Non-healing wound - any ideas?

Re: Non-healing wound - any ideas?

John Flynn — Wed, 26 Jun 2013 21:04:55 GMT

I'm not disagreeing, but I wouldn't want to totally rule out a superficial lesion based on description to date (though I think it's very unlikely)

I've seen acral lick deramitis type lesions post implant before, and they can be just as difficult to clear as in any other dog with such a lesion, and yes, might need the plate removed even if there's not deeper infection.

Re: Non-healing wound - any ideas?

Virginia Campbell — Wed, 26 Jun 2013 20:58:29 GMT

[quote user="GrooveJet"] insulin along the edges? Do you dribble it onto the wound or inject? How often?[/quote]

To induce epidermal growth factor. I think your manuka honey might do the same thing. We do a good bit of cats protection work and sometimes use it for the "armpit cats" - we see quite a few with yukky axilla wounds where they have got one leg through an elastic collar then wandered the streets for weeks. Once the wound looks clean and looks like it's making a bit of an effort round the edges but not fast enough, we start dribbling the insulin on twice a day. I read about it on VIN. The nurses think it helps; anecdotal and all that.

Re: Non-healing wound - any ideas?

Miriam Lodewyks — Wed, 26 Jun 2013 20:50:34 GMT

[quote user="Virginia Campbell"]

If I thought the problem was just superficial (which I think is unlikely) I would try vetericyn to kill the bugs then the out of date insulin in the fridge round the edges to encourage epithelisation. You should have achieved the same effect with all the excellent things you have tried like silver dressings and manuka though.

I would be particularly concerned about the fact that your beautifully healed debride and suture just fell apart weeks later. I am no orthopod or wound healing expert, but I think this would be an indicator that what lies beneath ain't pretty. Probably a biofilm on the implants but you asked for weird and wonderful: so consider the rank outsiders preventing wound healing in this case: trauma induced neoplasia and Cushings. (also, does anyone know if hypot4 inhibits healing?)

[/quote][quote user="Virginia Campbell"]

[/quote] That's an interesting one: insulin along the edges? Do you dribble it onto the wound or inject? How often?

Re: Non-healing wound - any ideas?

Virginia Campbell — Wed, 26 Jun 2013 20:44:15 GMT

Re: Non-healing wound - any ideas?

Gillian Mostyn — Wed, 26 Jun 2013 20:28:04 GMT

Re: Non-healing wound - any ideas?

Mark Hedberg — Wed, 26 Jun 2013 20:23:52 GMT

[quote user="Niall Taylor"]

... where's Malcolm Ness when you need him!

Cheers,

Niall

[/quote]

Re: Non-healing wound - any ideas?

Gillian Mostyn — Wed, 26 Jun 2013 19:38:44 GMT

[quote user="mariette asselbergs"]

Not being an equine vet but very much a generalist: I think I read a while ago that equine flesh wounds which fail to heal past the granulating stage are thought to be due to a bacterial film over the wound. Once that issue is addressed healing progresses normally. This would mean that just a superficial problem with resistant bacteria could be enough to cause a failure in healing. Reason to still try the salt water/manuka honey option and frequent wash/clean?

Mariette

[/quote]

but the OP has already tried many very effective ways to treat a superficial infection, plus the wound was debrided and sutured, healed, and then subsequently broken open again...... all indicating a 'deeper' issue.

Re: Non-healing wound - any ideas?

Niall Taylor — Wed, 26 Jun 2013 14:48:41 GMT

[quote user="mariette asselbergs"] I think I read a while ago that equine flesh wounds which fail to heal past the granulating stage are thought to be due to a bacterial film over the wound. Once that issue is addressed healing progresses normally. This would mean that just a superficial problem with resistant bacteria could be enough to cause a failure in healing. Reason to still try the salt water/manuka honey option and frequent wash/clean?[/quote]

In this area there is limited soft tissue, the implants will be pretty near the surface and it's almost certain that they will be acting as a nidus for the infection. It's unlikely that the infection will resolve as long as they are still there although bone will still continue to heal in the presence of infection which might explain the orthopod's decision to delay implant removal.

... where's Malcolm Ness when you need him!

Cheers,

Niall

Re: Non-healing wound - any ideas?

mariette asselbergs — Wed, 26 Jun 2013 13:39:44 GMT

Mariette

Re: Non-healing wound - any ideas?

Gillian Mostyn — Tue, 25 Jun 2013 19:28:46 GMT

[quote user="Niall Taylor"]Plated arthrodeses/fractures can take up to 12 months to come to full strength so they have a point. And the presence of infection doesn't necessarily reflect on the orthopod's perfomance, it may have occured some time post-op.[/quote]

I realise that in an elderly dog it could take quite a while to reach full strength, but would it really be at risk of catastrophic failure after 9 months if it was progressing normally? (Genuine question - I'm no orthopod!)

I don't think anyone is indicating that the ortho guy has done anything wrong - infection can happen to anyone - just that ignoring the underlying structures and treating it as a superficial wound is probably a flawed decision, no?

Re: Non-healing wound - any ideas?

Niall Taylor — Tue, 25 Jun 2013 17:28:33 GMT

[quote user="GrooveJet"] Our orthopod is reluctant to remove the plate as he fears the carpus will collapse.[/quote]

Plated arthrodeses/fractures can take up to 12 months to come to full strength so they have a point. And the presence of infection doesn't necessarily reflect on the orthopod's perfomance, it may have occured some time post-op.

Still, I think you need to have a word with him - what about removing the plate (it isn't going to heal until you do) and putting an ex-fix in in its place (well, obviously not ACTUALLY in its place, but you know what I mean!).

Cheers,

Niall

Re: Non-healing wound - any ideas?

Gillian Mostyn — Tue, 25 Jun 2013 16:18:42 GMT

If a wound won't heal then there has to be an underlying reason. Sounds like you have tried all the usual remedies for a superifical infection so there has to be something else going on. I also think that an infected implant is the most likely candidate, and that if an arthrodesis hasn't healed/fused after 9 months, it ain't gonna! If the dog still hasa non-union, then it has to be addressed at this stage as the quality of life sounds to be pretty poor, is it not?

Re: Non-healing wound - any ideas?

Mark Hedberg — Tue, 25 Jun 2013 15:48:47 GMT

[quote user="GrooveJet"]

but it seems to itch, so she rubs it on the carpet.

[/quote]

Or it might be sore as h-e-double-hockey sticks!

Re: Non-healing wound - any ideas?

Christopher Saul — Tue, 25 Jun 2013 14:56:07 GMT

Fair point Mark, I was had just noted that everyone was chatting about manuka honey, wondered if it had replaced flamazine.....

Re: Non-healing wound - any ideas?

Mark Holmes — Tue, 25 Jun 2013 14:53:32 GMT

[quote user="Christopher Saul"]

Flamazine? or has that gone out of fashion these days...

[/quote] Flamazine is brilliant, but only if the infection is superficial and I cannot believe after 9 months that it is. The body itself is likely to clear it in that time even discounting the different preparations that have been applied. Everything points to a nidus of deep infection and I cannot believe that the plate is innocent. Not wanting to sound blunt but the catastrophe has already happened and bailing out the titanic with a cup and saucer isn't going to work.

Re: Non-healing wound - any ideas?

Utlendigur — Tue, 25 Jun 2013 14:51:07 GMT

Something that hasn't been suggested so far....local delivery of antibiotics eg septopal beads (has it been tested against gentimicin?) or vet instrumentation have just brought out a collagen material that could be impregnated with antibiotic eg oxytet and packed into a wound

(ps still think that the implants need looking at - even if they aren't a nidus, a loosening screw could lead to a recurrent sinus tract)

Re: Non-healing wound - any ideas?

Anthony Dennison — Tue, 25 Jun 2013 12:50:10 GMT

[quote user="GrooveJet"]The owner is a retired A&E nurse, so he's quite competent at dressing the leg himself: currently thoroughly washing the entire limb with saline or dilute hibiscrub, then applying Manuka from a tube, covering with Allevyn, soffban, k-band and co-flex.[/quote]

Perhaps a lighter bandage? Try and get a little air to it?

Re: Non-healing wound - any ideas?

Christopher Saul — Tue, 25 Jun 2013 12:48:38 GMT

Flamazine? or has that gone out of fashion these days...

Re: Non-healing wound - any ideas?

Miriam Lodewyks — Tue, 25 Jun 2013 12:44:13 GMT

Given the general consensus so far, I think another word with the orthopod might be called for...

We're just really worried that further surgery might lead to loss of use of the limb, and that would be a disaster.

But I take on board your comments that the underlying source of infection or irritation (probably the metalwork) needs to be eliminated.

The owner is a retired A&E nurse, so he's quite competent at dressing the leg himself: currently thoroughly washing the entire limb with saline or dilute hibiscrub, then applying Manuka from a tube, covering with Allevyn, soffban, k-band and co-flex. Dog hasn't developed a taste for the Manuka yet, thank goodness, but it seems to itch, so she rubs it on the carpet. I'll suggest a more concentrated saline solution for the time-being.

Re: Non-healing wound - any ideas?

Anthony Dennison — Tue, 25 Jun 2013 12:22:02 GMT

When you say manuka dressings, have you been using the impregnated dressings or applying honey to the wound? It may be an idea to combine a concentrated salt solution TID followed by applying manuka honey from a tube. I've found this to be great for wounds, had one dog with horrible psuedomonas infected wound post-op on his feet, once it had dried a little went to the protocol above and it dried up nicely.

Until the owners took the buster collar off and the dog got a taste for manuka honey....

Re: Non-healing wound - any ideas?

Andrew Kent — Tue, 25 Jun 2013 11:15:21 GMT

Have you radiographed the region recently to assess whether there is osteomyelitis and the implants are involved? I would think this is fairly critical because if the implants are infected as others have implied you are wasting your time and giving the owners false hope to think it can be resolved without removing the metal work.

If it is purely the skin wound that is causing problems then continued other measures may be useful. What kind of sensitivity profile has your lab run? Have you requested any wider sensitivity testing? It would be useful to know if any other agents are suitable.

The fact that this resolves with treatment and then recurrs/bursts out presumably makes it highly likely the nidus of infection is deep (ie probably implants) in which case nothing you do topically will resolve it. Which also probably accounts for why the joint would collapse and hasn't healed because there is infection there.In which case again leaving in the implants in the face of infection is not doing the dog any favours either.

This is clearly a difficult case but personally I would be asking the orthopod to deal with it, and perhaps if he/she in unable to then a referral to a separate specialist orthopaedic surgeon might be the best thing to do in order to get resolution. It is likely this is not just skin deep!

Andy

Re: Non-healing wound - any ideas?

Miriam Lodewyks — Tue, 25 Jun 2013 11:08:01 GMT

[quote user="Noweia"]

We had a chronic (2 years) wound cat with a multi-resistant-something, I ended up trying concentrated salt water in the end, bathed it three times daily using a 20ml syringe and green needle and it finally shifted.

[/quote]

Thanks! That's something easy and simple we could try...

Re: Non-healing wound - any ideas?

Miriam Lodewyks — Tue, 25 Jun 2013 11:06:18 GMT

Wasn't intended to be terse, just factual.

Was hoping for some more lateral ideas regarding wound-healing techniques. Perhaps that didn't come across as I'd intended. Apologies.

If a highly experienced orthopod feels that the risk of removing the plate outweighs the potential benefits at this time, I am not going to argue. I am the dog's primary clinician trying to deal with a chronic, non-healing, granulated wound.

Re: Non-healing wound - any ideas?

David Mills — Tue, 25 Jun 2013 10:11:01 GMT

[quote user="GrooveJet"] happen to have a great deal of respect for this particular orthopod. If he's worried about removing the plate, it'll be for a good reason.[/quote]

On the details you gave on the case, there has obviously been somewhat of a long-term 'complication'. You may have the greatest respect for the orthopod, but, as far as the dog's concerned, this is neither here nor there. Its been 9 months - 9 months - since the operation and there is implant infection and the orthopod is afraid the leg will collapse. After 9 months.

I don't know you or the orthopod, whether it was a distant referral, in house, whatever. I would have thought, however, nay expected if this was my case, that he would have a big input into what to do from here.

There may be other things going on, professionally. I only offered a solution and interpretation. Obviously wasn't the one you wanted to hear. If that is what underlies this terse reply, I'm mystified as to why you posted on a semi-public forum.

Re: Non-healing wound - any ideas?

Miriam Lodewyks — Tue, 25 Jun 2013 09:48:37 GMT

I happen to have a great deal of respect for this particular orthopod. If he's worried about removing the plate, it'll be for a good reason. We're all trying to make the best of a difficult situation. The dog has use of the limb, and does not seem to object to the dressings. She has other OA issues so amputation, or risking collapse of this limb would be catastrophic for her.

I would post photos and x-rays if I knew how (am still new to this...)[quote user="David Mills"]

[quote user="GrooveJet"]Our orthopod is reluctant to remove the plate as he fears the carpus will collapse. [/quote]

Sounds like he's absolving himself of responsibility.

Poor dog - 9 months of dressings? Rubbing its leg 'til it bleeds? What sort of life is that?

Remove the leg - better for the dog, better for the community. I think from a public health perspective having MRSP around the place is very bad news. All the MRSP infected implants I've seen, the repair will fail as soon as you take them out, and the dog will break its leg - the bone is often like sand.

[/quote]