What's the next best step for a 50-year-old man with a non-healing wound on his right leg, status post (after) fibular fracture and debridement, with persistent wound presence 2 years after the initial injury?

Management of Chronic Non-Healing Wound Post-Fibular Fracture

For this 2-year non-healing wound despite debridement and culture-directed antibiotics, you must immediately assess for underlying osteomyelitis and evaluate the vascular status of the limb, as these are the most common reasons for treatment failure in chronic post-traumatic wounds.

Immediate Next Steps

1. Rule Out Osteomyelitis

• Obtain plain radiographs of the affected leg to look for bone changes including periosteal reaction, lucency, or sequestrum formation that would indicate chronic osteomyelitis 1
• Perform the probe-to-bone (PTB) test during wound examination - if you can probe to bone through the wound, osteomyelitis is highly likely 1
• If radiographs are negative but clinical suspicion remains high, obtain MRI which is the gold standard for diagnosing osteomyelitis in the setting of chronic wounds 1
• Consider bone biopsy for culture if osteomyelitis is confirmed, as this provides the most accurate microbiologic diagnosis 1

The key pitfall here is that superficial wound cultures do not reflect deep tissue or bone infection - your previous culture and sensitivity from wound swabs may be misleading 1. If osteomyelitis is present, treatment requires 4-6 weeks of antibiotics (or longer if infected bone cannot be completely removed surgically) 1.

2. Comprehensive Vascular Assessment

• Palpate pedal pulses bilaterally and document findings 2, 3
• Measure ankle-brachial index (ABI) immediately - critical thresholds requiring urgent vascular referral include ABI <0.5 or ankle pressure <50 mmHg 2, 3
• Obtain toe pressures and transcutaneous oxygen pressure (TcPO2) if available - toe pressure <30 mmHg or TcPO2 <25 mmHg indicates critical ischemia 2
• Refer urgently to vascular surgery if any of these critical thresholds are met, as revascularization must precede definitive wound healing 1, 2, 3

Even healed fractures can be associated with vascular compromise from the initial trauma or subsequent scarring. Wounds with adequate perfusion (toe pressure ≥30 mmHg, TcPO2 ≥25 mmHg) have at least 25% greater probability of healing 2.

3. Obtain Proper Deep Tissue Cultures

Since your previous cultures may have been from superficial swabs, you need to:

• Perform sharp surgical debridement to remove all necrotic tissue and biofilm 1
• Collect tissue specimens from the debrided wound base (minimum of 3 specimens) rather than surface swabs 1, 2
• Send specimens for aerobic, anaerobic, fungal, and acid-fast bacilli cultures 1
• Consider discontinuing all antibiotics for several days before obtaining cultures if the patient is clinically stable, as this improves culture yield 1

Treatment Algorithm After Assessment

If Osteomyelitis is Present:

• Surgical debridement of infected bone if feasible 1
• Culture-directed IV antibiotics for minimum 4-6 weeks 1
• Consider chronic suppressive oral antibiotics if complete surgical excision is not possible 1

If Vascular Insufficiency is Present:

• Urgent revascularization (endovascular or surgical bypass) takes priority over prolonged antibiotic therapy 1, 2, 3
• Do not delay revascularization in favor of medical management alone 1

If Neither Osteomyelitis Nor Vascular Disease:

• Reassess wound care fundamentals using the TIME principle 4:
  • Tissue debridement (regular sharp debridement to remove biofilm) 1, 2
  • Infection control (culture-directed antibiotics only if clinically infected) 1
  • Moisture balance (appropriate dressings for wound exudate) 1, 2
  • Edges and surrounding skin (address any undermining or maceration) 1

Advanced Therapies for Refractory Wounds

If the wound fails to show ≥50% reduction in size after 4 weeks of optimal management, consider advanced wound therapies 1, 5:

• Bioengineered skin equivalents or cellular therapies 1
• Negative pressure wound therapy 1
• Hyperbaric oxygen therapy (particularly if wound remains non-healing after revascularization) 1, 2, 3

Critical Pitfalls to Avoid

• Do not continue empiric antibiotics indefinitely without addressing underlying pathology (osteomyelitis or vascular disease) 1
• Do not rely on superficial wound swabs - they frequently grow colonizing organisms rather than true pathogens 1, 2
• Do not delay vascular assessment and intervention in non-healing post-traumatic wounds 2, 3
• Do not assume the fracture healing means adequate tissue perfusion - compartment syndrome sequelae or vascular injury may persist 2

Multidisciplinary Approach

Given the 2-year chronicity, refer to a wound care center with access to vascular surgery, infectious disease, and orthopedic surgery 3, 6. This patient requires coordinated care that addresses all potential barriers to healing simultaneously rather than sequential single-specialty interventions 3, 6.