Paths to Practice Perfection
Open 1st Ray Amputation: Bridging Traditional NPWT to Disposable NPWT and on to Closure
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Patient

A 71-year-old male with a history of chronic osteomyelitis of the first metatarsal and sesamoids that developed from a diabetic foot ulceration and diabetic foot infection failed conservative treatment. A multidisciplinary team approach to his care included specialists from podiatry, vascular surgery, internal medicine, infectious diseases, and wound care. Since the patient failed conservative medical therapy, he opted for a 1st ray amputation in hopes of averting a more proximal foot amputation.

Co-morbidities

In addition to his diabetes, past medical history included diabetic peripheral neuropathy, coronary artery disease, hypertension, autoimmune disorder, former nicotine use, and poor nutritional status.

Course of Treatment

The patient was taken to the operating room for a 1st ray amputation and primary closure was not possible due to extensive soft tissue infection. The wound was left open. While in the acute hospital setting the patient’s diabetes and other medical conditions were managed by the hospitalist. Infectious Diseases provided culture driven antibiotic therapy. On post-op day one packing from the open 1st ray amputation was removed and traditional negative pressure wound therapy (NPWT) was started with a 3M™ V.A.C.® Ulta Therapy Unit at -125mmHg continuous negative pressure.

3M™ V.A.C.® Ulta Therapy System: Designed for Acute Care

The patient was followed throughout his hospital stay by the author who was also his primary surgeon. The patient was discharged on oral antibiotics, offloading, and with follow-up at the author’s wound care center.

The patient had a small surgical wound with low exudate but a wound that would still benefit from NPWT.

(Figure 1) 1st ray amputation

The patient declined treatment with traditional NPWT, and a solution was needed to bridge NPWT from the acute setting to the post-acute setting.

The patient was agreeable to the 3M™ Snap™ Therapy System, which is a disposable NPWT that supports patient quality of life by combining the simplicity of advanced wound dressings with the proven benefits of negative pressure wound therapy in a discreet design.1 The Snap Therapy System was applied using -125mmHg continuous negative pressure to the patient in the wound care center upon discharge from the acute hospital setting.

Disposable NPWT: 3M™ Snap™ Therapy System

(Figure 2) Hydrocolloid ring

(Figure 3) 3M™ Snap™ Therapy System Applied

The patient’s post-operative course was uneventful and dressing changes were performed twice per week for a total of 16 days. After the 16 days using the Snap™ Therapy System, the patient’s wound depth had significantly decreased with granulation close to the peri-wound.

(Figure 4) Transitioned to Promogran Prisma™ Collagen Matrix with ORC and Silver

The Snap Therapy System was removed, and the patient’s wound care was then transitioned to 3M™ Promogran Prisma™ Collagen Matrix with ORC and Silver three times per week. Promogran Prisma Matrix has the added benefit of silver, a well-known antimicrobial agent. In the presence of exudate, Promogran Prisma Matrix transforms into a soft, conformable, biodegradable gel, and thus allows contact with all areas of the wound. When covered with a semi-occlusive dressing, like a foam, the dressing maintains a moist wound environment. This environment is conducive to granulation tissue formation, epithelialization and optimal wound healing. The silver-ORC in Promogran Prisma Matrix helps to provide a barrier to bacteria in the dressing. ORC combined with collagen provides enhanced reduction of protease activity compared with other naturally derived and collagen materials.2*

3M™ Promogran Prisma™ Collagen Matrix with ORC and Silver

The patient's surgical wound went on to full closure at post-operative day 44. Offloading was maintained throughout the post-operative course. The patient was referred to Prosthetics and Orthotics and received extra-depth diabetic shoes and custom insoles.

(Figure 5) Full closure at post-operative day 44

Treatment Modalities

  • Multidisciplinary team approach
  • Open 1st ray amputation
  • 3M™ V.A.C.® Ulta Therapy Unit
  • 3M™ Snap™ Therapy System
  • 3M™ Promogran Prisma™ Collagen Matrix with ORC and Silver

Conclusion

This case study reviewed a chronic osteomyelitis of the first metatarsal and sesamoids that failed conservative treatment leading to an open first ray amputation. The patient was treated by bridging negative pressure wound therapy from the acute hospital setting with V.A.C.® Ulta Therapy System to the post-acute setting using the Snap Therapy System. The wound was then taken on to closure using 3M™ Promogran Prisma™ Collagen Matrix .

References

  1. Armstrong DG, Marston WA, Reyzelman AM, Kirsner RS. Comparative effectiveness of mechanically and electrically powered negative pressure wound therapy devices: a multicenter randomized controlled trial. Wound Rep Reg. 2012;20(3):332-341.
     
  2. Gibson M, et al. Can natural materials be optimized to improve wound environment? Presented at European Wound Management Association; May 12-14, 2015; London, UK.
     

As with any case study, the results and outcomes should not be interpreted as a guarantee or warranty of similar results. Individual results may vary depending on the patient’s circumstances and condition.

NOTE: Specific indications, contraindications, warnings, precautions, and safety information exist for these products and therapies. Please consult a clinician and product instructions for use prior to application. Rx only.

Footnote:
*in-vitro

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