John Steinberg, DPM PRESENT Editor Assistant Professor, Department of Plastic Surgery Georgetown University School of Medicine

Conclusion of Guest Case Presentation:
Infected PTFE with Large
Open Wound Anterior Ankle

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With the clean anterior ankle wound now showing early granulation and progress, we wanted an option that would move the case to closure as quickly as possible and therefore decrease re-infection opportunity.  The tendon remained viable and the wound base was debrided again with skin edges revised and undermined for mobility.  We then applied an external tissue expander device (DermaClose RC) to the wound margins after laying down a protective sheet of Xeroform to the periwound surface.  We used 4 skin anchors medially, 4 skin anchors laterally, and 1 skin anchor distally to secure the device.  These anchors were all secured to the skin with 2 staples each and were positioned approx 1 cm from the skin margin.  The #2 nylon from the DermaClose RC was woven in a 'shoe-lace' pattern across the wound and tensioned to 1.2 kilograms.  The site was dressed with AquaCel AG and Mepilex AG for moisture retention and protection.

We returned the patient to the OR 4 days later.  The DermaClose device and skin anchors were removed and the wound site prepped and draped in usual fashion.  We revised and debrided the wound margins, noting the continued viability of the tendon and negative growth from deep tissue cultures.  Following pulse-lavage of the site with 3 liters of normal saline, we placed Integra TenoGlide™ tendon protector (without silicone) around the tendon and secured this with Monocryl suture to facilitate tendon gliding.  We then closed the wound site primarily under minimal tension using 2.0 Prolene in retention and vertical mattress sutures. 

The wound was dressed with Mepitel, Acticoat and an incisional negative pressure wound therapy dressing was applied over the area for 24 hours prior to discharge from the hospital.

Click on the images below for a larger view.
Figure 1: Wound Debrided and Dermaclose Device Applied	Figure 2: Post Dermaclose Application four days with Well Approximated Skin Margins
Figure 3: Intra Operative Placement of Integra TenoGlide™ tendon protector for Tendon Gliding	Figure 4: Intra Operative Closure with Minimal Tension

WHAT DO YOU THINK?
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