When Tendon is Involved

Problem:  A 78 year old male with diabetes was evaluated for bilateral lower leg ulcerations which he had for over a year following injury.  He underwent sharp debridement to patient tolerance, revealing two ulcers on the left and one on the right lateral ankle,  all with slough base. 

Management:  Wounds were treated with medical grade honey for wound debridement and compression wraps for leg edema.  He received weekly  sharp debridement and compression wraps.  After seven weeks of treatment, the right wound was nearly closed and the left wounds were larger in size, now expanded to the posterior ankle with granulation base and 1 cm diameter area of exposed tendon.  Wound cultures revealed Strep and Enterobacter cloacae and he was treated with oral antibiotics.   Living, bi-layered skin substitute was placed later to speed wound healing.  Three weeks later, increased redness, drainage, wound area and tendon exposure were noted at the posterior ankle.  Lateral ankle wound size had decreased.  Wounds were treated with silver calcium alginate and foam and the leg was compressed with a compression wrap.  Wound drainage was copious, requiring frequent visits for wound care.  Repeat cultures revealed multiple bacteria and the patient was hospitalized and placed on IV antibiotics.  Achilles tendon damage forced partial tendon debridement.  On discharge, the patient received wound care in the office.  Wound size and tendon exposure was minimally decreased. There was concern that further tendon debridement would be needed, threatening foot mobility.  Wound care was changed from silver calcium alginate to  Maltodextrin NF Powder with 1% ascorbic acid dressing.  Wound size decreased weekly with full covering over the tendon within two months.

Outcome:  This patient had complex wounds, complicated by infection and tendon involvement.  Antibiotic treatment, compression and change in wound care modality promoted decreased wound size and tendon coverage, retaining full mobility.