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A Novel and Alternative Treatment Method for Diabetic Heel Ulceration Exposing the Calcaneus Which Is Not Suitable for Flap Surgery: Vacuum Assisted Sandwich Dermal Matrix.

Bingol UA, Cinar C, Arslan H, Altındas M - Biomed Res Int (2015)

Bottom Line: Methods.Skin grafting was successful in ten patients.Conclusion.

View Article: PubMed Central - PubMed

Affiliation: Department of Plastic, Reconstructive and Aesthetic Surgery, Yeditepe Medical School, Yeditepe University, Devlet Yolu Ankara Caddesi No. 102-104, Kozyatağı, 34752 Istanbul, Turkey.

ABSTRACT
Background. Currently, free flaps and pedicled flaps are the first treatment choices for large heel ulcer reconstruction. However, flap reconstruction of heel ulcerations cannot be performed in all diabetics especially with concurrent severe peripheral vascular disease because of higher flap failure rate. In recent years, the use of acellular dermal matrix (ADM) has emerged as an alternative treatment option for extremity ulcers. Methods. We present 13 diabetic patients with a large heel ulceration exposing the calcaneus, who were not eligible for flap surgery due to the presence of only one patent artery of trifurcation. These cases were treated with the vacuum assisted sandwich dermal matrix (VASDEM) method. Results. None of the patients required amputation. Skin grafting was successful in ten patients. Although partial losses were observed in three patients, they were healed spontaneously without surgical interventions. During the follow-up period none of the patients developed ulceration on the treatment area. All patients maintained their preoperative ambulatory ability. Conclusion. VASDEM is a novel method offering opportunity for treatment before proceeding to amputation in diabetic heel ulceration exposing the calcaneus which is not suitable for flap surgery. It also has the potential to close wounds of all sizes independent of the vessel status and wound size in selected diabetic patients.

No MeSH data available.


Related in: MedlinePlus

Granulation tissue formation over ADM.
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Related In: Results  -  Collection


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fig8: Granulation tissue formation over ADM.

Mentions: A deep wound tissue biopsy culture was performed to determine wound infection before the procedure, and appropriate antibiotherapy was initiated as guided by the culture results. When osteomyelitis was diagnosed, bone debridement was performed in addition to soft tissue debridement (Figures 1–4). Following the debridement, negative pressure wound therapy (NPWT) (V.A.C. KCI, San Antonio, TX, USA) was administered using 125 mmHg negative pressure and silver impregnated polyurethane foam in an intermittent manner (2/6) at 72-hour intervals. The wound site was reassessed every 72 hours, and debridement was performed for new necrotic sites. After the observation of peripheral granulation tissue, drill holes were created 5 mm apart on the exposed calcaneus using a 2mm drill in patients who did not have osteomyelitis, and NPWT was continued (Figure 5). After the wound floor had been covered with granulation tissue, BellaDerm (MTF Musculoskeletal Transplant Foundation, NJ, USA) ADM mesh was applied together with NPWT to the wound as the dermal aspect would face the calcaneus if bacterial cultures did not show an infection (Figures 6 and 7). NPWT dressings were changed every 72 hours. After ADM had been completely covered by the granulation tissue, the second layer of the dermal matrix was placed as the dermal aspect would face the previous ADM. NPWT dressings were changed every 72 hours. After the formation of granulation tissue on the second layer of ADM, the wound was closed with split-thickness skin graft (0.4 mm) and NPWT (Figures 8 and 9). The dressings (NPWT) were controlled on day 6. If the grafts appeared normal, the operative site was opened and graft maintenance was performed every 72 hours. Lower extremity splints were not removed before day 10 in the postoperative period. After postoperative day 10, active range of motion (ROM) exercises were initiated for the ankle joint. The patients were mobilized with two walking aids without weight bearing for four weeks. Full-weight bearing was allowed at the end of the first month depending on the recovery status. The patients were trained on the application of dexpanthenol- and chlorhexidine dihydrochloride-containing (Bepanthen plus cream, Bayer) creams twice a day to avoid dryness and moisturize the grafted skin site (Figures 10 and 11).


A Novel and Alternative Treatment Method for Diabetic Heel Ulceration Exposing the Calcaneus Which Is Not Suitable for Flap Surgery: Vacuum Assisted Sandwich Dermal Matrix.

Bingol UA, Cinar C, Arslan H, Altındas M - Biomed Res Int (2015)

Granulation tissue formation over ADM.
© Copyright Policy - open-access
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC4592884&req=5

fig8: Granulation tissue formation over ADM.
Mentions: A deep wound tissue biopsy culture was performed to determine wound infection before the procedure, and appropriate antibiotherapy was initiated as guided by the culture results. When osteomyelitis was diagnosed, bone debridement was performed in addition to soft tissue debridement (Figures 1–4). Following the debridement, negative pressure wound therapy (NPWT) (V.A.C. KCI, San Antonio, TX, USA) was administered using 125 mmHg negative pressure and silver impregnated polyurethane foam in an intermittent manner (2/6) at 72-hour intervals. The wound site was reassessed every 72 hours, and debridement was performed for new necrotic sites. After the observation of peripheral granulation tissue, drill holes were created 5 mm apart on the exposed calcaneus using a 2mm drill in patients who did not have osteomyelitis, and NPWT was continued (Figure 5). After the wound floor had been covered with granulation tissue, BellaDerm (MTF Musculoskeletal Transplant Foundation, NJ, USA) ADM mesh was applied together with NPWT to the wound as the dermal aspect would face the calcaneus if bacterial cultures did not show an infection (Figures 6 and 7). NPWT dressings were changed every 72 hours. After ADM had been completely covered by the granulation tissue, the second layer of the dermal matrix was placed as the dermal aspect would face the previous ADM. NPWT dressings were changed every 72 hours. After the formation of granulation tissue on the second layer of ADM, the wound was closed with split-thickness skin graft (0.4 mm) and NPWT (Figures 8 and 9). The dressings (NPWT) were controlled on day 6. If the grafts appeared normal, the operative site was opened and graft maintenance was performed every 72 hours. Lower extremity splints were not removed before day 10 in the postoperative period. After postoperative day 10, active range of motion (ROM) exercises were initiated for the ankle joint. The patients were mobilized with two walking aids without weight bearing for four weeks. Full-weight bearing was allowed at the end of the first month depending on the recovery status. The patients were trained on the application of dexpanthenol- and chlorhexidine dihydrochloride-containing (Bepanthen plus cream, Bayer) creams twice a day to avoid dryness and moisturize the grafted skin site (Figures 10 and 11).

Bottom Line: Methods.Skin grafting was successful in ten patients.Conclusion.

View Article: PubMed Central - PubMed

Affiliation: Department of Plastic, Reconstructive and Aesthetic Surgery, Yeditepe Medical School, Yeditepe University, Devlet Yolu Ankara Caddesi No. 102-104, Kozyatağı, 34752 Istanbul, Turkey.

ABSTRACT
Background. Currently, free flaps and pedicled flaps are the first treatment choices for large heel ulcer reconstruction. However, flap reconstruction of heel ulcerations cannot be performed in all diabetics especially with concurrent severe peripheral vascular disease because of higher flap failure rate. In recent years, the use of acellular dermal matrix (ADM) has emerged as an alternative treatment option for extremity ulcers. Methods. We present 13 diabetic patients with a large heel ulceration exposing the calcaneus, who were not eligible for flap surgery due to the presence of only one patent artery of trifurcation. These cases were treated with the vacuum assisted sandwich dermal matrix (VASDEM) method. Results. None of the patients required amputation. Skin grafting was successful in ten patients. Although partial losses were observed in three patients, they were healed spontaneously without surgical interventions. During the follow-up period none of the patients developed ulceration on the treatment area. All patients maintained their preoperative ambulatory ability. Conclusion. VASDEM is a novel method offering opportunity for treatment before proceeding to amputation in diabetic heel ulceration exposing the calcaneus which is not suitable for flap surgery. It also has the potential to close wounds of all sizes independent of the vessel status and wound size in selected diabetic patients.

No MeSH data available.


Related in: MedlinePlus