Chronic plantar wound

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Would love some input into a patient of mine who I began to visit in an aged care facility with a chronic plantar wound. I realise he has plenty of co-morbidities working against him, however would like to think there maybe something I could try to get this thing resolved. I have come into the scene after the wound had already been present for 9+ months. I have now seen this fellow for 5 months with improvement, however very very slow improvement.

Patient:
male 78 years
cva 10 years ago, resulting in left side partial paralysis and moderate dysphagia.
Niddm 10+ years
Doppler - monophasic waveform
smoker 20 years (ceased 10 years ago)
chronic wound plantar 1st MTP joint right foot 10mm x 10mm. 0.3mm depth. Large amount of surrounding callous. Pinkish base, nil exudate or odour.

As I stated I realise I'm not treating an elite athlete here, so health is working against us. It is evident the wound started on his fully functioning foot as he compinsated for his weak left leg. When we first met the nurses had been persisting with solugel and melolin (sigh) despite not getting anywhere.

In the few months I have been looking after this gentlemans feet I routinely reduce the callous, have padded his footwear to offload the area (not a big concern now as he only walks about 15 steps a day with his increasing immobility), use iodosorb 3rd daily and arginaid bd. Bsl's have been very steady.

Since the change in treatment it is cerainly improved,but improvement is slow.

As someone who has tended to focus my career on biomech etc I'm hoping to further my knowledge in this area so would be much appreciative to gain some ideas from others.

 

Mr T,

You need to fully assess the peripheral blood flow. Try to arrange a Duplex Scan, because if there is very limited blood flow, the wound will never heal, despite your best efforts. You also need to assess how he is moving about the bed, and even though only 15 steps, on a vascularly comprimised foot, can undo any healing that may have occured. Think of the shear stresses rather than the direct pressure. Also, remember that it is not recomended to use iodosorb for more than 3 months, and it does have a mild cytotoxic effect, so if low exudate and no infection, I would move to a different dressing regieme, such as just a plain foam.

 

Hi there, here my two penneth worth, hope it helps

Biomech imo is still relevant - think hallux limitus (pain in the same area) how would you reduce the pain in that area fundamentals are similar if not the same.
Hope that helps

B
X

 

Thank you both for your interest. I must apologise, in order to be as concise as possible I may have left a little bit out...

I have been bothering GP regarding vascular studies, which have only just been completed (gp's tend not to be too interested when it comes to aged care....). I have not seen results as yet however have been told by nurse in charge there was significantly compromised supply in both legs (no surprises) however no surgical intervention will be utilized at this stage.

In my original post I did not clarify the biomechanical aspects to the issue, you are both spot on how important plantar pressures and shear stresses are, however within his extra depth footwear, a winged plantar pad (ie offloading 1st MTP joint) has been utilized. I have also removed the insole if the shoe in the area to ensure there is no pressure.

Tuckersm, thanks for the advice re iodosorb, when you mention using a plain foam, is there a particular product you find successful??

Toughspiders, I can only assume the heavy callous may be related to years of pressure and callous in this area with a long history of smoking as I feel the area is pressure free.

Appears it may be simply, as I suspected, too severely compromised circulation.... Frustrating.

 

Large amount of surrounding callous. Pinkish base, nil exudate or odour.


In the few months I have been looking after this gentlemans feet I routinely reduce the callous

Im sorry Mr T, i assumed from your comments that the wound was still producing callus.Ischaemic wound do not produce infection if they cannot heal they cannot grow skin. This and the nil presence infection is why i thought it wasnt very ischaemic.

Its good that you have expressed your concerns to the GP. It is then in his hands and should anything come of it later you have done what is right. I know of someone who didnt do this and later got procedings against them. Not by him..a family friend after his death. So good you have aired your concerns.

Ischaemic wounds can heal..i have aided in healing quite a few, they take a long time 18 month ++. It just depends on the level of ischaemia (below 0.5 and you have a battle) and great pressure relief and compliance - difficult in nursing homes i know.

Foams - usually are used for absorbing excess exudate, such as allevyn and lyofoam, i do know some use for their therapeutic properties. If it is critically ischaemic id be more worried anaerobic infection.

Good luck