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I have a stubborn wound that I can't get to heal. Patient wih 30 year h/o lipodermatosclerosis now with penetrating osteoma cutis. Always probes to bone - I can't get it covered after trying 6 months. Tried standard wound therapies, topical compound trial 1 month, Wound VAC, and Grafix stem cell X 6 applications. Considering hyperbarics.
Aug 26, 2020 by Jessica Hoge,
4 replies
Eugene Worth
MD, M.Ed., FABA, ABPM/UHM
Jessica:

Dr. Song asked me to address the hyperbaric aspect of you question. As for the wound itself, I've never seen such extensive calcific changes in the subcutaneous tissue. I can't tell if it follows muscle planes from the x-ray that you submitted. This is a long-winded introduction for ... "Good luck, and I've never seen anything as bad as this."

I have seen plenty of calcinosis cutis cases. Frequently the cause of the calcifications was scleroderma or some other autoimmune disorder. This etiology is followed by localized repetitive trauma, then a list of also rans for the differential diagnosis. By far and away, the most common diagnosis is some sort of autoimmune disorder.

What struck me in this case is your statement "always probes to bone." Yet, the wound is in a very unusual location (posterior calf???) for it to probe to bone. And, you did not say that you treated the patient for osteomyelitis, had an operative debridement to bone, culture, IV antibiotics, etc. etc.

So, I'm confused. I'm not surprised that your wound care topicals and interventions haven't worked, because I'm not sure that you have a certain diagnosis yet. Osteoma cutis (calcinosis cutis) is a finding, but it isn't a diagnosis.

So, have you established the presence of osteomyelitis? If not, then I suggest a very thorough workup with that in mind. PS: You have to do that in order to qualify for "chronic refractory osteomyelitis" as an indication for HBOT. Right now, you don't have any indication for HBOT. And, I'm pretty certain that this would not heal even if you added HBOT.

So, I'm going to stop rambling on ... this is a very difficult case that I'd like more information about ... and to see through to the resolution. I'm also suggesting that you look for auto-immune disease as well.

Please let us know what happens.
Aug 26, 2020
Lateral aspect of anterior tibia. Negative for osteo on x-ray, but never biopsied bone. Skin bx + osteoma cutis. Negative rheum and endocrine work-up. Considering bisphosphonate. I couldn’t remove the bone- it’s circumferential. Usually I can get some cover and slow resolution with stem cell substitute in these cases, but not this one!
Aug 26, 2020
Eugene Worth
MD, M.Ed., FABA, ABPM/UHM
Puzzling then ... seems like you've covered all the bases except osteomyelitis. In my estimation, a plain x-ray isn't too helpful in ruling out osteomyelitis. How about sed rate and CRP? My imaging routine includes MRI and tagged white cell scans ... even then (admittedly), Osteomyelitis is hard to diagnose.

When you say "couldn't remove the bone, it's circumferential," I"m assuming that you mean the calcinosis ... not that the probe/catheter goes circumferential around the tibia ... Is that correct?

Please review the Wound Reference pages on chronic refractory osteomyelitis and HBOT. There is a specific pathway that you must follow before adding HBOT. And, remember that HBOT does not replace any of the other treatments for Osteomyelitis, it is simply adjunctive.

Any other experts reading this that want to chime in? Help won't be turned down!!! Thanks.
Aug 26, 2020
Eugene Worth
MD, M.Ed., FABA, ABPM/UHM
Puzzling then ... seems like you've covered all the bases except osteomyelitis. In my estimation, a plain x-ray isn't too helpful in ruling out osteomyelitis. How about sed rate and CRP? My imaging routine includes MRI and tagged white cell scans ... even then (admittedly), Osteomyelitis is hard to diagnose.

When you say "couldn't remove the bone, it's circumferential," I"m assuming that you mean the calcinosis ... not that the probe/catheter goes circumferential around the tibia ... Is that correct?

Please review the Wound Reference pages on chronic refractory osteomyelitis and HBOT. There is a specific pathway that you must follow before adding HBOT. And, remember that HBOT does not replace any of the other treatments for Osteomyelitis, it is simply adjunctive.

Any other experts reading this that want to chime in? Help won't be turned down!!! Thanks.
Aug 26, 2020
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