PMC4309834_01
Sixty-six-year old male presented to our facility with a significant history of vascular insufficiency and an emergent case of bilateral gangrene of the forefoot. Upon arrival, patient was immediately taken to the operating room and received a right Chopart amputation and left trans-metatarsal amputation.
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F0001
He was transported from Colorado to our facilities in Tucson for emergent treatment of bilateral dry gangrene of the forefoot on November 7, 2013 (Fig. 1).
Following emergent amputation and debridement, the left extremity was allowed to close by secondary intention and became deeply fibrotic and gangrenous. At this time the patient was enrolled in 3 weeks of larval debridement therapy to reduce the presence of degenerative tissue.
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F0002
Following bilateral surgery, the left extremity became deeply fibrotic and remained gangrenous, at which time the patient enrolled in 3 weeks of larval tissue debridement therapy (Fig. 2).
After 1 month of inpatient therapy, the patient was again taken to the operating room for bilateral debridement. (a) represents the preoperative status of the patient's wounds. (b) represents the intraoperative status of the wounds following staple removal (right) and debridement of yellow, fibrous tissue (left). Postoperatively, the patient was initiated on routine Santyl and negative pressure wound therapy treatments, and kept in house for 1 week.
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F0003
This was followed by a repeat surgical debridement on December 11, 2013 (Figs. 3a and b), where intraoperative inspection exhibited a mixture of fibrotic and granular tissue base.
Following significant healing as a result of week-long Santyl and negative pressure wound therapy, the patient was taken to the operating room for a third debridement and irrigation, and was released to a skilled nursing facility.
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F0004
With this resolution, the patient was released to a skilled nursing facility on January 6, 2014 (Fig. 4).
During split-thickness skin grafting of the left plantar foot, the right extremity was debrided of plantar eschar and closed with a rotational flap. The SALSA 'Spike' technique was used to secure the skin flap using two 0.45 Kirschner wires. This is a strong, inexpensive and versatile solution to secure fasciocutaneous flaps when local soft tissue anchoring alone may not be possible.
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F0005
After a month of tandem therapy, sufficient granulation prompted split-thickness skin graft (STSG) application via the SALSA Spike (Fig. 5), which was applied with full incorporation.
Postoperatively, the right wound dehisced and after repeated use of Santyl with negative pressure wound therapy and surgical debridement the wounds presented as pictured on 5/20/14.
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F0006
Follow-up was noted as progressing well on May 20, 2014 (Fig. 6).
With 4 months of continued Santyl and negative pressure wound therapy, the wounds continued to close, and as of 9/8/14 the patient presented with a closed right wound (a) and nearly closed left (b).
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F0007
As of September 28, 2014, wounds of the right plantar foot are healed (Fig. 7), with wounds of the left nearly healed (Fig. 7).
PMC4309834_02
Preoperative presentation of a left, cellulitic, soft tissue abscess overlying the fifth metatarsal, extending both plantarly and dorsally. Magnetic resonance imaging of the left foot confirmed osteomyelitis of the bone, and the patient was taken to the operating room for emergent incision and drainage.
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F0008
Two days following admission, the patient underwent left foot incision and drainage with debridement to the level of the tendon and fifth metatarsal resection (Fig. 8).
Following 1 week of postoperative negative pressure wound therapy, the patient again underwent surgical incision and drainage of both the plantar (Fig. 8) and dorsal wounds (Fig. 9). Postoperatively, negative pressure wound therapy was applied to all wounds, with collagenase product applied to the partially fibrotic dorsal, medial, and lateral wounds faces.
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F0009
On January 15, 2014, the patient again underwent surgical incision and drainage (Fig. 9) and due to the significant size and circumferential nature of the postoperative wound the dorsal and plantar aspects were treated separately.
One month following the initial operative incision and drainage, significant wound granulation accumulated as a result of the persistent tandem use of Santyl and negative pressure wound therapy. This prompted the use of a split-thickness skin graft to the dorsal, medial, and lateral wound surfaces. After 1 month of continued postoperative n, the dorsal graft healed well.
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F0010
By February 12, 2014, significant wound granulation warranted a STSG (Fig. 10) to dorsal, medial, and lateral wound surfaces utilizing white foam NPWT to promote graft anchoring and wound drainage.
Two months following the initial operative incision and drainage, the plantar wound achieved sufficient granulation to warrant a split-thickness skin graft.
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F0011
The plantar wound eventually achieved granulation sufficient to warrant a second skin graft, this time to the plantar facet of the wound, on March 17, 2014 (Fig. 11).
During follow-up this appeared to be progressing towards healing, however, due to this patient's significant co-morbid state, the patient's deteriorated and he required multiple metatarsal head resections with extensor tenotomies.
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F0012
Unfortunately, before complete healing seemed likely (Fig. 12), the patient was lost to follow-up.
PMC4309834_03
PMC4309834_04
PMC4309834_05
Patient presented to our clinic for evaluation of a wound secondary to a descended left second metatarsal head remnant of a previous limb salvage attempt. This patient was taken to the operating room for a second metatarsal exostectomy with bursa excision and wound debridement. Postoperatively, the patient was managed with collagenase enzymatic debridement to perpetuate the removal of non-viable tissue.
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F0013
It was found that as a result of biomechanical changes due to a previous limb salvage attempt he developed this prominence, associated wound, and a sub metatarsal head adventitial bursa (Fig. 13).
Unfortunately, the patient was non-adherent to scheduled follow-ups, and after 1 month, presented with significant dehiscence of the surgical wound. The patient received empiric oral antibiotic therapy, debridement, negative pressure wound therapy, and was placed in a total contact cast. Gentian violet was also administered to the wound sites to reduce maceration caused by prolonged negative pressure therapy inside the cast.
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F0014
The patient failed to appear at the weekly scheduled follow-up but returned on December 5, 2013, presenting with incision dehiscence (Fig. 14).
After 2 weeks of post-dehiscence management, and due to the presence of persistent fibrosis, collagenase debridement was re-initiated in tandem with the continued negative pressure wound therapy and total contact cast. Within 1 month of concomitant usage, full healing of the plantar wound was noted, and confirmed again at the 1 month follow-up.
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F0015
Due to decreased healing and persistent fibrosis, collagenase was added to NPWT therapy on December 19, 2013 (Fig. 15).
PMC4309834_06