Cath Lab Digest

Given the potential complications associated with chronic wounds in high-risk patients, the authors debate the merits of different approaches to wound closure and explore emerging concepts in the combination of mechanical assistance and tissue expansion to facilitate improved healing.

   An estimated 15 percent of patients with diabetes will develop a lower extremity ulcer during the course of their disease. In addition, foot ulceration is the precursor to approximately 85 percent of lower extremity amputations in people with diabetes. Moreover, there is a 50 percent incidence of a contralateral amputation within two to five years of a lower extremity amputation.¹

   Treatment of infected foot wounds comprises up to one-quarter of all diabetes-related hospital admissions in the United States and Britain. Accordingly, it is the most common reason for diabetes-related hospitalization in these countries. People with diabetes have an increased risk of developing an infection of any kind and a several-fold risk of developing osteomyelitis. The same risk factors that predispose people to ulceration are also generally considered to be contributing causes of amputation.¹

   When a limb-threatening infection is present, early surgical treatment of the affected site is typically necessary as an integral part of infection management.¹

   The skin is the most important barrier against infection. It is well documented in the literature that people with diabetes have compromised immune systems. Therefore, their infection fighting capability becomes a real challenge. Obtaining wound closure is paramount in avoiding the additional complications associated with a chronic open wound.² Primary or delayed primary closure is ideal in achieving wound closure and decreasing the likelihood of a recurrent infection.

Should You Opt For Primary Closure, Delayed Primary Closure Or Closure By Secondary Intention?

   Primary closure involves the reapproximation of viable skin, most commonly involving the use of sutures.² Obtaining primary closure after debridement and/or partial foot amputations is ideal. Primary closure reduces the risk of infection by providing a skin barrier to the potential pathogens. However, wound care surgeons are constantly faced with the dilemma of whether they should leave the wound open or close it primarily.

   At our institution, we approach the question of leaving the wound open or closing it as follows: If we perform the surgical procedure on a semi-elective basis (the need for an amputation without the presence of an active infection), then we make every effort to close the wound primarily.

   However, if we are performing a partial foot amputation, or an incision and drainage (I&D) procedure due to either an acute or chronic foot infection, we almost always leave the wound open for at least two to five days prior to attempting delayed primary closure. Leaving the wound open for two to five days allows us to perform local wound care and evaluate the wound for any signs of a residual infection/necrosis.

   During these early postoperative days, the administration of intravenous antibiotics continues and helps in preparing the open wound for delayed closure. We found that this management process leads to lower readmission rates and less recidivism of infection.

   In situations in which there is viable tissue and the podiatrist is certain he or she has removed all infected tissue, he or she may opt to perform delayed primary closure. Surgeons usually perform delayed primary closure three to five days after the initial ablative procedure.² In this time interval, the patient’s natural defenses and antibiotic treatment reduce the bacterial load, therefore reducing the chance for an infection or re-infection.²