International Wound Journal ISSN 1742-4801
LETTER TO THE EDITOR
Unexpected wound occurring following negative pressure wound therapy Dear Editors, A 67-year-old man with type 2 diabetes mellitus of 2 years duration was presented 4 weeks after amputation of a gangrenous and infected toe, with a large non-healing wound at the surgical site (Figure 1). Pedal pulses were non-palpable and he had severe loss of foot sensation. The patient had a poor diabetes control with a haemoglobin A1c level of 8·4% (normal 3·3–6·4%). Apart from hypertension, he did not have any other known comorbidities. Infection markers at admission were as follows: white blood count = 13500 (mm3 /L), erythrocyte sedimentation rate = 105 mm/hour, C-reactive protein = 57 mg/l. The patient received comprehensive wound management including daily wound care, culture-driven antimicrobial treatment, hyperbaric oxygen therapy and negative pressure wound therapy (NPWT). The NPWT system, which has been shown to promote wound healing, consists of a vacuum pump and a canister connected to each other and to the wound site with several tubes. The system drains excess fluid from the wound base and thereby sustains an optimum moist milieu, helps control bacterial burden and restores microcirculation by decreasing interstitial pressure. In the current case, we had fixed the drainage tube, one of the pieces of the NPWT system, over the dorsal aspect of the patient’s foot. On opening the dressing 3 days after its application, to our great surprise we
realised a new wound developed underneath and along the trace of the draining tube (Figure 2). Apparently, continuous pressure transmitted from the bandage through the draining tube to the dorsal aspect of the foot resulted in an atypical pressure wound. This newly occurring wound was managed together with the former and showed a good tendency toward healing over time (Figure 3).
Figure 1 Large non-healing wound seen at the surgical site.
Figure 3 Wound showing healing over time.
Figure 2 The draining tube and the wound.
© 2014 The Authors International Wound Journal © 2014 Medicalhelplines.com Inc and John Wiley & Sons Ltd
289
E. Karabacak et al .
Letter to the Editor
To our knowledge, this is the first report to demonstrate such a wound occurring during the course of NPWT. Diabetes complicated with angiopathy and sensory neuropathy is a major risk factor for foot injuries (1). Health care professionals dealing with diabetic patients should, therefore, be careful when closing wounds with pressure. Ercan Karabacak, Assistant Professor1 , Mesut Mutluoglu, Associate Professor2 , Ali Memis, MD2 & Hakan Ay, Associate Professor2 1 Department of Dermatology GATA Haydarpasa Teaching Hospital Istanbul, Turkey.
290
2
Department of Underwater and Hyperbaric Medicine GATA Haydarpasa Teaching Hospital Istanbul, Turkey [email protected] doi: 10.1111/iwj.12232
Reference 1. Mutluoglu M, Uzun G, Karag¨oz H, Ay H. Unexpected thermal injury caused by non-contact heat exposure in a diabetic patient. J Burn Care Res 2013;34:e309–10.
© 2014 The Authors International Wound Journal © 2014 Medicalhelplines.com Inc and John Wiley & Sons Ltd
LETTER TO THE EDITOR
Unexpected wound occurring following negative pressure wound therapy Dear Editors, A 67-year-old man with type 2 diabetes mellitus of 2 years duration was presented 4 weeks after amputation of a gangrenous and infected toe, with a large non-healing wound at the surgical site (Figure 1). Pedal pulses were non-palpable and he had severe loss of foot sensation. The patient had a poor diabetes control with a haemoglobin A1c level of 8·4% (normal 3·3–6·4%). Apart from hypertension, he did not have any other known comorbidities. Infection markers at admission were as follows: white blood count = 13500 (mm3 /L), erythrocyte sedimentation rate = 105 mm/hour, C-reactive protein = 57 mg/l. The patient received comprehensive wound management including daily wound care, culture-driven antimicrobial treatment, hyperbaric oxygen therapy and negative pressure wound therapy (NPWT). The NPWT system, which has been shown to promote wound healing, consists of a vacuum pump and a canister connected to each other and to the wound site with several tubes. The system drains excess fluid from the wound base and thereby sustains an optimum moist milieu, helps control bacterial burden and restores microcirculation by decreasing interstitial pressure. In the current case, we had fixed the drainage tube, one of the pieces of the NPWT system, over the dorsal aspect of the patient’s foot. On opening the dressing 3 days after its application, to our great surprise we
realised a new wound developed underneath and along the trace of the draining tube (Figure 2). Apparently, continuous pressure transmitted from the bandage through the draining tube to the dorsal aspect of the foot resulted in an atypical pressure wound. This newly occurring wound was managed together with the former and showed a good tendency toward healing over time (Figure 3).
Figure 1 Large non-healing wound seen at the surgical site.
Figure 3 Wound showing healing over time.
Figure 2 The draining tube and the wound.
© 2014 The Authors International Wound Journal © 2014 Medicalhelplines.com Inc and John Wiley & Sons Ltd
289
E. Karabacak et al .
Letter to the Editor
To our knowledge, this is the first report to demonstrate such a wound occurring during the course of NPWT. Diabetes complicated with angiopathy and sensory neuropathy is a major risk factor for foot injuries (1). Health care professionals dealing with diabetic patients should, therefore, be careful when closing wounds with pressure. Ercan Karabacak, Assistant Professor1 , Mesut Mutluoglu, Associate Professor2 , Ali Memis, MD2 & Hakan Ay, Associate Professor2 1 Department of Dermatology GATA Haydarpasa Teaching Hospital Istanbul, Turkey.
290
2
Department of Underwater and Hyperbaric Medicine GATA Haydarpasa Teaching Hospital Istanbul, Turkey [email protected] doi: 10.1111/iwj.12232
Reference 1. Mutluoglu M, Uzun G, Karag¨oz H, Ay H. Unexpected thermal injury caused by non-contact heat exposure in a diabetic patient. J Burn Care Res 2013;34:e309–10.
© 2014 The Authors International Wound Journal © 2014 Medicalhelplines.com Inc and John Wiley & Sons Ltd
