Case Studies In Combination Therapy For Complex Wounds
Whether there are issues with durable coverage, infection or a comorbidity such as rheumatoid arthritis, complex wounds may require a combination of modalities. Accordingly, these authors emphasize the importance of optimal medical management and discuss the roles of hydrosurgical debridement, polymethylmethacrylate antibiotic-loaded cement beads, plastic surgery techniques and external fixation to help facilitate wound closure.
While the title of this article may evoke pictures of large wounds with wound beds that appear sick along with exposed tendon and bones, we have to move past the limited visual perception of what constitutes a complex wound.
When looking at the whole picture, a complex wound may not look so complex on patients who may have very complex conditions due to medical comorbidities such as diabetes or rheumatoid arthritis. Rather than having a complex appearance, the wound may be complex in regard to determining what biomechanical factors resulted in formation of the wound. Perhaps the wound is complex in regard to determining the best way to obtain durable coverage. There are many factors beyond the appearance of a wound that make it a complex wound.
Treatment of these wounds requires taking the whole patient into account and addressing not only the wound itself but the factors that have contributed to the formation and possibly delayed healing of the wound. Once one determines these factors, the physician should address them and the focus transitions to what will lead to wound healing and maintenance of a healed skin envelope.
The following cases highlight combination therapy of a complex wound due to postoperative complications and complications related to medical comorbidities.
Case Study One: When A Patient With Alcoholic Peripheral Neuropathy Has A Chronic First MPJ Ulceration
A 57-year-old male with alcoholic peripheral neuropathy presented with a six-month history of a chronic ulceration to the plantar first metatarsophalangeal joint (MPJ) on the left lower extremity. The ulceration measured 1.8 cm x 2.4 cm x 0.8 cm and probed to the joint capsule. The patient was admitted for optimal medical management and complete bed rest with limb elevation.
We performed serial surgical debridement of the wound via hydrosurgery (Versajet™, Smith & Nephew) and subsequently aspirated the first MPJ. Culture and sensitivity were negative for aerobic and anaerobic growth. We also obtained a bone biopsy of the hallux proximal phalanx. Culture and sensitivity and histopathological analysis were negative for osteomyelitis.
We placed polymethylmethacrylate antibiotic loaded cement (PMMA-ALC) beads in the plantar foot ulceration and subsequently applied negative pressure wound care with a silver reticulated foam dressing (NPWT/SRFD). We performed serial dressing changes with NPWT/SRFD. This included one additional operative debridement with hydrosurgery and exchange of the PMMA-ALC beads. This occurred until the physical exam and intraoperative cultures (negative for aerobic and anaerobic growth) confirmed eradication of the infection.
The final procedure occurred 14 days after the index surgical procedure and consisted of a V-Y fasciocutaneous flap for plantar ulceration coverage, an open gastrocnemius recession, a peroneal longus tendon recession and a posterior tibial tendon recession to correct the deforming forces that had contributed to formation of the wound. Extra-articular ankle pinning maintained the foot and leg in the proper position.
We continued to emphasize immobilization postoperatively with the aid of a Jones compression dressing. The patient received training with physical therapy while remaining strictly non-weightbearing on the left lower extremity. The plantar ulceration was fully healed at 28 days after the procedure and remains healed at 13 months postoperatively.
Case Study Two: When There Is Dehiscence Of The Donor Site Surgical Incision In A Patient With A History Of Malignancy And Edema
A 69-year-old male developed osteonecrosis of the mandible and underwent mandibular reconstruction with an osteocutaneous fibular free flap harvested from the left lower extremity. He had a history of squamous cell carcinoma of the left tonsil, which was treated with wide surgical excision and radiation therapy. Dehiscence of the donor site surgical incision occurred secondary to early mobilization and ambulation.
Upon presentation, the patient’s fibular free flap harvest site had been open for eight days. The patient had 3+ pitting edema of the left lower extremity with the wound located in the mid aspect of the lateral lower leg. The wound measured 10 cm x 4 cm with the peroneus brevis tendon exposed at the wound base and extruding 1 cm from the skin surface. Due to the patient’s history of malignancy and unilateral leg edema, physicians obtained a venous duplex ultrasound, which was negative for deep venous thrombosis.
The treating physicians provided optimal medical management and emphasized complete bed rest with limb elevation. The patient received a referral to dietary services and maintained his nutrition through liquid supplements administered via a nasogastric tube. Resolution of the patient’s lower extremity edema occurred in 12 hours.
We subsequently performed surgical debridement of the wound via hydrosurgery (Versajet). We removed all exposed peroneal tendon and applied NPWT/SRFD via VAC therapy (KCI). He received one dressing change with NPWT/SRFD. The wound bed became flush with the skin and had a healthy red granular base, which occurred four days after the index debridement.
Physicians discontinued NPWT/ SRFD and wound coverage occurred with a split-thickness skin graft (STSG) harvested from the ipsilateral thigh. Surgeons harvested bone marrow aspirate (BMA) from the ipsilateral lateral calcaneus and applied the BMA to the STSG recipient site.
We continued to emphasize immobilization postoperatively with the aid of a Jones compression dressing. The patient received training with physical therapy while remaining strictly non-weightbearing on the left lower extremity. The wound fully healed and matured at 28 days postoperatively. The wound remains healed at 18 months postoperatively.
A Closer Look At The Multimodal Approach To Complex Wounds
The aforementioned cases demonstrate the multimodal approach to the treatment of complex wounds resulting from postoperative complications and complications related to medical comorbidities. Prior to considering and utilizing various operative and topical modalities that are available for advanced wound care, one must first ensure medical optimization of the patients. Initial management of complex wounds requires a multidisciplinary approach for medical optimization of systematic factors that delay wound healing. These factors may include uncontrolled diabetes, peripheral vascular disease, tobacco use and poor nutrition.1,2
One must subsequently address the basic tenets of wound care: immobilization, elevation and infection eradication.3 Both of the aforementioned patients received initial inpatient treatment for optimal medical management, parental antibiotic therapy and complete bed rest with limb elevation. Once the patient has been medically optimized and the basic tenets of wound care are in place, the focus then shifts to wound bed preparation for definitive closure.
In both cases, hydrosurgery with the Versajet occurred in place of conventional sharp debridement. The Versajet offers a form of high technology fluid in which pressurized saline exits the hand piece parallel to the wound surface. One then performs tangential tissue debridement with aspiration of the debris created due to a localized Venturi effect.4
Physicians can easily control the depth of tissue removal by adjusting the settings on the unit’s power console, the orientation of the hand piece or the pressure to the wound surface through the hand piece. This mechanism of debridement allows for precise removal of necrotic and infected tissue while sparing viable tissue.
Debridement with the Versajet is also advantageous in tunneling wounds and wounds with irregular and complex surfaces that are often difficult to reach with conventional sharp debridement.4,5 Studies have shown the use of the Versajet for wound debridement decreases the overall time to formation of a clean wound bed due to a reduction in operating times, local bacterial burden and the number of repeat surgical debridements required to obtain a clean wound bed.6-8
Physicians also utilized NPWT/ SRFD in both patients to aid in wound bed preparation for closure. Negative pressure is the application of subatmospheric pressure to a reticulated foam dressing. This causes microdeformations at the cellular level. This induces cellular stretch, which promotes the release of growth factors and cell proliferation. This subsequently facilitates angiogenesis and granulation tissue formation.
The vacuum created also aids in wound contracture and removal of excess fluid and byproducts that inhibit wound healing. One may use a SRFD in place of non-silver impregnated foam dressings to decrease odor and bacterial burden.
The most common complications occurring with the use of NPWT are often related to improper application. These complications include wound edge maceration and breakdown from improper sponge placement, and/or lack of periwound skin protection and tissue necrosis secondary to contact of the TRAC pad (KCI) directly with the skin. Research has shown that NPWT is an effective temporary dressing for soft tissue defects, resulting in reduced times to wound closure due to production of a wound bed amenable to closure with various plastic surgery techniques.9
In the second case study, we had to eradicate infection as part of preparation of the wound bed for closure. In addition to aggressive surgical debridement, we employed PMMA-ALC beads as research has shown these beads are an effective adjunctive therapy in the treatment of soft tissue and osseous infections of the foot and ankle.10
Proceeding To Definitive Wound Closure
After preparing the wound and ensuring the infection has cleared, one may proceed to definitive closure of the wound, taking into account the most appropriate surgical techniques for wound closure.11 Physicians can also supplement this final procedure for wound closure with surgical procedures to correct deforming forces that have contributed to the formation of the wound. These deforming forces would remain risk factors for wound recurrence if not addressed.
Given the size and appearance of the wound bed of the patient in the first case study, we felt STSG was the most amenable plastic surgery technique for wound coverage. We followed previously published techniques for the STSG harvest, application and postoperative dressing of the donor and recipient site.12,13
Surgeons harvested BMA from the ipsilateral lateral calcaneus utilizing a BMA kit (Wright Medical Technology). One can determine the location for trocar insertion using previously published techniques.14,15 Researchers have shown that platelet rich plasma increases STSG take and healing rates in the high risk patient by aiding in graft adherence and minimizing the potential of STSG failure due to the most common complications of hematoma or seroma formation.16
While there are no published studies regarding the use of autogenous BMA with STSG, studies have shown increased healing rates in chronic wounds due to the inflammatory, hematopoietic and mesenchymal stem cells present in BMA.17-20 Animal studies have shown that BMA aids in chronic wound healing by causing a transient increase in vascularity and deposition of dermis at the wound site.21 Both of these factors would be beneficial in the adherence and incorporation of a STSG. Harvesting of BMA is a fast and simple procedure. When surgeons perform this procedure properly, there are reportedly no associated complications related to nerve injury, infection, wound healing complications or fracture.22
The location of the ulceration of the patient presented in the second case study required immediate soft tissue coverage of the exposed first MPJ with durable tissue capable of withstanding the forces sustained during ambulation. A V-Y fasciocutaneous flap was the most amenable for wound closure as this would provide rapid coverage with durable, native plantar skin. The literature has shown that this type of flap has a consistent vascular supply.23 Healing of this flap occurs with minimal complications with proper immobilization and the use of adjunctive surgical procedures to correct the underlying soft tissue and osseous deformities that contributed to formation of the ulceration.24
Pertinent Insights On External Fixation And Post-Op Recovery
When it comes to the deforming forces contributing to the formation of the plantar foot ulceration of the patient presented in the second case study, we corrected these with an open gastrocnemius recession, a peroneal longus tendon recession and a posterior tibial tendon recession using previously published techniques.25-27
A sugar tong splint could not facilitate immobilization due to the concern for potential necrosis of the plantar V-Y fasciocutaneous secondary to pressure. Accordingly, surgeons used extra-articular ankle pinning using previously published techniques.28 The use of extra-articular ankle pinning can be beneficial for patients in whom a compressive dressing and/or splint is contraindicated due to compromised blood flow, a partial foot amputation or plastic surgery procedures performed on the forefoot. However, immobilization of the foot is required due to the use of adjunctive tendon lengthening procedures.
The use of this form of external fixation minimizes the risk of articular cartilage damage, intra-articular infection and pin migration. The external fixation also provides stable immobilization of the foot — in a neutral position at 90 degrees in relation to the lower leg — which is required postoperatively for tendinous rebalancing procedures in order to prevent under- or over-lengthening.28,29
Both patients wore a Jones compression dressing until they were fully healed. We applied these dressings after an antimicrobial cleanse of the limb. Studies have shown the use of a compressive dressing and this protocol of postoperative dressing management aids in immobilization and edema control, and reduces complications related to hematoma formation, wound dehiscence and infection.30-32
The cases presented here are examples of a multimodal approach to the treatment of complex wounds. The modalities used to treat and heal these wounds attest to the fact that multimodal treatment of complex wounds extends beyond the myriad of advanced wound care products currently on the market.
One must first medically optimize the patient and address the basic tenets of wound care. Then prepare the wound bed and determine the most appropriate pathway for wound closure. Whether one employs advanced plastic surgery techniques and adjunctive surgical procedures, dressing management is paramount for the prevention of further complications.
Dr. Schade is the Acting Chief of the Limb Preservation Service, Vascular/ Endovascular Surgery Service in the Department of Surgery at the Madigan Army Medical Center in Tacoma, Wash. She is an Associate of the American College of Foot and Ankle Surgeons.
Dr. Roukis is a Staff Podiatrist in the Department of Orthopaedics, Podiatry and Sports Medicine at Gundersen Lutheran Medical Center in La Crosse, Wis. He is a Fellow and Member of the Board of Directors for the American College of Foot and Ankle Surgeons.
Editor’s note: The authors acknowledge that any opinions or assertions expressed in this article are their own and are not to be construed as reflecting the views of the Department of the Army or the Department of the Defense.
For further reading, see “Reconciling Combination Therapy With EBM: Where Do We Go From Here?” in the January 2006 issue of Podiatry Today or “Key Insights On Split-Thickness Skin Grafts” in the March 2006 issue.
1. Whiteford L. Nicotine, CO and HCN: the detrimental effects of smoking on wound healing. Br J Community Nurs 2003; 8(12):S22-S26.
2. Stechmiller JK. Understanding the role of nutrition and wound healing. Nutr Clin Pract 2010; 25(1):61-68.
3. Burgess EM. Wound healing. Bull Prosthet Res. Fall 1974:109-113.
4. Vanwijck R, Kaba L, Boland S, Gonzales y Azero M, Delange A, Tourbach S. Immediate skin grafting of sub-acute and chronic wounds debrided by hydrosurgery. J Plast Reconstr Aesthet Surg 2010; 63(3):544-54.
5. Gurunluoglu R. Experiences with waterjet hydrosurgery system in wound debridement. World J Emerg Surg 2007; 2:2-10.
6. Caputo WJ, Beggs DJ, DeFede JL, Simm L, Dharma H. A prospective randomized controlled clinical trial comparing hydrosurgery debridement with conventional surgical debridement in lower extremity ulcers. Int Wound J 2008; 5(2):288-294.
7. Mosti G, Iabichella ML, Picerni P, Magliaro A, Mattaliano V. The debridement of hard to heal leg ulcers by means of a new device based on Fluidjet technology. Int Wound J 2005; 2(4):307-314.
8. Granick MS, Posnett J, Jacoby M, Noruthun S, Ganchi PA, Datiashvili RO. Efficacy and cost-effectiveness of a high-powered parallel waterjet for wound debridement. Wound Repair Regen 2006; 14(4):394-397.
9. Capobianco CM, Zgonis T. An overview of negative pressure wound therapy for the lower extremity. Clin Podiatr Med Surg 2009; 26(4):619-631.
10. Schade VL, Roukis TS. The role of polymethylmethacrylate antibiotic-loaded cement in addition to debridement for the treatment of soft tissue and osseous infections of the foot and ankle. J Foot Ankle Surg 2010; 49(1):55-62.
11. Zgonis T, Stapleton JJ, Roukis TS. Advanced plastic surgery techniques for soft tissue coverage of the diabetic foot. Clin Podiatr Med Surg 2007; 24(3):547-568.
12. Roukis TS, Zgonis T. Skin grafting techniques for soft-tissue coverage of diabetic foot and ankle wounds. J Wound Care 2005; 14(4):173-176.
13. Schade VL, Roukis TS. Sterile cast padding as an alternative to commercially available cotton balls for split-thickness skin graft bolster dressing. J Foot Ankle Surg 2010; 49(1):98-100.
14. Schade VL, Roukis TS. Percutaneous bone marrow aspirate and bone graft harvesting techniques in the lower extremity. Clin Podiatr Med Surg 2008; 25(4):733-742.
15. Schweinberger MH, Roukis TS. Percutaneous autologous bone marrow harvest from the calcaneus and proximal tibia: surgical technique. J Foot Ankle Surg 2007; 46(5):411-414.
16. Schade VL, Roukis TS. Use of platelet-rich plasma with split-thickness skin grafts in the high-risk patient. Foot Ankle Specialist 2008; 1(3):155-159.
17. Badiavas EV, Ford D, Liu P, Kouttab N, Morgan J, Richards A, Maizel A. Long-term bone marrow culture and its clinical potential in chronic wound healing. Wound Repair Regen 2007; 15(6):856-865.
18. Badiavas EV. The potential of bone marrow cells to orchestrate homeostasis and healing in skin. Blood Cells Mol Dis 2004; 32(1):21-23.
19. Badiavas EV, Abedi M, Butmarc J, Falanga V, Quesenberry P. Participation of bone marrow derived cells in cutaneous wound healing. J Cell Physiol 2003; 196(2):245-250.
20. Badiavas EV, Falanga V. Treatment of chronic wounds with bone marrow-derived cells. Arch Dermatol 2003; 139(4):510-516.
21. Fathke C, Wilson L, Hutter J, Kapoor V, Smith A, Hocking A, Isik F. Contribution of bone marrow-derived cells to skin: collagen deposition and wound repair. Stem Cells 2004; 22(5):812-822.
22. Roukis TS, Hyer CF, Philbin TM, Berlet GC, Lee TH. Complications associated with autogenous bone marrow aspirate harvest from the lower extremity: an observational cohort study. J Foot Ankle Surg 2009; 48(6):668-671.
23. Roukis TS. The doppler probe for planning septofasciocutaneous advancement flaps on the plantar aspect of the foot: anatomical study and clinical applications. J Foot Ankle Surg 2000; 39(5):270-290.
24. Roukis TS, Schweinberger MH, Schade, VL. V-Y Fasciocutaneous advancement flap coverage of soft tissue defects of the foot in the patient at high risk. J Foot Ankle Surg 2010; 49(1): 71-74.
25. Schweinberger MH, Roukis TS. Surgical correction of soft-tissue ankle equinus contracture. Clin Podiatr Med Surg 2008; 25(4):571-585.
26. Roukis TS. Peroneus longus recession. J Foot Ankle Surg 2009; 48(3):405-407.
27. Roukis TS. Tibialis posterior recession. J Foot Ankle Surg 2009; 48(3):402-404.
28. Schweinberger MH, Roukis TS. Extraarticular ankle immobilization for protection of percutaneous tendo-achilles lengthening after transmetatarsal amputation and peripheral arterial bypass surgery. J Foot Ankle Surg 2008; 47(2):169-171.
29. Roukis TS. Extra-articular ankle stabilization: a case series. Foot Ankle Specialist 2010; 3(3):125-128.
30. Lehnert B, Jhala G. The use of foam as a postoperative compression dressing. J Foot Ankle Surg 2005; 44(1):68-69.
31. Schade VL, Roukis TS. Use of a surgical preparation and sterile dressing change during office visit treatment of chronic foot and ankle wounds decreases the incidence of infection and treatment costs. Foot Ankle Spec 2008; 1(3):147-154.
32. Schweinberger MH, Roukis TS. Wound complications. Clin Podiatr Med Surg 2008; 26(1):1-10.