Chronic Lower Extremity Wounds Research Articles

Autologous Stem Cell Therapy for Chronic Lower Extremity Wounds: A Meta-Analysis of Randomized Controlled Trials.

Lower extremity chronic wounds (LECWs) commonly occur in patients with diabetes mellitus (DM) and peripheral arterial disease (PAD). Autologous stem cell therapy (ASCT) has emerged as a promising alternative treatment for those who suffered from LECWs. The purpose of this study was to assess the effects of ASCT on LECWs. Two authors searched three core databases, and independently identified evidence according to predefined criteria. They also individually assessed the quality of the included randomized controlled trials (RCTs), and extracted data on complete healing rate, amputation rate, and outcomes regarding peripheral circulation. The extracted data were pooled using a random-effects model due to clinical heterogeneity among the included RCTs. A subgroup analysis was further performed according to etiology, source of stem cells, follow-up time, and cell markers. A total of 28 RCTs (n = 1096) were eligible for this study. The pooled results showed that patients receiving ASCT had significantly higher complete healing rates (risk ratio (RR) = 1.67, 95% confidence interval (CI) 1.28–2.19) as compared with those without ASCT. In the CD34+ subgroup, ASCT significantly led to a higher complete healing rate (RR = 2.70, 95% CI 1.50–4.86), but there was no significant difference in the CD34− subgroup. ASCT through intramuscular injection can significantly improve wound healing in patients with LECWs caused by either DM or critical limb ischemia. Lastly, CD34+ is an important cell marker for potential wound healing. However, more extensive scale and well-designed studies are necessary to explore the details of ASCT and chronic wound healing.

Evaluating Effectiveness of Medical Grade Honey-Containing Alginate Dressing in Patients with Chronic Lower Extremity Wounds

Background: Chronic wounds of the lower extremities are challenging to treat. Recently, honey-based dressings have been shown beneficial effects in diabetic foot ulcers and venous ulcers. Here, we compared Medihoney alginate with a standard alginate dressing in lower extremity chronic wounds.Methods: We performed retrospective chart reviews of 37 patients between January 2019 and January 2021 with chronic lower extremity wounds who were treated with an Algisite M dressing (group A) or a Medihoney alginate dressing (group B). Microorganisms isolated from wound cultures, weekly decrease in wound area over 4 weeks, the number of patients who achieved complete wound closure, and the amount of time required for wound closure were compared between the two groups. Results: Sixteen patients were assigned to group A and 21 to group B. The isolated microorganisms were confirmed as methicillin-susceptible Staphylococcus aureus most commonly, followed by methicillin-resistant S. aureus. Wound area decreased from 12.71 to 2.34 cm<sup>2</sup> in group A and from 14.07 to 1.71 cm<sup>2</sup> in group B (P<0.05). Seven patients achieved complete wound closure in group A (43.75%) and 15 patients in group B (71.43%). Mean duration of wound closure was 36.31 days in group A and 34.62 days in group B.Conclusion: Considering the more rapid decrease in wound area in group B, application of a honey-containing alginate dressing to lower extremity chronic wounds, especially those infected with antibiotic-resistant bacteria, was proved to be a good treatment option.

Guillotine Amputation Prior to Major Amputation Decreases Infectious Complications and Long-term Amputation Failure in Lower Extremity Chronic Wound Patients

PURPOSE: Chronic wounds of the lower extremity (LE) are often complicated by infection. Definitive treatment of wounds resistant to conservative management often entails major amputation and/or reconstruction. For severely infected chronic wounds, a guillotine amputation performed before definitive amputation can help control infection and maximize success of subsequent major amputation. A recent study demonstrated that this two-stage approach may decrease short-term complications; however long-term outcomes are yet to be evaluated.1 This study aims to assess the effect of guillotine amputation on rates of long-term success of major amputation. METHODS: A retrospective review of all major LE amputations performed between January 2017 and July 2020 at our tertiary wound center was conducted. Major amputation was performed in the setting of chronic and/or infected LE wounds that were not amenable to limb salvage. Patients who were lost to follow up or who expired during the study period, as well as patients undergoing amputation for trauma, chronic pain, a non-infected limb deformity, or cancer, were excluded. Patient characteristics, preoperative labs, and amputation data were collected. Postoperative complications assessed included rates of hematoma, dehiscence, infection, and infection requiring takeback to the operating room. Other outcomes of interest included stump revision, time to complete healing, and amputation failure, which was defined as failure to heal or need for more proximal amputation. Patients were separated into guillotine and no guillotine amputation groups. Statistical analysis was performed to compare patient characteristics and amputation outcomes between groups. Student t-test and Mann-Whitney U-test were used to analyze continuous variable while Chi-square test and Fisher exact test were used to analyze binary variables, as appropriate. RESULTS: An estimated 193 patients meeting inclusion criteria were identified: 54 did not undergo guillotine amputation; 139 underwent guillotine amputation before definitive major amputation. Demographics, comorbidities, relevant preoperative laboratories, and amputation location were not statistically different between the two groups. Rates of hematoma and dehiscence were similar between groups; however, the guillotine group had significantly decreased rates of infection (7.19% versus 22.22%, P = 0.003), infection requiring takeback to operating room (4.32% versus 20.37%, P < 0.001), stump revision (2.88% versus 10.91%, P = 0.032), and amputation failure (4.32% versus 12.73%, P = 0.035) compared with the no guillotine group. Time to healing for successful amputations (2.76 versus 2.32 months, P = 0.925) and follow-up (15.07 versus 14.33 months, P = 0.445) were similar between groups. CONCLUSIONS: The results of this study suggest that guillotine amputation prior to definitive major amputation play a significant role in limiting the spread of infection, resulting in decreased infectious complications and improved success rates following major amputation, compared with single-stage major amputations. A two-stage approach is also advantageous in decreasing the need to return to the operating room for infection or stump revision. Guillotine amputations should be considered in the setting of infected chronic lower extremity wounds to improve long-term patient outcomes. REFERENCE: 1. Cheun TJ, Jayakumar L, Sideman MJ, et al. Short-term contemporary outcomes for staged versus primary lower limb amputation in diabetic foot disease. J Vascular Surgery. 2020;72:658–666.e2. doi:10.1016/j.jvs.2019.10.083

Risk Factors for Loss to Follow-Up in the Lower Extremity Limb Salvage Population.

Limb salvage for chronic lower extremity wounds requires long-term care best delivered by specialized multidisciplinary centers. This optimizes function, reduces amputation rates, and improves mortality. These centers may be limited to urban/academic settings, making access and appropriate follow-up challenging. Therefore, the authors hypothesize that both system- and patient-related factors put this population at exceedingly high risk for loss to follow-up. Records were reviewed retrospectively for 200 new patients seen at the Georgetown Center for Wound Healing in 2013. The primary outcome was loss to follow-up, defined as three consecutive missed appointments despite explicit documentation indicating the need for return visits. Demographic, clinical, and geographic data were compared. Multivariate logistic regression analysis for loss to follow-up status controlled for variables found significant in the bivariate analysis. Spatial dependency was evaluated using variograms. Over a 6.5-year-period, 49.5 percent of patients followed were lost to follow-up. Male sex and increased driving distance to the limb salvage center were risk factors for loss to follow-up. Wound-specific characteristics including ankle and knee/thigh location were also associated with higher rates of loss to follow-up. There was no spatial dependency or discrete clustering of at-risk patients. This study is the first of its kind to investigate the demographic and clinical characteristics that predispose chronic lower extremity wound patients to loss to follow-up. These findings inform stakeholders of the high rates of loss to follow-up and support decentralized specialty care, in the form of telemedicine, satellite facilities, and/or dedicated case managers. Future work will focus on targeting vulnerable populations through focused interventions to reduce patient and system burden. Risk, III.

THE APPLICATION OF THE DISTAL POSTERIOR TIBIAL ARTERY PERFORATOR FLAPS IN CHRONICS WOUNDS

INTRODUCTION: The reconstruction of lesions in the distal third of the leg is one of the challenges for surgeons. In this scenario, the use of posterior tibial perforator flaps is being used more and more in surgical practice due to their versatility and aesthetic results. MATERIALS AND METHODS: This research consists of an integrative review carried out from a bibliographic survey in the PUBMED and Virtual Health Library (BVS) search platforms. After reading the full 20 articles in total, an overlap of four articles present in the two searches was observed, thus resulting in a total of 16 articles included in this review. RESULTS: The treatment of chronic lower limb wounds caused by infection, diabetes mellitus and osteomyelitis has always been a formidable task. Perforator-free flaps are generally recommended as the therapy of choice in the treatment of chronic lower limb wounds. DISCUSSION: The advantages of the application of the posterior tibial artery skin flap is ideal for small leg defects to reconstruct the exposed bone and tendon. As it is local tissue, it substitutes as tissue. The distal posterior tibial artery perforator flap is a beneficial technique, in the plastic and reconstructive surgery field, especially for the treatment of chronic lower extremity wounds. Keyword : CHRONIC WOUNDS, DISTAL POSTERIAL TIBIAL ARTERY, PERFORATOR FLAP, PLASTIC SURGERY

Treatment of Chronic Lower Extremity Wound Complicated by Osteomyelitis: Using Partial Biceps Femoris Muscle Flap

In many cases chronic wounds in the lower extremities are extremely difficult to heal because of inadequate blood supply, and when wounds are complicated by osteomyelitis, plastic surgeons and orthopedic surgeons must join forces to facilitate treatment. A 63-year-old man with bone exposure and a peripherally indurated chronic open wound complicated by osteomyelitis of the right distal thigh was admitted to the department of orthopedic surgery at our hospital. He was referred to our department for treatment of the right side chronic open wound. We report our successful experience with a partial biceps femoris muscle transposition flap with fasciocutaneous expanded-keystone advancement flap following wound and bone debridement for the coverage of complex wounds associated with bone infection. The results show two discrete layers of muscle. In patients with chronic osteomyelitis, fasciocutaneous flaps might provide a more effective means of covering full-depth soft tissue defects without donor site morbidity, compared to free flaps.

Long-term Results After Autologous Fat Transfer for Treatment of Chronic Lower Extremity Wounds.

Autologous fat transfer may offer a simple and effective treatment option for chronic wound patients, delivering adipose-derived stem cells, with potent regenerative attributes. Nevertheless, the clinical benefit has not yet been sufficiently demonstrated. A total of 39 wound patients were treated with autologous fat transfer (AFT) and matched with a control group, according to the identified confounding variables "gender" and "method of defect closure." All data were acquired retrospectively. Primary outcome was "wound closure" and "reduction of wound size."After a follow-up of 48 weeks, there was no significant difference in primary outcome (wound closure P = .54) between both groups. The relative wound reduction after fat transfer was 69.9% ± 42.7% compared to 53.4% ± 106.8% in the control group (P = .91). Subgroup analysis of all patients, healed by secondary intention, revealed an increased wound size reduction (P = .03) and wound closure rate (P = .20) in the case group after 12 weeks. No adverse events were recorded. Fat grafting can reduce the wound size if left to secondary healing and may be considered individually for reconstructive purposes. A repeated application of autologous fat might be beneficial due to a temporary effect.

The Role of Intermittent Pneumatic Compression in the Treatment of Lower Extremity Chronic Wounds

Intermittent pneumatic compression devices (IPC) are often used as noninvasive adjuncts in patients with lymphedema, and more recently with venous stasis disease, to promote flow and reduce the adverse effects of interstitial edema associated with both disorders. We will be focusing on lower extremity wounds associated with venous and/or lymphatic disease, the combination often referred to as “lymphophlebitic” disease, and the treatment effect of IPC on this disease process and its sequelae. The function and purpose of pneumatic compression is closely examined along with a variety of pneumatic compression devices that currently exist in the market. A thorough review of the literature was conducted to evaluate the utility of intermittent pneumatic compression in the treatment of lower extremity venous stasis ulcers. Additionally, the author describes personal experience with the use of pneumatic compression on 10 patients with venous stasis ulcers at a single center. There is significant data supporting the use of IPC in patients with lymphophlebitic disease. Overall, ideal patient selection may be crucial. Previous data has shown that patients with high body mass index (&gt;33 kg/m2) and poor functional status (walking less than 200m a day) are related to poor ulcer healing. Therefore, a study that looks primarily at this group (as our small quality assurance [QA] project did) may show increased benefit in this population. It is clear that IPC is of benefit to some patient cohorts with lymphophlebitic disease. This advanced therapy would help patients who have failure of their calf muscle pump and an inability to improve it through other means. However, it is only part of an algorithm that includes: direct wound bed management, moisture control, possible primary venous disease intervention, physical therapy, weight loss, and improved nutrition.

Use of Flap Salvage for Lower Extremity Chronic Wounds Occurs Most Often in Competitive Hospital Markets.

Background:Wounds in the comorbid population require limb salvage to prevent amputation. Extensive health economics literature demonstrates that hospital activities are influenced by level of market concentration. The impact of competition and market concentration on limb salvage remains to be determined.Methods:Admissions for chronic lower extremity wounds in nonrural hospitals were identified in the 2010–2011 National Inpatient Survey using ICD-9-CM diagnosis codes. The study cohort consisted of admitted patients receiving amputations, salvage without flap techniques (eg, skin grafts), or salvage with flap techniques. The all-service Herfindahl–Hirschman Index (HHI), which is a commonly used tool for market and antitrust analyses, was used to measure hospital competition. Multinomial regression analysis accounting for the complex survey design of the NIS was used to determine the relationship between the HHI and hospital adoption of limb salvage controlling for patient, hospital, and market factors.Results:The study cohort represents 124,836 admissions nationally: 89,880 amputations, 26,715 salvage without flap techniques, and 8241 salvage flap techniques. Diabetics accounted for 64.1% of all study admissions. Hospitals in highly competitive markets performed more flaps for chronic lower extremity wounds than noncompetitive markets. Controlling for other factors, hospitals in highly competitive markets, relative to those in highly concentrated markets, were 2.48 percentage points more likely to perform limb salvage with flaps (P < 0.01). Other factors were less predictive.Conclusion:Increased hospital competition is the strongest systems-level predictor of receipt of lower extremity flaps among patients with chronic wounds. Improving access to reconstructive limb services must consider the competitive structure of hospital markets.

Omental free flap for surgical treatment of chronic osteomyelitis of lower limb: A technical note.

Soft tissue reconstruction of chronic lower extremity wounds with bone infection entails an important challenge in reconstructive surgery. We report our experience using the omentum free flap to provide coverage in two patients suffering chronic osteomyelitis of the lower limbs. After extensive soft tissue and bone debridement, an omentum free flap was performed in both cases, providing dead space obliteration and soft tissue coverage in behalf of its large size and pliability. As a result, the chronic illness was eradicated in both patients, with satisfactory outcomes and infection resolution.

Telehealth-guided home-based maggot debridement therapy for chronic complex wounds: Peri- and post-pandemic potential.

Patients with complex chronic lower extremity wounds require a great deal of interaction with outpatient and inpatient services. Paradoxically, these are the very patients that, because of their chronic comorbidities, are at greatest risk for COVID-related morbidity and mortality. Disinfected Phaenicia (Lucilia) sericata (Medical Maggots; Monarch Labs, Irvine, California) were applied in a standardised fashion by a home-health nurse with direct monitoring, guidance, and collaboration of the attending surgeon. A family member was able to change the outer dressing daily based on normal wound exudate. The inner maggot debridement therapy (MDT) dressing was changed at 2 days showing dramatic reduction in necrotic tissue, elimination of profound malodor, and no evidence of local or advancing infection. The entire initial telehealth-guided application took approximately 20 minutes. The first telehealth-guided MDT dressing change took 14 minutes. We used an artificial-intelligence-based algorithm to measure changes in wound characteristics. At day 0, 46% of the total surface area was covered in malodorous black, necrotic tissue. The first dressing change saw an elimination in assessed malodor with necrotic tissue constituting 14% of total surface area. The second dressing change at 5 days showed a greater than 99% reduction in necrotic tissue. This manuscript constitutes what we believe to be the first telehealth-guided MDT conducted during a resource-limited peri-pandemic period. We believe that MDT, which is an extension of efforts regularly performed in clinic and hospital, may have the potential to reduce resource usage while potentially improving care and quality of life for people with limb and life-threatening complications of diabetes and other chronic diseases.

A possible role for inducible arginase isoform (AI) in the pathogenesis of chronic venous leg ulcer.

Chronic venous ulcer (CVU) is a major cause of chronic wounds of lower extremities and presents a significant financial and resource burden to health care systems worldwide. Defects in the vasculature, matrix deposition, and re-epithelialization are the main histopathological changes believed to impede healing. Supplementation of the amino acid arginine that plays a crucial role in the interactions that occur during inflammation and wound healing was proven clinically to improve acute wound healing probably through enhancing activity of inducible arginase (AI) locally in the wounds. However, the possible mechanism of arginine action and the potential beneficial effects of AI/arginine in human chronic wounds remain unclear. In the present study, using biopsies, taken under local anesthesia, from adult patients (n = 12, mean age 55 years old) with CVUs in lower extremities, we investigated the correlation between AI distribution in CVUs and the histopathological changes, mainly proliferative and vascular changes. Our results show a distinct spatial distribution of AI along the ulcer in the epidermis and in the dermis with the highest level of expression being at the ulcer edge and the least expression towards the ulcer base. The AI cellular immunoreactivity, enzymatic activity, and protein levels were significantly increased towards the ulcer edge. Interestingly, a similar pattern of expression was encountered in the proliferative and the vascular changes with strong correlations between AI and the proliferative activity and vascular changes. Furthermore, AI cellular distribution was associated with increased proliferative activity, inflammation, and vascular changes. Our findings of differential expression of AI along the CVU base, edge, and nearby surrounding skin and its associations with increased proliferative activity and vascular changes provide further support to the AI implication in CVU pathogenesis. The presence of high levels of AI in the epidermis of chronic wounds may serve as a molecular marker of impaired healing and may provide future targets for therapeutic intervention.

Use of the Keystone Perforator Island Flap in the treatment of chronic lower extremity wounds complicated by osteomyelitis

IntroductionReconstruction of chronic lower extremity wounds can be especially challenging when these wounds are complicated by osteomyelitis. They require the joint expertise of plastic and orthopaedic surgeons. MethodsWe report our experience using the Keystone Perforator Island Flap following wound and bone debridement as a valuable surgical tool for coverage of complex wounds with bone infection. ResultsTwelve patients underwent similar procedures with overall good outcomes, although two patients experienced a complication, specifically partial flap necrosis and wound dehiscence subsequent to recurrent osteomyelitis. We also reviewed the underlying physiological mechanisms of employing the Keystone flap in order to demonstrate its advantages and efficacy. ConclusionOur results confirm that the Keystone flap can be a safe, reliable and effective method for coverage of soft tissue defects and the preservation of bone integrity in the management of patients with chronic osteomyelitis.

152. Stem cell therapy for pressure injury: a pilot study with autologous bone marrow derived stem cell (BM-MNC)

BACKGROUND CONTEXT Pressure injuries (PIs) are a common yet challenging problem especially in people with spinal cord injury (SCI) because of immobility and anesthetic skin. They are difficult to treat with standard medical care and often recur. Recent interest in the treatment of chronic wounds like PIs has shifted from the type of dressing with or without pharmaceutical topical agents to different therapies like negative pressure wound therapy (NPWT), gene therapy and stem cell based therapies. The rationale behind the use of cell-based therapies is the fact that cells in chronic wounds are phenotypically altered or senescent or both. Therefore, they have a limited capacity to divide and are less responsive to stimulation by growth factors. Promising results have been reported in the treatment of small series of mainly chronic lower-extremity wounds with bone marrow-derived stem cells (BM-MNC). PURPOSE The purpose of this pilot study was to obtain the preliminary data on the use of autologous bone marrow derived mononuclear cells (BM-MNCs) to treat PIs in terms of clinical outcome and procedure safety. STUDY DESIGN/SETTING Pilot study. PATIENT SAMPLE We enrolled individuals with SCIs aged 16 to 60 years with stage 3-4 PIs. Ten Spinal cord injury (SCI) cases were recruited; five cases received autologous bone marrow derived mononuclear cells (BM-MNCs) therapy and five standard wound care. OUTCOME MEASURES Surface area and depth of PI, exudate volume and formation of granulation tissue. METHODS About 3 hours before cell therapy, autologous bone marrow (BM) (100 ml) was obtained from the posterior iliac crest aspiration. Mononuclear cells (MNCs) were separated from bone marrow using plasma expresser. The BM-MNCs suspension was injected into the wound bed by 1 ml syringe. For injection, the wound was subdivided with a grid into small areas of 1 cm2. Infusion was performed into the wound bed as well as subdermally at the borders of the wound. Wound dressings during the entire study period were performed with moist gauzes twice a day and followed up to 9 weeks. RESULTS Physical wound healing outcomes were compared at weeks 3, 6, and 9. Significantly reduced surface area of PI in the BM-MNC treated group was observed at week 6 (p=0.04) and at week 9 (p=0.001) as compared to the standard wound care group. Similarly, significant reduction of depth was observed in the BM-MNC group at week 9 (p CONCLUSIONS The procedure of BM-MNC therapy was safe and well tolerated by the subjects. The efficacy can be better assessed with a larger sample size. But in this study, the results were highly satisfactory. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Metabolites of the Nitric Oxide (NO) Pathway Are Altered and Indicative of Reduced NO and Arginine Bioavailability in Patients with Cardiometabolic Diseases Complicated with Chronic Wounds of Lower Extremities: Targeted Metabolomics Approach (LC-MS/MS).

Objective The status of metabolites of the nitric oxide (NO) pathway in patients with chronic wounds in the course of cardiometabolic diseases is largely unknown. Yet arginine supplementation and citrulline supplementation as novel therapeutic modalities aimed at increasing NO are tested. Material and Methods Targeted metabolomics approach (LC-MS/MS) was applied to determine the concentrations of L-arginine, L-citrulline, asymmetric and symmetric dimethylarginines (ADMA and SDMA), and arginine/ADMA and arginine/SDMA ratios as surrogate markers of NO and arginine availability in ulnar and femoral veins, representing systemic and local levels of metabolites, in patients with chronic wounds in the course of cardiometabolic diseases (n = 59) as compared to patients without chronic wounds but with similar cardiometabolic burden (n = 55) and healthy individuals (n = 88). Results Patients with chronic wounds had significantly lower systemic L-citrulline and higher ADMA and SDMA concentrations and lower L-arginine/ADMA and L-arginine/SDMA as compared to healthy controls. The presence of chronic wounds in patients with cardiometabolic diseases was associated with decreased L-arginine but with increased L-citrulline, ADMA, and SDMA concentrations and decreased L-arginine/ADMA and L-arginine/SDMA. Serum obtained from the ulnar and femoral veins of patients with chronic wounds differed by L-arginine concentrations and L-arginine/SDMA ratio, both lower in the femoral vein. Wound etiology affected L-citrulline and SDMA concentrations, lower and higher, respectively, in patients with venous stasis, and the L-arginine/SDMA ratio—lower in venous stasis. The wound type affected L-arginine/ADMA and citrulline—lower in patients with ulcerations or gangrene. IL-6 was an independent predictor of L-arginine/ADMA, VEGF-A of ADMA, G-CSF of L-arginine/SDMA, and GM-CSF of L-citrulline and SDMA. Conclusion Chronic wounds in the course of cardiometabolic diseases are associated with reduced NO and arginine availability due to ADMA and SDMA accumulation rather than arginine deficiency, not supporting its supplementation. Wound character seems to affect NO bioavailability and wound etiology—arginine bioavailability. Arginine concentration and its availability are more markedly reduced at the local level than the systemic level.

Discussion: The Utility of Preoperative Arteriography for Free Flap Planning in Patients with Chronic Lower Extremity Wounds.

Discussion: The Utility of Preoperative Arteriography for Free Flap Planning in Patients with Chronic Lower Extremity Wounds.

Outcomes of Split Thickness Skin Grafting on Lower Extremity Wounds in Diabetics

Background: Split thickness skin grafting is a widely used surgical technique for wound coverage. Despite the popularity of this procedure, outcomes data has been poorly reported. Methods: Under IRB approval we reviewed the records of all patients receiving split thickness skin grafting for lower extremity wounds from 2014 to 2016. We have defined success as wound healing of ≥99.5%. Results: 180 diabetic patients were included in this study. 103 (95%) had hypertension, 75 (69%) had hyperlipidemia, 29 (27%) had congestive heart failure, and 22 (20%) had venous stasis. Complete epithelialization was obtained for 29 (22%) patients at 30d, 48 (36%) patients at 60d, 63 (48%) patients at 90d, and 77 (58%) patients at 365d of follow-up. At last available follow-up 79 (60%) wounds obtained complete healing (≥99.5% coverage). Venous stasis led to inadequate healing at 30d (p&amp;lt;0.0371), 90d (p&amp;lt;0.0006), and 365d (p&amp;lt;0.0005) and trended toward significance at 60d (p&amp;lt;0.0809). Congestive heart failure led to inadequate healing at 60d (p&amp;lt;0.0334), and 90d (p&amp;lt;0.0015). The presence of bacteria on wound bed cultures did not show a significant effect on wound healing. The most common bacteria were coagulase negative Staphylococcus, MRSA, and Enterococcus faecalis. Only enterococcus faecalis showed significance at 30d if present following the initial debridement. Conclusion: The data suggests that split thickness skin grafting can be a successful coverage technique for diabetic patients with chronic lower extremity wounds. The bacterial milieu of chronic wounds in diabetics is diverse but with excisional debridement these bacteria have little impact on wound healing after split-thickness skin grafting. However, comorbidities (i.e., congestive heart failure and venous stasis) can significantly impact the healing of skin grafts and should be taken into consideration when contemplating split thickness skin grafting in a diabetic patient. Disclosure E. Walters: None. G. Stimac: None. N. Rajpal: None. I. Naz: None. T. Elmarsafi: None. J. Steinberg: Consultant; Self; Acelity, Integra LifeSciences. K. Evans: None. C. Attinger: Consultant; Self; Acelity, Integra LifeSciences. P. Kim: Consultant; Self; Acelity, Integra LifeSciences.

Peroneal artery perforator flap for the treatment of chronic lower extremity wounds

BackgroundReconstruction of chronic lower extremity wounds remains challenging. These wounds are mainly associated with diabetes mellitus, infections, and osteomyelitis. Although several reconstructive techniques are available, the peroneal artery perforator flap has unique advantages.MethodsIn this study, we discuss our experiences with peroneal artery perforator flaps in 55 patients who had suffered from chronic lower limb wounds. The size of the defect, comorbidities, etiology, flap size, and complications were recorded and analyzed based on a retrospective chart review.ResultsAll 55 flaps survived. In two cases, small superficial necrosis occurred, one of which healed with conservative treatment and the other was reconstructed with split thickness skin grafts. Partial necrosis was observed in nine cases, seven of which were covered with split thickness skin grafts and the remaining two sutured directly after adequate debridement. Vascular compromise was observed in one patient, which was salvaged successfully by performing an exploratory procedure and releasing a few sutures. No complications were seen in the remaining 44 cases.ConclusionThe peroneal artery perforator flap is a reliable option for reconstruction of chronic lower extremity wounds.

Chronic lower extremity wound infection due to Kerstersia gyiorum in a patient with Buerger\u2019s disease: a case report

BackgroundKerstersia gyiorum is an extremely rare pathogen of human infection. It can cause chronic infection in patients with underlying conditions. It can easily be misdiagnosed if proper diagnostic methods are not used.Case presentationA 47-year-old male patient with a history of Buerger’s Disease for 28 years presented to our hospital with an infected chronic wound on foot. The wound was debrided, and the specimen was sent to Microbiology laboratory. Gram staining of the specimen showed abundant polymorphonuclear leukocytes and gram-negative bacilli. Four types of colonies were isolated on blood agar. These were identified as Kerstersia gyiorum, Proteus vulgaris, Enterobacter cloacae, Morganella morganii by Maldi Biotyper (Bruker Daltonics, Germany). The identification of K. gyiorum was confirmed by 16S ribosomal RNA gene sequencing. The patient was successfully recovered with antimicrobial therapy, surgical debridement, and skin grafting.ConclusionsThis is the first case of wound infection due to K. gyiorum in a patient with Buerger’s Disease. We made a brief review of K. gyiorum cases up to date. Also, this case is presented to draw attention to the use of new and advanced methods like MALDI-TOF MS and 16S rRNA gene sequencing for identification of rarely isolated species from clinical specimens of patients with chronic infections and with chronic underlying conditions.

Multidrug-Resistant Microorganisms Colonizing Lower Extremity Wounds in Patients in a Tertiary Care Hospital, Lima, Peru.

Multidrug-resistant organism (MDRO) infections cause high morbidity and mortality, and high costs to patients and hospitals. The study aims were to determine the frequency of MDRO colonization and associated factors in patients with lower-extremity wounds with colonization. A cross-sectional study was designed during November 2015 to July 2016 in a tertiary care hospital in Lima, Peru. A wound swab was obtained for culture and susceptibility testing. MDRO colonization was defined if the culture grew with methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci, and/or extended spectrum beta-lactamase (ESBL) microorganisms. The frequency of MDRO wound colonization was 26.8% among the 97 patients enrolled. The most frequent MDRO obtained was ESBL-producing Escherichia coli, which was significantly more frequent in chronic wounds versus acute wounds (17.2% versus 0%, P < 0.05). Infection control measures should be implemented when patients with chronic lower-extremity wounds are admitted.