Introduction

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.

Case Presentation

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).

Conclusion

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.

Sources

1. Hinchliffe, R.J., et al., Specific guidelines on wound and wound-bed management. Diabetes Metab Res Rev, 2008. 24 Suppl 1: p. S188-9.
2. Rumenapf, G., et al., [The vascular surgeon’s role in interdisciplinary treatment of diabetic foot syndrome]. Chirurg, 2008. 79(6): p. 535-45.
3. Armstrong, D.G., L.A. Lavery, and A.J. Boulton, Negative pressure wound therapy via vacuum-assisted closure following partial foot amputation: what is the role of wound chronicity? Int Wound J, 2007. 4(1): p. 79-86.
4. Gesslein, M. and R.E. Horch, [Interdisciplinary management of complex chronic ulcers using vacuum assisted closure therapy and “buried chip skin grafts”]. Zentralbl Chir, 2006. 131 Suppl 1: p. S170-3.
5. Williams, R.L. and D.G. Armstrong, Wound healing. New modalities for a new millennium. Clin Podiatr Med Surg, 1998. 15(1): p. 117-28.
6. Apelqvist, J., et al., Resource utilization and economic costs of care based on a randomized trial of vacuum-assisted closure therapy in the treatment of diabetic foot wounds. Am J Surg, 2008. 195(6): p. 782-8.
7. Hogge, J., et al., The potential benefits of advanced therapeutic modalities in the treatment of diabetic foot wounds. J Am Podiatr Med Assoc, 2000. 90(2): p. 57-65.
8. Hinchliffe, R.J., et al., A systematic review of the effectiveness of interventions to enhance the healing of chronic ulcers of the foot in diabetes. Diabetes Metab Res Rev, 2008. 24 Suppl 1: p. S119-44.
9. Faglia, E., et al., The role of early surgical debridement and revascularization in patients with diabetes and deep foot space abscess: retrospective review of 106 patients with diabetes. J Foot Ankle Surg, 2006. 45(4): p. 220-6.
10. Armstrong, D.G. and B.A. Lipsky, Diabetic foot infections: stepwise medical and surgical management. Int Wound J, 2004. 1(2): p. 123-32.
11. Armstrong, D.G. and B.A. Lipsky, Advances in the treatment of diabetic foot infections. Diabetes Technol Ther, 2004. 6(2): p. 167-77.
12. Attinger, C.E., E. Bulan, and P.A. Blume, Surgical debridement. The key to successful wound healing and reconstruction. Clin Podiatr Med Surg, 2000. 17(4): p. 599-630.
13. Krishnan, S., et al., Reduction in diabetic amputations over 11 years in a defi ned U.K. population: benefits of multidisciplinary team work and continuous prospective audit. Diabetes Care, 2008. 31(1): p. 99-101.
14. Larsson, J., et al., Sustained reduction in major amputations in diabetic patients: 628 amputations in 461 patients in a defined population over a 20-year period. Acta Orthop, 2008. 79(5): p. 665-73.
15. Frykberg, R.G., B. Wittmayer, and T. Zgonis, Surgical management of diabetic foot infections and osteomyelitis. Clin Podiatr Med Surg, 2007. 24(3): p. 469-82, viii-ix.
16. Shank, C.F. and J.B. Feibel, Osteomyelitis in the diabetic foot: diagnosis and management. Foot Ankle Clin, 2006. 11(4): p. 775-89.
17. Armstrong, D.G., et al., Maggot therapy in “lower-extremity hospice” wound care: fewer amputations and more antibiotic-free days. J Am Podiatr Med Assoc, 2005. 95(3): p. 254-7.
18. Lavery, L.A., E.J. Peters, and D.G. Armstrong, What are the most effective interventions in preventing diabetic foot ulcers? Int Wound J, 2008. 5(3): p. 425-33.
19. Canavan, R.J., et al., Diabetes- and nondiabetes-related lower extremity amputation incidence before and after the introduction of better organized diabetes foot care: continuous longitudinal monitoring using a standard method. Diabetes Care, 2008. 31(3): p. 459-63.
20. Whitaker, I.S., et al., Larval therapy from antiquity to the present day: mechanisms of action, clinical applications and future potential. Postgrad Med J, 2007. 83(980): p. 409-13.