Case Study
INTRODUCTION:
Major Amputations are a world wide problem not only because the high mortality reported after 5 years , even because the local complications that could cause an procedure related death if it is not treated properly and in time
Figure 1
CASE PRESENTATION
84 years old Man with history of Medular syndrome after a spine trauma 35 years ago with complications like Diplejia , walking disability and anal incontinence managed with a colostomy
He presented a diabetic foot infected ulcer in the first toe of his left leg, managed with several local therapies included herbal preparations , it progressed to necrosis of all toes and infection of the leg, so he was practiced a Above the Knee amputation, 15 days later we presented necrosis, dehiscence of the stump and fever. We was sent to our Hospital to be evaluated .
At admission, he was presented with a surgical wound site dehiscence, infection and necrosis , inflammatory systemic response with fever 39,ªC. Elevated Leucocitary count (18,000 c/mm3) ,no pulse in femoral artery. (Figure 1 )
We decide to do a surgical debridement evacuating a 20 cc purulent content from the stump. We practiced microbial culture which found a Pseudomona aeruginosa and E .coli Blee + both resistant to Imipenem but sensitive to Piperaciline -tazobactam; antimicrobial therapy was
Figure 2
initiated
INITIAL THERAPY
We applied a NPWT with white and silver sponge and with Veraflo Therapy (Acelity) with Saline 0.9% 20cc three times per day for one week, first system change at 48 hrs with notable improvement, even the arterial occlusion was not treated (Figure 2)
After Sepsis was controlled we practiced an Iliac Angioplasty in Cath lab to assure blood supply , through a right femoral Endovascular approach.(Crossover)
PROGRESS AND FOLLOW UP
Figure 3
Because the improvements of his general and the wound conditions the patient was discharged and was managed by outpatient Wound Clinic Program (Figure 3) with black sponge for a total 5 weeks, at 125mmHg continue therapy for one week and intermitente the rest of there therapy. (Figure 4)
Negative culture at second week and closure of the 80% of the wound. Tissue with adequate granulation and perfusion ,
A Skin graft was practice to the patient at 8th week with acceptable cosmetic and functional results (Figure 5)
Figure 4
CONCLUSION
In our country unfortunately, major amputation are common practice in patient with critical limb ischemia, and because an incomplete vascular evaluation, patients are presented with infectious or ischemic complications, resulting in high morbid wounds . VAC VERAFLO have demonstrated to be a good option in very complicated patients where a NPWT alone could dry the wound in presence of vascular impairment and infection. We described a complicated stump ischemic and infected treated with VAC VERAFLO therapy
Figure 5
with very acceptable results , preventing for major complications and giving the patient the possibility of rehabilitation.