Case Study #6 - Ulcer Sub 5th Metatarsal Head

74 year old Hispanic male presents with ulcer sub 5th metatarsal head right foot on 2/3/03. Patient stated he has had the ulcer for at least 1 year, and he has been receiving periodic trimming of the callus under the 5th toe joint and his primary care physician prescribed oral antibiotic 1 month ago, which he completed several weeks ago. His complaint is that the foot is red and swollen and painful. Patient's past medical history is relevant for HTN and NIDDM. DM was diagnosed 5-6 years ago. Social history with occasional alcohol use and patient quit smoking 16 months ago. Medication history of Glucophage, Glypizide, Amitriptyline, Captopril, and a "salt depletion medication" that the patient did not know the name of. Initial exam revealed amputation of the 3rd toe on the left foot- 2 years ago, patient states this also occurred after a non healing ulcer and infection that did not resolve. No signs of infection to the left foot. Right foot with edema and erythema from the toes to the dorsum of the mid foot with increased warmth to the right foot. Hair distribution is equal and adequate to legs and digits bilateral. Muscle strength is equal and adequate bilateral. DP and PT pulses are palpable and strong bilateral. Sub 5th metatarsal head is with a hyperkeratotic lesion and when debrided, noted ulceration of 1 cm in diameter and 1 cm deep, down to bone. X-ray today, AP, MO and Lateral obtained did not show bone involvement at this time, soft tissue loss is noted on the films as tissue defect. Patient is afebrile and he states his appetite has been normal and he denies fever, chills and or nausea. Patient did not know what his A1c was and has not recently tested his blood sugars at home. Blood pressure was well controlled with medication. Patient today is referred to PCP for DM medical management and for referral to podiatry within his HMO plan.

Patient was wearing men's dress shoes today. He is instructed to be completely non weight bearing and the callus rim was reduced with #10 blade and he was instructed to go to the PCP office immediately today, which his son and daughter in law were planning to do. Patient was taken to urgent care 2/5/03 and patient was not seen in this office again until 3/17/03 due to patient's insurance coverage.

3/17/03 patient presented to the office, after he left the skilled nursing facility AMA. Patient after 2/3/03 was admitted to a local hospital and had undergone extensive debridement with amputation of the 5th toe and partial 5th metatarsal excision and wound left open with Nu gauze packing. Patient was advised to have a below knee amputation by the surgeon who performed the I&D. Patient denied this management plan and presented to this office for limb salvage.

I requested from the patient and his family that we get copies of the medical notes from his admission to the skilled nursing facility along with any follow up x-rays taken while admitted, the daughter in law was to arrange for getting them to my office at the earliest convenience.

On 3/17/03 wound debridement is performed with sharp debridement using #10 blade without use of local anesthetic, as patient has LOPS. Wound VAC is ordered and after debridement, wound is then cleansed with sterile normal saline and son will do daily dressing changes that he has been doing with normal saline and gauze pads for the next week, and Rx for Avelox 400 mgs x 10 days provided to the patient today.

Next visit on 3/20/03 wound vac is applied, using the black sponge and wound VAC setting at continuous 150mm Hg of pressure. Dressing changes every 48 hours. Next visit on 3/24/03 Maintained same VAC settings with the dressing being changed every 48 hours, wound debridement is performed in the office using #10 blade and tissue nippers to remove yellow necrotic and fibrotic tissue. The tendon to the 4th toe is noted to have a small area of necrosis and this is protected with application of a small cut sheet of Adaptic over the tendon and then the VAC sponge is applied over this area.

3/27/03 Wound VAC continues to be applied after sharp wound debridement, and change in regimen to include application of Cadexamer iodine under the black VAC sponge, and dressing change continues to occur at 48 hours.

Next visit is on 4/4/03 and Cadexamer iodine has helped to control the growth of yellow necrotic and fibrotic tissues. After cleansing wound with sterile normal saline change in wound management made to stop wound VAC, and addition of Xcell wound dressing, to provide moisture.

Continued use of Cadexamer iodine under the Xcell wound dressing. As secondary dressing, 4x4 gauze and Kling wrap are used over the Xcell wound dressing. Patient continues to be non-weight bearing and he is wearing sandals with the strap cut open so that there is no pressure being placed on the wound.

Next visit 4/10/03 - I decided to continue use of wound VAC for the next week, along with Xcell application under the black wound VAC sponge with the normal settings as previously described.

Next visit on 4/22/03 - On this date, 4/22/03, we discontinued use of wound VAC permanently, and continue to use Cadexamer iodine, Xcell wound dressing with 4x4 gauze and kling wrap. Patient is scheduled for Dermagraft bioengineered living skin equivalent application with wound bed preparation on 5/9/03, and scheduled for pre op and final check prior to surgery on 5/7/03.

5/7/03, patient has a new ulcer to the left 5th toe, and he has not presented me with the x-rays from his skilled nursing facility and the notes from his admission. Today new orders for follow up x-ray prior to surgery to prepare the wound bed and use of bioengineered living skin equivalent. Surgery is rescheduled for 5/16/03. In the mean time, patient's family cannot afford to fill the Rx for Xcell wound dressings, and no samples are available for dispensing. Patient advised to perform wound dressings with sterile saline soaked gauze and kling, bid until surgery. Patient has Cadexamer iodine and he may continue to use this under the gauze dressing.

On 5/16/03 wound appears ready for living skin equivalent, however the x-rays results are suggestive of osteomyelitis. An I&D is decided to be performed.

Intra operative photos 5/16/2003

Wound was first packed open and after wound had filled to some degree, the wound appeared to remain clean, no purulent drainage it was deemed ready for primary closure at the proximal wound site. This day the sutures were removed 6/11/03. During this time the wound was dressed with Xcell wound dressing, dressing changes performed by the family, every 2 days. Patient was allowed to ambulate for bathroom and kitchen privilege.

The wound progressed to point where the sutures were removed and wound continues to improve. This last photograph taken 6/19/03

The patient was then lost to follow up, he missed his follow up appointment scheduled one week later, when he was finally contacted on 7/1/03 his son stated he was completely healed up and he had to go out of town for a family situation and he was never able to be contacted again until 01/08/04 when he scheduled follow up appointment. His daughter taken over his care and removed him from patient's son's home and placed him under her care beginning in November of 2003. Patient's daughter stated that she had contact with while at brothers home and wound care utilizing Xcell had continued after surgical procedure to remove additional infected bone was performed May 2003. According to their estimates the wound was completely closed Mid July 2003.

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