When Wounds Require Multidisciplinary Care

By Eric H. Espensen, DPM

When A Patient Presents With Multiple Digit Gangrene

   With this in mind, let us consider a couple of case studies of patients who require multidisciplinary care. We evaluated a 56-year-old female who had diabetes and multiple medical comorbidities. She required extensive medical and surgical evaluation. The patient initially presented with multiple digital gangrene and underlying necrosis (see photo on the left). She had severe peripheral vascular disease with multiple vessel occlusion and stenosis.    The patient underwent a distal pedal revascularization and ultimately underwent transmetatarsal amputation due to underlying necrosis of tissue. The multidisciplinary team allowed the period of demarcation in order to facilitate tissue reperfusion after revascularization. Often, significant tissue healing occurs and allows for more distal salvage than what was considered at the initial presentation. This demarcation period is similar to cases of frostbite in which there is delayed intervention to allow for adequate reperfusion.10    The length of time for delay for proper demarcation varies but has been reported in several studies to range from days to weeks to months. However, this time frame is rather long and may allow for extended periods of exposure to infection. At our facility, we commonly allow up to two weeks for demarcation and subsequently perform an appropriate amputation. Typically, we prefer to perform closed amputations rather than open amputations, which would require subsequent delayed closure.

Treating An Infected Wound In A Senior With Longstanding Diabetic Neuropathy

   A 72-year-old male with longstanding diabetes, neuropathy and heart disease presented with a recent onset of a wound to the medial aspect of the right great toe. A local physician had been managing the wound until it developed a large eschar and infection with drainage (see above photo on the left).    The patient was admitted for wound care and infection control. He received a comprehensive evaluation and consultation. We referred the patient to infectious diseases and the patient received subsequent treatment. The patient underwent vascular surgery consultation with invasive angiography.    After obtaining a cardiac consultation and clearance, a vascular surgeon performed a lower extremity bypass on the right leg. In the absence of osteomyelitis and resolved infection, and after a brief period of demarcation and reperfusion, the team decided to perform an escharotomy versus a digital amputation. The resultant wound was healthy with adequate perfusion (see above photo on the right). The wound eventually healed with a period of wound care and offloading. We would have amputated the affected toe if we had encountered underlying necrosis and tissue destruction.

What You Should Know About Preventing Ulcers And Reulceration

   Diabetic education and screening programs may reduce the risk of amputation and complications, but there is little evidence base to support these programs. One study suggests the benefit of patient education is short-lived (six months) while another study suggests education has no beneficial effect.11    Clinicians and researchers have long believed the use of therapeutic footwear for diabetic patients is beneficial in both protecting and preventing foot ulcerations. Several journal articles compare and contrast the benefits of such footwear.12-14

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