John Steinberg, DPM
PRESENT Editor
Assistant Professor,
Department of Plastic Surgery
Georgetown University
School of Medicine |
Guest Case Presentation: Infected PTFE with
Large Open Wound Anterior Ankle
by Marie Keplinger, DPM — 3rd Year Resident,
Inova Fairfax Hospital Podiatric Residency Program
This patient is a 54 year old male with Buerger’s disease and a non-healing ischemic ulcer to the dorsum of his left hallux for almost two years. He has a 30 pack year smoking history and quit a year ago. An angiogram performed in July of this year showed severe medium and small vessel disease of the left lower extremity. Prior to any hallux wound intervention, a popliteal to anterior tibialis artery bypass with PTFE was performed by vascular surgery. Following this revascularization, the hallux wound was debrided in the OR and a bone biopsy revealed no evident osteomyelitis.
Three weeks status post revascularization, the patient developed cellulitis and abscess to the anterior ankle with failed PTFE graft. The patient was re-admitted to the hospital and vascular surgery removed the infected graft leaving a 7cm curvilinear incision open with exposed tibialis anterior tendon. The patient was taken to the operating room three days s/p removal of the graft for wound debridement and partial closure with Prolene. The distal 60% of the anterior ankle wound was left open and a negative pressure wound therapy dressing was applied using the white (polyvinyl alcohol) foam in order to keep the exposed TA tendon from desiccating. The wound was noted to expose deep fascia with healthy tendon exposed and no acute signs of infection. Deep aerobic and anaerobic soft tissue cultures show no growth post debridement. Three days later, the patient was returned to the OR for additional debridement and pulse lavage, but the wound margins were not able to be approximated over the TA tendon.
Click on the images below for a larger view. |
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What would you do at this point? Closure options? Plastics Consult? Please feel free to share via eTalk with the community and we'll follow up with discussion and photos of our closure in an upcoming edition of Residency Insight.
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