Case Study: Wound Care

By Lee Kirksey, MD

A 54-year-old male presented in Cleveland Clinic’s Emergency Department with a swollen left foot and black fifth toe. The patient noted that he had struck the toe on the shower door several days prior. He was found to be febrile, with a temperature of 101 degrees, and tachycardic, with a heart rate of 110 BPM. In addition, he had a discolored fourth toe; swollen, red foot and leg; and blood glucose level of 500 mg/dL.

Evaluation

Plain film of the foot demonstrated subcutaneous gas around the toes. Intravenous antibiotic therapy with vancomycin and pipercillin/tazobactam were initiated. Treatment of his diabetic ketoacidosis and sepsis was begun with aggressive fluid resuscitation and an insulin drip. After the patient was metabolically stable, he was taken to the operating room, where he underwent amputation of his fifth toe, with wide debridement of a tracking infection along the anterior and posterior dorsum on the plantar surface of the foot.

Treatment

On postoperative day one, treatment alternatives were discussed. These included a guillotine amputation for infection control, followed by a below-knee amputation, or revascularization with local wound management and potential wound closure. It was reinforced that the limb-salvage strategy would take place over a period of time and require his commitment. After consulting with his family, the patient opted for limb salvage. Forty-eight hours later, he underwent secondary debridement of remaining devitalized tissue, including his fourth toe and partial resection of the transmetatarsal bones to obtain clean, non-infected margins. Negative-pressure wound dressing was applied.

Angiography performed one week later demonstrated occlusion of his anterior tibial artery at the malleolar level and segmental occlusion of his posterior tibial artery at its mid-level. Recanalization was performed with angioplasty, restoring brisk blood flow in the posterior tibial to the foot. Intravenous antibiotics and negative-pressure wound dressings were continued.

Followup was performed in the clinic and consisted of staged application of an extra-cellular replacement product along with negative-pressure wound therapy on four visits over a 10-week period. After complete filling of the wound bed was achieved, the patient underwent a split-thickness skin graft harvested from his right lateral thigh, while continuing negative- pressure wound therapy. Approximately 80 percent of the graft took, leaving the patient with a plantar surface wound that persisted in draining. When MRI demonstrated infection of the residual third metatarsal head, revision transmetatarsal head resection was performed. The wound subsequently closed and has remained completed healed.

Discussion

Only a few days prior to coming to Cleveland Clinic, the patient had been seen at another ER, where he was told that his vascular condition would make amputation inevitable. Here at Cleveland Clinic, we have found that employing a multidisciplinary team approach enables us to provide state-of-the-art care limb-sparing treatment, while addressing underlying medical conditions. This patient had not seen a doctor in 20 years when he presented with uncontrolled hypertension, newly diagnosed diabetes and severe leg ischemia. With the help of vascular surgeons, podiatric surgeons and infectious disease specialists, we were able to save his leg and part of his foot. Endocrinologists and cardiologists helped modify his systemic disorders.

A former athlete and soccer coach, the patient has since dramatically changed his lifestyle. He has lost 60 lbs, and his diabetes and hypertension are now under control.