The management of lower extremity ulcerations can pose a significant challenge to wound care professionals around the world – this is especially true in instances of concomitant medical issues such as diabetes mellitus or vascular disease. These complicated wounds often require a combination of advanced wound-healing modalities to provide for appropriate wound closure. Advancements in wound care technology, such as negative pressure wound therapy (NPWT) and synthetically bioengineered tissues have significantly increased the clinician’s ability to promote wound healing in these complicated cases. Often, these modalities are used following wound-bed preparation via sharp debridement, either in the clinic or operating room setting. Studies have demonstrated that appropriate wound-bed preparation is vital to promote effective wound healing. In instances in where lower extremity ulcerations are complicated by concomitant disease, an interdisciplinary approach to the medical and surgical management of these patients is recommended to provide optimization of overall health, thus improving overall wound healing outcomes.
There is a subset of patients, however, who present significant co-morbidities which preclude the ability to provide aggressive wound care; either because they are not medically stable enough to undergo the anesthesia necessary for more aggressive surgical debridement, or their vascular status is compromised such that debridement will only increase the area of compromised tissue, leading to further tissue necrosis and wound extension. In these instances, where vascular reconstruction and reperfusion is unsuccessful, or in those cases where the patient is simply too sick to withstand the anesthesia necessary for surgical debridement, it is helpful that the clinician be able to provide these patients with “hospice” or palliative wound care. Should attempts at conservative wound care fail, these patients often go on to receive lower extremity amputations, which have significant morbidity and mortality rates.
As with advances in more aggressive wound-care techniques, technology in hospice would be equally developed to provide clinicians with new, or at least updated, modalities to broaden their armamentarium to provide the best possible outcomes for these patients. The case below describes the use of a number of these advanced “palliative” care modalities in the management of lower extremity ulceration in a patient with significant co-morbidities.
The patient is a 66 year old female who presents significant lower extremity vascular disease, diabetes, severe end-stage COPD and multiple ulcerations along her bilateral lower extremities and is receiving treatment in the Limb Salvage clinic for local wound care. Upon presentation on this clinic visit, the patient’s major compliant is one of extreme pain in her left lower extremity, which is increasing, constant, and debilitating. Additionally, the patient suffers from a shortness of breath, and a feeling of gasping for air. The patient states that she has been unable to eat anything for the last several days due to persistent nausea and that her pain is no longer being reduced by the pain medication – they only sedate her.
Upon physical exam, the patient is noted to be running a fever at 39.1, with blood pressure 101/85, heart rate 117 beats-per-minute, and respirations 22 breaths-per-minute. O2 Saturation is variable between 85-91 although the patient does not appear to be hypoxic. Evaluation of her left lower extremity demonstrates a large dorsal foot wound (fi g.1) that has a fibrotic base with necrotic margins. The wound and wound margins are exquisitely painful to palpation. There is a mild malodor but no gross purulence observed. The pedal pulses are non-palpable, but a monophasic Doppler signal is observed at the dosalis pedis artery, utilizing the hand Doppler.
Considering the patient’s symptoms, she was admitted to the hospital under the medicine service with a concern for an exacerbation of her COPD and pneumonia, which was observed on chest x-ray. Initial laboratory data demonstrated a leukocytosis that was attributed to her pneumonia. The patient was started on intravenous antibiotics and respiratory treatments to increase her oxygen saturation. The limb-salvage team continued to monitor the patient’s lower extremity wounds, although it was determined that the patient was not a good surgical candidate for a more extensive sharp debridement considering her significantly compromised respiratory status and her overall vascular impairment. Additionally, the patient’s constant pain provided a limiting factor with regard to local bedside debridement of her extensive dorsal left foot wound, even with the addition of local anesthetics in the form of an ankle block, and therefore other modalities were required.
To provide painless soft-tissue debridement of her left foot wound, Larvae therapy was utilized (fi g. 2). Maggot debridement therapy (MDT) has long been utilized to provide extensive debridement of necrotic soft tissue wounds. MDT is extremely useful in the management of chronic wounds because it removes only necrotic tissue, leaving all viable tissue behind, while also reducing bacterial load and stimulates wound healing. The Phaenicia sericata species is the fruit fly larvae that is commonly utilized in MDT (fi g. 3), and prior to implantation, these larvae are sterilized to limit risk of cross contamination in the recipient patient. In the case discussed, the wound dressing was changed at 48 hours, and the wound was noted to be significantly cleaner. Another round of MDT was performed to provide further debridement (fi g.4).
Once all of the infected and necrotic soft tissue was removed, it was necessary to provide soft tissue coverage over the wound to limit the infection potential and to reduce the patient’s pain. Irradiated cadaveric human skin allograft (GammaGraft™, Promethean LifeSciences, Inc, Pittsburgh, PA) was utilized to provide this soft tissue coverage (fi g.5). This modality was selected because it is bilayered (having both epidermal and dermal components), is self-adhering, and provides vapor control, which is necessary in the prevention of infection and for appropriate wound healing. Additionally, providing soft tissue coverage reduces the pain associated with the wound. In addition to these properties, the irradiation process allows for a long storage life of the product (up to 2 years), which gives the wound care clinician flexibility with regard to graft placement timing, unlike several other bilayer grafts available today.
Following graft placement, no further debridement is necessary – which benefits patients like the one described in this case with significant pain, who are poor candidates for sharp debridement, either locally or in the operating room. As the wound epithelializes, the graft margins may begin to curl up and lift at the wound edges, which can be trimmed. Ultimately, the graft will peel off as the wound heals (fi g. 6).
With the prevalence of diabetes on the rise, and the well demonstrated correlation between lower extremity ulceration as a major risk factor for non-traumatic amputation, especially in those patients presenting with elements of concomitant vascular disease, it is vital that every effort be made to appropriately address these underlying factors present in wound development, such as neuropathy, infection, and vascular insufficiency as part of patient management. Additionally, it is necessary that clinicians be well versed in all manners of advanced wound care modalities to therefore provide the greatest possible outcome in these challenging patients. While many of these advanced modalities are new and cutting edge technology, many are actually truly old therapies, as is the case with MDT, which have been revitalized and updated to appropriately manage those challenging wounds that are recalcitrant to other treatments. Certainly it is not a case of “one size fits all” with regard to wound care and wound care modalities. Each patient will present unique challenges that must be addressed and overcome to promote wound healing. In the case presented, the limitations imposed by patient’s diabetes, COPD, and vascular impairment necessitated the use of alternative, palliative therapies, such as MDT, in lieu of more aggressive treatment modalities. The irradiated cadaveric allograft allowed the ability to provide soft tissue coverage to the wound following MDT without having to take the patient to the operating room for graft placement, thus eliminating the anesthesia risk to the patient.
In those instances where a wound care patient is not a surgical candidate for aggressive sharp debridement and graft or flap placement, there are advanced palliative modalities which can be utilized to reduce the risk of infection, reduce a patient’s pain, and promote formation of granulation tissue and stimulate wound healing.
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