CASE 1

CASE 5

CASE 4

CASE 2

CASE 3

Dimitrios Lintzeris, DO, CWS; Kari Yarrow, RN; Laura Johnson, RN; Amber White, RN; Amanda Hampton, RN; Kristy Albert, PTA; Arlene Cook, PTA Wayne Memorial Wound Care Center, Goldsboro, NC

BACKGROUND AND PURPOSE The aging population and prevalence of multiple co-morbidities complicate the care of patients with chronic wounds of varying etiologies including diabetic foot ulcers, pressure ulcers, and wounds related to trauma. Physicians and clinicians face the challenge of treating chronic wounds of the foot that frequently fail to move through the healing cascade in an orderly and timely fashion. The medical world faces the fact that diabetic foot ulcers affect 2.5% to 2.7% of all patients with diabetes, which frequently result in amputations. This in turn has a dramatic effect on increased mortality rates. Off-loading to redistribute pressure is a basic principle in healing chronic wounds of the foot including diabetic and neuropathic foot wounds. There are various methods for off-loading, however, Total Contact Cast (TCC)* is considered the gold standard for off-loading foot wounds. This series of 5 patient cases with a total of 8 wounds provides evidence to further validate why TCC is and should continue to be the gold standard for off-loading.

METHODS The patients had multiple co-morbidities and wounds varying in longevity from 6 weeks to 8 months. Each patient’s wound was debrided and treated with several different types of wound dressings including; Active Leptospermum Honey (ALH)**,living skin substitutes, silver alginates, foams, hydrogels, antimicrobial packing, silver dressings, and collagen, as well as hyperbaric oxygen. All patients were off-loaded utilizing a new quick and easy form of TCC.

RESULTS In evaluating the outcomes, it is evident that using TCC had a direct effect on wound healing to include a significant impact on total days to heal. These 5 patients had an average of 35.6 days to healing, ranging from as few as 8 days to as many as 71 days. This is considerably faster than would be anticipated given the variety of co-morbidities, wound chronicity, and presence of diabetes. Further research is suggested with a larger variance of wound etiologies, more focused dressing applications, and evaluating healing times to substantiate observations.

References: 1. Bryant RA, Nix DP. Acute and Chronic Wounds: Current Management Concepts. St Louis, MO: Mosby Elsevier; 2012. 2. Kruse I, Edelman, Clinical Diabetes, April 2006 vol. 24 no. 2 91-93.

*TCC-EZ® Total Contact Casting System, Derma Sciences, Inc., Princeton, New Jersey. **MEDIHONEY, Derma Sciences, Inc., Princeton, New Jersey.

Derma Sciences provided an educational grant to support this research. The information may include a use that has not been approved or cleared by the Food and Drug Administration. This information is not being presented on behalf of Derma Sciences.

Case Discussion: 46 yo male with co-morbidities of diabetes, hypertension, and gout. He also had a history of developing blisters on the lower extremities, which had been difficult to heal. Patient presented to the wound care center with wound to the L plantar foot x 3 weeks.

Patient Outcomes: Ulcer closed 100% in 38 days with weekly follow up.

Case Discussion: 69 yo female with co-morbidities of diabetes, hypertension, thyroid problems, charcot feet, and cataracts. Patient acquired the wound on the R metatarsal head on 11/30/11 with previous treatments of wound debridement, living skin substitutes, and single layer compression. She had been followed weekly in the WCC.

Patient Outcomes: Wound was 100% closed in 22 days after TCC was initiated.

Case Discussion: 56 yo female with co-morbidities of diabetes, CHF, CAD, hypertension, MI, hypothyroid, and anxiety. Patient acquired the wound over the charcot deformity of her R foot on 7/4/12 with minimal drainage. The wound was previously treated with debridement, collagen, foam dressings, antimicrobial topical dressings, and living skin substitutes. She was followed weekly in the WCC.

Patient Outcomes: Wound closed 100% in 71 days after TCC was initiated.

Case Discussion: 62 yo male with co-morbidities of CHF, MI, hypertension, COPD, CA of gallbladder, diabetes, gout, and cirrhosis. Patient was being treated for a diabetic ulcer on his R plantar foot since 1/4/12. Previous treatments included HBO, off-loading with a wedge shoe, silver alginate dressings, collagen foam, debridement, and living skin substitutes. Patient is a heavy smoker.

Patient Outcomes: Wound closed 100% in 47 days after TCC was initiated.

Case Discussion: 32 yo female with co-morbidities of Type 1 diabetes, obesity, hypertension, asthma, PAD, hypokalemia, R great toe amputation, and patient is a smoker. She presented to WCC on 7/3/12 with wounds to the R heel and L lateral foot, R great toe amputation site staples were intact. Wounds were acquired on 6/3/12. Previous treatment included debridement, hydrogels, alginates, and off-loading with wedge shoe.

Patient Outcomes: Wounds to R foot and L foot closed 100% in 40 days with the use of ALH dressings and TCC. Unfortunately this patient never returned to the WCC and did not return any calls made by the WCC staff. Thankfully the patient only had the R heel wound remaining, which was significantly smaller.

8/20/12: Ulcer size – 0.6 cm x 0.5 cm x 0.3 cm. Slight amount of slough noted in wound bed, periwound callus noted.

TX: Excisional debridement with topical antimicrobial dressing applied.

8/29/12: Ulcer size – 0.3 cm x 0.1 cm x 0.3 cm. There is extensive maceration as well as periwound callus, moderate amount of slough within the wound, and no good granulation has developed.

TX: Excisional debridement with topical antimicrobial dressing was applied.

9/5/12: Ulcer size – 0.4 cm x 0.3 cm x 0.3 cm. Minimal maceration noted, slight periwound callus continues, wound bed clean without slough.

TX: Antimicrobial topical dressing, TCC was initiated.

9/7/12: Ulcer size – 0.3 cm x 0.2 cm x 0.2 cm. Minimal callus noted, wound bed pink and granulating.

TX: Wound cleansed, topical antimicrobial dressing applied, and TCC continued.

9/12/12: Ulcer size – 0.0 cm x 0.0 cm x 0.0 cm. Wound closed.

TX: TCC continued for one additional week for wound stabilization

8/22/12: Ulcer size – 0.4 cm x 0.1 cm x 0.4 cm. R metatarsal head with periwound callus, slough in wound bed, focal red granulation present and moderate serosanguinous (SS) drainage.

TX: Selective excisional debridement and application of a living skin substitute with a contact layer and foam dressing applied.

9/5/12: Ulcer size – 1.1cm x 1.6cm x 1.3cm with undermining of 1.0cm. Wound bed is clean with periwound callus present, minimal SS drainage.

TX: Excisional debridement of wound and callus, living skin substitute applied with a contact layer and foam dressing applied.

8/15/12: Ulcer size – 0.5cm x 0.5cm 0.4cm. Wound bed pale pink with focal areas of granulation, small amount of periwound callus, minimal amount SS drainage.TX: Excisional debridement, living skin substitute applied, covered with contact layer and foam dressing.

9/12/12: Ulcer size – 1.5cm x 2.0cm x 1.0cm with undermining of 1.0cm. Wound bed clean, minimal periwound callus continues, minimal SS drainage.

TX: Wound cleansed, new contact layer applied and covered with a foam dressing, TCC initiated.

8/23/12: Ulcer size – 0.5 cm x 0.5 cm x 0.7 cm. No visual changes noted. TX: Ex-cisional debridement, foam dressing applied, TCC initiated will follow weekly.

RIGHT GREAT TOE AMPUTATION

8/21/12: Ulcer size – 0.6 cm x 2.0 cm x 0.3 cm There is no eschar, there is significant slough and non-viable tissue within the wound bed, there is a mild odor with a large amount SS drainage

TX: Excisional debridement, dressings changed to ALH gel covered with alginate secured with gauze wrap, off-loading with a wedge shoe.

10/9/12: Ulcer size – 0.1 cm x 1.0 cm x 0.2 cm. Wound epithelializing, no drainage.

TX: Wound cleansed, ALH gel applied covered with foam dressing, off-loading with wedge shoe continued.

9/11/12: Ulcer size – 0.2 cm x 1.0 cm x 0.3 cm. Wound bed is granular, small amount of SS drainage.

TX: Wound cleansed, ALH gel covered with alginate secured with gauze wrap, off-loading wedge shoe continued.

10/16/12: Ulcer size – 0.0 cm x 0.0 cm x 0.0 cm. Wound has healed.

TX: Off-loading with wedge continued.

8/29/12: Ulcer size – 0.1 cm x 0.3 cm x 0.3 cm. Living skin substitute intact, minimal to moderate SS drainage continued.

TX: Wound cleansed, new contact layer and foam dressing applied, TCC initiated.

9/26/12: Ulcer size – 1.0cm x 1.5cm x 0.5cm with 0.6cm undermining, wound clean, minimal periwound callus continues, minimal SS drainage. TX: Wound cleaned, new contact layer and foam dressing applied, TCC contin-ued.

9/19/12: Ulcer size – 0.4 cm x 0.3 cm x 0.2 cm. Wound bed is clean, focal granulation and epithelialization noted.

TX: Wound cleansed, foam dressing applied, TCC continued.

RIGHT HEEL

8/21/12: Ulcer size – 2.8 cm x 2.5 cm x 0.2 cm with undermining of 0.3cm from 12 – 2 o’clock. Wound bed is red, yellow and granular with a large amount of SS drainage and focal periwound maceration.

TX: Excisional debridement, dressings changed to ALH gel covered with alginate and secured with gauze wrap, off-loading with wedge shoe.

10/9/12: Ulcer size – 1.5 cm x 1.0 cm x 0.3 cm. Wound bed is granular, minimal SS drainage.

TX: Selective debridement, ALH gel applied covered with alginate secured with gauze wrap, off-loading with wedge shoe continued.

10/3/12: Ulcer size – 1.1cm x 1.8cm x 0.1cm with undermining of 0.8cm. Wound bed is clean, periwound callus is diminishing, minimal SS drainage. TX: Wound cleansed, contact layer and foam dressing applied, and TCC continued.

10/3/12: Ulcer size – 0.1cm x 0.1cm x 0.1cm. Wound with minimal open area, clean and dry.

TX: Selective debridement, foam dressing applied, TCC continued.

9/11/12: Ulcer size – 1.9cm x 2.0cm x 0.3cm undermining has closed Wound bed is granular, moderate SS drainage.

TX: Wound cleansed, ALH gel applied covered with alginate secured with gauze wrap, off-loading with wedge shoe continued.

10/16/12: Ulcer size – 1.5cm x 1.0cm x 0.5cm. Wound bed is granular and epithelializing, minimal SS drainage.

TX: Selective debridement, ALH gel was applied covered with foam dressing, off-loading with wedge shoe continued.

9/5/12: Ulcer size – 0.0 cm x 0.0 cm x 0.0 cm. Wound closed. TX: TCC continued for 2 weeks for stabilization.

12/5/12: Ulcer size – 0.0 cm x 0.0 cm x 0.0 cm. Wound closed on 11/21/12. TX: Picture here is after 2 weeks of additional TCC for wound stabilization.

10/10/12: Ulcer size – 0.0cm x 0.0cm x 0.0cm. Wound closed, total days to closure = 47 days.

TX: TCC continued for 2 weeks for wound stabilization.

LEFT LATERAL FOOT

8/21/12: Ulcer size – 6.2cm x 3.4cm x 0.2cm. Wound has slough and non-viable tissue within the wound bed, there is mild odor with a large amount of SS drainage, and some focal maceration noted.

TX: Excisional debridement, dressings changed to ALH gel covered with alginate secured with gauze wrap, off-loading with wedge shoe.

9/25/12:Ulcer size – 2.5cm x 0.6cm x 0.1cm. Wound bed is granular and epithelializing, minimal SS drainage.

TX: Wound cleansed, ALH gel covered with alginate dressing, TCC continued.

8/29/12: Ulcer size – 6.0cm x 2.0cm x 0.3cm. Wound has slight amount of slough, there is less odor, large amount of SS drainage continued.

TX: Wound cleansed, ALH gel applied covered with alginate dressings,

TCC initiated.

10/9/12: Ulcer size – 0.0cm x 0.0cm x 0.0cm. Wound closed

TX: TCC continued for 2 weeks for wound stabilization.

Limb Salvage 101: Utilizing an Easier Total Contact Cast along with Active Leptospermum Honey and Advanced Wound Care Modalities to Heal Chronic Wounds of the Foot in less than 36 Days

Presented at 2011 DF Con, Washington D.C

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