Case Studies In Combination Therapy For Complex Wounds

Valerie L. Schade, DPM, AACFAS, and Thomas S. Roukis, DPM, PhD, FACFAS

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.

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