Diabetic Wound Case Report – Ms. M.D.
Ms. M.D. is a 49-year old owner of a dry cleaning facility who suffers from diabetes, hypertension, and obesity. As a result of her unhealthy body weight, poor glucose control, combined with the requirement for prolonged periods of standing to oversee her business, Ms. M.D. had suffered from diabetic wounds in the distal aspect of her lower extremities bilaterally for the past 13 years. Furthermore, due to her impaired circulation, reduced sensation to pain, and the previously described constant stresses imparted to her feet throughout the day, the wounds continued to deepen and enlarge overtime despite attempts at mitigating their progress. At the advice of her treating physician, she was diligent at keeping the wounds properly cleaned and dressed. However, managing her blood glucose levels remained an ongoing struggle. Unfortunately, the wound in the right foot developed an uncontrolled infection and Ms. M.D. was required to undergo a below-the-knee (transtibial) amputation in 2012.
Following surgery, Ms. M.D.’s right knee was placed in a temporary splint to provide stability, avoid stretching of the incision, and allow for an ideal fit with a prosthetic limb. A great deal of care and caution was required to manage the stump over a period of two weeks prior to meeting with the prosthetist. After being fitted, Ms. M.D. then underwent a grueling and extensive post-surgical rehabilitation program to learn how to walk with the artificial limb. The physical toll that Ms. M.D experienced during this period was overwhelming and far exceeded her expectations. She was required to attempt ambulation as early as possible to accelerate shrinkage of the stump and to avoid the possibility of a flexion contracture. Psychological counselling sessions were also required as a result of the emotional component associated with losing a limb.
Ms. M.D. was eventually able to ambulate in roughly the same capacity that she did prior to amputation. However, it is estimated that walking with the prosthesis requires a 20% increase in energy expenditure due to the biomechanical alterations. The stump required constant care and inspection to verify there were no emerging breaks in the skin. Her blood glucose levels needed to be monitored with greater care to ensure there is maintained blood flow to the lower extremities. In addition to the pain associated with her surgery and rehabilitation, Ms. M.D. reported that she experienced a common but unpleasant phenomenon termed ‘phantom limb pain’ where there is a sensation of pain perceived in the missing limb. Although Ms. M.D. had made a concerted effort to maintain her independence and continues to run her dry cleaning business independently, her quality of life has suffered dramatically as a result. Her walking tolerance is significantly reduced and the pain, care and maintenance required for the stump and prostheses had impacted her ability to function within her home and effectively manage her business as she did prior to the amputation.
It had been repeatedly been advised that Ms. M.D. continue to monitor the condition of her lower limbs as the wounds involving the left leg had not demonstrated significant healing at the time of her amputation. Additionally, she was now required to alter the stresses through the left leg during standing and walking as a result of the permanent structural defect to the right leg. Despite greater attempts at managing her glucose levels and body weight, the risk of infection and amputation to the left lower leg remained an ominous possibility in 2013.
Ms. M.D. believed that she would not be able to endure undergoing a subsequent amputation to her left lower extremity. The pain, rehabilitation, maintenance, and increased level of disability associated with losing her remaining leg would likely require her to lose her business. The emotional toll of such an event in conjunction with the physical consequences would be too much to bear. Accordingly, Ms. M.D. began inquiring into solutions that would accelerate the healing of her chronic diabetic wounds.
One of the wound nurses had suggested that she investigate into an Intermittent Pneumatic Compression (IPC) device. It has been demonstrated in the biomedical research literature that external mechanical compression from a sequential or pneumatic device can accelerate the healing of chronic diabetic wounds. Ms. M.D. reviewed the possibility of an external device with her treating physician and it was determined that the inflatable bladders that are placed over the lower leg and foot could potentially compound her problem. Additionally, due to the complexity of the devices and the requirement for an external power source, there is maintenance and immobility associated with their usage which could potential increase the burden connected to Ms. M.D.’s already dire situation. However, after consulting with a colleague, the treating specialist was informed of a unique and compact battery-powered compression device called the Venowave. This device attaches to the proximal aspect of the calf and would not interfere with the existing wounds at the distal aspect of the left lower extremity. Furthermore, the device compresses the calf and increases blood flow through a unique waveform motion rather than via rapid and inflation and deflation of bladders as is the case with conventional IPCs. Accordingly, Ms. M.D. was provided a Venowave device to assist in the management of her ulcers.
Ms. M.D. immediately began utilizing the Venowave for all hours of the day. Compliance was not an issue as she found the device comfortable, easy to operate, and did not limit her movement or ability to function. Within a period of three months, she reported that there was reduced pain in the left leg and there were observable changes in the colour of the skin. After a period of eight months, there was evidence of healing as demonstrated by granulation tissue within the wounds of the left leg. Ms. M.D.’s treatment team remarked that her wounds have been healing at a rate that was not observed prior to incorporating the Venowave into her regimen. She had been advised that the possibility of amputation had been greatly reduced based on the improving condition of the wounds in the left leg.
Currently, Ms. M.D. continues wearing the device throughout the day and evening. As amputation is no longer a consideration, she believes that the Venowave was largely responsible for salvaging her left leg and preventing a prolonged course of pain and disability.
Chronic non-healing leg wounds and subsequent leg amputations represent some of the most prevalent and debilitating complications of vascular and metabolic pathologies. The consequential strain imparted by the treatment and management of chronic leg wounds on healthcare systems throughout the world is well-documented. It is estimated that 10 to 15% of diabetic patients will develop a foot wound in their lifetime and become a victim of its associated functional limitations. Amputations are reported to occur at rates of 1.5% for diabetic ulcers and 0.4% for venous leg ulcers. More specifically, according to the Canadian Association of Wound Care, 85% of all amputations are a result of a non-healing foot ulcer. The estimated healthcare costs associated with limb amputations is in excess of $60,000.
As suggested by this case report and the research literature, the cost of a portable compression device such as the Venowave relative to the long-term hospital expenses for in-patient therapy, surgery, and amputation allows for a more efficient allocation of healthcare spending. Moreover, the improved quality of life and expedited return to pre-ulcerative functional states experienced by this patient group will lead to greater and sustained benefits for the population at-large.