Healing of diabetic foot ulcer in an amputation candidate with below-knee cellulitis using combination of negative pressure wound therapy and platelet-rich plasma injection: A case report study

Abstract

Introduction and importance

Diabetic foot ulcers, especially when complicated by cellulitis, pose a significant challenge in diabetes management, often leading to amputation. This case report highlights the successful treatment of a diabetic foot ulcer in an amputation candidate using a combination of negative pressure wound therapy and platelet-rich plasma injection, potentially reducing the risk of amputation in high-risk patients.

Case presentation

A 62-year-old male with poorly controlled diabetes presented with a chronic diabetic foot ulcer and cellulitis. After surgical debridement, negative pressure wound therapy was initiated, followed by platelet-rich plasma injection into the wound bed. This combination therapy led to rapid granulation tissue formation and complete wound closure within 8 weeks, with no adverse events observed. The patient successfully avoided amputation.

Clinical discussion

Negative pressure wound therapy played a vital role in managing the complex wound by removing exudate, reducing edema, and promoting granulation tissue formation, thereby accelerating healing and preparing for skin grafting. Alongside careful wound care, negative pressure wound therapy aided infection control and patient recovery. Additionally, platelet-rich plasma therapy enhanced healing by providing growth factors and proteins that support cellular proliferation and collagen synthesis. This combination of negative pressure wound therapy and platelet-rich plasma therapy demonstrates the effectiveness of advanced wound care for patients with complex diabetic foot ulcers.

Conclusion

This case underscores the potential benefits of combining negative pressure wound therapy and platelet-rich plasma injection in managing diabetic foot ulcers complicated by cellulitis. Further studies are needed to validate the efficacy of this approach, which could significantly improve patient outcomes and reduce amputation rates in high-risk patients.

Highlights

• •Diabetes is associated with 80% of lower limb amputations, significantly increasing the risk of mortality.
• •DFUs are a common complication of diabetes, leading to significant morbidity, mortality, and healthcare costs.
• •The use of advanced wound care techniques (NPWT and PRP) with traditional surgery effectively managed patients' DFU.

1. Introduction

Approximately 18.6 million individuals worldwide develop diabetic foot ulcers annually, with 1.6 million of these cases occurring in the United States alone [1]. Diabetes is associated with 80 % of lower limb amputations, significantly increasing the risk of mortality [2]. Diabetic foot ulcers (DFUs) are a prevalent complication of diabetes, contributing to substantial morbidity, mortality, and healthcare expenditures. It is estimated that 19–34 % of diabetic patients will develop a DFU at some point in their lives, with the International Diabetes Federation reporting that 9.1–26.1 million people develop DFUs annually [3].

The clinical significance of DFU development is profound. A population-based cohort study in the United Kingdom revealed that the onset of DFUs is associated with a 5 % mortality rate within the first 12 months and a 42 % mortality rate over 5 years. Patients with DFUs are 2.5 times more likely to die compared to diabetic patients without foot ulcers [4].

Open wounds and their management are a common challenge in veterinary medicine. Negative Pressure Wound Therapy (NPWT) has been utilized in clinical veterinary practice for nearly 15 years, with its availability expanding in both Europe and the United States [5]. This treatment has the potential to significantly enhance the healing rate of open wounds and is beneficial for free skin grafting in small animals, occasionally being used for wound management in cats [6].

In addition to NPWT, Platelet-Rich Plasma (PRP) injection has emerged as a promising adjunctive therapy for wound care, including DFUs. PRP is derived from the patient's own blood and contains a high concentration of growth factors and bioactive proteins that can promote healing and tissue regeneration [7]. The chronic disruption of the wound healing process in diabetic patients, along with the associated complications, necessitates ongoing research to identify new strategies for accelerating healing and minimizing scar formation. As effective modalities like NPWT and PRP are explored, they hold the potential to significantly improve outcomes in the management of diabetic foot ulcers and other complex wounds. The work has been reported in line with the SCARE 2023 Criteria [8].

2. Case presentation

2.1. Patient profile

An 80-year-old male, previously a rancher, is currently unemployed and living with his family. He weighs 76 kg and has a height of 179 cm. This retired rancher is married and shares his home with his wife, daughter, and son-in-law. His family's support is vital during this new phase of his life. Despite his previous occupation, he is adjusting to the changes that come with retirement. Together, they engage in various activities, fostering a close-knit family dynamic.

2.2. Medical history

The patient's medical history reveals several significant health concerns, including the amputation of two toes on his right foot. This suggests the presence of underlying vascular or neuropathic issues likely related to uncontrolled blood sugar levels indicative of diabetes. Furthermore, the patient has suffered a chronic systemic infection characterized by a middle ear infection, which has led to imbalances affecting his daily functioning and social interactions. These factors further complicate his overall health status and underscore the necessity for an integrated approach to address both his physical and social well-being.

2.3. Presenting complaint

The patient presented to our clinic with a severe infection of the left big toe accompanied by cellulitis extending up to 4 cm below the knee (Fig. 1). The patient exhibited weakness, lethargy, balance issues while walking, and significant hearing impairment due to the ear infection.

Fig. 1.

The initial shape of the wound.

2.4. Clinical assessment

The patient exhibited limited mobility, requiring assistance for short-distance movements despite being able to eat and drink independently. Communication was hindered by hearing difficulties and challenges in understanding verbal cues attributed to an ear infection. An examination revealed significant swelling, inflammation, and pain localized around the left big toe, indicating a concerning focus of infection that required prompt evaluation and targeted intervention to mitigate potential complications.

2.5. Intervention plan

The patient was referred to the infectious disease specialist for management of the infection. The following treatment plan was initiated:

2.5.1. Antibiotic therapy

• -Clindamycin 600 mg IV once daily.
• -Metronidazole 500 mg IV once daily.
• -Ciprofloxacin 500 mg orally every 12 h.
• -Clindamycin 300 mg orally every 12 h.
• -Metronidazole orally every 12 h.
• -Daily multivitamin supplement.

2.5.2. Surgical intervention

Due to the severity of the infection and the potential for below-the-knee amputation, an orthopedic consultation was conducted. The initial surgical debridement and amputation of the left big toe were conducted on the patient's third day of hospitalization (Fig. 2). A 12 cm incision was made over the front of the ankle, resulting in the amputation of the left big toe along with its associated phalanges and metatarsals (Fig. 3). This was successful in preventing the need for the more extensive amputation below the knee due to wound management.

Fig. 2.

The surgeon performed a partial amputation of the large toe.

Fig. 3.

The wound appeared clean and well-approximated after irrigation and suturing.

2.6. Post-surgical care

2.6.1. Ear infection resolution

Notably, within 6 days post-operatively, the patient's ear infection significantly improved, leading to enhanced verbal communication and social interaction.

2.6.2. Wound management

2.6.2.1. Wound dressing

The patient underwent a series of 5 sessions for local infection control, which included meticulous debridement and irrigation with normal saline to cleanse the wound bed thoroughly. Debridement sessions occurred every three days during the treatment period. This schedule enabled thorough cleaning of the wound bed, elimination of dead tissue, and evaluation of healing progress, thereby creating ideal recovery conditions and enhancing the overall treatment plan's effectiveness. Subsequently, a specialized modern wound dressing, such as a silver alginate dressing or a hydrocolloid dressing, was carefully applied to promote optimal healing conditions. These dressings were changed daily to maintain a clean and moist wound environment, supporting the body's natural healing processes and reducing the risk of further infection (Fig. 4).

Fig. 4.

The condition of the wound after successive wound care by modern dressing and irrigation.

2.6.2.2. Negative pressure wound therapy

The NPWT system was applied to the ulcer site, exerting negative pressure to remove excess exudate, reduce edema, and promote granulation tissue formation (Video 1). Through regular dressing changes every 3 days for 45 days, the wound was meticulously managed to prevent infection and facilitate optimal healing conditions. This therapy not only facilitated wound bed preparation but also helped in reducing wound dimensions, which was crucial in preparing the wound for subsequent interventions.

2.6.2.3. Platelet-rich plasma therapy

PRP preparation involved several key steps: first, a sample of the patient's blood, typically around 20–60 mL, was drawn to achieve the desired platelet concentration. The blood was then centrifuged at a speed of 1500–3000 RPM for 10–15 min, which separated the components and concentrated the platelets. Following this, the platelet-rich plasma was carefully extracted from the centrifuged sample, ensuring no contamination with red blood cells. For the injection protocol, approximately 3–5 mL of the prepared PRP was injected directly into the ulcer site using a sterile syringe and needle. This process was repeated weekly for a total of 10 doses, providing consistent delivery of growth factors and bioactive proteins to optimize healing and enhance granulation tissue growth (Fig. 5). By delivering a concentrated blend of bioactive components to the wound bed, PRP acted as a potent stimulant for cellular proliferation, angiogenesis, and collagen synthesis, fostering the growth of healthy granulation tissue and hastening the overall healing process. This targeted approach aimed to enhance granulation tissue growth, improve vascularization, and ultimately contribute to superior wound closure and functional recovery, synergizing with the ongoing negative pressure wound therapy and advanced wound dressing protocols to maximize the patient's healing potential and mitigate the risk of complications.

Fig. 5.

The condition of the wound after Platelet-Rich Plasma Therapy.

2.7. Outcome

The combination of surgical intervention continued antibiotic management, NPWT, and PRP therapy yielded favorable results (Fig. 6). The wound showed significant signs of healing, leading to the decision to suture the wound closed with a simple dressing consisting of gauze applied after the final assessment (Fig. 7).

Fig. 6.

Significant progress of wound healing after the combination therapy.

Fig. 7.

Final condition of the wound after completion of treatment.

2.8. Follow up

The patient's follow-up care consisted of consistent monitoring of both the wound healing and general health condition. This involved weekly evaluations during the PRP injection sessions, where the wound was checked for indications of infection, the development of granulation tissue, and overall healing progress. Furthermore, the patient's vital signs and any possible complications were carefully monitored. Records of the wound's condition and measurements were kept to assess improvements over time. Treatment plans were adjusted as needed based on these assessments, promoting a comprehensive approach to the patient's recovery.

2.9. Limitations

One limitation noted during treatment was the patient's initial poor response to conventional wound care, which necessitated the combination of advanced therapies. Additionally, while negative pressure wound therapy is effective, it can sometimes lead to discomfort or pain at the wound site and may not be suitable for all patients, particularly those with certain underlying conditions. Platelet-rich plasma therapy, though generally well-tolerated, carries a risk of local reactions such as swelling, bruising, or infection at the injection site. It is important to monitor patients closely for any adverse effects and adjust treatment protocols as necessary to ensure patient safety and optimal healing outcomes.

3. Discussion

This case report highlights the successful management of a severe diabetic foot ulcer with cellulitis in an elderly patient who was a candidate for below-knee amputation [9]. The implementation of a comprehensive treatment approach, involving a combination of surgical intervention, antibiotic therapy, NPWT, and PRP injection, resulted in favorable outcomes for the patient [10].

The use of NPWT played a crucial role in this case. NPWT has been shown to effectively manage complex wounds by removing excess exudate, reducing edema, and promoting granulation tissue formation [11]. By applying negative pressure to the wound site, NPWT can create an environment that accelerates the natural healing process and prepares the wound bed for subsequent interventions, such as skin grafting or wound closure [12]. The regular dressing changes and meticulous wound management during the NPWT application in this case were instrumental in controlling the infection and facilitating the patient's recovery [13].

The addition of PRP therapy further enhanced the healing trajectory. PRP is a rich source of growth factors, cytokines, and other bioactive proteins that can stimulate cellular proliferation, angiogenesis, and collagen synthesis [14]. By delivering these essential components directly to the wound site, PRP can promote the growth of healthy granulation tissue and ultimately contribute to improved wound closure and functional recovery. The synergistic effect of NPWT and PRP therapy in this case highlights the potential of combining advanced wound care techniques to optimize the healing process in patients with complex diabetic foot ulcers [15].

Complications during treatment were handled using a thorough and proactive strategy. The severe infection in the patient was a major concern, addressed with a customized antibiotic plan that included intravenous clindamycin and metronidazole, as well as oral ciprofloxacin and other medications to ensure effective infection management. Regular evaluations of the wound were performed, enabling timely actions like surgical debridement to remove dead tissue and facilitate healing. The use of negative pressure wound therapy was essential in controlling swelling and encouraging the formation of granulation tissue, which helped reduce complications. Furthermore, the patient's simultaneous ear infection was treated swiftly, improving overall communication and interaction, which are crucial for recovery. This comprehensive approach aimed to reduce complications and support the patient's healing process throughout treatment. The integrated approach in this case, addressing both the local wound management and the patient's overall well-being, demonstrates the value of a multidisciplinary care model.

The advanced wound care strategies employed in this case, including NPWT and PRP therapy, have shown promising results in the veterinary field as well [16]. The availability and expanding use of these techniques in clinical veterinary practice suggest their potential applicability across various species, highlighting the cross-disciplinary nature of wound management principles [17].

In summary, managing complex wounds, especially in patients with conditions like diabetes, requires a comprehensive strategy to improve healing results [18,19]. This case illustrates how effective it can be to incorporate advanced treatment methods, such as NPWT and Platelet-Rich Plasma PRP therapy, within a holistic care model. By focusing on both the local wound conditions and broader systemic issues, healthcare providers can create the best environment for healing [20,21]. The combined effects of these therapies not only aided in the healing of the diabetic foot ulcer but also highlighted the critical role of thorough infection management and overall patient care. This case demonstrates that teamwork among healthcare professionals and the thoughtful use of advanced wound care techniques can greatly enhance patient outcomes, setting the stage for innovative practices in both human and veterinary medicine. Such collaborative approaches are crucial for progressing the field of wound healing, particularly in difficult cases that could otherwise result in serious complications or amputations [22,23].

4. Conclusion

This case exemplifies the importance of multidisciplinary collaboration in treating complex infections in elderly patients, particularly those with underlying conditions such as diabetes. The integration of advanced wound care techniques (NPWT and PRP) alongside traditional surgical interventions facilitated effective management of the patient's infection and contributed positively to his recovery trajectory.

The following is the supplementary data related to this article.

Funding declaration

This CASE REPORT did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.

CRediT authorship contribution statement

Salar Zayeri (Corresponding author), Mohammad Reza Faramarz, and Ahmad Shotorbani: study concept, data collection, writing the paper.

Mohsen Sayahi, Babak Sofizadeh, and Farzam Boustanchi: writing the paper, reviewing and validating the manuscript's credibility.

Informed consent

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

Ethical approval

Ethical clearance was not necessary by Research Committee of Urmia University of Medical Sciences as the format of this paper is a case report.

Guarantor

Salar Zayeri.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.