Dx: Chronic Diabetic Foot Ulcer
Click on each image to enlarge.
Right foot severely edematous with erythema, necrosis at site of injury; note pre-gangrenous changes at distal 5th toe.
Post I&D, debridement note exposed extensor tendons and frank gangrene of 5th toe.
Healthy granulation tissue following negative pressure and HBO therapy; 5th toe ultimately required amputation.
Complete reepithelialization of wound following incorporation of Apligraf.
A 57-year-old male with type II diabetes mellitus presented to The Center For Wound Healing with a traumatic, non-healing wound of the dorsal right foot and pre-gangrenous changes of the distal 5th toe following crush injury one month earlier. His primary care physician had been treating the wound with standard topical care but noted advancing tissue necrosis and referred the patient for more advanced wound care. The patient’s past medical history included a previous injury to the area 30 years earlier requiring a full-thickness skin graft for repair.
Surgical I&D revealed a large, subcutaneous hematoma at the point of injury proximal to the fourth and fifth toes with a resultant Wagner grade III defect measuring 4.7 cm x 3.5 cm x 0.8 cm. Extensor tendons remained intact with no radiologic evidence of fracture and no sign of abscess. Frank gangrene with eschar had now developed at the distal 5th toe and amputation was ultimately required.
Post-operatively, negative pressure therapy (KCI VAC) was initiated to optimize local tissue perfusion and control wound exudate and bacterial proliferation. One week following debridement, hyperbaric oxygen therapy (2.0 ATA, 90 minutes, full-body monoplace chamber) was instituted due to the depth and chronicity of the wound. Hyperbaric oxygen therapy reverses chronic wound hypoxia to re-establish healing at the cellular level, augment granulation tissue formation and achieve eventual re-epithelialization. The ultimate goal of hyperbaric oxygen therapy for this patient was prevention of lower extremity amputation.
The wound demonstrated 25% reduction in overall depth at hyperbaric treatment #18, and the patient was continued on this regimen for a total of 40 treatments. At the conclusion of hyperbaric therapy, the wound measured 3.3 cm x 1.3 cm x 0.3 cm with a clean, shallow base of healthy granulation tissue. A living, bi-layered skin substitute (Apligraf by Organogenesis Inc.) approved in the treatment of diabetic foot ulcers was placed over the wound to supply vital growth factors and structural proteins integral in the healing process. The patient had complete wound closure eight weeks post-Apligraf and was discharged with no recurrence.
Click here to download all case studies in PDF format.
