Problem: In March 2006 a 68-year old man came to the outpatient wound center with a left pretibial ulcer. He had history of paraplegia and distant history of non-Hodgkin's lymphoma. Despite multiple interventions, the ulcer remained unhealed by September 2006. Edema was a barrier to wound healing as the patient spent the majority of his day in a wheelchair with legs dependant.

Past Management: Interventions included sharp debridement and enzymatic debridement using papain-urea copper chlorophyll agent (1), silver hydrofiber dressing (2), zinc paste dressing with light compression (3), foam dressing (4), and trypsin-balsam peru ointment(5). The wound got as large as 10.6 cm x 1.9 cm x 0.2 cm. By August 2006 it bridged into two smaller wounds growing methacillin resistant staph aureus (MRSA). The MRSA was appropriately treated. In September 2006 the proximal wound cultured negative and measured 2.4 cm x 1.4 cm x 0.2 cm. The distal wound had resolved.

Current Approach: September 20, 2006 an acellular human dermal matrix graft* was sutured to the pretibial ulcer following minimal debridement. A primary dressing of nonadherant silicone mesh (6) was secured, followed by a bolster of mineral oil-impregnated gauze, and secondary dressing of gauze. The leg was wrapped with zinc paste dressing and light compression. The patient was seen weekly in the wound center for evaluation and dressing changes.

Patient Outcomes: As of November 7, 2006 the graft was a complete take.

Conclusion: The acellular human dermal matrix graft* is a viable option for bringing recalcitrant wounds to closure. As with any wound care, management of contributing factors and co-morbid conditions is essential for optimal wound healing.

*GraftJacket® Regenerative Tissue Matrix (Wright Medical) (1)Gladase C (Smith & Nephew) (2)AquaCel Ag (ConvaTec) (3)GeloCast (BSN Jobst) (4)Lyofoam (ConvaTec) (5)Xenaderm (Healthpoint) (6)Mepitel (Molnlycke)