A 66-year-old female presented to the outpatient wound center with a left foot surgical dehiscence following left first metatarsophalangeal joint arthrodesis with hardware placement, second digit hammer toe repair with proximal interphalangeal joint arthrodesis, flexor extensor tendon transfer, and second metatarsophalangeal joint contracture release that occurred 5 months prior to presentation at the wound clinic (Figure 1). Pertinent past medical history included prediabetes, fibromyalgia, hypothyroidism, methotrexate therapy for large granular lymphocytic leukemia, vitamin D deficiency, and rheumatoid arthritis. The wound had completely granulated and was nearly epithelialized when the patient's clinical course was complicated by COVID-19 infection, wound decline, and osteomyelitis. In addition to antibiotic treatment for osteomyelitis, the patient was returned to the operating room for hardware explantation and a single application of a dermal repair scaffold, which remained in place for 2 weeks. At presentation to the wound clinic, the wound measured 3.0 × 0.9 × 0.1 cm (surface area, 2.7 cm2). The patient underwent a total of 17 mNPWT dressing changes over 13 weeks. Time to healing, defined as presentation to the wound clinic to documented wound closure, was 19 weeks, 1 day (134 days). Mechanical NPWT was selected for the wound due to minimal depth, lack of undermining, moderate exudate, and wound size and placement fitting comfortably beneath the mNPWT dressing. The periwound skin, including the skin bridge between ulcers, was protected using an ostomy ring to prevent the foam dressing from contacting and irritating the periwound.
(A) Dehisced surgical incision at presentation. (B) Dehisced surgical incision 15 weeks after presentation to the wound clinic following treatment for osteomyelitis, hardware explantation, and dermal scaffold application. Granulation tissue cobblestoning from mechanical negative pressure wound therapy is visible. (C) Dehisced surgical incision at week 19.
A 66-year-old female presented to the outpatient wound center with bilateral venous leg ulcers of the lateral calves that had been open for 6 months but had opened intermittently for several years (Figure 2). Pertinent past medical history included a peptic ulcer provoked by ibuprofen intake related to wound pain prior to presentation, venous insufficiency, renal insufficiency, venous stasis dermatitis, recurrent cellulitis, family history of thrombi contributing to mortality, and vitamin D deficiency. The patient's right leg epithelialized following treatment with a microfiber pad between surgical debridements, gentian violet, methylene blue foam, and 2-layer compression system in addition to standard of care. However, the left leg ulcer remained stalled. At presentation to the wound clinic, the left leg wound measured 19.1 × 16.5 × 0.1 cm (surface area, 315.15 cm2). Venous duplex ultrasound indicated left common femoral, superficial femoral, popliteal, and superficial saphenous veins with partially occlusive thrombi, which did not resolve following chronic anticoagulation with apixaban. Hypercoagulability panels were negative. Sclerotherapy of the left leg was performed. Per an interventional radiology consultation, the patient was not a candidate for additional intervention. The use of advanced therapies, including noncontact, low-frequency ultrasound as well as cellular tissue products, was initially delayed and eventually intermittent due to sporadic and challenging insurance coverage. The patient underwent a total of 11 mNPWT applications over 4 weeks. The portability of the product allowed her to continue to work during use. The wound improved from 25% granulation tissue and 75% yellow fibrin to nearly 100% granulation tissue; however, mNPWT was discontinued due to dermatitis. At the time of this writing, the patient continued to receive treatment in the outpatient wound clinic. Her wound was selected for mNPWT due to the need for frequent activity at work, minimal depth, lack of undermining, moderate exudate, periwound inflammation, and the need for granulation tissue formation.
(A) Venous leg ulcer at initiation of mechanical negative pressure wound therapy (mNPWT). (B) Venous leg ulcer prior to debridement at completion of mNPWT.
A 57-year-old male presented to the outpatient wound center with a right medial ankle ulcer that had been open intermittently for 8 months following an open tibiofibular fracture sustained during a fall from a roof while intoxicated (Figure 3). He underwent open reduction and internal fixation with hardware placement; the hardware was removed before the patient presented to the wound clinic. Pertinent past medical history included active alcohol and tobacco misuse, peripheral arterial disease, alcohol-induced polyneuropathy, atrial fibrillation, and venous insufficiency. At presentation to the wound clinic, the wound measured 1.4 x 0.8 x 0.7 cm (surface area, 1.12 cm2). An out-of-state hospitalization for atrial fibrillation complicated the clinical course because gauze was applied beneath a foam bordered dressing without skin protectant and remained in place for an unknown period of time, with associated wound decline and dimension enlargement. The patient underwent a total of 16 mNPWT applications over 11 weeks. Successful use of mNPWT was facilitated by drape breaks or periods without application of the device to allow resolution of dermatitis flair-ups using silicone bordered foam dressing to maintain a moist wound environment. The portability of the product allowed him to continue to perform manual labor during use. Mechanical NPWT was discontinued 4 weeks prior to epithelialization due to periwound dermatitis with drainage and pruritus. Time to healing, defined as presentation to the wound clinic to documented wound closure, was 18 weeks, 2 days (128 days). The wound was selected for mNPWT due to the need for frequent activity at work, minimal depth, lack of undermining, exudate, stabilization and protection of the site from repeated trauma, and the need for granulation tissue formation.
Wounds. 2021;33(12):E85-E89. © 2021 HMP Communications, LLC