A Closer Look At Combination Therapy For Chronic Wounds
Case Study: Combining Skin Substitutes With Weekly Debridement Of A Chronic Wound
A 70-year-old male presented with a diabetic ulceration on the medial aspect of his left heel. The ulceration has been present for nearly two years without evidence of healing. The patient previously received oral antibiotics and local dressing changes consisting of antibiotic ointment. The patient has had diabetes for 18 years and has experienced complications such as peripheral neuropathy as well as peripheral vascular disease. He also suffers from hypertension and coronary artery disease.
His physical examination showed normal skin color, turgor and temperature. His dorsalis pedis and posterior tibial artery pulses were non-palpable. There was an ulceration on the medial aspect of his left heel that measured approximately 1.0 cm in diameter and 8 mm deep. The ulceration did not undermine nor probe to bone. The base of the ulceration contained yellow, fibrotic tissue.
Initial treatment consisted of local debridement of the ulcer, an offloading pad and topical dressings using normal saline. We obtained a formal vascular consultation.
Noninvasive pulse volume recordings showed monophasic waveforms at the level of the dorsalis pedis and posterior tibial arteries. The patient subsequently had angiographic evaluation to help determine whether stent replacement was necessary. The angiogram revealed a totally occluded anterior tibial artery at the trifurcation and a severely diseased and diminutive peroneal artery down to the foot. His posterior tibial artery was widely patent down to the foot with inline flow from the femoral artery. Since the posterior tibial artery was widely patent to the foot and this was a medial heel ulceration, the vascular surgeon determined that stenting of the artery would provide no added benefit.
We continued to provide local wound care along with an offloading pad. However, after four weeks, no progress had occurred. We subsequently initiated a series of Dermagraft treatments. Weekly visits consisted of debridement of the ulceration down to healthy bleeding tissue. This involved removal of all fibrotic tissue as well as macerated hyperkeratotic tissue around the margins of the ulceration. We applied a 1 cm2 double layer of Dermagraft weekly for five weeks. Dressings remained intact until the next visit and treatment. By week five, the ulceration had reduced to a diameter of 5 to 6 mm and 2 to 3 mm in depth. We applied a sixth application of double layer Dermagraft. At that point, the patient was ready for application of Apligraf in an effort to achieve 100 percent epithelialization.
With this myriad of treatment choices, podiatric clinicians have the tools to combat chronic lower extremity ulcers. Depending on patient selection and wound type, one can use biologic therapies independently or in combination with other modalities to optimize the chances of wound closure. The increasing number of chronic foot wounds with poor prognosis demand attention and further research in an attempt to improve outcomes.
Dr. Kim is the Chief Resident at Beth Israel Deaconess Medical Center in Boston. She is a Clinical Fellow at Harvard Medical School in Boston.
Dr. Giurini is the Chief of the Division of Podiatric Medicine and Surgery at Beth Israel Deaconess Medical Center. He is an Associate Clinical Professor in Surgery at Harvard Medical School.