Case Study

Jean Sheehan, Clinical Nurse Specialist University Hospital Limerick
Helen Meagher, Advanced Nurse Practitioner, University Hospital Limerick

This case presentation provides an overview of the holistic and multidisciplinary wound management of an 82 year old lady who developed wound complications as a result of an infected total knee replacement.

Case Presentation:
An 82 year old patient presented with a surgical wound site haematoma as a result of an infected total knee replacement (TKR).
Past Medical History included: Ischemic heart disease, hypertension, osteoarthritis, chronic kidney disease, gout, high BMI, Diabetes. Ankle Brachial Pressure Index was normal with palpable dorsalis pedis pulse.
Following insertion of a TKR 2 years previously, the patient required repeated courses of antibiotics to manage recurrent knee infections. She presented to ED with erythema and leg swelling post aspiration of a knee collection
She was taken to the operating theatre and had first stage knee revision surgery. Extensive debridement of the soft tissues was undertaken and static spacer pins were inserted. Intravenous antibiotic treatment was given to treat a Staphylococcus infection as advised by the Infectious Diseases team.
On day 6 post operatively the wound was inspected by the Orthopaedic team, who requested Tissue Viability Clinical Nurse Specialist (CNS) review. On assessment, (See Figure a) signs of surgical site infection were evident, i.e. increased peri wound oedema, high exudate volume and the surgical site had begun to dehisce.
Vac™ was applied using a bolstering technique to optimise the suture line. One week later Vac™ was discontinued and a haematoma had developed to the medical aspect of the wound (Figure B). The remainder of the suture line remained intact. The patient was referred to a Plastic surgeon to assess suitability for a Flap graft. However after consultation
with the Orthopaedic team, she was deemed unsuitable for this surgery. The Tissue Viability CNS discussed with the Orthopaedic consultant and suggested Veraflo™.

Initiating Vac Veraflo™
Veraflo™ was commenced following initial sharp debridement of the haematoma. Cleanse choice dressing was used with Lavanid 2™ solution, instilling every 3.5hrs with a soak time of 10mins. Wound measurement following debridement prior to commencing Veraflo™ was 7cm long x 6.9cm wide, 1.5cm deep with undermining of 4cm from 9 o’clock to 11 o’clock. (See figure C -wound post debridement). This treatment was continued 2 weeks.

Following 2 weeks of Veraflo™ there was evidence of healthy granulation tissue to the wound bed. Veraflo™ was discontinued and Vac™ therapy was commenced. Vac™ White foam wick was used to loosely fill the undermined areas of the wound with granufoam directly to the wound bed. Negative Pressure Wound Therapy (NPWT) at -125mmhg was used. NPWT was continued for a further 6 weeks with intermittent conservative sharp debridement as required by the Tissue Viability CNS (See figure E). NPWT was discontinued and the wound was dressed with Promogran, AMD foam and duoderm to manage hypergranulation and promote epithelialisation.
Management of this very complex wound in a patient with multiple co-morbidities required a multidisciplinary approach involving Primary Orthopaedic team, Infectious diseases team, Endocrinology team, Dietician, Physiotherapist and Tissue Viability. Optimisation of co-morbidities including diabetes was essential to optimise healing. The dietician advised re dietary intake to ensure adequate nutritional requirements were met for healing, particularly in the setting of a high BMI. The Infectious Diseases team continued to advise on anti microbials and blood tests to monitor white cell count and C reactive protein in addition to clinical examination were essential in determining the need for anti microbials. The Physio therapists advised on exercises and worked with the nursing team to maintain and improve mobility as the wound condition allowed.
Patient and family education was essential at each step of the journey to ensure clear communication. Questions were encouraged and answered as openly as possible to ensure both the patient and her family were involved in care planning. In addition to reassuring both the patient and her family, this assisted with compliance to the treatment plan.

Discharge and follow up
The patient was transferred to a continuing care facility for rehabilitation and to continue increasing her independence and mobility. Wound and Orthopaedic OPD follow ups were co-ordinated and will be ongoing until the wound us fully healed. Close liaison with the care facility the patient was transferred to was essential to ensure continuing care and to create links in the event of any adverse outcome, which might warrant a more urgent review.

Clinical outcomes/Conclusion
This complex case highlights the need for a Multi disciplinary approach to the management of wounds. The authors have demonstrated the use of Veraflo™ and Vac™ therapy at the appropriate stages of wound healing in addition to holistic management of the patient. The use of Veraflo™, as demonstrated in the attached photographs, had a positive impact in promoting ongoing debridement and formation of granulation tissue for this patient.

This case study highlights the holistic and wound management of a very complex wound in a patient with significant co-morbidities. As is demonstrated, the patient was at the centre of all care planning and decision making. This wound required a number of treatment changes at intervals based on thorough holistic wound assessment. The care plan was changed in response to changes in the wound and the effects of any changes were closely monitored. The Tissue Viability CNS had a pivotal role in co-coordinating wound reviews and liaising with members of the multi-disciplinary team to optimise the outcome for the patient.

Figure 1 29/04/2019 Day 6 post op

Figure 2 06/05/2019 Day 13 post op (1 week Post Initial Review)

Figure 3 22/05/2019 Post debridement & prior to application of Veraflo™

Figure 4 04/06/2019 Following 2 weeks of Veraflo™

Figure 5 18/09/2019 Pre Discharge

Figure 6 25/09/2019 OPD Review