Healing chronic infected foot wounds with human fibroblast-derived dermal substitute and silver dressings

Thirty consecutive patients with diabetes, ischemia, and chronic wounds of the lower leg, ankle, and foot were treated over an 18-month period. Patients had appropriate moist wound care, and their wounds failed to heal for 5 weeks or more (average = 11 weeks, range 5-60 weeks). All patients were considered candidates for limb salvage and were referred for a final effort to avoid amputation. Based on previous experiences in the authors' wound care program, wounds were treated with debridement, silver-coated cloth dressings, and a dermal substitute. All wounds were colonized with methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococcus (VRE), or a combination of MRSA and another organism, usually pseudomonas or a streptococcus species. All cultures from the episodes of cellulitis were positive for VRE, MRSA, or both, and these were the suspected infecting organisms. All patients gave informed consent for their procedures and wound care. All patients' wounds were located in ischemic areas determined by toe pressures of 35-50 mmHg and ankle brachial indices. Ischemia was corrected as much as possible in all patients, and 20 patients received bypass or angioplasty for their lower-extremity ischemia. Seventeen patients progressed to satisfactory healing and spontaneous closure by 84 days (average 46 days, range 32-94 days). Eight patients required skin grafts, which healed. All patients had ankle brachial indices recorded, and none of the patients were categorized into the incompressible group. Five patients did not heal and required amputation. Debridement, silver-coated cloth dressings, and dermal substitute appear to be efficacious in healing diabetic, ischemic, lower-extremity chronic wounds.