Successful Outpatient Treatment of Full-thickness, Necrotic, Lower- extremity Ulcers Caused by Traumatic Hematomas in Anticoagulated Patients.

UNLABELLED Outpatient wound care centers are encountering patients with more complex wounds and an increased incidence of concomi- tant complicating comorbidities. As the population ages, patients with chronic wounds are presenting with multiple active disease processes that cause initiation of the wounds, impede wound healing, and pre- clude safely proceeding with surgical procedures, under anesthesia, to treat those wounds. METHODS Four warfarin-anticoagulated patients presented with large, full-thickness, necrotic, lower extremity wounds induced by hematomas from blunt trauma. Two of the wounds under- went scalpel debridement under local anesthesia while continuing anticoagulation. Following brief initial wound care with normal saline wet-to-moist dressing changes, continuous negative pressure therapy at 125 mmHg was initiated and continued for all wounds until the ex- pansive tissue defects were decreased for 23.8 ± 3.2 days. All wounds were treated with application of a living bilayered skin substitute (LSS) in an outpatient setting while maintaining therapeutic anticoagulation. RESULTS All wounds completely epithelialized (100% closure) by 39.0 ± 21.9 weeks. One wound was completely relieved of its deep tissue defect to total epithelialization with one application of LSS. The largest wound (21.0 cm x 14.5 cm x 2.8 cm) with the greatest undermining (5 cm) was relieved of its tissue defect with a combination of nega- tive pressure therapy and three applications of the LSS. The second largest wound (8.6 cm x 24.0 cm x 2.1 cm), which had an exposed knee joint capsule, required two applications of LSS. These results indicate that patients with large, full-thickness, necrotic, lower extrem- ity wounds caused by traumatic hematomas while on anticoagulation therapy, can be appropriately managed as outpatients with aggressive sharp debridement under local anesthesia, negative pressure therapy for relief of the tissue defect, and bilayered skin substitute application to induce epithelial coverage. CONCLUSION This approach eliminates the need for cessation of anticoagulation therapy and the use of more complex surgical procedures, such as myocutaneous flaps and skin grafts in patients with multiple underlying comorbid conditions.