Dx: Compromised Tissue Flap/Graft
Failing transmetatarsal amputation at presentation; note ischemic plantar flap and dehisced surgical incision.
Wound status post 37 hyperbaric dives and VAC therapy; plantar flap viable with healthy granulating wound base.
Complete epithelialization of wound and flap preserved.
This is a 68-year-old female with history significant for type II diabetes mellitus, peripheral neuropathy, lower extremity occlusive arterial disease and status post right transmetatarsal amputation from digital gangrene two weeks earlier. Prior to amputation she underwent atherectomy with stent placement in the right lower extremity. Despite the revascularization efforts, the patient demonstrated gradual necrosis of the amputation's plantar tissue flap with dehiscence of the surgical incision and advancing cellulitis. She was at risk for complete failure of the tissue flap, which would necessitate below-knee amputation.
Following admission for IV antibiotics and stabilization of her medical conditions, the patient was referred to The Center For Wound Healing for advanced wound care and hyperbaric oxygen consultation. Hyperbaric oxygen therapy (full-body monoplace chamber) is indicated in this case to stabilize tissue loss, improve flap microvasculature and maximize tissue viability in the presence of compromised arterial perfusion. The goal of treatment was tissue flap salvage, prevention of lower extremity amputation and maintenance of quality of life.
The patient initiated hyperbaric oxygen therapy (90 minutes @ 2.0 ATA depth) in January 2006. Wound care initially consisted of topical debriding agents with sharp debridement as needed and the use of a post-operative shoe and four-point walker. Additionally, packing of a peripheral wound bed tunnel with absorbent silver dressing was maintained.
When the wound bed displayed healthy, clean granulation tissue at hyperbaric treatment #14, negative pressure therapy (KCI VAC) was introduced to stimulate granulation tissue, advance wound contraction and control exudate.
The patient continued to demonstrate effective wound healing with this regimen and was able to discontinue daily hyperbaric therapy at treatment #50. She continued VAC therapy for an additional two weeks while utilizing a collagen matrix dressing at home every other day until complete wound closure was achieved in late May. Accommodative diabetic shoes were prescribed at this time, and the patient was discharged from care on June 6, 2006.
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