Subcutaneous Ossification of the Legs in Chronic Venous Insufficiency

Abstract

The presence of subcutaneous ossification in the legs associated with chronic venous insufficiency has recently been described by one of us in a preliminary report (1). The present paper is concerned with the correlation of radiologic and clinicopathologic features and with some refinements in the roentgenographic demonstration of this condition. Chronic venous insufficiency is defined as tissue damage due to abnormalities in venous blood flow (2, a). In the lower extremities, these abnormalities are frequently caused by varicosities of the greater saphenous system or by pathologic conditions in the deep veins (obstruction or insufficiency). Less frequently, varicosities in the lesser saphenous system are contributory. Other less common causes are acquired arteriovenous fistulas and vascular malformations. Dependent edema is an important mechanism in the development of chronic venous insufficiency. Clinical manifestations of chronic venous insufficiency are chronic dermatitis and cellulitis, and atrophy of skin and subcutaneous tissue with induration and brown discoloration. Later sequelae include recurrent ulceration and subcutaneous ossification. Material and Methods Sixty patients with subcutaneous ossification of the leg were studied. These include 23 described in the preliminary report. Of the latter group, all were reevaluated roentgenographically and some were re-examined with special technics. The condition was unilateral in 33 and bilateral in 27 patients. This report, therefore, is based upon the study of 87 legs in 60 patients. In six cases there was pathologic confirmation of subcutaneous ossification from biopsy specimens which were obtained during surgical treatment for complication of chronic venous insufficiency. In all legs, the clinical and roentgenographic findings appeared sufficiently distinctive to warrant a diagnosis of subcutaneous ossification. Of the 60 patients, 9 were observed at the peripheral vascular clinic and the wards of the Bronx Municipal Hospital Center, 29 at the peripheral vascular clinic of the Sidney Hillman Health Center, and 22 in private practice. The national and racial origin of these patients corresponded to that of the general population in these three groups. All 60 patients were females and past the menopause. Their average age was 60.2 years at the time of the first examination (forty-six to seventy-eight years). The incidence of associated diseases and other clinical data are summarized in Table I. The diagnosis of chronic venous insufficiency was established by conventional methods (1). Blood concentrations of calcium, phosphorus, alkaline phosphatase, and total proteins were determined in 50 patients and were found to be within normal range in each instance. Sulkowitch reagent tests were performed in random urine specimens in the first 23 patients. They were omitted in all subsequent cases, since the results could not be correlated with the clinical findings. Roentgenographic Technics Laminagraphic studies were made in 13 cases, in the anteroposterior and lateral projections. Venography was performed by injecting 5 to 15 ml. of contrast medium (usually 35 per cent Diodrast) into a superficial varicosity proximal to the site of ossification, with the leg in a dependent position at 30 to 40°.