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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