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. 2020 Oct;17(5):1496-1507.
doi: 10.1111/iwj.13428. Epub 2020 Jun 22.

Limb salvage procedure in immunocompromised patients with therapy-resistant leg ulcers-The value of ultra-radical debridement and instillation negative-pressure wound therapy

Alexander Geierlehner  1 , Raymund E Horch  1 , Wibke Müller-Seubert  1 , Andreas Arkudas  1 , Ingo Ludolph  1
Affiliations

Limb salvage procedure in immunocompromised patients with therapy-resistant leg ulcers-The value of ultra-radical debridement and instillation negative-pressure wound therapy

Alexander Geierlehner et al. Int Wound J. 2020 Oct.

Abstract

The purpose of this study was to analyse the outcome of our established triple treatment strategy in therapy-resistant deep-thickness chronic lower leg ulcers. This limb salvage approach consists of ultra-radical surgical debridement, negative-pressure wound therapy (NPWT) with or without instillation, and split-thickness skin grafting. Between March 2003 and December 2019, a total of 16 patients and 24 severe cases of lower leg ulcers were eligible for inclusion in this highly selective population. A total of seven patients received immunosuppressive medication. Complete wound closure was achieved in 25% and almost 90% of included lower leg ulcer cases after 3 and 24 months of our triple treatment strategy, respectively. The overall limb salvage rate was 100%. Bacterial colonisation of these wounds was significantly reduced after multiple surgical debridements and NPWT. Fasciotomy and radical removal of devitalised tissue such as deep fascia, tendons, and muscles combined with NPWT showed promising results in terms of the overall graft take rate. This treatment strategy was considered as last resort for limb salvage in such a critically ill and immunocompromised patient population. Surgeons should be aware of its efficacy and consider the triple treatment strategy especially if no other limb salvage option remains.

Keywords: chronic leg ulcer; negative-pressure wound therapy; skin transplantation; ultra-radical debridement.

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Conflict of interest statement

R. E. H. has received third party funding for scientific research on NPWT from KCI—an Acelity company in the past and has served as a member of a Scientific Advisory Board of KCI‐Acelity in the past. R. E. H. and A. A. served as speakers on scientific symposia of KCI‐Acelity in the past. The authors have no other relevant affiliations or financial involvement with any organisation or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Figures

FIGURE 1
FIGURE 1
Wound duration of included chronic lower leg ulcers
FIGURE 2
FIGURE 2
Wound healing outcome of chronic leg ulcers in percentage. Category A: completely healed ulcers; Category B: wound control (75%‐99% wound closure); Category C: failed wound closure
FIGURE 3
FIGURE 3
Kaplan‐Meier estimate of time to complete wound healing
FIGURE 4
FIGURE 4
Wound swabs. Average number of different bacteria (NDB) at the time of the first and last wound swabs. Average amount of bacteria (AB) in chronic lower leg ulcers at the time of the first and last wound swab (summation of bacteria load 1 , 2 , 3 , 4 of different bacteria) (* indicates significant difference.)
FIGURE 5
FIGURE 5
A, Chronic, therapy‐resistant circumferential lower leg ulcer of a 47‐year‐old immunocompromised patient. B, Wound at the lower leg after ultra‐radical debridement and negative pressure wound therapy. C, Split‐thickness skin grafting (STSG) of the lower leg defect. D, Wound healing outcome 3 months after STSG
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