CASE STUDY #1

DEHISCED STERNAL MUSCLE FLAP, DEHISCED LEG, ABDOMINAL WOUND

The Patient•55 years old

•Female•Married

•5 children•22 grandchildren

•Non-smoker

CO-MORBIDITIES• Diabetic

• Hypertension• Coronary Artery Disease

• Hyperlipidemia• Probable Sleep Apnea

• Obesity

Treatment CourseBypass Surgery

10/01Dismissed from hospital

10/04Sternal Wound and Donor Site Infection- Readmitted

10/28Incision and debridement of leg and sternum - sternum removal

11/06Closure of chest with muscle flap

Debridement of leg wound11/14

Transferred to NHS Clarkson Hospital12/05

Hyperbaric Oxygen Treatments Initiated12/06

Debridement of Sternal/chest/leg wounds - VAC Therapy Initiated12/12

Treatment CourseDebridement of sternal and leg wounds - abdominal

wound 01/13

STSG to sternal and leg wounds with VAC therapy1/20

Transferred from acute care to sub-acute rehab unit02/05

TRANSFERRED TO NHS12/05

Sternal muscle flap and donor site are openLower leg is dehisced and infected

legsternum

rectus

STERNAL, RECTUS AND LEG WOUNDS IMPROVE QUICKLY

12/12Use of HBO and VAC therapy along with Multi-

disciplinary approach

leg

sternum

rectus

STERNUM AND LEG GRANULATEABDOMINAL WOUND DEBRIDED

01/13Abdominal wound measures 15x10x4cm

leg

abdomen

rectus

sternum

SKIN GRAFT TO STERNUM AND LEG1/20

VAC therapy replaced post skin graft for 5 days

leg

sternum

abdomen

COMPLETE TAKE ON SKIN GRAFTS TO LEG AND STERNUM

1/26At first dressing change grafts have 100% take

legsternum

ABDOMEN CONTINUES TO HEAL2/5

Patient is transferred to Sub-acute rehab floor

abdomen

INTERDISCIPLINARY PLAN OF CARE

• Plastic Surgery• General Surgery

• Infectious Disease• Cardiology

• Pulmonary Medicine• Endocrinology

• Nutrition• Nursing

• Physical and Occupational Therapy

STERNUMPHOTOGRAPHIC REVIEW

1 32

4 5

RECTUSPHOTOGRAPHIC REVIEW

1 2

3 4

LEGPHOTOGRAPHIC REVIEW

1 2

3 4

5

ABDOMENPHOTOGRAPHIC REVIEW

1 2

3

CASE STUDY #2

SHOULDER WOUNDOSTEOMYLITIS

REMOVAL OF HARDWARE

THE PATINET• 39 Years Old

• Male• 2 Children

• Non-Smoker• In Nebraska visiting family

CO-MORBIDITIES• Healthy Young Man• No co-morbidities

• Wound occurred when dirt biking

Treatment CourseAccident occurred

Closed, grossly displaced clavicle fracture11/10

Presented at ER11/15

Surgical reduction/fixation with plate and 6 screws11/24

Released from hospital without any problems11/25

Presented with signs and symptoms of infection11/29

Staph cultured – plate and screws noted to be dislodgedIV antibiotics initiated

12/01Plate and screws surgically removed

Systemic reaction to Nafcillin and oral dicloxacillin12/12

Released to home12/20

Treatment CourseReadmitted for further evaluation of non-healing wound

1/23Surgical resection of mid third of clavicle with debridement of

soft tissue infectionInfectious disease consulted

1/30Plastics called in – V.A.C. placed

2/2Released with home care and V.A.C.

2/7Clinic follow-up – V.A.C. discontinued-alginate initiated

2/14IV antibiotics discontinued

2/21Released from care-healed

2/28

Resection of Clavicle with debridementVAC placed

2/02

First VAC dressing change2/05

ABDOMEN

Released to home with Home Care2/07

V.A.C. therapyIV antibiotics

ABDOMEN

First Clinic Follow Up2/14

V.A.C. discontinuedAlginate dressing applied

ABDOMEN

Clinic Follow up2/21

IV antibiotics discontinued

Wound is closed 2/28

Hypergranulation area in centerRemoved with silver nitrate stick

ABDOMEN

INTERDISCIPLINARY PLAN OF CARE

• Plastic Surgery• Orthopedic Surgery • Infectious Disease

• Nutrition• Nursing

• Home healthcare

CLAVICLEPHOTOGRAPHIC REVIEW

1 2 3

4 5 6

CASE STUDY #3

Perineal cystNecrotizing Component

Radical Surgical Debridement

THE PATINET• 51 years old

• Female• Single

• Smoker

CO-MORBIDITIES• Diabetic

• Hypertension• Hyperlipidemia

• Probable Sleep Apnea• Obesity

Treatment CoursePresented to Emergency Room with Perineal Cyst Infection

Adult Onset Diabetes Mellitus DiagnosisMassive Infection with necrotizing features

Emergency Surgery for debridement1/16

Infectious Disease Consult1/18

Plastic Surgery ConsultV.A.C. Placement

1/24Sub Acute Care Transfer

1/28Released to Home

2/28Healed4/21

1/24Vac placed

18cm – length7cm – width

5cm tunnel @ 4:005cm tunnel @ 9:00

1/2618cm length5cm width

1cm undermining0 tunnels

2/1412cm length5cm width

2/19

10cm length4cm width

Released to Home2/28

9cm length4cm width

Clinic Follow-up3/07

6cm length4cm width

Clinic Follow-up3/14

6cm length3cm width

V.A.C. discontinuedNormal Saline Moist dressings

Clinic Follow-Up03/21

6cm length3cm width

Clinic Follow-Up03/28

5cm length3cm width

Clinic Follow-Up4/05

2.5cm length2cm width

Clinic Follow-Up4/13

2cm length2cm width

4/21Healed

Released from care

INTERDISCIPLINARY PLAN OF CARE• Plastic Surgery

• General Surgery • Infectious Disease

• Endocrinology• Nutrition• Nursing

• Home health care

Photographic ReviewGroin/peri-rectal

1 2 34

5 6 78

9 10 1112

CASE STUDY #4

Perirectal AbscessNecrotizing Component

Radical Debridement

The Patient

•62 year old•Female•Widow

•2 Children

CO-MORBIDITIESAdult Onset Diabetes Mellitus

• Hypertension• Hyperlipidemia

• Status Post hysterectomy related to cervical cancer with abdominal

radiationtherapy

• Obesity• Nutritional Deficit

Treatment CourseSurgical debridement of necrotizing rectal-perineal abscess

Performed at rural hospital3/24

Further surgical debridement and diverting colostomy performed at rural hospital

3/25Transferred to NHS Clarkson for Interdisciplinary care

Infectious Disease Consult3/26

Hyperbaric Oxygen Treatments StartedHyperalimentation for Nutrition

3/26Plastics ConsultedMany organisms

¼ strength Betadine packs q8hours3/30

Treatment CourseAcute Renal Failure

AtelectasisBronchoscopy with Removal of Large Mucous Plug

4/5Transferred from Intensive Care Unit to Floor

Tube feeding initiated4/10

V.A.C. Placed4/13

Respiratory ArrestVentilator Placement

4/21Removed from Ventilator

4/23Retention Sutures Placed in Wound

4/25Patient Requested “No Code Status

Last Dressing Change4/27

Respiratory and Cardiac Arrest5/1

4/13Status Post Radical Debridement

V.A.C. Placed

4/16First V.A.C. dressing Change

4/18NG tube feeding

Hyperbaric Oxygen Treatments

4/23V.A.C. continues

I.V. Antibiotics – Hyperbaric Oxygen Treatments

4/25Retention Sutures placed to

encourage adhesion of skin flapsV.A.C. continues

4/27Multiple setbacks

Renal Failure

INTERDISCIPLINARY PLAN OF CARE• Plastic Surgery• General Surgery

• Infectious Disease• Pulmonology• Endocrinology

• Oncology• Nutrition• Nursing

• Social Services• Physical Therapy

• Occupational Therapy

Peri-rectalPhotographic Review

1 23

4 5 6

7

CASE STUDY #5

Diabetic Foot WoundRadical DebridementPartial Bone Removal

The Patient77 Year Old Woman

Married3 Children

9 Grandchildren3 Great Grandchildren

CO-MORBIDITIESBreast Cancer

Ongoing ChemotherapyPeripheral Neuropathy

CADCABG

Treatment CourseAdmission related to acute infection left foot

9/20Infectious Disease Consultation

Orthopedic Consultation9/21

Surgical Debridement of left foot9/24

Surgical Debridement of left foot9/28

Plastic Surgery Consultation10/1

V.A.C. Placed 10/3

Prior to first V.A.C. dressing change

First Metatarsal debridement for osteo – bone exposed

Measures5cm Length2.5cm Width4cm Depth

First V.A.C. Dressing Change

I.V. antibiotic continue

Hyperbaric Oxygen continues

Measures3.5cm Length1.2cm Width2cm Depth

Last V.A.C. Dressing Change

Patient dismissed to home with alginate dressing changes qod

Measures2cm Length0.9cm Width

<0.2cm Depth

INTERDISCIPLINARY PLAN OF CARE

Plastic Surgery• Orthopedic Surgery• Infectious Disease

• Pulmonary Medicine• Endocrinology

• Nutrition• Nursing

• Pedorthics• Physical and Occupational Therapy

Photographic Review

Foot

1 2 3