Management:  Treatment options included lower extremity amputation as viable choice for early return to rehabilitation.  The patient chose optimized wound care, not amputation, and arterial flow was improved through interventional revascularization of the right iliac, SFA, profunda and popliteal arteries.  The patient was discharged to skilled nursing facility with plan of nutritional supplementation, tendon stabilization with heel protective boot, tendon/bone protection using petroleum based dressing¹, and negative pressure wound therapy² to promote granulation.  At 6 weeks, partial tendon coverage was noted at outpatient visit.  The patient underwent further operative debridement and placement of bi-layer wound matrix of cross-linked bovine tendon collagen³ over the wound.   Negative pressure wound therapy² resumed with bi-weekly office visits for wound check and wound maintenance.  Selective conservative sharp debridement was used for removal of non-viable tissue.  At 9 weeks, bone and anterior tendon were covered while lateral tendon had ¼ coverage and still required minimal selective sharp debridement by the APN.  The patient participates in Physical Therapy and anticipates discharge to home with Home Care within the next 4-5 weeks.

Outcome:  This patient’s wound care remains on-going, but limb salvage has moved from possibility to likelihood.  Collaboration between patient, surgeon, CWCN, and nursing at the skilled nursing facility has kept the patient functional and without amputation.

¹Xeroform, Kendall,Mansfield,MA.

 ²V.A.C. (Vacuum-assisted Closure), KCI, San Antonio, TX.

 ³INTEGRA Bilayer Matrix Wound Dressing™, Integra, Burlington, Massachusetts.