The Use of Silver-Impregnated Packing Strips in the Treatment of Osteomyelitis: A Case Report

Author(s): 
Michael F. Moore, MD, FACS, CWS;1 Nanci Dobson, RN;1 Jeffrey T. Glattly, BBA2

Case Report

History. An 84-year-old man with type II adult onset diabetes and sensory and motor neuropathy presented with a malperforans ulcer of the right first metatarsal head in September 2005. According to the patient, a small, draining ulcer developed on the plantar surface of the first metatarsal head. The patient denied any change in shoe apparel and direct trauma to the foot but did admit to increased walking activity prior to the onset of his symptoms. Conservative treatment with antimicrobial ointments and gauze bandages was ineffectual. His primary care physician referred him to the wound center for further evaluation and treatment (Figure 4). Past medical history included essential hypertension, atrial fibrillation, macular degeneration, gait disturbance secondary to sensory neuropathy, bilateral internal fixation of both tibia and fibula following a motor vehicle accident, and bilateral carotid endarterectomies.
Evaluation at the time of presentation revealed mild arterial restrictive disease by duplex scan with an ankle brachial index of 0.9, normal chemical profile, normal HgbA1C, normal complete blood count and differential, normal venous duplex exam, atrial fibrillation, and no evidence of osteomyelitis on x-ray (Figure 5).
Positive findings of the physical examination were macular degenerative changes, well healed carotid incisions, irregular heart rate, healed lower leg incisions, and a malperforans ulcer involving the plantar surface of the base of the first metatarsal head, which extended down into and included the plantar fascia but did not extend into the metatarsal head on examination.
Hospital course. The patient underwent exploration and operative debridement of the ulcer, and negative pressure wound therapy (NPWT) was initiated. Operative findings and pathology revealed chronic ulceration with inflammatory changes and granulation tissue. The patient was seen on a weekly basis during which progressive decrease in the size of the ulcer occurred (Figure 6).
Eight weeks after initial presentation, the NPWT was discontinued, and the use of oxycellulose (Promogran®, Johnson & Johnson Wound Management, Somerville, NJ) was initiated.
Concomitant with the cessation of NPWT at Week 8 was the onset of tenderness and erythema of the metatarsophalangeal joint along the medial aspect. Laboratory testing revealed a normal uric acid level. Aspiration of the metatarsophalangeal joint revealed blood that grew Enterococcus sensitive to ciprofloxacin on culture. The patient was placed on ciprofloxacin and was continued on oxycellulose dressings to the plantar malperforans ulcer. Twelve weeks after initial presentation, the plantar wound healed; however, tenderness of the metatarsophalangeal joint persisted, and an ulcer developed (Figure 7). Radiographic examination of the joint confirmed osteomyelitis. Surgical exploration and debridement of the new area of ulceration revealed necrosis of the underlying subcutaneous tissue and bone. Operative cultures and pathologic examination confirmed acute osteomyelitis with Enterococcus isolated form bone cultures (Figure 8).
Cultures again revealed Enterococcus sensitive to ciprofloxacin. The patient was continued on the same regime of ciprofloxacin, and the wound was packed open with cotton gauze. The patient continued on this therapy to Week 2 with no decrease in wound size. At Week 2, the patient’s packing was changed to silver-impregnated wound packing strips. Four weeks after the initiation of packing with the silver-impregnated strips, the patient presented with both wounds completely healed (Figures 9–12).
A 22-week follow-up exam showed no evidence of recurrence, and 26-week follow-up x-ray examination showed healing bone.

References: 

1. Poljicanin T, Pavlic-Renar I, Metelko Z, Coce F. Draft program of prevention of diabetic foot development and lower extremity amputation in persons with diabetes mellitus. Diabetol Croat. 2005;34-2:43–50.
2. Robson MC. Wound infection. A failure of wound healing caused by an imbalance of bacteria. Surg Clin North Am. 1997;77(3):637–650.
3. Bergstrom N, Allman RM, Alvarez OM, et al. Clinical Practice Guideline No. 15: Treatment of Pressure Ulcers. Rockville, Md: Agency for Health Care Policy and Research; 1994. AHCPR Publication 95-0652.
4. Ovington LG. The truth about silver. Ostomy Wound Manage. 2004;50(9A Suppl):1S–10S.
5. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR, the Hospital Infection Control Practices Advisory Committee. Guideline for the prevention of surgical site infection, 1999. Infect Control Hosp Epidemiol. 1999;20(4):250–280.



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