Degloving injuries of the lower extremity usually result in amputation. We present a case of successful application of hyperbaric oxygen therapy (HBOT) in a severely degloved foot (MESS 6 - 7). HBOT is increasingly employed in the management of extremity trauma, especially crush injuries. Additionally, the use of leeches, to relieve venous congestion, was found to be highly advantageous.

The patient, a 49-year-old African-American woman, sustained a severe degloving injury with compound comminuted fractures of the foot and ankle when an 18 wheel truck ran over her right foot. There was no significant past medical history. After stabilization in the emergency department, she was taken to be Hyperbaric and Wound Healing Center for immediate treatment, prior to surgery. Treatment was at 2.5ATA for 90 minutes. She was then taken to the operating room where she underwent open reduction and internal fixation of her fractures by the orthopedic service. The plastic surgical procedure simply repositioned the skin in its normal anatomical location. As soon as she recovered from anesthesia, she was returned for an additional hyperbaric oxygen treatment at 2.5ATA for 90 minutes. The following day she received two additional treatments, at the same pressure. Treatments were continued, on a daily basis, at the same pressure and time. Beginning the second day after injury, daily application of leeches was begun, to relieve venous congestion. Fourteen days after injury she underwent partial thickness debridement of the dorsum of the foot and amputation of the second toe, for dry gangrene. Definitive surgery was done two weeks later, at which time the remaining toes were amputated and a split thickness skin graft was applied to the dorsum of her foot. Hyperbaric oxygen treatments continued at 2.0ATA for 90 minutes, daily for a total of 33 treatments.

Prior to discharge, normal sensation was noted of the entire plantar aspect and the patient was beginning to ambulate with crutches. She was then transferred to a rehabilitation facility and was discharged home six weeks following her injury. Late follow-up shows normal ambulation without the need for special shoes.

Severe degloving injuries of the lower extremity are devastating and most often result in amputation. This report presents salvage of just such an injury with the use of aggressive traditional wound care, the use of leeches and hyperbaric oxygen therapy.

Aggressive wound care consists of close observation and appropriate management for a given situation. In this case, it included the use of an antibiotic cream (silver sulfadiazine), debridement when needed and skin grafting when necessary.

The use of leeches for relief of venous congestion is an ancient remedy, which has found new life in modern medicine. With the advent of microvascular surgery, leeches have been used for just this purpose. They are available through, at least, two suppliers in United States. It is our impression that leeches are underutilized in wound care and that a greater awareness of their value is warranted.

We feel that hyperbaric oxygen therapy was the key to success in this patient. Recent work, particularly that of Zamboni and more recently, Buras in addition to the early work by Hart and Strauss and several articles from Sweden have clearly demonstrated the value of hyperbaric oxygen therapy with regard to the treatment of ischemia and reperfusion injury. This is the aspect which we feel was key to the successful outcome for our patient. In addition, the pre-surgical treatment and resulting hyperoxia added to the margin of safety for this severely compromised skin and soft tissue. The "antimicrobial" effect of hyperbaric therapy is well documented.

In short, this combination of old and new therapies and aggressive/attentive wound management can lead to limb salvage in a situation which would traditionally result in amputation. We conclude that HBOT, combined with aggressive wound care, is of significant benefit in severe degloving injury.