004: Diabetic Foot Salvaged, Wounds Closed in Only Two Months Using Polymeric Membrane Dressings        
Submission Category: Case Series/Study        
Submitter and Primary Author: Linda Benskin, PhD, RN, SRN (Ghana), CWCN, CWS, DAPWCA, WOCNF - Primary Investigator and Clinical Research, Education, and Charity Liaison - Independent Researcher - Ferris Mfg. Corp.

Introduction 

An elderly woman with previously undiagnosed Type II diabetes came into the clinic with massive right foot abcesses of over 3 months' duration. The dorsum had a small pus-filled open area, the great and small toes were oozing pus and the skin on both the dorsal and plantar surfaces of the was stretched tight. The great toe had self amputated at the first interphalangeal joint. The area filled with malodorous thick yellow exudate extended between the plantar skin and muscle from the bases of the toes to the middle of the major arch and wrapped around the lateral edge of the foot. Pain in the deeper tissues of her foot prevented weight-bearing, but the patient was unaware of the extent of her infection. She had wrapped the foot in cloth but had not otherwise treated the wounds.

Following the extensive sharp debridement, polymeric membrane cavity filler was inserted into the cavernous sole wounds, the lateral edge of the foot and through a tunnel at the great toe. All exposed polymeric membrane cavity filler was then covered with standard polymeric membrane dressings. Dressing changes were daily for the first few weeks.         

Results   

Blood and bits of slough adhered to the dressing surfaces, but the wound beds were consistently clean, so no manual cleansing was done. Granulation tissue quickly filled in the now-clean cavities created by the initial removal of copious malodorous exudate and dead bones. When the sole cavity was completely filled in, the area was permitted to seal shut. The cavity along the proximal edge of the foot filled in more gradually; polymeric membrane cavity filler was used in this area almost to complete closure.  The woman walked with a cane throughout the treatment. Using only polymeric membrane cavity filler and polymeric membrane dressings, all of the wounds closed within 8 weeks. The woman’s foot mobility was restored.         

Discussion  

The components of polymeric membrane dressings work together to continuously loosen slough, which is then pulled into the dressings. Usually no manual wound cleansing is needed at dressing changes, so cooling and disruption of fragile newly formed tissue is minimized. This promotes rapid wound closure.  

007: A Sequence of Unfortunate Events: COVID 19, Septic Arthritis, and a Diabetic Patient       
Submission Category: Case Series/Study       
Submitter and Primary Author: Alexandria Armstrong, DPM - Podiatry Resident, University of Texas Health Science Center, San Antonio 

Introduction 

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is known worldwide. Patients with confirmed COVID-19 show a wide range of nonspecific symptoms, such as fever, cough, fatigue, loss of smell, joint pain, and diarrhea. A septic joint is defined by the presence of purulent discharge or abscess in deep soft tissue or bone. It is considered a surgical emergency with high risk of limb loss. Isolated ankle and foot joint sepsis is rare, and is usually associated with either a contiguous ulcer or concomitant infection, or a history of injection into the joint, intravenous drug abuse, prosthetic surgery, or immunocompromised

Methods

A wheelchair-bound 79y M with PMH of: DMII with neuropathy, ESRD on dialysis, PAD, colostomy, indwelling foley, osteoarthritis, with hx right foot TMA (2023) presented to the ED for complaints of left foot pain. Patient was somnolent and unable to provide complete history, however endorsed pain from below his knee to the top of his ankle. Temperature was 97.5 F, BP 106/56, pulse 78, RR 16, WBC 15.8, creatinine 4.5, SED rate 102, negative blood cultures, positive urine culture for 2 or more gram negative rods, with a positive COVID PCR test. Patient had no visible open wounds or lesions to the left foot, with slight redness along the lateral aspect of his left 5th MTPJ, however had no pain on palpation. Left foot x-ray showed destructive osseous changes of 5th MTPJ concerning for septic joint, with osteoarthritis noted along metatarsal heads 2-4.

Results 

Patient presented to OR the following day, no purulent drainage noted, no malodor noted, but fragmentation along the 5th metatarsal head and portions of the proximal phalanx base were discovered. Bone culture resulted with light growth of pseudomonas aeruginosa and staphylococcus caprae. The patient remained COVID positive for another 5 days, while his WBC continued to fluctuate between 11-14. Infectious disease recommended 6 weeks of IV abx with Vancomycin and Cefepime. No further surgery was planned and the decision was made to allow the patient to heal secondarily along the surgical site. 

Discussion

While no other study has examined the relationship between COVID-19 infection and a hyperinflammatory response leading to a previously controlled arthritis in the foot, other studies have shown a potential correlation between COVID-19 and reactive arthritis. For podiatric patients with multiple comorbidities with a concomitant COVID-19 infection, may further exacerbate an already stressed immune system which further puts a patient at risk for more opportunistic infections.

015: Closure of a Diabetic Foot Ulcer with a Fish Skin Graft in a patient with multiple co-morbidities and vascular compromise.    
Submission Category: Case Series/Study    
Submitter: Michael Romberg – SAS Surgical 

Primary Author: Wendy Stephens, ACNP, FCCS - Nurse Practitioner, Southwest Health System

Introduction 

This is a 66 yr old female who is a noncompliant diabetic and smoker with PAOD, PVD, HTN, and history of MI x 2 with PTCA and stent placements. This patient presented to the ER in October with cellulitis of her right foot due to a gangrenous right great toe. She had an open wound to her right lateral foot from walking to avoid ambulating on her black toe. CTA showed bilateral SFA occlusions. Due to her labs being normal and the fact that she was not bacteremic, antibiotics were started as an outpatient and a right SFA stent was placed within 2 weeks. She was then taken to OR for a right great toe amputation.The right lateral foot wound was debrided surgically in OR and wound care resumed in clinic.

Methods

The FSG was applied once weekly in the Wound Clinic and secured with a veil, then backed with an absorbent silver hydrofiber (Aquacel), foam borderless dressing, kerlex, and ACE wrap.She required weekly debridement to prep the wound bed for FSG application with each clinic visit. A total of 7 applications of decellularized fish skin graft was applied to her right lateral foot ulcer over 3 months. She required close monitoring of the right foot due to recent amputation of her right great toe as well. She was instructed to wear a CAM walking boot and came to clinic twice per week. She refused compression wraps after 2 visits and eventually only wore a diabetic shoe due to refusing a walking boot as well.

Results

Within 1 month of 3 applications of FSG to her right lateral foot wound, her ulcer size reduced in width by 50% as she developed granulation tissue that filled in the defect quickly. Drainage decreased as well. Six applications and 2 months later, her foot ulcer was 90% healed. She closed after 7 applications of FSG by end of March.

Discussion

North Atlantic Cod fish skin was effective at healing her right lateral foot DFU despite her co-morbidities, heavy tobacco use, and noncompliance with offloading. She went on to receive 3 more FSG applications for a right heel ulcer that developed 12 months later which also healed without complications. She remained closed with soft pliable tissue, no contractures, no pain, and minimal scarring. No further skin injuries occurred over the next 1.5 years and she is now deceased.