You can follow this link to the entire eZine and view the images at full size, but here's the rundown on the patient of interest:

HPI: The patient is a 62-year-old male who presents with a history of a large posterior leg wound for approximately the last month. The patient is a diabetic with nephropathy who recently began to require hemodialysis treatment. The patient was initially referred to a general surgeon who recommended below-knee amputation, and the patient subsequently sought out the high-risk diabetic foot clinic for a second opinion.

VS: Tc:987, BP:132/84, RR: 18, HR: 82 BPM
PMH: Diabetes, Hypertension, ESRD on HD
MEDS: Novolog 70/30, Atenolol, plavix, aspirin
ALL: Iodine
SOCIAL: Previous Tobacco history, 20 pack years (stopped 17 yrs. ago), social ETOH, denies illicit drug use.

PHYSICAL EXAM: the pedal pulses are palpable, and graded +1/4 at the dorsalis pedis and posterior tibial arteries to the left lower extremity. There is a large partially circumferential wound along the posterior aspect of the patient’s leg measuring approximately 15.3cm x 8cm x 0.3cm (fig. 1). The wound demonstrates a mixed fibro-granular base, with fibrinous exudate and there are additional superficial wounds noted around the anterior lateral aspect of the patient’s leg, measuring 4cm x 5 cm x 0.2cm (fig. 2). At the inferior aspect of the large posterior wound, approximately 7cm of achilles tendon is noted to be exposed and mildly dissected (Fig. 3). Protective sensation is grossly intact to distal extremity via 5.07 semmes-weinstein monofilament test and vibratory sensation is grossly intact. There is no significant malodor noted, and there is no bone exposed.

Considering the history, physical exam, and clinical images presented, how would you proceed with this case?

I would obtain noninvasive vascular studies. Obviously evaluate the microcirculation, nutrition, HBA1c and x-rays. Rule out malignancy with biopsy. Once optimized, VersaJet debridement and placement of Integra and wound vac, HBO, immobilize in a posterior splint and go from there.

I would obtain non-invasive vasc flow studies to access peripheral blood flow (PVR, ABI, SPP and segmental pressures). Pending acceptable results, the non-viable, necrotic tissue from all ulcerations needs to be debrided- my method of choice is Versa Jet.

A potential concern here is what to do with the Achilles tendon, remove or not to remove. It looks reasonably healthy in the pictures but in many instances I have seen this tendon resected, which is probably what I would lean towards (depending of course on what it looks like intra-op).

The next the decision for grafting comes into play. STSG versus synthetic substitute? Financial reasons would tend to make bio-engineered skin difficult, as multiple pieces would be needed creating quite the bill. At the same time, multiple large pieces of STSG would also be necessary, which could potentially create other chronic wounds from the graft sites. Pending all the red tape, I would lean towards DermaGraft application. I choose this as it’s easy to apply in clinic and its checked weekly with up to 8 applications permitted in a row. Weekly inspection is very important in this case, as its important to recognize any signs of graft rejection, which could very well occur with ESRD/HD.

Edema is not an issue here so compressive therapy isn't necessary but I do think immobilizing the pt is important. Total contact casting is an option but the cast must be very well padded and changed frequently to avoid any complications. Weekly follow-ups with measurements of the wounds, as well as pictures, are a reasonable plan. Pending the success of the grafts, plan B would be executed (consider another skin substitute? Wait and see?

I would get an Arterial Duplex, ABIs, PVRs, and an Arteriogram. If the patient has adequate perfusion, proceed with debridement including complete Achilles tenectomy. This does not appear to be grossly infected, however, deep cultures should be taken at time of debridement and managed accordingly. The post-op course would include NPWT, pristine wound care, limb preservation dressings, and formal reconstruction of the soft tissue envelope including a STSG once adequate granulation tissue has been established.

If the patient lacks adequate perfusion, then revascularization from an endovascular approach would be needed. If an endovascular approach is untenable, then a traditional bypass would be in order. If the patient is deemed non-bypass-able then proceed with trans-tibial amputation with Ertl procedure.

First I would order vascular studies and a TcPO2. If normal I would proceed with the local wound care. If the results were abnormal, of course, I would consult a cardiologist and/or a vascular surgeon to fix the circulation problem right away. The future treatment plan pending on how patient responds to the present treatment.

I think wound cultures would be a good start. In addition some antibiotics as well pending culture sensitivities. This patient ultimately needs some aggressive debridement with the use of some wound care biological dressing (apligraf, dermagraft). The exposed portions of Achilles tendon may have to be removed though in order to allow complete granulation. A nutritional consult wouldn't hurt either.

Since pulses are palpable you can next r/o infection, tissue cultures, x-ray and possible MRI. If neg. then debride wound and control edema (Unna’s if no CHF) , Acticoat 7 for the wound dressing and CAM walker or custom walking boot. If the edema is controlled a cast can be applied for immobilization which can be modified to offload all boney prominences. If the wound does not get smaller and start to granulate then debride any remaining necrotic tissue including the Achilles, apply growth factor therapy (Apligraf), adaptic, Acticoat 7, Unna’s and CAM or cast. If still no change consider a VAC with Alloderm.

Treatment Plan:

In our management of this complex patient, upon confirmation of appropriate vascular status via noninvasive vascular studies, the patient was taken to the operating room for an initial debridement (Figure 1). During this debridement, deep wound cultures were obtained to evaluate for the presence of infection, and a full thickness excisional biopsy was taken to evaluate for the presence of vasculitides and to rule out malignancy. Additionally, a portion of the Achilles tendon was deemed nonviable and was resected. The wound was dressed with mepitel and acticoat 7-day, and was covered with a compressive dressing.

Looking at the foto on top, you can see granulation tissue that has grown enough, so there is definitely potential to close, discard malignancy, venous disease, and infection.  In our clinic we have done several cases similar to this, one of the complications we´ve had are undetected abcess, once even under achilles tendon, and another I remember as a head ache infection going under gemini muscles, good wound exploration or imaging is required. Once cleansed under anesthesia in the OR, the first two weeks we do daily cleansing with non cytotoxic solutions and then initiate long term dressings.  Patient education and collaboration really necessary.