Combined Regenerative Approach for a Complex Lower Extremity Wound: A Case Report

More than 400 million patients worldwide are affected by diabetes; over their lifetime, at least 25% will develop foot ulcers that often result in high rates of nonhealing wounds and amputation. The authors present the case of a 43-year-old female patient with multiple comorbidities who presented with a large (8 cm x 4 cm), noninfected, hindfoot plantar ulcer that extended down to the bone and calcaneus. Over 2 weeks, the patient was successfully treated using a combination of an acellular dermal matrix, nanofat grafting, and negative pressure wound therapy, lessening the effects of the ulcer on the patient’s quality of life and achieving limb salvage. Utilizing the regenerative procedures described herein may improve patient care and decrease costs.

Efficacy of 5% Tea Tree Oil Hydrogel on Healing Morbus Hansen's Chronic Plantar Ulcer

Background: The damage of the peripheral nerves that occurs in Morbus Hansen (MH) patients can cause disability due to loss of sensory, motor and autonomic functions can cause wounds, infections, ulcers and disability. Ulcers are the most common cause of disability complications in MH patients and requires a certain time of healing. As many as 10-20% of MH patients experience ulcers on the soles. Tea Tree Oil (TTO) is extracted from steam distillation of the leaves and twigs of the Australian native shrub Melaleuca Alternifolia. In ulcers, TTO can work as an antimicrobial, anti-inflammatory, and antioxidant. TTO preparation in the form of hydrogel is believed to help the wound healing process. Purpose: To investigate the effect of TTO hydrogel 5% on the healing of Chronic Plantar Ulcer of Leprosy (CPUL). Methods: Tea tree oil hydrogel 5% was applied every 3 days for up to 8 weeks in 22 subjects with chronic MH plantar ulcers. Ulcer size, side effects, and possible side effects are evaluated weekly. Result: There were significant clinical and statistical differences in ulcer size (p = 0.000) and in ulcer depth (p = 0.000) after TTO hydrogel 5%. No side effects occurred in this study. The ulcer healed was 59%, the ulcer improved by 36.4%, the persistent ulcer was 4.6%, and there was no ulcer that got worse. Conclusion: TTO hydrogel 5% is effective in the healing process of chronic MH plantar pedis ulcers.

Microvascular Dysfunction in Peripheral Artery Disease: Is Heat Therapy a Viable Treatment?

Peripheral artery disease (PAD) is characterized by the development of atherosclerotic plaques in the lower-body conduit arteries. PAD is commonly accompanied by microvascular disease, which may result in poor wound healing, plantar ulcer development, and subsequent limb amputation. Understanding the mechanisms underlying the development of plantar ulcers is a critical step in the development of adequate treatment options for patients with PAD. Skin is classified into two major components: glabrous and non-glabrous. These skin types have unique microcirculation characteristics, making it important to differentiate between the two when investigating mechanisms for plantar ulcer development in PAD. There is evidence for a microcirculation compensatory mechanism in PAD. This is evident by the maintenance of basal microcirculation perfusion and capillary filling pressure despite a reduced pressure differential beyond an occlusion in non-critical limb ischemia PAD. The major mechanism for this compensatory system seems to be progressive vasodilation of the arterial network below an occlusion. Recently, heat therapies have emerged as novel treatment options for attenuating the progression of PAD. Heat therapies are capable of stimulating the cardiovascular system, which may lead to beneficial adaptations that may ultimately reduce fatigue during walking in PAD. Early work in this area has shown that full-body heating is capable of generating an acute cardiovascular response, similar to exercise, which has been suggested as the most efficient treatment modality and may generate adaptations with chronic exposure. Heat therapies may emerge as a conservative treatment option capable of attenuating the progression of PAD and ultimately impeding the development of plantar ulcers.

PO 18216 - Ultrasound evaluation of the tibial nerve in leprosy patients

Introduction: Brazil is the second country in the world in cases of leprosy. Early diagnosis of neural involvement is one of the most important goals of treatment. Traditionally, clinical examination is used for diagnosis; however clinical palpation has limitations that can lead to a delay of diagnosis. Ultrasonography (USG) provides objective measurements of neural thickening. The most important parameter in the USG is the cross-sectional area (CSA) of the nerve. To our knowledge, studies evaluating leprosy of the tibial nerve through the USG have not yet been performed. This work aims to analyze USG as a method of evaluation of the posterior tibial nerve in leprosy patients. Methods: This is a nonrandomized, prospective study in patients with leprosy of the tibial nerve, comparing the findings of the USG performed with clinical data for these patients. Results: Sixteen tibial nerves were evaluated in 8 patients, with a mean age of 53.4 years; the highest CSA was 24.6 mm2 with an average of 15.0 mm2, 75% had sensitivity alterations, 33.3% had anesthesia, 16.7% had loss of deep sensitivity, 25% had loss of protective sensitivity and another 25% had decreased sensitivity. Clinically, 25% of the patients had claw toe and 18.75% plantar ulcer. Discussion: USG demonstrated increased CSA of the tibial nerve in 87.5% of the cases; there was considerable variation in CSA size for patients with thickening palpation, which could represent different levels of neural involvement for the same clinical finding. We observed a greater loss of sensation in patients with higher CSA of the tibial nerve, as well as the presence of claw toe and plantar ulcer. Conclusion: USG is a suitable method for assessing neural thickening in leprosy patients. Other studies are necessary for a better correlation of CTA with clinical data and the determination of clinical conducts.

Early Foot Structural Changes After Lateral Column Exostectomy in Patients With Charcot Foot

Although exostectomy for chronic midfoot plantar ulcers in Charcot foot is apparently effective, with healing rates of nearly 75%, a subset of patients develop recurrent ulceration and show an unstable foot position, especially after undergoing exostectomy confined to the lateral column. The reasons for this failure have not been investigated. The main objective of this study was to evaluate the early changes in radiographic alignment after an exostectomy in patients with Charcot neuropathic osteoarthropathy (rocker bottom) and plantar ulcer located in the lateral column. The present study evaluated retrospectively changes in radiographic alignment after an exostectomy in 12 Charcot feet (rocker bottom) with plantar ulcer located in the lateral column. Indication for plantar exostectomy was the treatment of ulcer affected by osteomyelitis. We evaluated the early changes in the alignment of the foot on weight-bearing lateral radiographs 6 months after exostectomy. Paired sample Wilcoxon test was used to calculate the differences between preoperative and postoperative measurements. Furthermore, the relationship between revision surgery and early changes in radiographic angular measurements was determined by using the Mann-Whitney U test. After exostectomy, the inclination of the calcaneal bone decreased ( P = .003; r = 0.849) and declination of talus bone increased ( P = .041; r = 0.589). The change in calcaneal inclination was associated with revision surgery ( P = .042; r = 0.586). The present case series demonstrates that exostectomy procedure for the lateral column in patients with Charcot foot results in radiological changes in the hindfoot over the sagittal plane. The inversion of the calcaneal pitch angle suggests the possibility of further adverse events and the need for revision surgery.

Complicated plantar ulcer in diabetic patient with multiple comorbidities

Diabetic foot syndrome is characterized by an intrinsic patient fragility and involves complex medical and surgical therapeutic approach. Lesions, often chronic, have a high risk of recurrence and amputation. The patient with diabetic foot is more frequently affected by comorbidities, not only for micro-angiopathic complications of diabetes mellitus but also for the frequent presence of cardiovascular disease. We report the case of a 63-year-old diabetic patient with multiple comorbidities. Treatment with linagliptin allowed to simplify the therapy for glycemic control, switching from a injective therapy four times daily to a therapy with only basal insulin and linagliptin. This therapy has proven to be safe and suitable to maintain good glycemic control even in a fragile patient with diabetic foot and middle-severe renal insufficiency of diabetic origin (Diabetology).