5945/12/17
(Continued from previous page)
Conclusion: Chronic lower limb ulcers remain a major public health problem in this part of Tanzania. The majority
of patients in our environment present late when the disease is already in advanced stages. Early recognition and
aggressive treatment of the acute phase of chronic lower limb ulcers at the peripheral hospitals and close
follow-up are urgently needed to improve outcomes of these patients in our environment.
Keywords: Chronic lower limb ulcers, Patterns, Treatment outcome, Predictors of outcome, Tanzania
Background
Chronic ulceration of the lower limb constitutes a major
public health problem of great important all over the
world and contributes significantly to high morbidity and
long-term disabilities [1]. It is a stressful disease to those
affected as well as their family and the community in
general, and its impact on hospital resources is great due
to prolonged hospitalization, high cost of health care,
loss of productivity and reduced quality of life [1-3].
Lower limb ulceration presenting late may end up being
treated by limb amputation and is associated with
increased risk of recurrence and malignant change [3].
Globally, the prevalence of chronic lower limb ulcers in
the community has been reported in literature to range
from 1.9 to 13.1% [1-3]. In developed countries, chronic
ulceration of the lower limb affects approximately 2% of
the population [4]. In the United Kingdom, the prevalence
of chronic lower limb ulcers in the adult population is 1%
and the prevalence in the more than 65 years age group is
3–5% [4,5]. In the United States of America, approxi-
mately 6,000,000 new lower limb ulcer cases are reported
each year and in Sweden, 4–5% of the population over the
age of 80 years presents with this pathology. The annual
cost for treating chronic lower limb ulceration patients
globally is estimated at some $25 million [6,7].
In Tanzania, chronic lower limb ulceration continues
to be one of the leading causes of morbidity and long
term disabilities. The disease tends to affect the young,
reproductive age group. Observation at Bugando Med-
ical Centre shows; chronic lower extremity ulceration is
the single commonest indication for admission reported
in the surgical wards and the majority of patients
present late with advanced disease [8]. The etiological
patterns of lower extremity ulceration in most develop-
ing countries have been reported to differ from that in
developed countries. While, most of lower limb ulcer-
ation in the Western population is related to vascular
diseases such as venous and arterial disease; trauma, ma-
lignancies, diabetes mellitus and infections are the most
common causes in developing countries [2,9,10].
The effective treatment and outcome of lower limb ul-
ceration is highly dependent upon establishing the eti-
ology of the ulceration and the identification of other
associated conditions that may have an adverse effect on
healing [11].
The majority of chronic lower limb ulcers are prevent-
able and have a multifactorial etiology, therefore under-
standing the etiological pattern of this condition in our
local setting will provides information that is important
for accurate diagnosis, prediction of outcome and may
help in hospital resource allocations and establishment
of prevention strategies as well as treatment protocols
[12].
The aim of this study was to describe the patterns and
treatment outcome of chronic lower limb ulcers in our
local setting and to identify factors predicting the out-
come. The study provides basis for establishment of
treatment guidelines as well as prevention strategies.
Methods
Study design and setting
This was a descriptive prospective hospital-based study
of patients with chronic lower limb ulcers carried out at
Bugando Medical Centre (BMC) in Northwestern Tanzania
between November 2010 and February 2012. BMC is
located in Mwanza city along the shore of Lake Victoria in
the northwestern part of Tanzania. It is a tertiary care and
teaching hospital for the Catholic University of Health and
Allied Sciences- Bugando (CUHAS-Bugando) and other
paramedics and has a bed capacity of 1000. BMC is one of
the four largest referral hospitals in the country and serves
as a referral centre for tertiary specialist care for a catch-
ment population of approximately 13 million people from
Mwanza, Mara, Kagera, Shinyanga, Tabora and Kigoma
regions.
Study subjects and procedures
The study included all patients with chronic lower limb
ulcers of all age groups and both genders seen in the
surgical wards and surgical outpatient clinics of BMC
during the study period. Patients who failed to consent
for the study, treatment (e.g. limb amputation) and HIV
testing were excluded from the study.
Recruitment of patients to participate in the study was
done at the Accident and Emergency department, surgi-
cal outpatient clinic and in the surgical wards. Patients
were screened for inclusion criteria and those who met
the inclusion criteria were offered explanations about
the study and requested to consent before being enrolled
into the study. Convenience sampling of patients who
Mbunda et al. BMC Dermatology 2012, 12:17 Page 2 of 10
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met the inclusion criteria was performed until the sam-
ple size was reached. The diagnosis of chronic lower
limb ulcers was made by clinical history and physical
examination and chronic lower limb ulcers was defined
as defect in the skin on the lower extremities that
remains unhealed for at least four or more weeks. Pus or
pus swabs were obtained from the ulcer and transported
to the laboratory within an hour of collection. In the la-
boratory, the specimens were registered in the log books
and processed as per standard operative procedures.
Bacterial identification was done using an in house bio-
chemical panel [13]. Antibacterial susceptibility testing
to various antibiotics was performed using disc diffusion
methods as previously described [14,15]. In addition,
blood was taken from all patients for random blood
sugar testing and CD4 enumeration in HIV positive
patients. HIV test was done using national algorithm of
rapid test. Mycological investigation was not performed
due to logistic problems. Biopsies from chronic lower
limb ulcers were taken under sterile technique and spe-
cimens were transported in a formalin solution to the
histopathology laboratory for processing.
All recruited patients were managed accordingly. The
authors ensured that the study patients were receiving
the appropriate treatment and supportive care as pre-
scribed by the surgeon. Patients were followed up until
discharge or death. After discharge patients were fol-
lowed up at our surgical outpatient clinic for up to six
months.
Data were collected using a pre-tested coded question-
naire. Data administered in the questionnaire included;
patients characteristics (e.g. age, sex, premorbid illness,
history of smoking and use of immunosuppressive
drugs), causes of chronic lower limb ulcers, clinical pat-
tern, investigations, treatment modalities and postopera-
tive complications. Length of hospital stay (LOS) and
mortality were recorded at the end of study period.
Statistical data analysis
Statistical data analysis was done using SPSS software
version 17.0 (SPSS, Inc, Chicago, IL) and STATA version
11.0. Data was summarized in form of proportions and
frequent tables for categorical variables. Continuous
variables were summarized using means, median, mode
and standard deviation. P-values were computed for cat-
egorical variables using Chi –square (χ
2
) test and Fish-
er’s exact test depending on the size of the data set.
Independent student t-test was used for continuous vari-
ables. Multivariate logistic regression analysis was used
to determine predictor variables that are associated with
outcome. Post-operative complications were entered into
univariate and multivariate analysis after been categor-
ized into presence or absence of post-operative compli-
cations. LOS was arbitrarily categorized as ≤14
and > 14 days. A p-value of less than 0.05 was considered
to constitute a statistically significant difference.
Ethical consideration
Ethical approval to conduct the study was obtained from
the CUHAS-Bugando/BMC joint institutional ethic re-
view committee before the commencement of the study.
Informed consent was sought from each patient before
being enrolled into the study.
Results
During the period under study, a total of 312 patients
with chronic lower limb ulcers were managed at
Bugando Medical Centre. Of these, 12 patients were
excluded from the study due failure to meet the inclu-
sion criteria. Thus, 300 patients were studied. The ages
of the study population ranged from 3 months to
85 years with a median of 32 years. The modal age
group was 21–30 years. Out of 300 patients recruited
into the study, two hundred (66.7%) were males and 100
(33.3%) were females. The male to female ratio was 2:1
with a male predominance in each age group (Figure 1).
Fifty-four (18.0%) patients presented with history of
premorbid illness such as diabetes mellitus in 32
(59.3%), chronic pulmonary diseases in 8 (14.8%), hyper-
tension in 6 (11.1%), peripheral vascular diseases in 4
(7.4%) and congenital cardiac diseases and obstructive
jaundice in 2 (3.7%) patients each respectively. In this
study, sixty-eight (22.7%) patients had history of
cigarette smoking. There was no history of immunosup-
pressive drugs use or radiotherapy.
The median duration of illness was 44 days (range 31
to 3218 days). Traumatic ulcers were the most frequent
type of ulcer accounting for 60.3% of patients. Road traf-
fic accidents (RTAs) were the most common cause of
traumatic ulcers accounting for 122 (67.4%) patients
(Table 1). Seventy-three (59.8%) of RTAs were related to
motorcycle injuries. Other causes of traumatic ulcers
included burn in 45 (24.9%), falls in 8 (4.4%), gunshot in-
juries in 3(1.7%0, hit by falling object and sport injuries
A
g
e
g
roup (in years)
>70
61-70
51-60
41-50
31-40
21-30
11-20
0-10
Percentages of patients
60
50
40
30
20
10
0
60
50
40
30
20
10
0
SEX
Male
Female
Figure 1 Sex distribution according to age group (In years).
Mbunda et al. BMC Dermatology 2012, 12:17 Page 3 of 10
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in 2(1.1%) and 1(0.6%) respectively. Table 1 shows distri-
bution of study population according to the type of
ulcers.
The leg was commonly affected in 33.7% of cases
(Figure 2) and the right, left and both limbs were
involved in 146 (48.7%), 126 (42.0%) and 28 (9.3%)
patients respectively. The size ulcers ranged from 2 to
30 cm with a median of 5 cm.
Out of 300 patients with CLLUs, 212 (70.7%) had posi-
tive aerobic bacterial growth within 48 hours of incuba-
tion. Of these, 10 (4.7%) patents had polymicrobial
growth. Pseudomonas spp. (25.5%) and Proteus spp.
(21.2%) were the most common bacteria isolated, while
the least isolated bacteria were Enterobacter spp (2.8%)
and Enterococcus spp (1.4%). Forty-one (19.3%) bacterial
isolates were found to be Extended Spectrum Beta-
Lactamases (ESBL) producers (i.e. resistant to first,
second, third and fourth generation cephalosporins).
Methicilin Resistant Staphylococcus aureus (MRSA) was
detected in 23 out of 29 (79.3%) Staphylococcus aureus
isolates.
In this study, twenty (6.7%) patients were HIV positive.
Of these, 6 (30.0%) patients were known cases on ant-
retroviral therapy (ARV) and the remaining 14 (70.0%)
patients were newly diagnosed patients. Their CD 4+
count, available in 15 patients, ranged from 180 to 480
cells/μl (median = 350cells/μl). A total of two HIV
patients (13.3%) had CD4+ count below 200 cells/μl and
the remaining 13 patients (86.7%) had CD4+ count of
≥200 cells/μ.
Plain x-rays of the affected limbs were performed in 235
(78.3%) patients. Of these, 195 (83.0%) patients had abnor-
mal x-ray findings including associated fractures, chronic
osteomyelitis, bone tumors and others in 144 (73.9%), 47
(24.1%), 3 (1.5%) and 1 (0.5%) patients respectively.
Doppler ultrasound of the affected limbs was done in
203 (67.7%) patients. Of these, only seventeen (8.4%)
patients had abnormal Doppler ultrasound findings.
A total of 56 histopathological examinations were per-
formed. Of these, 20 (35.7%) had a histopathologically
proven malignancy, of which malignant melanoma was
the most common histopathological type in 9 (45.0%)
patients. This was followed by Kaposi’s sarcoma in 5
(25.0%), squamous cell carcinoma in 4 (20.0%), neurofi-
brosarcoma and liposarcoma in 1 (5.0%) patient each
respectively.
A total of 287 (95.7%) patients were treated as inpati-
ents and the remaining 13 (4.3%) patients were treated
as outpatients. The vast majority of patients, 270 (90.0%)
were treated surgically (Figure 3). The remaining 30
(10.0%) patients were treated conservatively (non-surgi-
cal approach) with daily dressing, antimicrobial agents,
compression bandage, antibiotics.
A total of 178 post-operative complications were
recorded in 175 (58.3%) patients. Of these, surgical site
infection (77.5%) was the most common post-operative
complications (Figure 4). Table 2 shows predictors of
postoperative complications among patients with
Table 1 Distribution of study population according to the
type of ulcers
Type of ulcers Frequency Percentage
Traumatic ulcers 181 60.3
•Mechanical trauma 131 72.4
•Burns 50 27.6
Infective ulcers 43 14.3
•Osteomyelitis 30 69.8
•Tropical ulcer 6 13.9
•Cellulitis 5 11.6
•Others 2 4.7
Metabolic ulcers 35 11.7
•Diabetic ulcer 32 91.4
•Pellagra 3 8.6
Neoplastic/malignant ulcers 20 6.7
•Malignant melanoma 9 45.0
•Kaposi’s sarcoma 5 25.0
•Squamous cell carcinoma 4 20.0
•Others 2 10.0
Vascular ulcers 11 3.7
•Arterial ulcers 5 45.5
•Venous ulcers 4 36.4
•Mixed ulcers 2 18.2
Neuropathic ulcers 8 2.7
•Pressure sores 6 75.0
•Others 2 25.0
Ulcerating skin lesions e.g.
Pyogenic Granulomatous
2 0.7
Figure 2 Part of lower limb affected.
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chronic lower limb ulcers according to univariate and
multivariate logistic regression analysis
The overall length of hospital stay (LOS) ranged from
1 day to 180 days with a median of 23 days. The LOS
for non-survivors ranged from 1 day and 42 days
(median = 10 days). Table 3 shows predictors of LOS
among patients with chronic lower limb ulcers according
to univariate and multivariate logistic regression analysis
In this study, thirteen patients died giving a mortality
rate of 4.3%. The causes of death were complications of
diabetes mellitus (5 patients), HIV infection (4 patients)
and advanced malignancy (2 patients). The cause of
death was not established in 2 patients.
Out of the two hundred and eighty-seven (95.7%) survi-
vors, 253 (91.6%) were treated successfully and discharged
well (healed). Thirteen (4.5%) patients were discharged
with permanent disabilities resulting from lower limb am-
putation and the remaining six (2.1%) patients were dis-
charged home advised to continue with daily dressing at
their nearby health facilities. Thirteen (4.5%) patients
were treated as outpatients and two (0.7%) patients dis-
charged themselves against medical advice.
Discussion
In this review, chronic lower limb ulcers were in the
third decade of life and tended to affect more males than
females, with a male to female ratio of 2:1 which is com-
parable with other studies in developing countries
[16,17]. Our demographic profile is in sharp contrast to
what is reported in developed countries where the ma-
jority of the patients are in the sixth decade and above
[17-19]. Male predominance in this age group may be
due to their increased susceptibility to trauma which
was found to be the major etiological agent of chronic
lower limb ulcers in this study.
The presence of pre-morbid illness, such as diabetes
mellitus, chronic obstructive pulmonary disease, arterio-
sclerosis, peripheral vascular disease, heart disease, and
any conditions leading to hypotension, hypovolaemia,
edema, and anemia has been reported elsewhere to have
an effect on the outcome of patients with chronic lower
limb ulcers [20,21]. Pre-morbid illnesses influence the
healing process as a result of their influence on a num-
ber of bodily functions [20-23]. In the presence study,
diabetes mellitus was the most common premorbid ill-
ness accounting for 59.3% of cases which is agreement
with other studies in developing countries [21,22,24].
Diabetes mellitus is associated with delayed cellular re-
sponse to injury, compromised cellular function at the
site of injury, defects in collagen synthesis, and reduced
wound tensile strength after healing. Diabetes-related
peripheral neuropathy, reducing the ability to feel pres-
sure or pain, contributes to a tendency to ignore pres-
sure points and avoid pressure relief strategies [25].
In the present study, cigarette smoking was reported
in 22.7% of cases which is in keeping with other studies
[26,27]. Cigarette smoking has been reported to have an
impact on wound healing through impairment of tissue
oxygenation and local hypoxia via vasoconstriction [28].
Tobacco smoke has high concentration of carbon mon-
oxide, which binds hemoglobin, forming carboxyhemo-
globin. Carboxyhemoglobin binds to oxygen with high
affinity and thereby interferes with normal oxygen deliv-
ery to hypoxic tissues [29].
The etiological pattern of chronic lower limb ulcers
have been reported in literature to vary from one part of
the world to another depending on the prevailing socio-
demographic and environmental factors [2,9]. In West-
ern societies, most chronic lower limb ulcers are due to
vascular diseases, whereas in developing countries,
trauma, infections, malignancies and poorly controlled
diabetes remain the most common causes of chronic
lower limb ulceration [2,9,10]. In the present study, trau-
matic ulcers secondary to road traffic accidents were the
most common type of chronic lower limb ulcers
accounting for more than sixty percent of cases, which
is in keeping with other studies done in developing
countries [9,10,20,21]. High incidence of traumatic
ulcers secondary to road traffic accidents may be attribu-
ted to recklessness and negligence of the driver, poor
Figure 4 Distribution of patients according to postoperative
complications.
Sur
g
ical procedures performed
Others
Amputation
Wide local excision
Skin grafting
Debridment
Percentages of patients
30.0
20.0
10.0
0.0
30
20
10
0
22.6
4.8 4.8
8.5
5.9
Figure 3 Distribution of patients according to surgical
procedure performed.
Mbunda et al. BMC Dermatology 2012, 12:17 Page 5 of 10
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maintenance of vehicles, driving under the influence of
alcohol or drugs and complete disregard of traffic laws.
In agreement with other studies in developing coun-
tries [3,24], the majority of patients in the present study
presented late to hospital with advanced and compli-
cated chronic lower limb ulcers which may end up being
treated by limb amputation with increased risk of recur-
rence and malignant change. Late presentation in this
study may be attributed to poor economic capabilities in
cost shared healthcare systems, inadequate knowledge of
self-care and socio-cultural reasons. Other contributing
factors for late presentation include attempts at home
Table 2 Predictors of Postoperative complications according to univariate and multivariate logistic regression analysis
Predictor (Independent) variables Post operative complications n (%) Univariate analysis Multivariate analysis
Absent Present OR 95% CI P value OR CI P value
Age
≤20 39(48.8) 41(51.3)
>20 83(37.7) 137(62.3) 1.6 0.9-2.6 0.087 3.0 1.4-6.3 0.004
Sex
Male 102(51.0) 98(49.0)
Female 20(20.0) 80(80.0) 4.2 2.4-7.3 <0.001 4.3 2.1-8.7 <0.001
HIV status
Positive 4(20.0) 16(80.0)
Negative 118(42.1) 162(57.9) 2.9 0.9-8.9 0.062
CD4 count
<200 cells/μl 1(50.0) 1(50.0)
≥200 cells/μl 3(23.1) 10(76.9) 1.3 0.2-2.7 0.082
Pre-morbid illness
Absent 11(20.4) 43(79.6)
Present 111(45.1) 135(54.9) 3.2 1.6-6.5 0.001 0.4 0.2-1.0 0.041
Tobacco smoking
Yes 30(44.1) 38(55.9)
No 92(39.7) 140(60.3) 1.9 0.4- 5.4 0.897
Duration of illness
1/12-3/12 115(48.7) 121(51.3)
3/12-1 year 3(7.1) 39(92.9) 12.4 3.7-41.1 <0.001 8.0 2.1-30.0 0.002
>1 year 4(18.2) 18(81.8) 4.3 1.4-13.0 0.010
Type of ulcer
Traumatic ulcer 107(59.1) 74(40.9)
Vascular ulcer 4(36.4) 7(63.6) 2.5 0.7-9.0 0.150
Neoplastic ulcer 4(20.0) 16(80.0) 5.8 1.9-18.0 0.002
Infective ulcer 3(7.0) 40(93.0) 19.3 5.7-64.7 <0.001 17.6 4.7-66.0 <0.001
Metabolic ulcer 2(5.7) 33(94.3) 23.9 5.6-102.5 <0.001 8.4 1.8-39.4 0.007
Neuropathic ulcer 2(25.0) 6(75.0) 4.3 0.9-22.1 0.077
Ulcerating skin disease 0(0.0) 2(100) –– –
Ulcer size in cm
≤5 90(47.9) 98(52.1)
>5-10 28(31.8) 60(68.2) 2.0 1.2-3.4 0.013
>10 4(16.7) 20(83.3) 4.6 1.5-13.9 0.007
Mode of treatment
Conservative 14(36.8) 24(63.2)
Surgical 108(41.2) 154(58.8) 0.8 0.4-1.7 0.608
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surgery, trust in faith healers, poor management of acute
lower limb ulcers and delayed referral in most health
centers and peripheral hospitals.
As reported in other studies [30,31], the leg was the
most frequent anatomical site affected in our series and
the right side was frequently involved. We could not find
the reasons for this anatomical site distribution.
The microbiological profile of chronic ulcers of the
lower limbs has application to general principles of
treatment as well as institution-specific guidelines for
management [32]. In the present study, Pseudomonas
aeruginosa was the most frequent gram negative bacteria
isolated, whereas gram positive bacteria commonly iso-
lated was Staphylococcus aureus. Similar bacterial profile
was reported by Lim et al. [32]. The study also found
that most of the pathogens were multiply resistant to
the commonly prescribed antibiotics such as Ampicillin,
Augmentin, Cotrimoxazole, Tetracycline, gentamicin,
Table 3 Predictors of length of hospital stay (LOS) among patients with chronic lower limb ulcers according to
univariate and multivariate logistic regression analysis
Predictor (Independent) variables LOS n (%) Univariate analysis Multivariate analysis
≤14 >14 OR 95% CI P- value OR CI P-value
Age
<20 14(17.5) 66(82.5) 1
>20 45(20.4) 175(79.6) 1.1 0.4-1.6 0.570
Sex
Male 42(21.0) 158(79.0) 1
Female 17(17.0) 83(83.0) 1.3 0.7-2.4 0.412
HIV status
Positive 2(10.0) 18(90.0) 1
Negative 57(20.4) 223(79.6) 2.3 0.5-10.2 0.273
Pre-morbid illness
Absent 51(20.7) 195(79.3) 1
Present 8(14.8) 46(85.2) 1.5 0.7-3.4 0.324
Duration of illness
1/12-3/12 47(19.9) 189(80.1) 1
3/12-1 year 7(16.7) 35(83.3) 1.2 0.5-3.0 0.624
>1 year 5(22.7) 17(77.3) 0.8 0.3-2.4 0.753
Type of ulcer
Traumatic ulcer 42(23.2) 139(76.8) 1
Vascular ulcer 2(18.2) 9(81.8) 1.4 0.3-6.5 0.701
Neoplastic ulcer 4(20.0) 16(80.0) 1.2 0.4-3.8 0.746
Infective ulcer 6(14.0) 37(86.1) 1.9 0.7-4.7 0.189
Metabolic ulcer 3(8.6) 32(91.4) 3.2 0.9-11.1 0.063 3.5 1.0-12.5 0.056
Neuropathic ulcer 1(12.5) 7(87.5) 2.1 0.3-17.7 0.489
Ulcerating skin disease 1(50.0) 1(50.0) 0.3 0.01-4.9 0.401
Ulcer size in cm
≤5 38(20.2) 150(79.8) 1
>5-10 17(19.3) 71(80.7) 1.1 0.6-2.0 0.862
>10 4(16.7) 20(83.3) 1.3 0.4-3.9 0.682
Mode of treatment
Conservative 13(34.2) 25(65.8) 1
Surgical 46(17.6) 216(82.4) 2.4 1.2-5.1 0.018 3.2 1.4-7.1 0.005
Postoperative complications
Absent 26(21.3) 96(78.7) 1
Present 33(18.5) 145(81.5) 1.2 0.7-2.1 0.553
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erythromycin, and Ceftriaxone. Similar antimicrobial
susceptibility pattern has been reported previously [33].
These findings reflect the widespread and indiscriminate
use of antibiotics, coupled with poor patient compliance
and self treatment without prescription among African
patients [32,33]. The majority of gram negative isolates
were sensitive to Meropenem while gram positive being
sensitive to Vancomycin; this could be explained by the
fact that these antibiotics are relatively rare in the hos-
pital and are more expensive so they are rarely misused.
The prevalence of HIV infection in the present study
was 6.7% that is relatively similar to that in the general
population in Tanzania (6.5%) [34]. High HIV seropreva-
lence among patients with CLLUs was reported in a
Zimbabwean study [35]. HIV seropositive patients have
been reported to have a higher risk of developing post-
operative complications and have a greater risk of pro-
longed hospital stay and mortality [16,18]. HIV infection
has been reported to increase the risk of wound sepsis
and poor healing [35]. However, in the present study,
there were no significant differences in the outcome be-
tween patients who are HIV infected and those who are
non-HIV infected.
Fungal infections have been reported to be common in
chronic lower limb ulcers with the prevalence ranging
from 4.5%–50% and [36,37], are also responsible for
some chronic lower limb ulcers e.g. Madura foot [38,39].
In the present study, fungal infection was not investi-
gated due to logistic problems. This calls for other
authors to investigate on this.
Histopathological examination remains the most im-
portant definitive diagnostic procedure, and it should be
performed on any suspicious lesion or any chronic non-
healing ulcers, especially those with any recent change
in appearance or considerable drainage [40]. In the
present study, malignant ulcers were histopathologically
proven in 8.4% of cases, a figure closely to 10.4%
reported by Senet et al. [41]. In our study, malignant
melanoma was the most frequent histopathological type
as previously reported by Chalya et al. [42] at the same
centre, but at variant with Senet et al. [41] who reported
squamous cell carcinoma as most common histopatho-
logical type. This difference in histopathological type
reflects geographic differences in exposure to risk factors
for developing malignant ulcers. While solar radiation
has been suggested as a major cause of malignant mel-
anoma among Caucasians, many of malignant melanoma
among black Africans has been reported to be unrelated
to solar exposure since they occur on the unexposed
plantar of the foot [43-51]. Higher incidence of malig-
nant melanoma in our study may be attributed to
repeated trauma and constant pressure on the weight
bearing areas of the foot as shoe-wearing is less frequent
among people especially those from rural areas [42,52].
In the present study, Kaposi’s sarcoma ranked third after
squamous cell carcinoma. Since the emergence of HIV
infection, there has been a steady increase in the preva-
lence of KS worldwide [53,54]. The rate of HIV infection
among patients with Kaposi’s sarcoma in our study was
60%, a figure slightly lower than that reported by Chalya
et al. [42]. Thus it is obvious that successful HIV control
will go a long way to reduce the incidence of this vascu-
lar malignancy.
The treatment of chronic lower limb ulcers requires
multidisciplinary approach [54,55]. The treatment mo-
dalities of chronic lower limb ulcers include surgical
treatment (such as wound debridement, wide local exci-
sion, split thickness skin graft (STSG) or flap cover,
block dissection of the regional nodes and limb amputa-
tion in advanced lesions) and non-surgical treatment
such daily dressing, compressive bandages and anti-
microbial agents bases on drug sensitivity pattern
[54,56-58]. In the present study, wound debridement
with or without STSG or flap cover was the most com-
mon surgical procedure performed which is in keeping
with studies done elsewhere [55].
The presence of complications has an impact on the
final outcome of patients presenting with chronic lower
limb ulcers [21]. Most complications are related to late
presentation to hospital following ignorance, treatment
at home, cost, poverty, advanced malignancy, premorbid
conditions like diabetes mellitus, hypertension, and the
treatment choices made and the procedures performed.
In the present study a total of 178 complications were
recorded in 175 (58.3%) patients, mostly being post op-
erative complications. Of these, surgical site infections
(77.5%) was the most common post operative complica-
tion followed by recurrent ulceration (11.2%) and skin
grafting failure (6.2%). Callam et al. [21] reported a simi-
lar observation.
The length of hospital stay is an important measure of
morbidity in which estimates of length of hospital stay
are important for financial matters and accurate early
estimates so as to facilitate better financial planning by
the payers since it takes long for the chronic lower limb
ulcers to heal so increasing the costs as well as seen in
other studies as well [16,18]. In this study, the overall
mean length of hospital stay was 28.9 days, a figure
which is higher than that reported in other studies
[59,60]. A mean length of hospital stay of 38.2 days was
also reported in Nigerian study [16]. A mean of 36.2 days
and 64.2 days were reported in Tanzanian and Nigerian
studies respectively [16,24]. Prolonged LOS in our study
was observed in patients with diabetic foot ulcers and in
patients who required surgical treatment.
In this study, the mortality rate was 4.3% which is rela-
tively lower than that reported in other studies [16].
Mortality rate in the present study was attributed to
Mbunda et al. BMC Dermatology 2012, 12:17 Page 8 of 10
http://www.biomedcentral.com/1471-5945/12/17
complications of diabetes mellitus, hypertension, HIV
infection and advanced malignancy. The causes of death
in our study is at variant with a Nigerian study which
reported anemic heart failure, septicemia and multiple
organ failure as causes of death [16]. Addressing these
factors responsible for mortality in our patients is
mandatory to be able to reduce mortality associated with
chronic lower limb ulcers.
In this study, complete healing at discharge from the
hospital was achieved in more than 90% of the patients,
which is comparable with other studies [16,61]. This is
satisfactorily acceptable to both the patient and the sur-
gical team.
Self discharge by patient against medical advice is a
recognized problem in our setting and this is rampant,
especially amongst patients with chronic lower limb
ulcers [62]. In the present study discharge against med-
ical advice was noted in 0.7% of cases. Discharge against
medical advice in our study is attributed to patients feel-
ing well enough to leave and dissatisfaction with treat-
ment received.
Poor follow up visits after discharge from hospitals re-
main a cause for concern in most developing countries
[63]. These issues are often the results of poverty, long
distance from the hospitals and ignorance. In the present
study, only 33.1% of patients were available for follow up
at three months, the reasons for low follow up rate at
our study may be attributed to long distance from the
hospital, lack of funds for transport and feeling of being
cured.
Delay in getting histopathological results was the
major limitation in this study and this might have
affected the treatment outcome of patients who needed
this confirmatory diagnostic investigation for definitive
treatment.
Conclusion
Chronic lower limb ulceration remains a major public
health problem in this part of Tanzania. Traumatic
ulcers are the most common type of chronic lower limb
ulcers. The majority of patients in our environment
present late when the disease is already in advanced
stages predisposing them to increased risk of recurrence,
malignant change and limb amputation. Early recogni-
tion and aggressive treatment of the acute phase of
chronic lower limb ulcers at the peripheral hospitals and
close follow-up are urgently needed to improve out-
comes of these patients in this environment. Further
study looking at the factors associated with late presen-
tation to tertiary health facilities is highly recommended.
A population based study is highly needed to be able to
assess the better picture of the magnitude of the prob-
lem in this region.
Competing interests
The authors declare that they have no competing interests.
Authors’contributions
FM conceived the study and did the literature search, participated in data
analysis, writing of the manuscript and editing. MDM and BBK participated in
the literature search, writing of the manuscript and editing. SEM participated
in writing of the manuscript, editing and performed the microbiological
analysis. PFR participated in writing of the manuscript, editing and
performed the pathological work up. PLC participated in writing of the
manuscript, editing, data analysis and submission of the manuscript. JMG
coordinated the write-up, editing and supervised the study. All the authors
read and approved the final manuscript.
Acknowledgements
The authors would like to thank all those who participated in the
preparation of this manuscript.
Author details
1
Department of Surgery, Catholic University of Health and Allied Sciences-
Bugando, Mwanza, Tanzania.
2
Department of Surgery, Muhimbili University
of Health and Allied Sciences, Dar Es Salaam, Tanzania.
3
Department of
Pathology, Catholic University of Health and Allied Sciences- Bugando,
Mwanza, Tanzania.
4
Department of Microbiology, Catholic University of
Health and Allied Sciences- Bugando, Mwanza, Tanzania.
5
Department of
Biochemistry and Molecular Biology, Catholic University of Health and Allied
Sciences- Bugando, Mwanza, Tanzania.
Received: 28 May 2012 Accepted: 23 September 2012
Published: 28 September 2012
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doi:10.1186/1471-5945-12-17
Cite this article as: Mbunda et al.:Experiences with Surgical treatment
of chronic lower limb ulcers at a Tertiary hospital in northwestern
Tanzania: A prospective review of 300 cases. BMC Dermatology 2012
12:17.
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