Efficacy of a Urinary Bladder Matrix for Treating Wound Dehiscence With Hardware Exposure in a Patient With Rheumatoid Arthritis

Roger D. Bui, BSc; Kenrick Lam, MD; Vinod K. Panchbhavi, MD, FACS

Disclosures

Wounds. 2020;32(4):E27-E30. 

In This Article

Case Report

A 35-year-old woman with a past medical history of hypothyroidism, osteoporosis, and RA presented to the clinic at the University of Texas Medical Branch following right great toe arthrodesis, metatarsal neck osteotomies, extensor tendon lengthening, and capsulotomy of the second, third, fourth, and fifth toes 2 weeks prior, with wound dehiscence of the right great toe and subsequent exposure of surgical hardware complicated by infection. She reported a 9 on the visual analogue scale (VAS), and the open wound was malodorous and erythematous with purulent discharge (Figure 1). Erythrocyte sedimentation rate and C-reactive protein were elevated at 49 mm/HR and 5.8 mg/dL, respectively, but these would have been potentially poor surrogates for inflammation secondary to infection due to the patient's chronic RA. The patient reported being unable to use her walker and crutches due to her debilitating RA. When the patient had to use them, she accidentally stepped onto her foot and the sutures came out. She reported no fever or chills.

Figure 1.

Dehisced right hallux with hardware exposure.

Treatment Course

Despite negative methicillin-resistant Staphylococcus aureus (MRSA)/methicillin-sensitive S aureus polymerase chain reaction (PCR) of nares, treatment was initiated with prompt administration of intravenous vancomycin 1000 mg every 12 hours for 7 days. She was seen by rheumatology, who recommended adalimumab and methotrexate (MTX) be discontinued until the right foot became clear of infection to facilitate wound healing. Plaquenil (hydroxychloroquine; Concordia Pharmaceuticals Inc) was recommended as an alternative, but the patient was not amenable to trying the drug. Wound care involved twice daily Dakin's solution (sodium hypochlorite; Century Pharmaceuticals, Inc) dressing changes. The wound improved after 5 days of antibiotics, at which time the transitioned to oral trimethoprim/sulfamethoxazole (TMP/SMX) 400/80 mg twice daily. The decision was made to use negative pressure wound therapy (NPWT; V.A.C. Therapy; 3M+KCI) on the wound to expedite healing and closure. The NPWT device, which consisted of an open-pore polyurethane ether foam sponge, adhesive cover, fluid collection reservoir, and a suction pump, was employed. A week into admission, an X-ray of the foot showed moderate soft-tissue swelling of the great toe with soft-tissue emphysema consistent with cellulitis (Figure 2). No acute hardware complications were noted.

Figure 2.

X-ray of right foot.

After noticeable clinical improvement, including increased range of motion of toes and diminished swelling and erythema, NPWT was discontinued after 10 days due to poor suction caused by the location and irregular contour of the wound. The wound was still open and extremely susceptible to major infection. Ultimately, a Cytal 1-Layer Wound Matrix graft (ACell) was placed on the wound. While biological materials composed of extracellular matrix may be harvested from a wide variety of tissues and organs, the porcine urinary bladder matrix (UBM) has a unique bimodal surface that consists of an intact basement membrane and organized connective tissue comprised of urinary bladder lamina propria. This serves as a robust scaffold for cell infiltration and expedited wound healing. In addition, the prefenestrated design is conformable to irregular wound beds and optimizes fluid management. The conformability of the UBM was the reason why treatment was sought with this matrix following discontinuation of NPWT.

The UBM graft was in place for 7 days before the patient was discharged. The patient was instructed to keep the dressing clean, dry, and intact for 2 weeks. Following that, the dressing was changed every other day; the patient was instructed to remove the elastic bandage, gauze dressing, and gauze pad using the following instruction. The yellow Xeroform layer (Xeroform Occlusive Dressing; Cardinal Health) was to be taken off with care; with clean gloves and a tongue depressor, a generous amount of SURGI-gel (Orion Laboratories Pty Ltd) was to be applied to the UBM graft. Subsequently, the wound was to be recovered with a Xeroform, gauze pad, Kerlix (Cardinal Health), and elastic bandage. The patient was instructed to do so every other day for 1 week until the follow-up appointment with orthopedic surgery. At that point in time, the patient was stable for discharge and scheduled to be seen for follow-up in 1 week at the clinic. At discharge, adalimumab was held and MTX was restarted to prevent disease progression of RA. The patient was discharged on Bactrim (trimethoprim/sulfamethoxazole; Roche) 80 mg twice daily.

Outcomes

At the 1-week follow-up from discharge, the patient reported feeling much better with an improvement in pain. The UBM graft on the patient's right great toe stayed intact and had been kept clean. Physical examination revealed that the patient could move her toes more freely, and sensation was returning as well. The dehisced right great toe incision had no evidence of purulence, was minimally odorous, and had mild erythema. The patient did not report any fever or chills but endorsed dorsal toe numbness that was chronic. At the 2-month follow-up, the patient reported doing much better. Despite restarting the previous regimen of MTX 2.5 mg tablets, 8 tablets per week, the wound was healing very nicely and was devoid of any drainage or odor. At the 3-month follow-up, the patient reported a significant improvement in pain with a VAS of 3, and with adherence to weight-bearing restrictions. The wound was closed and without any drainage (Figure 3). There was no sign of infection related to the implant at that time, and further follow-up was unnecessary.

Figure 3.

At 3-month follow-up, wound closure achieved with urinary bladder matrix.

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