A wound that has gone more than four to six weeks without closing is not a slow wound: it is a wound with a cause behind it that is still at work. Finding that cause is half the treatment.
The most frequent chronic wounds are the diabetic foot ulcer, the venous leg ulcer, the pressure ulcer — the bedsore of a patient confined to bed — and complex wounds after trauma, surgery or infection. They all have something in common: the body is capable of closing them and is not doing so because something is preventing it. It may be poor blood supply, sustained pressure on the area, bone infection, uncontrolled blood sugar, dead tissue, malnutrition or smoking. It is almost always more than one thing at once.
This explains something that frustrates patients and their families a great deal: wounds that close and open again within a few months. If a pressure ulcer is covered without resolving the pressure, if a diabetic foot is grafted without studying the circulation, or if a wound is closed over infected bone, failure is only a matter of time. That is why the first consultation is not about which cream to use, but about why this wound is not closing. In Peru, with the prevalence of diabetes we have, the diabetic foot is the most frequent cause and also the one that produces the most avoidable amputations.
It usually helps when there is
- A wound that has gone more than four to six weeks without closing.
- A diabetic foot ulcer, with or without exposed bone or tendon.
- A pressure ulcer over the sacrum, heel, hip or sitting bone.
- A venous leg ulcer not responding to compression treatment.
- A wound with bone, tendon, plates or prosthesis exposed.
Worth discussing first if
- Insufficient arterial circulation: revascularisation is needed before surgery.
- Untreated bone infection, which makes any closure fail.
- Uncontrolled diabetes or marked malnutrition.
- Sustained pressure that cannot be removed at home.
- Current smoking, which multiplies the risk of failure.
None of these rules the procedure out on its own; all of them change the conversation.
How it is closed
The simplest thing that solves the problem is chosen, not the most elaborate.
Debridement and wound care
Removing dead and infected tissue and preparing the bed. It is frequently combined with negative-pressure therapy.
Skin graft
When the bed is clean and well vascularised. A simple closure, with no bulk and no resistance to pressure.
Flap
When bone, tendon or material is exposed, or the area bears pressure. It brings your own tissue with its circulation.
The cause before the closure
The order is not changed. Before any closure is considered, the circulation of the area is studied — in the leg and foot, with a vascular study — bone infection is ruled out, blood sugar and nutritional status are controlled, and the pressure is removed if it is a pressure ulcer. Operating on an active cause is scheduling a recurrence and putting the patient through pointless surgery.
Once the cause is under control, the technique follows the rule of the simplest thing that works: direct closure if possible, a graft if the bed is clean, and a flap when important structures are exposed or the area is going to bear pressure routinely. A sacral ulcer covered with a thin graft opens again as soon as the patient sits down; there you need padding, that is, a flap with thickness.
Negative-pressure therapy is a very useful tool for preparing the bed and reducing the size of the wound, but it is not a definitive treatment on its own and it does not replace correcting the cause. And in the diabetic foot, redistributing the pressure when walking and suitable footwear are as much part of the treatment as the surgery.
What the process is like
A staged treatment, with more than one intervention in most cases.
Investigating the cause
Assessment of the circulation, a culture if there is infection, study of the bone and control of diabetes and nutrition.
Preparing the wound
Debridement of dead tissue, control of infection, dressings and negative-pressure therapy where indicated.
Closure
Graft or flap according to the area and what is exposed. In some cases it is done over more than one operation.
Prevention
Pressure offloading, suitable footwear, metabolic control and periodic reviews. It is what stops it coming back.
What to expect
The timings are longer than in other surgery because the ground is compromised.
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Weeks 1 to 2
Rest and strict offloading of the operated area. Frequent dressings and monitoring of the circulation of the flap or graft.
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Weeks 3 to 6
Progressive healing. Weight-bearing or sitting is reintroduced gradually and under supervision.
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Months 2 to 4
The closure consolidates. Footwear or support surfaces are adapted and activity resumes progressively.
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Afterwards
Lifelong periodic reviews in the diabetic foot and in the patient confined to bed. Prevention does not end.
Risks, and what is not promised
Partial or total failure of the graft or flap, infection, breakdown of the suture, haematoma, problems at the donor site and the need to reoperate. In patients with poor circulation, diabetes or malnutrition, the risk of failure is notably higher than in surgery on healthy tissue.
Recurrence of the ulcer, which is the risk most characteristic of this group of wounds and depends largely on the cause staying under control afterwards: pressure offloading, footwear, blood sugar control and giving up smoking weigh as much as the surgery.
In advanced cases of diabetic foot with bone infection or poor circulation, amputating a toe or part of the foot may be the correct treatment, and sometimes the only one that avoids losing the whole limb later. Saying so beforehand is part of dealing honestly. A definitive closure is not promised, nor skin like the original: what is sought is to close the wound stably and preserve function. These risks are reduced by correcting the cause before operating and keeping up the prevention afterwards. They are not eliminated. The ones that apply to your case are set down in writing in the informed consent.
The information on this page is for guidance and does not replace an in-person medical consultation. Medical practice is an obligation of means, not of result.
The questions we are asked most
Because something is preventing it: poor blood supply, sustained pressure, bone infection, uncontrolled blood sugar, dead tissue, malnutrition or smoking. Almost always more than one thing at once.
The first consultation sets out to identify those causes, because closing the wound without correcting them guarantees that it opens again.
That is what most often happens when the wound is treated and the cause is not. A pressure ulcer covered without removing the pressure, or a diabetic foot grafted without studying the circulation, reopens as soon as life goes back to normal.
That is why offloading, footwear and metabolic control are part of the treatment, not optional advice.
Most diabetic feet treated in time are saved. What most increases the risk is coming late, with bone infection or with uncorrected poor circulation.
In advanced cases, amputating a toe or part of the foot may be the right thing to preserve the rest of the limb. If that is the scenario, it is said clearly beforehand, not afterwards.
They help prepare the wound, but none of them closes an ulcer whose cause is still active. A great many months and a great deal of money have been spent changing dressings without studying the circulation.
Dressings and negative-pressure therapy are tools within a plan, not the plan.
Question not answered here? There are more answers in the frequently asked questions.
