References
Maggot debridement therapy in critical limb ischaemia: a case study
Abstract
Objective:
In critical limb ischaemia (CLI), first-line therapy is revascularisation, but alternative treatment options are needed in certain cases. Maggot debridement therapy (MDT) is historically considered to be contraindicated in ischaemic ulcers. Wound care in patients with CLI is becoming increasingly diverse with the development of novel revascularisation strategies; therefore, CLI now needs to be reconsidered as an indication for MDT.
Method:
We retrospectively reviewed five legs with CLI (five male, one female) treated with MDT between January 2013 and December 2017. Changes in skin perfusion pressure (SPP) around the ulcer before and after MDT were evaluated. One or two cycles of MDT were performed (eight in total). We also evaluated the proportion of necrotic tissue in the ulcer and the presence of exposed necrotic bone. The proportion of necrotic tissue in the ulcer was classified as NT 1+ (<25%), NT 2+ (25–50%), NT 3+ (50–75%) or NT 4+ (>75%).
Results:
When the proportion of necrotic tissue was >50%, with no exposed necrotic bone in the wound, an increase in SPP was observed after five (62.5%) of eight cycles of MDT. And with a proportion of necrotic tissue of <25% and/or exposed necrotic bone in the wound, a decrease in SPP was observed after three (37.5%) of eight cycles. Wound healing was accelerated in the presence of increased SPP.
Conclusion:
Effective MDT with increased SPP requires an ulcerative state of necrotic tissue grade > NT 3+, with no exposed necrotic bone.
The prevalence of peripheral arterial disease (PAD) involving the lower extremities is increasing worldwide as a result of ageing populations, continued cigarette smoking, the diabetes epidemic and increasing obesity rates.1 Critical limb ischaemia (CLI) is the most advanced form of PAD, and is defined as the presence of chronic ischaemic pain at rest, ulceration or gangrene attributable to objectively proven arterial occlusive disease.2 CLI is associated with a high risk of cardiovascular events, including major limb loss, stroke and death.3 There are a number of treatments available for CLI, including pharmacologic therapy, interventional procedures and surgery, as well as other additional treatments, such as hyperbaric oxygen therapy, spinal cord stimulation4 and intermittent pneumatic compression.5
Maggot debridement therapy (MDT) plays an important role in the management of hard-to-heal infected wounds and is used worldwide. MDT has a long history in the clinical setting and its effectiveness has been recognised since ancient times. In more modern times, Baron Dominique Jean Larrey, Surgeon-General in Napoleon's army, was the first to describe the benefits of MDT in writing. In 1931, William Baer, an orthopaedic surgeon at Johns Hopkins Hospital in Baltimore, reported the usefulness of MDT in patients with chronic osteomyelitis.6 Although the mechanisms underlying MDT are still not completely understood, laboratory studies have identified various effects of larval secretions/excretions.7 MDT is now a widely accepted medical practice that has three main actions: debridement, disinfection and stimulation of tissue growth.8 Moreover, clinical and cellular evidence for the effect of MDT on wound healing has recently been discussed in detail.9
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