Given the comprehensive approach chronic wounds require, these authors present the treatment of a patient with diabetic peripheral neuropathy who developed osteomyelitis and extensive soft tissue loss.
Chronic non-healing wounds are common and challenging to most practitioners. All too often, the focus revolves around the application of various wound therapies and optimizing host biology alone. Though these are vital areas for careful consideration, non-healing wounds require a more comprehensive approach, which must often include surgery and ancillary methods for healing.
We present the case of a 36-year-old African-American female who has had type 2 diabetes since age 13 and requires insulin. She also has a history of essential thrombocytopenia and retinal detachment. Her diabetes is complicated by peripheral polyneuropathy and Charcot neuroarthropathy. Since her diagnosis of diabetes, her medical treatment has been tenuous.
In January 2013, as a result of a fulminant deep tissue abscess and cellulitis of the left foot and the development of osteomyelitis, the patient required admission, long-term antibiotics and multiple operative debridements of infected soft tissue and bone. This resulted in extensive soft tissue loss and significant mechanical compromise of the foot. Resection of the distal one-third of the fourth and fifth metatarsals occurred with salvage of her fourth and fifth toes.
In June of 2013, the right dorsal wound remained chronic and required additional debridement. Clinicians applied EpiFix (MiMedx), a dehydrated human amnion/chorion membrane (dHACM) allograft, in an outpatient procedure. After this point, the patient became lost to follow-up.
What The Patient’s Treatment Entailed
On March 4, 2014, the patient presented to the MedStar Washington Hospital Center Podiatric Surgery Clinic with concerns of increasing drainage and malodor. The physical examination revealed a right chronic dorsal wound containing fibrotic tissue and biofilm as well as a malodorous, draining lateral ulcer. The patient also had a significant equinovarus deformity. We provided treatment for the soft tissue infection (and possible osteomyelitis), and performed definitive correction of the equinovarus deformity.
A multistage operative plan included surgical debridement of all infected soft tissue and bone with collection of intraoperative cultures to direct antibiotic therapy. We addressed definitive eradication of the etiologic source of the lateral ulcer. We excised the lateral ulceration, resected the fifth and partial fourth metatarsal bases and performed a planing resection of the cuboid. Then we harvested the peroneus brevis tendon and tagged it for a subsequent Bio-Tenodesis technique (Arthrex).
While the patient awaited culture results, we utilized negative pressure wound therapy (NPWT) with a bridging technique to accommodate both surgical wounds. The second phase included additional soft tissue debridement. Using a biotenodesis technique, we attached the remaining peroneus brevis tendon to the cuboid. We also lengthened the anterior tibialis tendon in a Z-plasty fashion to decrease the varus tension. The patient also had a percutaneous tendo-Achilles lengthening. We secured a fenestrated Integra Bilayer Matrix Wound Dressing (Integra LifeSciences) allograft to the dorsal wound and performed primary closure for the lateral surgical site. The patient subsequently utilized a posterior splint.
Current Insights On Facilitating Limb Salvage
Early and frequent surveillance in anticipating problematic wounds in high-risk patients, and the proper use and timing of limb salvage procedures all play crucial roles in short- and long-term outcomes.
A comprehensive limb salvage approach consisted of surgical debridement of infected tissue, intravenous antibiotic therapy, excision of the lateral ulceration on the right foot, osseous correction to eradicate the causative pressure point and the use of a modified tendon balancing technique to ensure a plantigrade postoperative outcome. The addition of a comprehensive wound management plan included initial simple postoperative wound care with acetic acid dressing changes every other day, frequent wound surveillance, subsequent utilization of advanced bioengineered alternative tissue allograft, multilayered compressive dressings, offloading and physical rehabilitation.
This chronic non-healing dorsal wound ultimately required advanced wound healing methods. Our comprehensive plan included the use of Integra and multiple serial applications of Grafix (Osiris Therapeutics) to the non-healing site. Grafix is a bioengineered alternative tissue allograft comprised of a three-dimensional cryopreserved placental membrane matrix. The processing for Grafix occurs in a manner that preserves the integrity of the extracellular matrix, growth factors, endogenous fibroblasts, epithelial cells and mesenchymal stem cells of the native tissue.
For offloading, the patient used a posterior splint and crutches in order to ambulate in a non-weightbearing fashion. The patient subsequently used an offloading diabetic shoe and crutches. After a period of acetic acid dressing changes, we subsequently applied an allograft. We transitioned the patient into a non-weightbearing controlled ankle motion (CAM) walker and crutches with progression into weightbearing in the later months. We eventually allowed the patient to transition into regular shoe gear in the late follow-up visits. Always customize the offloading protocol to the individual case.
We used multilayered compression dressings concomitantly with a bioengineered alternative tissue allograft. In our experience, this combination lends to better wound healing trends, decreases periwound edema, maintains a sterile environment, is cost-efficient and has high patient tolerance.
Ultimately, we have succeeded in balancing our patient’s foot into a more neutral rectus position with significant reduction of the offending osseous pressure points that caused the lateral ulceration. Moreover, the advanced wound management technique utilizing offloading, serial debridement, bioengineered advanced tissue allografts and multilayered compression were successful in reducing our patient’s chronic non-healing wound by 99 percent over a seven-month period.
Patient factors that promote wound susceptibility are based on stratification risk. Host factors, particularly those that relate to undulant glycemic levels and erratic high random glucose levels play a critical role. The development of neuropathy is the single most important factor that initiates the risk stratification process. Frequent surveillance and pertinent patient education, regardless of circumstance, are the best tools and key for physicians in helping to facilitate optimal outcomes.
Dr. Elmarsafi is a second-year resident within the Division of Podiatric Surgery at MedStar Washington Hospital Center in Washington, DC.
Dr. Steinberg is an Associate Professor at the Georgetown University School of Medicine. He is a Fellow of the American College of Foot and Ankle Surgeons.