by W. Randall Russell MD, FACS Medical Director Lankenau Hospital Wound Healing Center

Often times a complicated lower extremity wound requires a well thought out and comprehensive treatment plan to achieve a satisfactory outcome.   Advanced wound care often requires a multi-specialty approach involving the expertise of plastic & reconstructive surgeons, podiatrists, vascular surgeons and infectious disease consultants.  Coordination of services, careful planning and the use of available technologies often results in satisfactory outcomes with maintained function status.

D. M. is a 71 year old male, who for the past three decades, has struggled to preserve his severely injured left lower extremity.  At age forty, he was involved in a serous motor vehicle accident that left him with a tri-malleolar fracture of the left ankle.

He underwent open-reduction and internal fixation (ORIF) and eventually had the hardware removed. Despite the excellent surgical result noted above, he has suffered significantly with decreased range of motion, and often times severe pain, which has restricted his physical activity. Within a few years of his injury he started to note moderate edema in his left leg. Instinctively, he knew to elevate his leg when possible. However, the edema continued to progress and he started developing trophic skin changes, later recognized as secondary lymphedema. 

He sought the advice of his primary care physician, who referred him to a vascular medicine specialist. The daily use of knee-high compression stockings, 30-40mmHg, was recommended and the patient was compliant in adhering to this regimen. However, the edema continued to worsen and eventually he developed a stasis ulceration over his lateral malleolus, corresponding to where his ORIF incision was made years ago.

Appearance at Presentation

Week #1

Appearance at beginning of sclerotherapy

At this point, the patient presented to the Lankenau Hospital Wound Center and entered our lymphedema program. An immediate venous doppler ultrasound was obtained, and ruled out deep vein thrombosis. The doppler exam also evaluated the superficial veins (lesser and greater saphenous) for insufficiency and location of communicating perforator veins. Additionally, the peri-ulcer region was examined to identify any enlarged perforators that might be leading into the ulcer bed. The doppler study concluded that significant reflux was present in both superficial systems, and at least one large perforator vein was feeding into the lateral malleolar stasis ulcer.

Aggressive treatment started with Unna Boot applications twice weekly. The patient met the required criteria for intermittent pneumatic compression therapy. Medical Solution Supplier (medsolsupplier.com) handled the pre-insurance authorization for a 4-chamber pump with thigh high leg garments. The patient initiated intermittent pneumatic compression therapy within one week and was compliant in applying the device three times daily, for 60 minute sessions, at 50mmHg.  Rapid fluid off loading of the extremity was noted within a few days, allowing planned endovenous laser ablation of the saphenous veins using VenaCure EVLT. One week later, the large peri-ulcer perforator was ablated using ultrasound-guided foam sclerotherapy.  Rapid healing of the stasis ulcer was noted, along with improvement in leg volume, and overall appearance of the extremities.

Week 2	Week 4

Week 7

The use of a multi-modality approach, including ultrasonography, aggressive topical wound care combined with compression dressings, endovenous laser ablation, and intermittent pneumatic compression resulted in prompt and steady resolution of the ulcerations within 7 weeks. The concurrent use of several modalities can yield improved outcomes as compared to the same treatment modalities used separately. Intermittent pneumatic compression therapy accentuates and compliments the off loading effects of leg elevation and compression garments combined.

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