Notes on Practice: Thinking Out of the Box to Treat Challenging Ankle Wounds
By David Davidson, DPM, Erie County Medical Center, Center for Wound Care, Buffalo, NY. email@example.com History. A 41-year-old man presented with chronic ulcerations (7-year duration) along the medial and lateral aspects of both ankles. His medical history included T10 paraplegia (15 years), anxiety, chronic ankle wound infections resulting in hospital admissions, depression, and multiple suicide attempts. His medications included Ditropan (Ortho-McNeil-Janssen-Pharmaceutical, Inc) 5 mg bid, Seroquel (Astra-Zeneca) 25 mg bid, Dulcolax (Boehringer Ingelheim), Trazadone 50 mg bid, magnesium, and multiple vitamins. He denied alcohol or recreational drug use; he was a former cigarette smoker. He had been in the care of his primary care doctor, orthopedic surgeons, and vascular surgeons for multiple (failed) skin grafts and multiple spinal surgeries and other conventional wound care, but the wounds never resolved. He lived alone and, despite his paralysis (he is wheelchair-bound), seemed reasonably self-sufficient. Presenting examination. Upon examination, the patient appeared undernourished and somewhat hostile; he seemed to be in significant distress. His bilateral lower extremities demonstrated pedal palpable pulses +2/4. He had loss of protective sensation, proprioception, and vibratory sensation. Deep tendon reflexes were absent. Along the right ankle, the patient demonstrated a medially based ulceration measuring approximately 3.5 cm x 2.0 cm x 0.1 cm in greatest dimension located directly over the medial malleolus (see Figure 1). A similar wound was located over the lateral malleolus measuring 1.6 cm x 1.5 cm x 0.1 cm (see Figure 2) and similar wounds on the medial (2.5 cm x 2.2 cm x .1 cm) and lateral (2.5 cm x 1.0 cm x 0.5 cm) aspects of the left ankle (see Figures 3 and 4). All wounds exhibited exuberant hypergranulation with serous drainage. The bilateral ankle wounds had been present for several years failing skin grafting and other wound care by various specialists. Initially, the wounds exhibited exuberant amounts of granulation tissue but never any frank, purulent drainage. The patient noted that when sleeping, his legs “spasm” and constantly “flop” from one side to the next. Imaging studies. Radiographs of the both ankles were obtained and revealed some periosteal proliferation under the medial right ankle wound. Considering the length of time these wounds had been present, the decision was made to obtain an MRI. However, the patient was claustrophobic; therefore, a bone scan was ordered to evaluate the osseous structures in the area of the patient’s chronic wound on the right ankle. Bone scan findings. The flow and blood pool images revealed increased blood flow and blood pool activity involving the medial malleolus region of the right ankle. The delayed views revealed increased uptake of the radiotracer in the medial malleolus region. In addition, several areas of increased three-phase activity in the feet were noted, including the lateral malleolar region of the left ankle, the lateral mid left foot, and the left first and second toes and the right first toe. A blood pool image of the posterior pelvis revealed mild increased activity in the upper sacrum and left sacroiliac joint region. However, the delayed views revealed no increase in bone activity. The three-phase bone scan showed possible osteomyelitis involving the medial malleolus region of the right ankle as well as several other areas in the left foot. The bone scan findings were expected based on the length of time this patient had these wounds. Cultures. Following this examination, an aerobic and anaerobic culture was taken of the right medial wound using a 3-mm punch. The Gram stain showed 1+ leukocytes and 3+ Gram-positive cocci. Organism 1 was methicillin-resistant Staphylococcus aureus (MRSA), and organism 2 was classified as Diptheroids. Organism 1was sensitive to gentamycin, rifampin, tetracycline, trimethyloprim/sulfa, and vancomycin Treatment. Because the patient was paraplegic and his legs constantly spasmed during the night, he was brought to the OR for aggressive debridement of the hypergranulation tissue of all wounds. A PICC line was placed. The patient was admitted to a rehabilitation facility to monitor his leg movements during sleep. He also was referred to a local infectious disease specialist for the management of the parenteral antibiotics. Vancomycin was started at 1 g every 12 hours. After 6 weeks of 100% bed rest and IV vancomycin, the patient was discharged, showing some slight clinical improvement (see Figures 5 and 6). The infectious disease physician thought the antibiotics could be stopped. The patient was scheduled to be followed at the wound center. Because improvement of the condition of all four wounds was slower than hoped, the author decided to take a traditional offloading heel rest (see Figure 7) and modify it to offload the sides of the ankle rather than the posterior heel as it was originally designed to do. A new Milsport Heel Rest (Milsport Medical LLC) was used; it has antimicrobial properties and is light-weight and washable. The calf pad in the heel rest is designed to offload the posterior aspect of the heel. However, due to the locations of the wounds on this patient, the device was modified using movable foam blocks to redistribute the pressure away from the wounds (see Figures 8 and 9). The changes in the condition of the wounds were both swift and remarkable. Figures 10 through 13 show all four wounds following 4 weeks of offloading. The patient was been discharged with instructions to continue use of the heel rests when in bed. Summary. This was a very difficult wound case due to the fact the patient presented with four wounds that had been present for several years before he arrived at our wound center. In addition, he had paraplegia and uncontrollable spasms of both legs. The successful outcome of this case required a multidisciplinary approach including vascular, infectious disease, internal medicine, and podiatric/wound specialties. The vascular specialist was consulted initially to ascertain the adequacy of perfusion to the areas. Infectious disease prescribed appropriate antibiotics, and internal medicine controlled the patient’s comorbidities. At times, one needs to think out of the box. In this case, clinicians modified an existing and somewhat conventional offloading heel rest to remove all pressure from all four wounds at the same time, facilitating healing for all.