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Issue Number: 

Volume 28 – Issue 7 – July 2015

Author(s): 

Brett Chatman, DPM, Tammer Elmarsafi, DPM, and John S. Steinberg, DPM, FACFAS

These authors discuss how serial debridement, split thickness skin grafts and negative pressure wound therapy salvaged the limb of a 71-year-old patient with diabetes who presented with gas gangrene.

Gas gangrene of the lower extremity is one surgical emergency that normally requires extensive debridement and frequently results in lower extremity amputation. The physician must take into account the advantages of serial debridement with the use of split thickness skin grafts (STSG) and negative pressure wound therapy (NPWT) to salvage limbs.

We present a case of a 71-year-old female with a past medical history consisting of diabetes mellitus, hypertension and hyperlipidemia. She also had a previous ankle fracture with hardware in place from four years prior to the right ankle. The patient presented to the ER with complaints of pain, swelling and redness to the right ankle and foot that became worse over the previous five days. X-rays revealed gas gangrene of her right foot and ankle (figures 1 and 2).

The patient’s Tmax was 101ºF and her white blood cell count was 16,900. Upon examination, she presented with severe pain on palpation as well as a large blister formation with extensive erythema of the right lateral ankle and on the lateral portion of the right great toe (figures 3 and 4). 

We performed an emergent incision and drainage, and removed the hardware of the right lateral leg and hallux (figure 5). Three days later, we debrided the right lateral ankle and amputated the right great toe (figure 6 and 7).

One week after the hallux amputation, the patient went to the OR for wound debridement of the amputation site. We subsequently applied a graft over the entire lateral wound and used VAC therapy (Acelity) over the graft. The patient followed up at the hospital one week later as instructed for a final debridement with split thickness skin graft (STSG) placement. Seven weeks after the patient’s initial ER visit, she presented to the podiatric wound care clinic with the right lateral leg and hallux amputation site being completely healed (figure 8).

A Closer Look At The Research On NPWT And STSG

As DeCarbo and Hyer showed, NPWT uniformly draws wounds closed by helping to remove interstitial fluid, which contains inflammatory and potentially infectious exudate that could impair healing.1 Using NPWT causes increased growth of granulation tissue and increased angiogenesis in the wound bed, creating an optimal base for graft application.2 In a clinical trial comparing NPWT with standard non-adherent gauze dressings for skin-grafted diabetic foot wounds, Lone and colleagues found that the percentage of patients with complete skin graft healing was higher in the NPWT group.3

At the start of care, several consulting physicians had identified this patient as requiring a below-knee amputation. Vascular surgeons performed a diagnostic angiogram, which showed three-vessel runoff to the foot. An infectious disease consult lead to initial broad spectrum antibiotics for the patient. After performing the initial debridement, we sought a plastic surgery consult for a possible free flap due to the size of the wound and the exposed fibula. However, a consensus decision of the multidisciplinary team resulted in serial debridement, NPWT, an Integra graft (Integra LifeSciences) and STSG in order to salvage her lower extremity.

It was not the effort of one service yet the collaboration of all teams that led to our ultimate goal of limb salvage.

In Conclusion

It is important for the clinician to explore all possibilities when it comes to limb salvage. In a time full of advances in wound care, we can salvage what we used to consider non-salvageable and patients can return to having a fully functioning limb. We recommend utilizing a team approach and performing repeat debridement with the use of split thickness skin grafts and negative pressure wound therapy in limb salvage.

Dr. Chatman is a first-year resident within the Division of Podiatric Surgery at MedStar Washington Hospital Center in Washington, DC.

Dr. Elmarsafi is a second-year resident within the Division of Podiatric Surgery at MedStar Washington Hospital Center in Washington, DC. 

Dr. Steinberg is an Associate Professor at the Georgetown University School of Medicine. He is a Fellow and a member of the Board Of Directors for the American College of Foot and Ankle Surgeons.

References

1. Decarbo WT, Hyer CF. Negative-pressure wound therapy applied to high-risk surgical incisions. J Foot Ankle Surg. 2010; 49(3):299-300.

2. Moellenhoff G, Bernadette M. Infected internal fixation after ankle fractures—a treatment path. J Foot Ankle Surg. 2012; 51(1):9-12.

3. Lone AM, Zaroo MI, Laway B. Vacuum-assisted closure versus conventional dressings in the management of diabetic foot ulcers: a prospective case-control study. Diabetic Foot Ankle. 2014; epub April 8.

4. Capobianco CM, Stapleton JJ, Zgonis T. Surgical management of diabetic foot and ankle infections. Foot Ankle Specialist. 2010; 3(5):223-30.