Diana Anghelescu DVM
Georgiana Ciochina DVM
Florin Cristian Delureanu DVM, MRCVS, OCQ(V)
February 2022
Abstract
Wounds that fail to heal through the normal healing phases in a routine timely manner are classed as chronic wounds. Factors like improper nutrition, hypovolemia, anemia, infection, excessive motion and endocrinopathies contribute to delay wound healing. The patient presented with chronic bilateral wounds over the calcaneal extremities without progression after approximately two months of conservative management consisting of local bandaging techniques. Therefore, a surgical approach was used to close both defects. In order to achieve closure of these particular lesions, a single releasing incision was utilized. After surgery the patient was hospitalized for 10 days and a “donut type” bandage was used to minimize the local trauma. The sutures were removed at 21 days after surgical intervention.
Key words: Chronic wound, “donut-type” bandage, calcaneal extremities.
Signalment and history
A six months old Sphinx cat weighing 2.1 kg was brought for a second opinion in december 2021 because of non-healing wounds at the calcaneal extremities. It was not clear the cause of these lesions but the owner noted a slowly progression of the wounds in approximately one month. At the initial veterinary practice the patient was locally treated with an antibacterial-steroid based ointment which was applied twice a day and a light bandage to cover the wounds. Afterwards, the owner was advised to improve the comfort of the home environment to prevent further trauma. There was no improvement noted after this treatment.
Clinical examination and findings
At the time of presentation, the wounds from both calcaneal extremities were quite similar in appearance. In terms of depth, a full thickness skin defect was present measuring approximately 1cm diameter. The wound from the left side presented mild moisture and small amount of slough was covering the surface while the wound from the right side was covered by a dry crust. There was no local pain and or purulent discharge and no bone exposure. A concurrent parasitic otitis was found during examination.
Treatment
Cytological examination of the lesions revealed a mild superficial bacterial infection along with an inflammatory response. The options of conservative and surgical management were discussed with the owner. Initially the owner opted for second intention healing. The bacterial infection was treated locally using chlorhexidine gluconate solution 0.02% daily for three days followed by application of medical grade Manuka gel covered by a light protective bandage. A recommendation of daily bandage changes was made for the first three days until the first recheck. An Elizabethan collar was recommended to prevent self-trauma but the owner declined. An otic swab confirmed the presence of Otodectes Cynotis and the patient received one dose of lotilaner for the parasitic infection and daily ear cleansing with clorhexidine with TRIS-EDTA for 2 weeks.
Fig.1 Left (A) and right (B) calcaneal lesions. There is no marginal reepithelialisation and the wound margins are not inflamed. The left defect present a chronic pale granulation tissue and the right lesion is covered by a dry crust.
At the first check-up the lesions were considerably larger but also the owner reported that the patient managed to remove the bandages during the night. Moderate amount of slough was present on both defects and mild moisture was present (Figure 2).
Fig.2 Left (A) and right (B) calcaneal wounds. There is an increase in size of both wounds and the wound edges present mild inflammation.
At this moment a “dounut-type” bandage with hydrogel representing the contact layer for the next ten days was recommended (Figure 3). This type of bandage was ment to prevent against any further trauma and the hydrogel to help by wound debridement and keeping a moist environment. The the bandage was changed every three days.
Fig.3 Donut Type bandage. A “donut” pad was made by rolling long strip of cotton in a circular manner and was applied over the bony proeminence. The “donut” was fixed in place with padding gauze and tape.
At the ten days recheck there was no more slough or necrotic areas over the wounds but was no improvement in terms of size or granulation tissue quality. The surgical intervention was recommended at this state and the owner accepted.
Complete blood work, including a CBC and a biochemistry panel, was done before surgery. The results were within reference levels. The patient underwent general anesthesia using dexmedetomidine (4.5mcg/kg IM) and methadone (0.18 mg/kg IM) as premedication followed by induction with propofol (6mg/kg IV) and maintenance with isoflurane and oxygen.
After wound bed preparation, the local skin assessment was performed aiming to obtain a robust and tension free closure. The assessment involved manipulation of the skin that surround the defects but also the skin from the nearby area (Figure 4). More skin was available proximal to the hock, medial and lateral compared with other areas. The options of surgical closure taken in consideration were: undermining, tension-relieving techniques in form of single releasing incision, Z-plasty, V-Y plasty and transposition flap from the lateral or medial aspect of the distal tibia. Initially undermining of the wound edges was performed and closure was attempted but there was too much tension. A single releasing incision was the option used to close these particular wounds.
Fig.4 Caudal view of the right hock. A manual manipulation of the skin that surround the wound is perform.
The following steps were used for both wounds:
Initially the fibrotic thickened wound edge was removed and undermining was performed around in a circular manner (Figure 5). A 2cm parallel incision with the wound was made approximately 2cm dorsally and 1cm medial on the medial aspect of the distal tibia (Figure 6). Undermining was performed in a cranio-caudal direction connecting the incision with the wound bed. The skin was advanced into the defect and 3/0 monofilament in a simple interrupted suture pattern was used for closure (Figure 7).
Fig 5
Fig 6
The medial donor defect was left to heal by second intention. The surgical site was covered by a “donut-type” bandage placed over the hock and a nonadherent dressing over the new defect.
After surgery the patient was hospitalized in a padded room the same “donut” bandage but polyurethane foam was used as a contact layer over the new defects and the closed wound was not covered with any dressings. The bandage was changed every 3 days. The new defects ressolved within 8 days and no complications were noted at the surgical site.
Fig.7 Medio-caudal view of the right hock. The final appearance of the wound after closure.
The cat was discharged after 10 days and was sent home with the same bandage until the suture material was removed. In day 14 and 21 the sutures were removed an Elizabethan collar was appied to prevent self-trauma at home for the next 4 days. At the last recheck both hocks presented with normal scar tissue and no local discomfort. The owner reported that after the collar was removed the cat was not interested in her previously affected areas.
Discussion
The present case report describes the conservative and surgical approach of two symmetric chronic non-healing wounds associated with the calcaneal tuberosity together with the macroscopic description of the lesions.
Fig.8 Caudal view left (A) and right (B) calcaneal extremities four days after suture removal.
The patient was presented with a history of more than four weeks of non-healing wounds at both calcaneal extremities. We treated conservatively with specific dressings and bandaging techniques for another two without improvement. Hence, a surgical intervention was recommended.
To achieve the maximum skin advancement the purposed skin incision was planned to be perpendicular to the wound. The reason why the releasing incision was performed slightly proximally to the defect and not perpendicular to it was to avoid exposure of the medial malleolus of the tibia which was sharp and was not covered by robust soft tissue. Therefore, this extremity could represent another pressure point exposed.
In order to minimise the chances of self-trauma, the patient was hospitalised in a soft padded room. The “donut” type bandage was still used for another 10 days. A follow up recheck four days post suture removal was made to make sure there are no post-operative complications. There was a normal scar tissue formed and no local discomfort present functional deficits (Figure 8).
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