02/18/2014    Ed Davis, DPM,

Non-Healing Wound S/P Neuroma Surgery

Non-healing post-operative wounds can be a source
of frustration for both the surgeon and the
patient. Wound healing is the natural order of
things so failure to heal occurs when there are
impediments to healing. Consider what the body
needs to heal a wound both locally and
systemically so that a systematic approach is used
as opposed to "trying" various products and seeing
what happens. I am not sure that an MRI will add a
lot of information to this case.

Start with local factors and consider the
condition of the wound. Are there foreign bodies
that are an issue? That can include deep sutures,
possible foreign body reaction to deep sutures,
excessive fibrosis, infections. No mention was
made of wound cultures. I cannot tell from the
photo alone but the deep portion of the wound bed
appears somewhat fibrotic. If that is the case,
consider enzymatic debridement with products such
as collagenase. Is there adequate perfusion to
the wound/vascular status of the patient.

Once infection is ruled out or treated and
fibrosis reduced, than negative pressure wound
therapy has a better chance of stimulating
granulation tissue. Remember that products like
Apligraft and Dermagraft typically require a base
of granulation tissue to work. Products like
Theraskin, which is a dermis based, may work
better when the wound is deeper or one cannot get
sufficient granulation tissue started.

Systemic factors include nutritional issues,
glycemic control, vasculature, hormonal issues.
Has this patient had other issues with wound
healing?

Consider a referral to a wound care center or
plastic surgeon if you do not see improvement in a
reasonable period of time.

Wound healing is the subject of textbooks and
numerous papers so I am just touching on some
important things to consider but encourage
approaching the issue comprehensively and
systematically.

Ed Davis, DPM, San Antonio, TX,
ed@sanantoniodoc.net

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