Sometimes when we think back on the things that have we have done for a patient it gives us a feeling of great satisfaction. Sometimes, however, these past reflections give us feelings of sadness and futility.

Patient Case: Transmetatarsal Flap Failure

I was recently reflecting on a past patient that I was treating for toe wounds on his right foot, trying to avoid amputation. His toes kept getting necrotic, to the point he went for a transmetatarsal amputation (TMA) by a fine surgeon. The surgery was very successful and there was a beautiful flap covering the amputation site of his TMA. Unfortunately, within a day, this flap started turning blue and was showing signs of failure. Once the flap failed, he had a large open wound on his right forefoot. We followed the wound and had it nearly closed after several months, using even bone grafts for the exposed bones.

The thing that is remarkable about this case is that I had just recently begun using leeches and this case would have been the perfect one for using leeches—salvaging flaps is the main use of leeches in the U.S. I regret so much that I didn’t think of this or I would have used leeches to salvage this patient's flap. Perhaps the flap would have been saved by intervening with leech therapy and we would not have had the wound to work with. Would it have worked? We will never know of course, but it probably would have worked in salvaging this particular patient's flap. Leeches have the amazing ability to secrete substances to heal the injured tissue and salvage a dying flap. I am just sorry that I didn’t think of using leeches and witnessing the success. Now, that I have had much success using leeches, I would hope it would be the first thing I would think of in the case of failure, but when I was at the beginning, it just didn’t occur to me.

I think the lesson here is always be aware of and think about all of the wound treatment options available. Don’t discard one just because you don’t know that much about it or haven’t used it before on a patient. Had I thought about it and researched it, I would have found that leech therapy was a very popular way of preserving flaps. It is embarrassing for me to realize that I, as a strong advocate of biotherapy, did not use it in a most effective situation. But that just serves as a reminder to us to explore all of the options.

About The Author
Aletha Tippett MD is a family medicine and wound care expert, founder and president of the Hope of Healing Foundation®, family physician, and international speaker on wound care.