Long-Term Wound Palliation to Manage Exposed Hardware in the Setting of Peripheral Arterial Disease

Abstract

Exposed orthopedic hardware in the lower extremity complicated by peripheral arterial disease typically demands multiple operative procedures by several disciplines to maintain skeletal integrity and achieve complete wound healing. For ambulatory patients that are either not candidates for lower extremity revascularization or prefer not to pursue surgical attempts at limb preservation, wound palliation is a potential management strategy. We discuss a patient with a history of severe peripheral arterial disease and a left pilon fracture previously treated with open reduction and internal fixation. He presented with a 2-month history of open wounds and exposed hardware over his left tibia. Though he initially underwent surgical revascularization to improve circulation to his lower extremity, the arterial bypass occluded within 6 months of the operation. At that point, the patient decided to forego any additional surgical intervention, including hardware removal, in favor of local wound care and expectant management. Remarkably, the wound remained stable in size over the next 14 years, he remained ambulatory, and never developed a deep wound infection. Though palliative wound care alone is understandably not the recommended first-line therapy for managing nonhealing wounds, it may be a safe and potentially durable alternative to major lower extremity amputation when revascularization and soft-tissue coverage cannot be achieved.

Fig. 1.

Appearance of the patient’s chronic nonhealing wound with exposed hardware located over the distal left tibia in 2005 (A), 2012 (B), and 2017 (C). The patient’s foot is toward the bottom of the photographs.

Fig. 2.

Initial radiograph from 2003 showing stable and intact hardware in the distal left tibia and fibula.