Closing A Chronic DFU At A TMA Site

Author(s): 
Ronald Guberman, DPM, Lida Faroqi, DPM, and Joseph Spencer, DPM

These authors discuss a combination of modalities they utilized to successfully close a chronic diabetic foot ulcer (DFU) at a transmetatarsal amputation (TMA) site in a 70-year-old patient.

   Treating chronic diabetic foot ulcers is a challenge for wound care professionals, patients and the entire medical community. The Wound Care Center at Wyckoff Heights Medical Center in Brooklyn, N.Y., treats a wide variety of these ulcers in patients who have numerous comorbidities.

   During the treatment of diabetic ulcers, many of these patients experience significant complications, which can lead to hospitalizations and loss of part or all of the foot and leg. It is clear that there is an association between the presence of non-healing diabetic ulcer and other limb threatening complications. It is certainly advisable to attempt to heal these ulcers as quickly as possible utilizing whatever means are necessary to maximize the healing potential. This includes optimization of diabetes control, diet, reducing risks factors such as smoking and improving the vascularity when necessary.

   The patient was a 70-year-old African-American male. About six weeks before presenting to our wound care center, he had undergone a transmetatarsal amputation (TMA). He had type 2 diabetes, hypertension, peripheral vascular disease, end-stage renal disease, anemia and was on hemodialysis. The patient was 6 feet, 2 inches tall and weighed 220 lbs.

   At the time of admission, the patient had an infected non-healing ulcer at the right TMA site with wet gangrene. The wound measured 3 cm x 14 cm x 1 cm. The wound base was 20 percent fibrotic and 80 percent necrotic with moderate seropurulent drainage and malodor.

How Multiple Modalities Facilitated Ulcer Closure

The patient went to the OR for surgical debridement of the infected ulcer and an Achilles tendon lengthening. Upon discharge, the patient followed up weekly in the wound care clinic. We performed sharp debridement on multiple occasions and provided a total of eight Dermagraft (Advanced Biohealing) applications before achieving full closure of the wound.

   Dermagraft is a cryopreserved, human fibroblast–derived dermal substitute. The fibroblasts are seeded onto a bioabsorbable polyglactin mesh. As they proliferate across the mesh, the fibroblasts secrete human dermal collagen, matrix proteins, growth factors and cytokines to create a three-dimensional human dermal substitute containing metabolically active, living cells. Dermagraft is designed to restore the dermal bed in a diabetic foot ulcer, thereby improving the wound healing process and allowing the patient’s own epithelial cells to migrate and close the wound.

   Finally, we provided custom fitted diabetic shoes and orthotic insoles to help relieve pressure at the TMA site especially at the plantar distal portion of the amputation site.

   There was ongoing communication with the patient’s internist and nephrologist throughout the course of treatment. We routinely inspected the wound for any signs of infection and poor or delayed healing. A major contributory factor for this positive outcome was the patient’s adherence. Therefore, we carefully monitored changes to the treatment plan and the patient’s activities and instructions, explaining and reinforcing these measures at each visit. Having the patient understand and partner with you as part of the positive outcome is key.

Comments

Suggestion: Once the infection is controlled, add arterial pump therapy to assist the dermal graft with increased blood flow and to open collateral arteries for a more permanent answer to the PAD and prevent future breakdown.

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