Case Presentation:
Diabetic with nephropathy requiring
hemodialysis treatment (Part 2)
We received a lot of excellent responses from YOU regarding the management of this challenging patient, and your excellent responses are posted bellow, along with the conclusion of this case presentation.
| ***Letters to the Editor*** |
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.
—Travis Montgomery, DPM
I would recommend starting with maggots and using them in conjunction with negative pressure.
—Debra Manheim, DPM, FACFAOM
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?
—Jaytinder Sandhu, DPM
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.
—Kevin Fallon Kline, D.P.M., M.A.
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.
—Juan A. Gonzalez, DPM, DABPOPPM, CWS
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.
—Justin Ogbonna, DPM
Endoscopic gastroc recession or TAL proximal depending on ROM, and skin grafting if cultures are negative. AFO may be needed long term due to adhesions. BKA also an option if patient re-infects.
—J.D. Miller, DPM
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.
—Peter J. Mancuso, DPM
So, Your email responses have been great—keep those letters coming. But this Case presentation seemed like an ideal time for us to get acclimated with the great new eTalk discussion forum on PRESENT Podiatry. Its designed specifically for this type of discussion. NOW IT'S YOUR TURN...
| WHAT DO YOU THINK? |
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Considering the history, the status and clinical images presented, how would you proceed with this case?
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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.
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Figure 1: The patient was brought to the operating room for initial debridement at which time both deep cultures and biopsy were obtained. |
Following obtaining negative wound cultures and a negative biopsy the patient was returned to the operating room approximately 36hrs later at which time GraftJacket® (Wright Medical) was applied to provide soft tissue coverage over the exposed achilles tendon as well as to the largest portion of the posterior medial leg wound. The patient was then placed in a compressive dressing that included a posterior splint to limit range of motion at the ankle. The patient was seen at seven days post op and the graft was noted to be incorporating into the wound site (Figure 2). The patient is currently two weeks following graft placement and has begun hyperbaric oxygen therapy (HBOT) to further promote wound healing. Moving forward, the plan is to complete the course of HBOT while providing local wound care to the remaining areas of granulation tissue. Should the need arise STSG will be placed to provide definitive soft tissue coverage.
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Figure 2: At 1-week post-op, one can begin to observe the incorporation of the GraftJacket as demonstrated by the arrows. As the wound heals, the GraftJacket will take on a number of differing appearances as vascular in-growth and neoepithelialization occurs. |
Editors Note:
When considering attempts at limb salvage it is important that all those involved recognize that it is a difficult and time-consuming process. It is vital that both the clinician and patient understand the commitment required prior to embarking upon attempts at limb salvage. While limb preservation is the overall goal, it is essential that the patient’s realistic functional outcomes be determined to guide the overall treatment course.
| WHAT DO YOU THINK? |
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Considering the history, the status and clinical images presented, how would you proceed with this case?
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