Research Article
Transverse Flatfoot is a Potential Risk Factor for Development of Varicose Veins in the Lower Extremities of Middle-Aged Women
Bakhmetev AS1, Kaliaev AO2, Zotkin VV1, Sukhoruchkin AA3, Loiko VS1 and Malikova MA4*
1Saratov State Medical University named after V. I. Razumovsky, Saratov, Russia
2Avesta Central Hospitals, Saratov, Russia
3Stroygrad Medical Centers, Kirsanov, Russia
4Department of Surgery, Boston Universities, Boston Medical Center, USA
*Corresponding author: Malikova MA, Department of Surgery, Boston Universities, Boston Medical Center, MA, 02181, USA
Published: 11 Jul 2017
Cite this article as: Bakhmetev AS, Kaliaev AO, Zotkin VV,
Sukhoruchkin AA, Loiko VS, Malikova
MA. Transverse Flatfoot is a Potential
Risk Factor for Development of
Varicose Veins in the Lower Extremities
of Middle-Aged Women. Clin Surg.
2017; 2: 1552.
Abstract
Objectives: To evaluate the effect of transverse flatfoot on the severity of varicose veins in the lower
extremities (VVLE) of middle-aged women.
Materials and Methods: This was a cross sectional study which included 50 women between
39-54 years old who were scheduled for their routine care outpatient visit for their varicose vein
lower extremity (VVLE) disease at the Mirotvortseva hospital, which is affiliated with Saratov State
Medical University (SSMU). Both orthopedic and vascular surgeons examined all patients. Patients
were excluded, if they were diagnosed prior with any of the following conditions: veins affected
by thrombosis, post-thrombophlebitic disease, isolated severe varicose transformation of the main
trunk of the great saphenous vein at hip level, ectasia and ultrasound signs of valvular insufficiency
of the iliac and deep femoral veins, as well as women with clinical manifestations of chronic venous
disease of the C4 to C6 categories by CEAP classification. All patients underwent triplex scanning
(TS) ultrasound test of the lower extremities. All images were acquired on the Philips HD 11 XE
scanner and expert class linear (2-5 MHz) transducer was utilized for all ultrasound tests.
Results: The VVLE was found in majority of patients: out of 50 patients initially screened for
this study, 48 patients have had clinics symptoms of varicose vein disease in their limbs with coexistent
flatfoot condition and were included into final analysis, which had resulted in 88 lower
limbs qualified after vascular surgeon clinical examinations and TS test of the lower limbs (96%
participation rate). Varicose transformation of reticular or saphenous veins, corresponding to C1
category by CEAP classification, was found only in 3 out of 48 examined subjects (6%) with 6 of the
lower limbs affected by venous disease. The C2 category of venous disease by CEAP classification was
detected in 36 patients with 68 lower limbs out of 48 assessed subjects (75%). Clinical manifestations
of C3 category of venous disease were detected in 9 women with 14 lower extremities affected
(18.75%). There was no more severe degree of venous disease observed in this study. TS ultrasound
of superficial and deep veins of the lower limbs revealed varicose transformation in the great
saphenous vein in 43 women. In majority of cases expanded and/or incompetent perforating veins
were detected (86% noted in 60 of the lower limbs). Small saphenous veins were less often affected:
as observed in 8 patients only out of 48 (16%) with 10 lower limbs examined. Also noteworthy was
ectasia of shin vein in 33 women (66%) with 46 of the lower limbs examined. The most common
cause of deep vein extension was attributed to ectasia of medial sural veins (observed in 26 patients
out of 48 (52%) with 32 of the lower limbs examined. Ectasia of soleus veins was detected in 24
patients out of 48 (48%) with 30 of the lower limbs examined.
Conclusion: Transverse flatfoot is a potential risk factor in VVLE in middle-aged women. Despite
an active lifestyle flatfoot was found to be associated with VVLE in 96% of cases. The main cause of
VVLE was attributed to the reflux in the great saphenous vein, and in some occasions the expansion
of perforators was observed. In addition, ectasia of deep shin veins was detected in 66% of analyzed
subjects, which considerably affects patients’ quality of life. Based on the finding of this study women
diagnosed with flatfoot and at risk for development of varicose vein disease should be screened once
a year prophylactically to prevent further exacerbation of venous disease.
Keywords: Flatfoot; Varicose veins; Lower extremities; Risk factors for venous diseases
Introduction
The varicose veins disease is very common in modern society. Incidence rate of varicose veins vary widely from 2% to 56% in men and 1% to 60% in women worldwide [1]. According to the National Women's Health Information Center as many as 60% of all American adults have some form of varicose veins. However, women are more affected by this disease, on average by 50% as compared to men [1]. At our institution, which is located in Eastern Europe, we treat similar population of patients with chronic venous diseases. In recent studies it was noted that half of all examined patients with venous problems were office workers and people who stand on their feet for prolonged periods of time due to their occupation [1,2]. Moreover, 81.2% of patients with varicose disease are females as observed in a recently conducted study called SPECTRUM [2]. In this study only 25.8% of patients were reported to have flatfoot as co-existent disease [2]. Criqui M.H. et al. [3] noted that office employees have a combination of risk factors for varicose diseases such as family history venous disease, hypodynamia, flatfoot condition, obesity, etc [4]. We examined our population of female patients with varicose vein disease and attempted to find correlations between flatfoot condition and venous system diseases.
Materials and Methods
Study design and procedures
This was a cross sectional study which included 50 women
between 39-54 years old (average age was 43.5 years) who were
scheduled for their routine care outpatient visit for their varicose vein
lower extremity (VVLE) disease at the Mirotvortseva hospital, which
is affiliated with Saratov State Medical University (SSMU). There was
no randomization applied (Figure 1). In accordance with Declaration
of Helsinki, Institutional Review Board (IRB) approval and informed
consents from each individual patient were obtained prior to any
study procedures been performed. Both orthopedic and vascular
surgeons examined all patients. The examination included: physical
exam, ultrasound test and orthopedic assessment. The physical
exam consisted of the following assessments: pitting or non-pitting
edema, skin conditions (i.e. redness, macerations, discolorations,
etc.), appearance of veins, tissue loss and/or ulcerations. All women
were diagnosed with transverse flatfoot and symptoms of venous
insufficiency of the lower limbs.
Patients were excluded, if they were diagnosed prior with any
of the following conditions: veins affected by thrombosis, postthrombophlebitic
disease, isolated severe varicose transformation
of the main trunk of the great saphenous vein at hip level, ectasia
and ultrasound evidence of valvular insufficiency of the iliac and
deep femoral veins, as well as women with clinical manifestations
of chronic venous disease of the C4 to C6 categories by CEAP
classification (C4 - included skin pigmentation or eczema, C5 -
characterized by healed venous ulcer and C6 – subject has an open
venous ulcer). The CEAP classification was utilized to further assess
study population for severity of the venous disease: C0 – no visible or
palpable signs of venous disease, C1 – telangiectasiaor reticular veins,
C2 – varicose veins, C3 – edema, C4a – pigmentation or eczema, C4b
– lipodermatosclerosis, atrophie blanche, C5– healed venous ulcers,
C6 – active venous ulcer) (Figure 1) [5].
It is important to note that almost all study subjects had an active
lifestyle (i.e. exercising at least 2-3 times a week, walking, and running
weekly, etc.). Patients with hypodynamia and/or obesity were not included in this study.
In order to assess varicose transformations and measure vein
diameters all patients underwent triplex scanning (TS) test of the
lower extremities by a standard of care ultrasound-based method
in the Department of Ultrasonic and Functional Diagnostics at the
Mirotvortseva hospital, which is affiliated with Saratov State Medical
University (SSMU). All images were acquired on the Philips HD 11
XE scanner and expert class linear (2-5 MHz) transducer was utilized
for all ultrasound tests.
Incompetent veins were categorized and varicose transformation
was staged by summary of contributing factors as detected by
ultrasound: reflux, condition of the valve, time to valve closure, length
and diameter of examined veins, etc. Ectasia of muscle veins was
assessed and categorized as “Normal” versus “Abnormal”. Diameter
of sural and soleus veins was measured on images obtained by
ultrasound technique as a distance between vessel walls in the biggest
portion of the vein as it appeared on the image. The average diameter
(mean value) of measurements obtained was calculated.
Statistical data analysis
The data obtained from 48 subjects with 88 lower limbs affected
were analyzed using SAS program, version V 9.1 (SAS Institute Inc.,
Cary, NC, USA). The non-parametric analysis was performed to
evaluate correlation between varicose transformation of veins and
anatomic location. The CEAP category assigned based on clinical
diagnosis was utilized to further examine study population in order
to assess prevalence of varicose disease.
We performed stratified data analysis and controlled for multiple
variables (i.e. age, race, family history of venous disease) as potential
confounders by using multiple linear regression models or stratified
Mantel-Haenszel chi-squared analysis as appropriate.
Also, Student’s t- test was performed to examine correlation
between diameter of the affected veins and the type of the vein by
anatomic location.
Figure 1
Figure 1
Study design and procedures: Cross sectional study of 50
women (average age = 43.5 years old) who were scheduled for routine
clinical care for their varicose vein of lower extremity (VVLE). Both vascular
and orthopedic surgeons examined all patients, which participated in this
study. Physical exam, triplex scanning (TS) ultrasound test of the lower
extremities (LE) and assessment of varicose veins was perform to assess
eligibility criteria. The CEAP classification was utilized to further assess
study population: C0 –no visible or palpable signs of venous disease, C1
– telangiectasia or reticular veins, C2 –varicose veins, C3 –edema, C4a –
pigmentation or eczema, C4b – lipodermatosclerosis, atrohie blanche, C5
–healed venous ulcers, C6 –active venous ulcer) [5]. Forty eight subjects
(N=48) qualified for this study and had VVLE confirmed by physical exam and
TS test, with diagnosed co-existent flatfoot condition.
Figure 2
Figure 2
Prevalence of varicose disease stage by CEAP classification
(clinical, etiology, anatomy, and pathophysiology): C1 category included
group of subjects with small varicose vein issues such as telangiectasies or
reticular veins, C2 category consisted of subjects with large varicose veins,
C3 group included small and large vein problems with edema.
Figure 3
Figure 3
Varicose transformations of veins by anatomic location:
Varicose transformations in the great saphenous veins were assessed by
triplex scanning (TS) ultrasound test and observed in 43 out of 48 of examined
women (86%). There was a small amount of varicose transformations in the
small saphenous vein observed in this study (16%). Ectasia of shin veins was
detected in 66% of subjects. Ectasia of soleus veins and medial sural veins
was observed in 48% and 52% examined subjects, respectively.
Figure 4
Figure 4
Diameter of sural and soleus veins: Student’s t-test demonstrated
statistically significant difference in the diameter of sural and soleus veins in
patients affected by varicose vein disease (p=0.00483). The average mean
value of the sural and soleus veins diameter was 6.83 ± 0.70 mm and 7.45 ±
0.78 mm, respectively.
Results
The VVLE was found in majority of patients: out of 50 patients
initially screened for this study, 48 patients have had clinical
symptoms of varicose vein disease in their limbs with coexisting
flatfoot condition and were included into final analysis (N= 48),
which had resulted in 88 lower limbs qualified after vascular surgeon’s
clinical examination and TS test of the lower limbs (96% participation
rate) (Figure1).
CEAP classification of venous disease was utilized to further
characterize study population [5]. Varicose transformation of only
reticular or saphenous veins, corresponding to C1 category by
CEAP classification (C1 included telangiectasia or reticular veins),
was found only in 3 out of 48 examined subjects (6%) with 6 of the
lower limbs affected by venous disease (Figure 2). The C2 category of
venous disease by CEAP classification (C2 - included varicose veins)
was detected in 36 patients with 68 lower limbs out of 48 assessed
subjects (75%) (Figure 2). Clinical manifestations of C3 category
of venous disease, which included edema of lower extremity, were
detected in 9 women with 14 lower extremities affected (18.75 %).
There was no more severe degree of venous disease observed in this
study (Figure 2).
TS ultrasound test of superficial and deep veins of the lower limbs
revealed reflux and varicose transformation in the great saphenous
vein in 43 out of 48 examined subjects. In majority of cases expanded
and/or incompetent perforating veins were detected (86%; noted in
60 of the lower limbs) (Figure 3). Small saphenous veins were less
often affected; as observed in 8 patients only out of 48 (16%) with 10
lower limbs examined (Figure 3).
Also noteworthy was ectasia of shin vein which was found in 33
women (66%) with 46 of the lower limbs examined (Figure 3). The
most common cause of deep vein extension was attributed to ectasia
of medial sural veins (observed in 26 patients out of 48 (52%) with 32
of the lower limbs examined (Figure 3). Ectasia of soleus veins was
detected in 24 patients out of 48 (48%) with 30 of the lower limbs
examined (Figure 3).
Student’s t-test demonstrated statistically significant difference in
the diameter of sural and soleus veins in patients affected by varicose
vein disease (p= 0.00483). The average mean value of the sural and
soleus veins diameter was 6.83 ± 0.70 mm and 7.45 ± 0.78 mm,
respectively (Figure 4).
Discussion
Both vascular and orthopedic surgeon examined all 50 patients,
which participated in this study. Almost all patients were office
workers diagnosed with flatfoot and had clinical symptoms of
varicose vein disease (N=48).
In terms of prevalence of venous disease, the C2 category of
venous insufficiency by CEAP classification, which included varicose
veins on physical examination, was observed in 75% of assessed
subjects (Figure 2). Typically this group of patients has visible issues
and/or cosmetic defects on their legs attributed to the symptoms
of chronicve in disease which has developed over prolonged
period of time without seeking medical attention. Unfortunately,
it is a very common situation in Eastern Europe where majority of
patients ignore C1 earlier stage of venous disease. The current study
population was reflective of these social trends and consisted only of
6% of patients with C1 category by CEAP classification (Figure1,2).
That, in part, contributes to the higher prevalence of patients with
more advanced stage of the disease been enrolled into this study with
more severe outcomes observed (Figure 2).
In addition, forty three women had transformations in the
great saphenous vein as confirmed by TS ultrasound test (Figure 3).
Moreover, most of them had incompetent perforating veins. These
observations can serve as indication for endovascular interventions
and/or surgical treatment.
Based on the results of this study, we suggest that women who are
office workers as well as individuals with other occupations, which
require standing on their feet for prolonged periods of time, should
be examined by vascular surgeon once a year for preventive screening
of venous disease. Specifically, patients seen by orthopedic and/or
podiatry physicians and diagnosed with flatfoot should be referred
to vascular surgeon for further evaluation. Based on the findings of
this study 72% of examined subjects, who have been diagnosed with
flatfoot, had this condition associated with C2 category of venous
disease, which is associated with varicose veins. Therefore, flatfoot
seems to be an emerging risk factor for development of varicose vein
disease in the lower extremities.
The limitations of this study are cross sectional design and a
small sample size. Inherently, due to study design causality cannot
be established directly between contributing factors and the outcome.
Therefore, association between flatfoot and development of varicose
veins of the lower extremities (VVLE) needs to be evaluated further
in larger prospective cohort studies.
Conclusion
Transverse flatfoot is an additional risk factor in VVLE in middleaged
women. Despite an active lifestyle flatfoot condition may have
led to VVLE in 96% of all examined subjects. This possible association
of flatfoot with development of varicose vein disease, among other
contributing factors, needs to be further evaluated in prospective
studies to establish causality.
Although, the main cause attributing to development of varicose
veins was the reflux in the great saphenous vein, there were some
cases observed when patients had no reflux but developed symptoms
of venous disease due to damaged valve in the calf perforators. In
addition, ectasia of deep shin veins was observed in 66% of assessed
subjects, which considerably affects patients’ quality of life.
Based on the finding of this study we recommend that women
diagnosed with flatfoot and at risk for development of varicose vein
disease should be assessed once a year prophyl actically by a vascular
surgeon to prevent further exacerbation of venous disease.
References
- Robertson L, Evans C, Fowkes FGR. Epidemiology of chronic venous disease. Phlebology. 2008;23:103-11.
- Saveliev VS, Kirienko AI, Zolotukhin IA, Seliverstov EI. Prospective observational study SPECTRUM: register of patients with chronic diseases of the veins of the lower extremities. Phlebologiya. 2012;6:4-9.
- Michael H, Criqui, Denenberg JO, Bergan J, Langer RD, Fronek A. Risk factors for chronic venous disease: The San Diego Population Study. J Vasc Surg. 2007;46:331-7.
- Carpentier PH, Maricq HR, Biro C, Ponçot-Makinen CO, Franco A. Prevalence, risk factors, and clinical patterns of chronic venous disorders of lower limbs: A population-based study in France. J Vasc Surg. 2004;40:650-9.
- Eklof B, Rutherford RB, Bergan JJ, Carpentier PH, Gloviczki P, Kistner RL, et al; American Venous Forum International Ad Hoc Committee for Revision of the CEAP Classification. Revision of the CEAP classification for chronic venous disorders: consensus statement. J Vasc Surg. 2004;40:1248-52.