When Not To Use Advanced Wound Care Modalities
Case Study One: When A Patient Opts For Palliative Wound Care
The first case concerns a 74-year-old male veteran treated for a chronic ulceration to the plantar central aspect of a Chopart amputation stump. His history includes diabetes mellitus, hypertension, coronary artery disease following three vessel coronary artery bypass grafts, dyslipidemia, chronic lower extremity edema and peripheral neuropathy. In 2009, he presented with osteomyelitis of the right fifth ray, which I resected. The osteomyelitis failed to heal after surgical intervention. Two subsequent surgeries resulted in a Chopart level amputation that successfully healed. I obtained appropriate shoes, inserts and a brace for the healed limb.
Two months after healing, a blister appeared on the plantar stump after he was barefoot in the shower. The wound became a full thickness ulcer and the patient subsequently received aggressive treatment with living skin equivalents and total contact casting, resulting in a healed wound once again six weeks later. I modified his insert and brace to accommodate the area of high pressure. Three months later, the wound opened again from minimal transfers to and from bed without his shoe. Again, I used an aggressive approach and achieved wound closure.
I offered the patient a surgical intervention to address the plantar prominent bones visible on radiographs but he refused. He received education on the high potential for wound recurrence, which ended up happening. A lengthy discussion with the patient, including his family members, determined the course of treatment. I advised the patient that wound healing was a possibility but keeping the wound healed did not seem realistic. Options included a proximal amputation versus palliative wound care.
After completely discussing the risks, complications, benefits and alternatives to these two options, the patient elected for palliative wound care. He was adamantly opposed to proximal amputation and accepted the risk associated with living with an open wound. He has been receiving palliative wound care every three weeks or prn in our clinic. For the past 18 months, he cleans and changes his dressing daily, applies hydrogel and wears a removable cast boot.
Case Study Two: When A Recurring Wound In A Diabetic Smoker Leads To A TMA And Subsequent Proximal Amputation
The second case involves a 60-year-old male veteran treated in a community outpatient wound clinic for a chronic great toe wound. His past medical history includes diabetes mellitus, hepatitis, peripheral neuropathy, a history of illicit drug use and active tobacco use of two cigarette packs per day. Attempts at healing the wound with eight applications of living skin equivalents and offloading in the outpatient setting were unsuccessful.
He presented to the ER with gas gangrene of the first ray. He immediately went to the OR for a partial first ray amputation with wide debridement resulting in a 17 cm x 5 cm open wound to the medial foot. After eliminating the infection, the patient’s options included conversion to a transmetatarsal amputation (TMA) with closure versus wound care in an attempt to heal the wound. After understanding the risks, benefits, complications and alternatives to each option, he chose wound care. He received aggressive porcine small intestinal submucosa, negative pressure wound therapy (NPWT), hyperbaric oxygen treatment (HBOT) and remained hospitalized in the extended care unit for four months. The wound became stable enough so we could manage the patient on an outpatient basis and continued advanced care reduced the wound size to 1.5 cm x 0.8 cm.
The patient once again presented with gas gangrene originating from the unhealed wound. Seven months after the initial infection, the TMA that I offered to him happened out of necessity. He was once again admitted and had an open TMA followed by delayed primary closure. There was dehiscence with the lateral TMA incision. The patient subsequently received living skin equivalents and NPWT, and ultimately healed during an 11-month process.