David Davidson, DPM

We received a number of great responses to part 1 of this case presentation in the eTalk thread on this topic, and as many of you noted, there are a number of possibilities to include in the treatment for this challenging patient.

Considering the length of time these wounds had been present, the decision was made to obtain an MRI. However, the patient was claustrophobic and therefore a bone scan was ordered to evaluate the osseous structures in the area of the patient’s chronic wound on the right ankle.

Bone Scan Results

The flow and blood pool images revealed increased blood flow and blood pool activity involving the medial malleolus region of the right ankle.  The delayed views reveal increased uptake of the radiotracer in the medial malleolus region. In addition, several areas of increased three-phase activity in the feet are noted,   including the lateral malleolar region of the left ankle, the lateral mid left foot and the left first and second toes and the right first toe. A blood pool image of the posterior pelvis revealed mild increased activity in the upper sacrum and left sacroiliac joint region.  The delayed views, however, revealed no increase in bone activity. Impression:  Positive three-phase bone scan for possible osteomyelitis involving the medial malleolus region of the right ankle. In addition, several other areas in the left foot with increased activity in the 3 phases as described above.

The bone scan findings were expected, based on the length of time this patient had these wounds. Following this examination, an aerobic and anaerobic culture was taken of the right medial wound using a 3mm punch. The gram stain showed 1+ leukocytes and 3+ gram positive cocci. Organism 1 was Staphylococcus Aureus, Methicillin Resistant and organism 2 was classified as Diptheroids.  Organism 1 was sensitive to Gentamycin, Rifampin, Tetracycline, Trimethyloprim/Sulfa and Vancomycin.

Due to the fact that the patient was paraplegic and his legs constantly spasmed during the night, the patient was brought to the OR for aggressive debridement of the hypergranulation tissue of all wounds. A PICC was then placed, and the patient was admitted to a rehabilitation facility to monitor his leg movements during sleep. He was also referred to a local infectious disease specialist for the management of the parenteral antibiotics. Vancomycin was started at 1GM Q12h.

After six weeks of 100% bed rest and IV Vancomycin, the patient showed some slight improvement (Figure One and Figure Two) and was discharged. The infectious disease physician felt the antibiotics could be stopped and the patient was scheduled to be followed at the wound center.

Figure 1

Figure 2

Since the improvement of the condition of all four wounds was slower than one would hope for, it was decided to take a traditional off-loading heel rest Figure Three) and modify it to off-load the sides of the ankle rather than the posterior heel, as it was originally designed for. The new, Milsport Heel Rest was used as it has antimicrobial properties, is light-weight and washable. The calf pad in the heel rest is designed to off-load the posterior aspect of the heel. However, due to the locations of the wounds on this patient, we decided to modify the device using foam blocks that were designed to be movable with Velcro and redistributed the pressure away from the wounds (Figure Four and Figure Five). The changes in the condition of the wounds was both swift and remarkable. Figures Six, Seven, Eight and Nine show all four wounds four weeks following off-loading. The patient has been discharged with instructions to continue use of the Millsport heel rests when in bed.

Figure 3

Figure 4	Figure 5

Figure 6

Figure 7

Figure 8

Figure 9

Discussion:

This was a very difficult wound case due to the fact the patient presented with four wounds that had been present for several years prior to arriving at our wound center. In addition, he had paraplegia and also uncontrollable spasms of both legs. At times, one needs to “think out of the box”.  In this case, we were able to modify an existing and conventional off-loading heel rest to remove all pressure from all four wounds at the same time.

Please share your thoughts and insights with our online community by following this link to the eTalk thread on this topic.