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Oral Abstracts (Session 1 of 5)
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(Presentation 32.1) The challenge of healing wounds in the noncompliant patient: a case study Brock A. Liden, DPM, Jodi F. Hartman, MS, Michelle L. Wright, BS A 49-year-old obese man with uncontrolled diabetes, neuropathy, hypertension, and ischemia presented with a 3-month-old UT Class IIID plantar foot abscess measuring 13.8 cm x 3.4 cm x 1.8 cm. After incision and drainage of the abscess with implantation of vancomycin-impregnated calcium sulfate beads, traditional wound management, intravenous antibiotic therapy, and vacuum-assisted closure (VAC)* techniques were employed. The patient was noncompliant with dressing changes and applications, resulting in excessive wound drainage and severe maceration of the surrounding skin and exposed tendon. Magnetic resonance imaging demonstrated osteomyelitis of the first metatarsal. Calcium sulfate mixed with vancomycin was injected into the first metatarsal, the extensor tendon was repaired utilizing an acellular tissue matrix, and wound closure was achieved with an acellular tissue matrix. Despite warnings by medical staff, noncompliance continued with repeated incidences of improper dressing treatment and weight-bearing ambulation. However, no signs of infection were evident, the sutures remained intact, and the graft was well incorporated. During an appointment for intravenous antibiotic therapy, another physician incorrectly applied gauze pads directly onto the graft without soaking them in mineral oil. At the next wound assessment, the dry pads were adhered to the graft. Several sutures were disrupted, and the graft pulled away from the skin during pad removal. Because the graft could not be salvaged, traditional wound management techniques and VAC application were employed. Following continued noncompliance and recurrence of osteomyelitis, with no improvement in wound closure, a final attempt was made to salvage the extremity. Vancomycin-impregnated calcium sulfate beads were implanted into the wound cavity and an acellular tissue matrix was used for wound closure. Graft incorporation and 100% granulation occurred at 5 and 12 days, respectively. Although patient noncompliance resumed, complete healing was achieved at 7.7 weeks, at which time the patient was permitted to return to work on a part-time basis, wear a regular shoe, and ambulate. Despite noncompliance in following the standard wound management protocol by both a physician and the patient, this case study illustrates a successful outcome through continued aggressive treatment in a patient who other clinicians may have resigned to lower-extremity amputation. *V.A.C.® Therapy System, KCI USA, San Antonio, Tex |
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