It has long been realized that NPWT does not make its greatest impact by bioburden reduction. Other work has demonstrated that debridement alone does not reduce wound bioburden by more than 1 Log. Wounds treated with NPWTi (in this case with quarter strength bleach instillation solution) had a statistically significant reduction in bioburden, while wounds treated with NPWT had an increase in bioburden over the 7 days.

In many series of diabetic foot ulcer care, heel ulcers greater than 4 cm across have been identified as an independent predictor of limb loss. Therefore, we set out to pursue the most aggressive limb salvage algorithm in patients with heel ulcers greater than 4 cm in diameter. Over 5 years, we identified 21 patients, 39-84 years of age, all with diabetes mellitus, with heel ulcers greater than 4 cm in diameter and had magnetic resonance imaging or bone scan evidence of osteomyelitis. Seven of the 21 patients had end-stage renal disease defined as being haemodialysis dependent. All patients had ankle brachial indices <0·4 or monophasic pulse volume recordings. All patients underwent distal bypass surgery with vein. After adequate perfusion was obtained, all patients underwent partial calcanectomy and intra-operative negative pressure wound therapy (NPWT) placement. This was followed by treatment with recombinant platelet-derived growth factor (PDGF). One patient underwent amputation during the healing process secondary to ongoing sepsis. Twenty of 21 patients healed acutely (within 6 months). Three of 20 patients went on to subsequent below knee amputation within 12 months of healing primarily. At 2 years, 12 of 21 (57%) were ambulating independently, 1 of 21 was dead, 4 of 21 had undergone amputation, 4 (19%) had limbs that were intact but were not ambulating. A total limb salvage rate of 76% at 2 years mirrored the secondary patency rates, with 100% follow up. Heel ulcers require multimodality therapy if they are going to have any chance to heal. We believe the algorithm presented allows for the required revascularisation and a modulation of the heel ulcer microenvironment by augmenting the microcirculation through NPWT, and improving the proliferative capacity with PDGF.

Patients with massive venous stasis ulcers that have very high bacterial burdens represent some of the most difficult wounds to manage. The vacuum-assisted closure (VAC) device is known to optimise wound bed preparation; however, these patients have too high a bacterial burden for simple VAC application to facilitate this function. We present the application of the VAC with instillation of dilute Dakins solution as a way of bacterial eradication in these patients. Five patients with venous stasis ulcers greater than 200 cm(2) that were colonised with greater than 10(5) bacteria were treated with the VAC instill for 10 days with 12.5% Dakins solution, instilled for 10 minutes every hour. Two patients had multi-drug-resistant pseudomonas, three with MRSA. All the five had negative quantitative cultures, prior to split thickness skin graft with 100% take and complete healing at 1 year. Adequate delivery of bactericidal agents to the infected tissue can be very difficult, especially while promoting tissue growth. By providing a single delivery system for a bactericidal agent for a short period of time followed by a growth stimulating therapy, the VAC instill provides a unique combination that appears to maximise wound bed preparation.

No abstract