Challenges in Healing Foot Wounds: A Case Study of Elderly Care

Poor wound healing in the foot?

My grandmother is 90 years old and has developed small wounds on her ankles and the tops of her feet due to her habit of walking barefoot.
These wounds became infected after coming into contact with water while bathing, and the infection worsened due to inadequate dressing changes, eventually requiring skin grafting.
She has undergone skin grafting at the hospital, but the wound healing was poor, leading to graft failure, and no further grafting has been pursued.
The wound has been maintained with dressing changes, but there was a period of infection.
She has undergone wound debridement and hyperbaric oxygen therapy.
Currently, during dressing changes, we have noticed that a previously healing wound has developed some yellowish tissue and has a foul odor, indicating a deterioration in healing.
The physician has applied burn ointment, stating that it is intended to help remove the poorer quality tissue from the wound.
However, after maintaining this treatment for over a month, we feel that the effectiveness of the medication is limited.
Is it necessary to perform wound debridement again, or are there other ointments available that can address the issue of yellow necrotic tissue on the wound?

Qi, 20~29 year old female. Ask Date: 2023/01/07

Dr. Li Zhonghuai reply Surgery

Hello! Each physician has their own method for dressing changes.
The key points are to avoid contact with tap water and not to walk barefoot.
Dressings should be changed twice daily, and any necrotic tissue or biofilm must be removed.
Therefore, if the wound condition is poor, it is important to frequently return to the outpatient clinic for debridement by the physician.
Additionally, be vigilant for any signs of bone involvement, which could lead to chronic osteomyelitis.
As for the choice of ointment, it depends on the physician's preference.
Take care! Changhua Hospital cares about you.

Reply Date: 2023/01/07

More Info

Healing foot wounds in elderly patients, particularly those with underlying health issues, presents a significant challenge. In your grandmother's case, her 90 years of age, combined with the history of barefoot walking leading to small wounds, has resulted in complications that have escalated to the need for skin grafting. Unfortunately, the failure of the graft and subsequent infections highlight the complexities involved in wound healing in older adults.

The factors contributing to poor wound healing in the elderly include reduced blood flow, decreased immune response, and the presence of comorbidities such as diabetes or vascular diseases. In your grandmother's situation, the initial injury was exacerbated by inadequate wound care and exposure to water, which can introduce bacteria and lead to infection. The subsequent infections and the development of necrotic tissue (the yellow, foul-smelling tissue you mentioned) indicate that the wound is not healing properly and may require more aggressive intervention.

The use of hyperbaric oxygen therapy (HBOT) is a recognized treatment for chronic wounds, particularly those that are ischemic or infected. However, its effectiveness can vary, and it is not a standalone solution. The fact that your grandmother has undergone HBOT and still experiences issues suggests that additional measures are necessary.

Regarding the treatment of necrotic tissue, it is crucial to address this promptly. Necrotic tissue can impede healing and serve as a breeding ground for bacteria. The use of topical agents, such as enzymatic debriding agents or specialized wound care products, may help in managing the necrotic tissue. These agents work by breaking down dead tissue and promoting the growth of healthy tissue. However, if the necrotic tissue is extensive or if there is a significant infection, surgical debridement may be necessary to remove the dead tissue effectively.

In terms of topical treatments, there are several options available. For instance, silver sulfadiazine cream is often used for burn wounds and can help prevent infection while promoting healing. Additionally, hydrocolloid dressings can create a moist environment conducive to healing and may help in managing exudate. However, it is essential to consult with a healthcare professional before starting any new treatment to ensure it is appropriate for your grandmother's specific condition.

If the current treatment regimen is not yielding results, it may be time to consider a referral to a wound care specialist or a surgeon who specializes in chronic wounds. They can provide a comprehensive evaluation and may suggest advanced therapies, such as negative pressure wound therapy (NPWT), which can help promote healing by applying a vacuum to the wound, thereby reducing edema and increasing blood flow to the area.

In summary, the challenges in healing foot wounds in elderly patients like your grandmother are multifaceted. It is crucial to address the necrotic tissue, consider advanced wound care options, and possibly seek specialized care. Regular follow-ups with healthcare providers are essential to monitor the wound's progress and adjust treatment plans as necessary. The goal is to create an optimal healing environment while minimizing the risk of further complications.

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