How I Treat: Complex Wound Closure Case Presentation

Case 1

• 58-year-old male
• Past medical history included hepatitis C as well as methamphetamine and heroin use
• The patient presented with a cut to his left knee from a fall while “urban camping” that had progressed to cellulitis in his entire leg with pus draining from the wound
• The infection affected the skin, muscle, fascia, joint capsule, and some areas of periosteum, which required aggressive serial debridement (Figure 1)

Case 2

• 41-year-old female
• Past medical history included morbid obesity and type 2 diabetes
• The patient presented with an abscess to the buttocks that had progressed to necrotizing fasciitis of the perineum bilateral buttocks and sacrum, which required 2 rounds of debridement with IV antibiotic therapy (Figure 2)

Case 1

• After the infection was controlled, meshed human reticular acellular dermal matrix (HR-ADM) was secured to the wound bed using temporary surgical staples, and negative pressure wound therapy was applied
• After 10 days, the knee and lower leg received skin grafts, with autografting of the upper leg and hip 4 days later (Figure 3)

Case 2

• Once the infection was cleared, tunneling wounds of the right buttock and ischiorectal fossa were closed using soft tissue advancement flaps
• The dead space was filled using meshed HR-ADM, which was also utilized to maintain contour and avoid fluid collections
• Contour and bulk were created in the area by injecting allograft adipose matrix into the fatty tissues, and dehydrated amnion/chorion membrane was applied to the wound to support skin grafting (Figure 4)

Case 1

The wound was nearly closed and the knee had near normal range of motion within 6 weeks (Figure 5)

Case 2

The patient was fully continent of stool and flatus at 4 weeks (Figure 6)

• Meshed HR-ADM promotes tissue integration and incorporation
• Allograft adipose matrix can supplement the fat layer to cushion the wound bed
• Dehydrated amnion/chorion membrane and dehydrated amniotic particulate help support the wound bed for autologous skin grafting

• This case report highlights how the addition of meshed HR-ADM can help achieve wound closure and improve quality of life