Contralateral Limb Salvage in a Diabetic Amputee With Necrotizing Fasciitis: A Case Report Supporting the Use of Viable Cryopreserved Umbilical Tissue to Prevent Bilateral Amputation
BACKGROUND: Necrotizing fasciitis can be life threatening in patients with severe comorbidities, especially in amputees. Amputation is often the recommended treatment, due to the severity of the infection and extent of tissue destruction.
OBJECTIVE: This case report presents a morbidly obese diabetic woman with previous right sided below-knee amputation (BKA) who was admitted with contralateral lower extremity infection. The patient was treated with staged surgical procedures with the goal of avoiding left leg amputation. Surgical intervention consisted of incision and drainage followed by staged midfoot and rearfoot reconstruction with external fixation and subsequent aggressive treatment of the remaining plantar wound. The large plantar wound failed treatment with dehydrated human amniotic membrane and proceeded to surgical debridement with application of viable cryopreserved umbilical tissue (vCUT). Placental tissue has been used to treat wounds due to its anti-inflammatory, antioxidant, antimicrobial, and angiogenic properties.
CASE REPORT: A 56-year-old morbidly obese woman was admitted with necrotizing fasciitis of the left foot, with a plantar medial midfoot wound that extended to the lateral rearfoot. The patient’s past medical history included type 2 diabetes mellitus, neuropathy, hypertension, malignant gastric neoplasm, congestive heart failure, morbid obesity (weight, 362 lbs), chronic lymphedema, chronic stage 4 kidney disease, obstructive sleep apnea, deep vein thrombosis, osteomyelitis, right leg BKA, and venous thromboembolism high-risk category. The patient refused a left BKA and understood the serious risks associated with any surgical intervention. Initial treatment was incision and drainage, debridement, irrigation of the extensive wounds, and vacuum-assisted closure. This aggressive limb salvage procedure resulted in destabilization of the foot due to extensive tissue loss of the plantar and lateral tendons. The next procedure was performed 2 weeks later and consisted of midfoot and rearfoot arthrodesis with external fixation to reconstruct the destabilized foot. A revision of the fixation was performed 2 weeks later, with surgical debridement and manipulation of the ankle joint and application of dehydrated human placental tissue allograft to 2 wounds measuring 384 cm2 and 16 cm2 on the plantar and lateral aspects of the foot, respectively. The dehydrated human placental allograft failed to remain adequately in the wound beds. The wounds were treated with 5 bedside applications of viable cryopreserved placental membrane (vCPM), followed by surgical debridement and application of vCUT in staged procedures 4 weeks apart. The external fixator was removed at 4 months, and the wounds were healed at 12 weeks post vCUT application. The patient was transferred to a skilled nursing facility to begin physical therapy and ambulation. All of the patient’s wounds granulated and subsequently closed with a combination of reconstructive foot surgery with external fixation and 5 applications of vCPM/2 applications of vCUT, after failure of the wounds to heal with dehydrated amnion. The wounds were closed within 12 weeks of the initial vCUT application.
CONCLUSIONS: This complicated limb salvage case reports a favorable outcome using a combination of vCPM and vCUT in conjunction with major midfoot/rearfoot reconstruction to avoid left leg amputation in a severely comorbid patient with previous right BKA. The viable components of vCPM and vCUT may be effective in the closure of extensive complex wounds resulting from necrotizing fasciitis. The use of vCPM in this case prevented a bilateral lower extremity amputation and reduced the risk of mortality associated with double amputations. The ulcers all remained healed without recurrence or further breakdown.
CITATION
Weiland J, Kurtz Phelan DH. Contralateral limb salvage in a diabetic amputee with necrotizing fasciitis: a case report supporting the use of viable cryopreserved umbilical tissue to prevent bilateral amputation. Poster presented at: Symposium on Advanced Wound Care Fall; November 2-4, 2018; Las Vegas, NV.
Products: Stravix and Grafix, both products of Osiris Therapeutics, Inc (Columbia, MD)
This abstract was not subject to the WOUNDS peer-review process.
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