[Procedure to follow with a resistant venous ulcer of the ankle].

In this study the authors present details of the clinical and paraclinical examination, in particular, examination of vascular function, which enable identification of the reasons why a venous ulcer on the lower leg fails to heal or recurs despite the usual treatment. Two important possibilities are stressed: 1. Progressive aggravation of the causal venous insufficiency, in which incompetence of calf perforators plays a fundamental role in both varicose veins and phlebitis. 2. Combination of venous insufficiency with a loco-regional or general factor, which contributes to trophic tissue deterioration. It is, thus, at a loco-regional level that ankle stiffness, major sub-ulcer sclerosis with possibility of formation of calcified plaques, lymphatic stasis and exceptionally malignant degeneration should be systematically investigated. It is necessary to act effectively on the various associated factors in order that treatment of the venous insufficiency responsible for the ulcer may succeed in spontaneous healing or allow successful grafting. However, the most important occurrence in the event of resistant ulceration is due to a combination, in patients over 60 years, of arterial insufficiency and venous insufficiency of variable duration. This is the context of mixed ulceration, in which treatment of both etiological factors must be modulated as a function of good identification of concomitant venous and arterial lesions.