Maggot therapy, alginate dressing, and surgical sharp debridement: Unique path to save unresponsive diabetic foot ulcer

Abstract

Introduction and importance

Diabetic foot ulcers are a severe complication of diabetes mellitus, affecting a significant proportion of the diabetic population. In some cases, ulcer progression and infection can lead to the need for amputation.

Case presentation

An 84-year-old male with a history of poorly controlled type 2 DM and HTN presented with an infected DFU on the plantar aspect of his right foot. This case report illustrates the successful management of an 84-year-old patient with a DFU amputation candidate, emphasizing the effectiveness of a combined treatment approach.

Clinical discussion

Conventional treatment options, including antibiotic therapy, often fail to provide adequate healing in these high-risk patients. Alternative approaches, such as maggot therapy, which involves the application of sterile maggots to the wound bed, have shown promising results.

Conclusion

This case highlights the potential therapeutic benefits and clinical efficacy of such a combined treatment approach, particularly in challenging cases with limited response to conventional therapies. Further studies and randomized trials may be warranted to support the incorporation of this therapy combination into clinical practice guidelines for DFU management.

Highlights

• •DFUs can lead to amputation.
• •DFUs do not respond to common approaches.
• •DFUs can be managed by Maggot Therapy, Alginate Dressing, and Surgical Sharp Debridement.

1. Introduction

Diabetic foot ulcers (DFUs) are a common and serious complication of diabetes mellitus, affecting a significant proportion of individuals with diabetes (1). These ulcers can lead to severe morbidity, reduced quality of life, and a higher risk of lower extremity amputations (2). DFUs result from a combination of neuropathy, vascular impairment, and infection, causing a delay in wound healing and an increased susceptibility to complications (3).

Traditional methods of DFU management include wound dressings, offloading devices, vascular interventions, and antibiotic therapy (4). However, in some cases, these conventional approaches fail to achieve satisfactory healing outcomes, particularly in patients with chronic and infected ulcers. In such scenarios, alternative therapies and combination approaches need to be considered (5).

One such combination therapy approach involves the utilization of maggot therapy, surgical sharp debridement, and alginate dressings (6). Maggot therapy, also known as biosurgical debridement, involves the application of sterile maggots from the larvae of certain fly species onto the wound bed (7). These maggots feed on necrotic and infected tissue, promoting debridement and disinfection of the wound area. This therapy has demonstrated efficacy in stimulating wound healing and preventing amputation in DFU patients (8).

Surgical sharp debridement is a procedure where trained healthcare professionals utilize sterile instruments to remove non-viable tissue, slough, callus, and other contaminants from the wound bed (9). This intervention helps promote the formation of healthy granulation tissue and reduces bacterial burden, thereby facilitating wound healing.

Alginate dressings, derived from seaweed, are highly absorbent wound dressings that form a gel in the presence of wound exudate (6). These dressings promote a moist wound environment, facilitate autolytic debridement, and effectively manage exudate levels. Alginate dressings also have antimicrobial properties and can assist in preventing infection, a common hindrance to DFU healing (2).

The combination therapy of maggot therapy, surgical sharp debridement, and alginate dressings has shown promising results in the management of DFUs, particularly in cases where conventional treatments have proven unsuccessful (10). This approach facilitates wound debridement, eradicates infection, promotes granulation tissue formation, and accelerates wound healing, ultimately reducing the need for amputations. The work has been reported in line with the SCARE 2020 Criteria (11).

2. Presentation of case

An 84-year-old male with a history of poorly controlled type 2 diabetes mellitus (DM) and hypertension (HTN) was admitted with an infected diabetic foot ulcer (DFU) on the plantar aspect of his right foot (Fig. 1). The patient had been taking meropenem, clindamycin, and ciprofloxacin as antibiotic therapy, which showed limited efficacy in wound healing. The patient was identified as a potential candidate for amputation due to the chronicity and severity of the DFU.

Fig. 1.

DFU before starting the combination therapy.

2.1. Treatment protocol

A multidisciplinary wound care team consisting of a podiatrist, wound care nurse, and infectious disease specialist collaborated to develop a treatment plan utilizing a combination therapy approach. The treatment protocol involved maggot therapy, alginate dressing, and surgical sharp debridement, with sessions scheduled at regular intervals over a period of 6 months. Additionally, the management of blood glucose levels has conventionally involved the administration of insulin via subcutaneous injection thrice daily throughout the course of treatment, aiming to facilitate the wound healing process. The patient was subjected to continued administration of antibiotics as a precautionary measure against the potential development or persistence of infection. Doppler Ultrasound has been utilized for the purpose of vascular evaluation.

2.2. Surgical sharp debridement

Surgical sharp debridement was performed by a skilled podiatrist under local anesthesia. Precautions were taken to ensure sterile conditions and minimize patient discomfort. Trained healthcare professionals utilized sharp surgical instruments to carefully remove necrotic tissue, slough, callus, and other contaminants from the wound bed. This intervention was performed during five sessions over the course of treatment. After each debridement session, the wound bed was thoroughly cleaned using 0.9 % saline solution to prevent infection and promote healing (Fig. 2). We must note, that the amputation of the phalanges mediae and phalanges distal of the second toe was necessitated by severe necrosis, rendering any salvage attempts futile.

Fig. 2.

DFU after surgical debridement.

2.3. Maggot therapy

Maggot therapy was initiated during the second session of the treatment plan. Sterile Lucilia sericata (green bottle fly) maggots were obtained from a reliable supplier. The maggots were applied to the wound bed using a specialized mesh dressing, ensuring uniform distribution and coverage. The larvae were left in place for 48 h. After this period, the maggots, along with the wound exudate and necrotic tissue, were gently removed using saline washing. This process was repeated for a total of six sessions, with regular assessment of wound progress following each maggot therapy session (Figs. 3; 4). Debridement has been consistently performed in each session promptly after the maggots have effectively eliminated the necrotic tissue within a period of 48 h.

Fig. 3.

DFU after maggot therapy.

Fig. 4.

DFU following maggot therapy.

2.4. Alginate dressing

Following each maggot therapy session, alginate dressings were applied to the wound bed. Sterile, non-adhesive alginate dressings were selected based on their absorbent properties and ability to maintain a moist wound environment. The alginate dressings were changed every three days throughout the treatment period. During the dressing changes, the wound bed was inspected for any signs of infection or complications, and appropriate measures were taken (Fig. 5).

Fig. 5.

DFU after Alginate dressing.

2.5. Follow-up and evaluation

The patient's progress was closely monitored throughout the treatment period (Fig. 6). Regular follow-up visits were scheduled to assess wound healing and manage any complications or concerns. Parameters such as wound size, presence of necrotic tissue, undermining, exudate levels, odor, and patient-reported pain were recorded at each visit. Adherence to the treatment protocol, including medication regimen and dressing changes, was also ensured.

Fig. 6.

DFU after combination therapy.

2.6. Outcome measurement

The primary outcome measure was complete healing of the DFU, defined as complete closure of the wound with absence of necrotic tissue and undermining. Secondary outcome measures included reduction in wound size, alleviation of pain, disappearance of foul odor, and avoidance of amputation. Adverse events, such as infection, allergic reaction, or excessive bleeding, were also noted and managed accordingly.

3. Discussion

The treatment combination utilized in this case, involving maggot therapy, alginate dressing, and surgical sharp debridement, proved highly effective in promoting wound healing in an 84-year-old patient with a DFU amputation candidate. Maggot therapy has been shown to assist with debridement, antimicrobial activity, and promotion of granulation tissue formation, while alginate dressings help manage exudate and create a favorable environment for wound healing. Surgical sharp debridement further facilitates thorough removal of necrotic tissue and callus.

Sharp debridement is a well-established treatment for DFUs that involves the removal of necrotic tissue from the wound bed. This process promotes healing by removing the barrier to tissue regeneration and reducing the bacterial load in the wound. Maggot therapy, also known as larval therapy, involves the use of sterile maggots to debride the wound and promote healing (8). The maggots secrete proteolytic enzymes that digest necrotic tissue while leaving healthy tissue intact. Maggot therapy also has antibacterial properties, which can help to reduce the risk of infection. Silver bandages are dressings that contain silver ions, which have antimicrobial properties (9). In the end, it must be said that our team's approach in this case is not universally applicable or ideal for every cases, our purpose was to increase awareness and enhance the surgeon's ability to effectively manage a challenging diagnosis.

The combination therapy of maggot therapy, surgical debridement, and alginate dressing offers a holistic approach to DFU management. By leveraging the benefits of each component, this treatment modality aims to improve wound healing, reduce infection risk, and potentially decrease the economic burden associated with DFUs. Further research and clinical trials should be conducted to establish the efficacy, safety, and optimal implementation guidelines for this therapy (2).

Maggot therapy, also known as larval therapy, involves the controlled application of sterile maggots to the wound bed to promote debridement. Maggots secrete enzymes that break down the necrotic tissue, effectively debriding the wound and promoting wound healing (6). Their selective feeding on non-viable tissue and the stimulation of granulation tissue formation contribute to wound bed preparation.

Surgical debridement is a mechanical method performed by healthcare professionals to remove necrotic tissue, foreign bodies, and biofilm from the wound bed. It helps to reduce bacterial load, control infection, and promote granulation tissue formation. Surgical debridement can be performed by sharp instruments, such as scalpel or curette, or by using various debridement devices (10).

3.1. Benefits of combination therapy

• 1.Effective Debridement: Maggot therapy and surgical debridement complement each other in removing necrotic tissue and biofilm from the wound bed, promoting a clean wound environment.
• 2.Enhanced Wound Healing: The synergistic effect of maggot therapy, surgical debridement, and alginate dressing creates an optimal wound healing environment, allowing for improved granulation tissue formation and accelerated healing (12,13).
• 3.Reduced Infection Risk: Combination therapy reduces the bacterial burden in the wound bed, minimizing the risk of wound infections and associated complications.
• 4.Cost-Effectiveness: Although the use of maggot therapy may have additional costs, the potential reduction in hospitalization time, decreased need for repeated surgeries, and improved healing rates may lead to long-term cost savings (14).

In line with this case report study, Arad et al. (5) and Parizad et al. (6) showed that the Negative Pressure Wound Therapy (NPWT), along with maggot debridement therapy and silver foam dressing, is an appropriate treatment method for DFU. Hajimohammadi et al. showed that maggot debridement therapy with silver foam dressing effectively treats DFU (2). In line with the present case report study results, Choobianzali et al. (3) indicated that maggot debridement therapy is a safe and effective method for the treatment of DFU. In addition, Parizad et al. concluded that maggot debridement therapy is an effective and new treatment for complex DFUs which are resistant to conventional and routine therapies (10).

4. Conclusion

The combination of maggot therapy, alginate dressing, and surgical sharp debridement has proven to be an effective approach for treating unresponsive diabetic foot ulcers. Maggot therapy promotes wound healing by utilizing medical-grade maggots to clean the wound and encourage healthy tissue growth, while alginate dressings create a moist environment and aid in debridement. Surgical sharp debridement removes dead tissue and allows new tissue to regenerate. This approach addresses factors such as infection, necrosis, and bacterial resistance, leading to promising results in healing and preventing complications. These therapies offer advantages such as cost-effectiveness, shorter hospital stays, and improved patient comfort. However, individual factors must be considered for suitability. Overall, this combination provides an alternative for healthcare professionals in tackling unresponsive diabetic foot ulcers, with continued research potentially leading to more effective treatments in the future.

Consent

Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Provenance and peer review

Not commissioned, externally peer-reviewed.

Ethical approval

This study is exempt from ethical approval in our institution because there is already consent from the patient and all identifying personal health information has been removed from the presentation.

Funding

None.

Author contribution

Rasoul Goli; Mojde Bagheri; Navid Faraji: Study concept, data collection, writing the paper and making the revision of the manuscript following the reviewer's instructions. Naser Parizad; Kazem Hajimohammadi: Study concept, reviewing and validating the manuscript's credibility.

Guarantor

Rasoul Goli

Research registration number

Not applicable.

Conflict of interest statement

None.