maggot debridement and leech - woundsresearch.com online_wounds.pdfmaggot debridement and leech...

In dogs, laceration and partial amputation injuries of digits are commonlesions resulting from crushing or digit-trapping accidents.1 The severityof the lesion depends on the anatomical location, level of contamination,

extent of vascular injury, and presence or absence of deep tissue or ortho-pedic trauma.2 Because of their role as primary weight-bearing digits, thirdand fourth digital amputations may have a poorer prognosis than other digitinjuries, and cause more significant gait abnormalities.3,4 For this reason

Maggot Debridement and LeechTherapy as Treatment of a PartialDigital Amputation Injury in a Dog

Alessio Vigani, DVM; Allison Schnoke, DVM;Antonio Pozzi, DVM, MS

WOUNDS 2011;23(5):E9–E15

From the College of VeterinaryMedicine, University of Florida,Gainesville

Address correspondence to:Alessio Vigani, DVMP.O. Box 1001262015 SW 16th Ave.Gainesville, FL 32610-0126Email: [email protected]

Vol. 23, No. 5 May 2011 E9

Abstract: A 23-kg, 3-year-old spayed female boxer was admitted forevaluation of a traumatic partial amputation of the fourth digit of theright front limb. The injuries were self-induced by the dog trapping thelegs under a metallic fence. The dog had multiple lacerations on bothfront limbs and a partial amputation of the right front fourth digit. Thedog otherwise appeared to be healthy. Methods and Results. The mul-tiple lacerations were treated with repeated wet-to-dry bandages fol-lowed by non-adherent bandages on the established granulation bed.Epithelization of the numerous superficial skin lacerations was notedwithin 7 to 10 days. Initial management of the digital injury wasunsuccessful. In spite of the aggressive medical and surgical treat-ment, the deep laceration progressively worsened. Serial attempts todebride the necrotic subcutaneous and muscular tissues failed toresult in granulation. Maggot debridement was considered as a lastresort of treatment following limited progress with tissue healing andthe owner firmly declining the amputation of the digit. The treatmentconsisted of a single continuous application of sterile larvae over theopen wound for 3 days to debride the necrotic tissues through the pro-teolitic action of maggot secretions, while sparing the surrounding livestructures. When the complete maggot debridement was achieved,medical grade leeches were used for four consecutive applications 12hours apart to control venous congestion. At the end of the treatmentthe wound was healed and completely re-epithelialized. Conclusion.Maggot debridement and leech therapy were used as alternativewound management of a nonhealing traumatic partial amputation of adigit in a dog. The treatment was safe, successful, and efficient for adifficult wound in a challenging anatomical location.

ONLINE EXCLUSIVE

Vigani online:WOUNDS 5/10/11 1:52 PM Page E9

DO DO N

OT NOT NOT debride the necrotic subcutaneous and muscular tissues failed to

NOT debride the necrotic subcutaneous and muscular tissues failed toresult in granulation. Maggot debridement was considered as a last

NOT result in granulation. Maggot debridement was considered as a lastresort of treatment following limited progress with tissue healing and

NOT resort of treatment following limited progress with tissue healing andthe owner firmly declining the amputation of the digit. The treatment

NOT the owner firmly declining the amputation of the digit. The treatmentconsisted of a single continuous application of sterile larvae over the

NOT consisted of a single continuous application of sterile larvae over theopen wound for 3 days to debride the necrotic tissues through the pro-

NOT open wound for 3 days to debride the necrotic tissues through the pro-

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Therapy as Treatment of a Partial

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Therapy as Treatment of a PartialDigital Amputation Injury in a Dog

DUPLICATEDigital Amputation Injury in a Dog

A 23-kg, 3-year-old spayed female boxer was admitted for

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A 23-kg, 3-year-old spayed female boxer was admitted forevaluation of a traumatic partial amputation of the fourth digit of the

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evaluation of a traumatic partial amputation of the fourth digit of theright front limb. The injuries were self-induced by the dog trapping the

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right front limb. The injuries were self-induced by the dog trapping thelegs under a metallic fence. The dog had multiple lacerations on both

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legs under a metallic fence. The dog had multiple lacerations on bothfront limbs and a partial amputation of the right front fourth digit. The

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front limbs and a partial amputation of the right front fourth digit. Thedog otherwise appeared to be healthy.

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dog otherwise appeared to be healthy. tiple lacerations were treated with repeated wet-to-dry bandages fol-

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tiple lacerations were treated with repeated wet-to-dry bandages fol-lowed by non-adherent bandages on the established granulation bed.

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lowed by non-adherent bandages on the established granulation bed.Epithelization of the numerous superficial skin lacerations was noted

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Epithelization of the numerous superficial skin lacerations was notedwithin 7 to 10 days. Initial management of the digital injury was

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within 7 to 10 days. Initial management of the digital injury wasunsuccessful. In spite of the aggressive medical and surgical treat-DUPLIC

ATE

unsuccessful. In spite of the aggressive medical and surgical treat-ment, the deep laceration progressively worsened. Serial attempts toDUPLIC

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ment, the deep laceration progressively worsened. Serial attempts todebride the necrotic subcutaneous and muscular tissues failed toDUPLIC

ATE

debride the necrotic subcutaneous and muscular tissues failed toresult in granulation. Maggot debridement was considered as a lastDUPLIC

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result in granulation. Maggot debridement was considered as a last

numerous medical and surgical procedures, have beendescribed in order to preserve or replace weight-bearingdigits.1 Non-surgical treatments include autolytic or enzy-matic debridement, wet-to-dry dressings, and negativepressure wound therapy (NPWT). Several surgical recon-struction techniques have also been reported, includinglocal or distant flaps, free grafts, or digital pad transfers.5

Independently from the chosen type of management,negative prognostic factors attributed to failure of effec-tive digital salvage are presence of infection, tissue necro-sis, and inadequate circulation.1 Decreased availability ofvital tissue and inadequate blood flow impede a success-ful surgical debridement and also prevent systemic ortopical antibacterials from reaching the targeted site.These factors ultimately lead to further progression ofnecrosis, development of nonhealing wounds and aworse clinical outcome.2

In severe wound cases complicated by the presenceof necrosis and infection, alternative forms of woundtherapy have been successful when traditional medicinehave failed.6 Among these alternative methods, biothera-py consists of using living organisms such as fly larvaefor treating, for example, infected or sterile nonhealingwounds.7,8 The application of fly larvae (maggots) isreferred to as maggot debridement therapy (MDT).9

Worldwide, another organism used for biotherapy, theleech, is considered standard of care for venous conges-tion after reconstructive plastic surgery.10–13 While the lit-erature on use of biotherapy in human medicine is onthe rise, there is a paucity of clinical reports in veterinarymedicine.14 Application of MDT in veterinary medicineis more diffuse in large animals, in particular horses, com-pared to companion animals.14–16 A published survey ofthe use of maggot therapy by small animal practitionersdescribed the treatment in two dogs, four cats and onerabbit over a 6-year period.17 A previous article reportedthe outcome of maggot-treatment of chronic bed soresand ulcers in rabbits.18 To the authors knowledge thereare not reports presenting the combined use of MDT andleech therapy for digit injuries in small animals.

This case report describes the sequential use of mag-gots and leeches as treatment of a nonhealing, progres-sive, non-septic necrosis of a primary weight-bearingdigit in a young boxer. The procedures, patient manage-ment, and outcome are discussed.

Case ReportA 23-kg, 3-year-old female spayed boxer was present-

ed to the Ohio State University Small Animal Hospital

Emergency Service for evaluation of multiple lacerationson both front limbs and partial amputation of the rightfront fourth digit. According to the owner, the injurieswere self-induced by the dog trapping the legs under ametallic fence while playing with his playmate. On pres-entation, the dog was bright, alert, and no systemicabnormalities were identified. Multiple abrasions and lac-erations were present on the right front limb up to levelof the elbow. Approximately 60% of the girth of thefourth digit was involved with a 2 cm wide, 0.5 cm deep,severely contaminated laceration at the level of the prox-imal interphalangeal joint. The distal portion of the digitlooked cyanotic and felt cool to the touch. Pain sensationwas still present on manipulation.

The multiple abrasions were immediately treated withsurgical debridement, and then by repeated wet-to-drybandages followed by non-adherent bandages on theestablished granulation bed. A prophylactic broad-spec-trum antibiotic was prescribed for 15 days. Epithelizationof the numerous superficial skin lacerations was notedwithin 7 to 10 days. However, the initial management ofthe digital injury was unsuccessful. In spite of the aggres-sive medical and surgical treatment, the deep lacerationprogressively worsened. Due to the progression of tissuenecrosis, venous congestion and infection, a tissue biop-sy for bacterial culture was obtained. Both aerobic andanaerobic bacterial cultures resulted in no growth.Complete blood count and biochemical profile werewithin normal limits except for a moderate leukocytosis(WBC:15000/mcL) with mature neutrophylia(PMN:11000/mcL). Serial attempts to debride the necrot-ic subcutaneous and muscular tissues failed to result ingranulation. The tendon of the common digital extensor,the proximal interphalangeal joint capsule and the ven-tral portion of the digit were preserved. The remainingvital tissue on the distal segment of the digit becameinsufficient for any further surgical intervention.Biotherapy with maggots and leeches was considered asa last resort of treatment following limited progress withtissue healing, and the owner firmly declining the ampu-tation of the digit.

The first phase of treatment consisted of the continu-ous application of sterile larvae of the common green-bottle fly (Luicilia sericata) over the open wound for 3days. The goal was to debride the necrotic tissues throughthe proteolitic action of maggot secretions, while sparingthe surrounding live structures.19 When the completemaggot debridement was achieved, medical grade leech-es were used for four consecutive applications twelve

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E10 WOUNDS www.woundsresearch.com


DO described the treatment in two dogs, four cats and one

DO described the treatment in two dogs, four cats and onerabbit over a 6-year period.

DO rabbit over a 6-year period.the outcome of maggot-treatment of chronic bed sores

DO the outcome of maggot-treatment of chronic bed soresand ulcers in rabbits.

DO and ulcers in rabbits.are not reports presenting the combined use of MDT and

DO are not reports presenting the combined use of MDT andleech therapy for digit injuries in small animals.DO leech therapy for digit injuries in small animals.

This case report describes the sequential use of mag-DO This case report describes the sequential use of mag-

gots and leeches as treatment of a nonhealing, progres-DO gots and leeches as treatment of a nonhealing, progres-sive, non-septic necrosis of a primary weight-bearingDO sive, non-septic necrosis of a primary weight-bearing

NOT Worldwide, another organism used for biotherapy, the

NOT Worldwide, another organism used for biotherapy, theleech, is considered standard of care for venous conges-

NOT leech, is considered standard of care for venous conges-tion after reconstructive plastic surgery.

NOT tion after reconstructive plastic surgery.10–13

NOT 10–13 While the lit-

NOT While the lit-erature on use of biotherapy in human medicine is on

NOT erature on use of biotherapy in human medicine is onthe rise, there is a paucity of clinical reports in veterinary

NOT the rise, there is a paucity of clinical reports in veterinarymedicine.14 Application of MDT in veterinary medicine

NOT medicine.14 Application of MDT in veterinary medicineis more diffuse in large animals, in particular horses, com-

NOT is more diffuse in large animals, in particular horses, com-pared to companion animals.NOT pared to companion animals.14–16NOT

14–16 A published survey ofNOT A published survey of

the use of maggot therapy by small animal practitionersNOT the use of maggot therapy by small animal practitionersdescribed the treatment in two dogs, four cats and oneNOT described the treatment in two dogs, four cats and onerabbit over a 6-year period.NOT rabbit over a 6-year period.

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therapy have been successful when traditional medicine

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therapy have been successful when traditional medicineAmong these alternative methods, biothera-

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Among these alternative methods, biothera-py consists of using living organisms such as fly larvae

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py consists of using living organisms such as fly larvaefor treating, for example, infected or sterile nonhealing

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for treating, for example, infected or sterile nonhealingThe application of fly larvae (maggots) isDUPLIC

ATE

The application of fly larvae (maggots) isreferred to as maggot debridement therapy (MDT).DUPLIC

ATE

referred to as maggot debridement therapy (MDT).9DUPLICATE

9

Worldwide, another organism used for biotherapy, theDUPLICATE

Worldwide, another organism used for biotherapy, theleech, is considered standard of care for venous conges-DUPLIC

ATE

leech, is considered standard of care for venous conges-

front fourth digit. According to the owner, the injuries

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front fourth digit. According to the owner, the injurieswere self-induced by the dog trapping the legs under a

DUPLICATEwere self-induced by the dog trapping the legs under a

metallic fence while playing with his playmate. On pres-

DUPLICATEmetallic fence while playing with his playmate. On pres-

entation, the dog was bright, alert, and no systemic

DUPLICATEentation, the dog was bright, alert, and no systemic

abnormalities were identified. Multiple abrasions and lac-

DUPLICATEabnormalities were identified. Multiple abrasions and lac-

erations were present on the right front limb up to level

DUPLICATEerations were present on the right front limb up to level

of the elbow. Approximately 60% of the girth of the

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of the elbow. Approximately 60% of the girth of thefourth digit was involved with a 2 cm wide, 0.5 cm deep,

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fourth digit was involved with a 2 cm wide, 0.5 cm deep,severely contaminated laceration at the level of the prox-

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severely contaminated laceration at the level of the prox-imal interphalangeal joint. The distal portion of the digit

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imal interphalangeal joint. The distal portion of the digitlooked cyanotic and felt cool to the touch. Pain sensation

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looked cyanotic and felt cool to the touch. Pain sensationwas still present on manipulation.

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was still present on manipulation. The multiple abrasions were immediately treated with

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The multiple abrasions were immediately treated withsurgical debridement, and then by repeated wet-to-dry

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surgical debridement, and then by repeated wet-to-drybandages followed by non-adherent bandages on the

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bandages followed by non-adherent bandages on theestablished granulation bed. A prophylactic broad-spec-

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established granulation bed. A prophylactic broad-spec-trum antibiotic was prescribed for 15 days. Epithelization

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trum antibiotic was prescribed for 15 days. Epithelizationof the numerous superficial skin lacerations was noted

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of the numerous superficial skin lacerations was notedwithin 7 to 10 days. However, the initial management of

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within 7 to 10 days. However, the initial management ofthe digital injury was unsuccessful. In spite of the aggres-

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the digital injury was unsuccessful. In spite of the aggres-sive medical and surgical treatment, the deep laceration

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sive medical and surgical treatment, the deep lacerationprogressively worsened. Due to the progression of tissueDUPLIC

ATE

progressively worsened. Due to the progression of tissuenecrosis, venous congestion and infection, a tissue biop-DUPLIC

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necrosis, venous congestion and infection, a tissue biop-

hours apart. The goal ofthe leech therapy was totemporarily maintainblood drainage until com-plete revascularization ofthe digit occurred.

Sedation of the patientwas needed for the mag-got application. The con-finement of the larvaewithin the lesion was criti-cal for maximizing theeffect of MDT and foravoiding complications.Under antiseptic condi-tions a wound-sized holewas cut out of self-adhe-sive hydrocolloid dressingthat served as foundationfor the “maggot cage.” Weused a pre-manufactureddressing called Le Flap™

(Monarch Labs, Irvine,CA). The dressing wasshaped to conform to thedigit and the two adjacentinterdigital spaces. Thesterile maggots were thenmoved from their contain-er to the wound, whichhad been previously isolat-ed by the hydrocolloid pad(Figure 1). A total ofapproximately 30 larvaewere transferred from thecontainer by wiping themoff the sides of the vialwith a sterile saline-mois-tened swab. Directly afterthe transfer, the larvaewere quickly covered witha piece of nylon nettingaffixed to the hydrocolloiddressing with the adhesive glue provided in the Le Flapdressing kit. The netting was finally covered with anabsorbent air permeable pad of gauzes to maintain airflowto the larvae as well as to draw moisture and tissue debrisfrom the wound. A bivalved fiberglass cast reaching theelbow was applied for preventing displacement of the

“cage” during movement. A distal window on the castallowed the three times daily changes of the top absorbentpad and re-evaluation of the wound. Maggots were leftover the laceration for three days, free to move within theconfinement dressing. An Elizabethan collar was main-tained at all times to prevent direct patient interference.

Vigani et al

Vol. 23, No. 5 May 2011 E11

Figure 1. Day 0: Maggots placed into thewound isolated by the hydrocolloid paduse as foundation for the “maggot cage.”

Figure 2. Wound after 3 days of MDT (Day3).

Figure 3. Day 4: Three leeches attachedto the congested distal portion of thedigit.

Figure 4. Day 9: Wound completelyhealed and re-epithelialized.


DO were transferred from the

DO were transferred from thecontainer by wiping them

DO container by wiping themoff the sides of the vial

DO off the sides of the vialwith a sterile saline-mois-

DO with a sterile saline-mois-tened swab. Directly after

DO tened swab. Directly afterthe transfer, the larvaeDO the transfer, the larvaewere quickly covered withDO were quickly covered witha piece of nylon nettingDO a piece of nylon nettingaffixed to the hydrocolloidDO affixed to the hydrocolloid

NOT er to the wound, which

NOT er to the wound, whichhad been previously isolat-

NOT had been previously isolat-ed by the hydrocolloid pad

NOT ed by the hydrocolloid pad(Figure 1). A total ofNOT (Figure 1). A total ofapproximately 30 larvaeNOT approximately 30 larvaewere transferred from theNOT were transferred from thecontainer by wiping themNOT container by wiping themNOT

NOT DUPLIC

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Day 0: Maggots placed into the

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Day 0: Maggots placed into thewound isolated by the hydrocolloid pad

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wound isolated by the hydrocolloid paduse as foundation for the “maggot cage.”

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use as foundation for the “maggot cage.”

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Figure 2.

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Figure 2.3).

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3).

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On the third day of treatment we removed the dress-ing and disposed of the maggots. The dog was carefullyinspected to ensure that no larvae had escaped. Woundgranulation was sufficient to enable the secondary clo-sure without any further debriding interventions (Figure2). Horizontal pattern stent sutures were placed in orderto relieve wound tension during the healing process.Twenty-four hours after the maggots were removed, thedistal portion of the digit was still significantly swollenand congested, most likely secondary to both the inflam-matory process and the inadequate venous return.

In an attempt to relieve the venous congestion andimprove blood flow to the distal digit, four sequentialapplications of medical grade leeches were performed.Before each application the area was cleaned thoroughlywith warmed heparinized saline to enhance vasodilationand promote ongoing bleeding. The area was notscrubbed with antiseptic agents that would impede theleech attachment. The skin surrounding the lesion waspricked with a hypodermic needle to encourage eachleech to attach a targeted location. Each leech was gentlypicked up using standard exam gloves and the leech’shead was steered to the target spot on the skin. Two tothree leeches at a time were applied (Figure 3). Onceattached, each leech remained safely in place until fullydistended (20–30 minutes). The leeches’ activity wasmonitored over the entire duration of the procedure toensure that each leech had not migrated or detached pre-maturely. The prophylactic regimen of antibiotic wascontinued also for the entire duration of leech therapy.Giving that the therapeutic effect of leech application isgained almost entirely in the post-suction period eachbite was encouraged to bleed by gently removing anylocally forming clot at regular intervals (4–6 hours). Acompressive bandage was put on the extremity between

the re-checks in order to prevent excessive bleeding.Packed cell volume and total solids were checked dailyfor the duration of leech therapy to monitor blood loss.

At the end of the treatment pain medications andantibiotics were discontinued and the patient was dis-charged. Sutures were removed ten days after applica-tion. At that time (4 days after the last leech treatment)the wound was healed and completely re-epithelialized(Figure 4). The degree of weight bearing on each digitwas assessed with a pressure platform (Tek-Scan®,Boston, MA) that allowed us to objectively measure limbfunction of both front limbs during consecutive strides.No statistical difference was found between the percent-ages of weight borne by each digit on the treated legcompared to the respective contralateral digits (Table 1).Three months later, telephone contact was made withthe owner who reported that there were no residualwound problems, evidence of lameness, or other painrelated behaviors.

DiscussionThe efficacy of biotherapy in wound management

has been demonstrated in both people and animals.14,20

Fly maggots have been known for centuries for theirability to debride wounds. Today, MDT is used in morethan 20 countries worldwide and more than 2000 med-ical institutions. Greater than 30,000 patients have beentreated successfully in the last 20 years.21 Lately, thistreatment modality received the approval from thenational health authorities of the United States, GreatBritain, and Israel.21 In veterinary medicine examples ofMDT are relatively rare, more commonly found inbovine and equine medicine.14–16 Our case report is thefirst describing the combined use of MDT and leechtherapy in the attempt to prevent a digital amputation.

Vigani et al


Difference betweenmean values (L-R)

P

Metacarpal pad 0.38 (± 0.11) 0.41 (± 0.23) -0.03 0.80Digital pad-2 0.88 (± 0.29) 0.94 (± 0.13) -0.06 0.70Didital pad-3 4.62 (± 1.09) 3.72 (± 0.55) +0.9 0.15Digital pad-4 6.98 (± 0.90) 6.44 (± 0.65) +0.54 0.23Digital pad-5 4.66 (± 0.32) 5.36 (± 0.79) -0.7 0.16Total 17.44 (± 1.44) 16.88 (± 1.54) 0.56 0.57

Table 1. Data of Vertical Impulse during walk measured with Pressure Platform Gait Analysis (TekScan®, Boston,MA). Measurements are shown in percentage of body weight born by each digital pad of both front legs. Theresults showed that the percentage of weight borne by the pad of the right front fourth digit (injured digit) is notstatistically diffent from the one borne by the contralateral fourth digit.

Right front leg (injured leg [mean ± SD])

Left front leg(mean ± SD)

Pad/Digit


DO leech to attach a targeted location. Each leech was gently

DO leech to attach a targeted location. Each leech was gentlypicked up using standard exam gloves and the leech’s

DO picked up using standard exam gloves and the leech’shead was steered to the target spot on the skin. Two to

DO head was steered to the target spot on the skin. Two tothree leeches at a time were applied (Figure 3). Once

DO three leeches at a time were applied (Figure 3). Onceattached, each leech remained safely in place until fully

DO attached, each leech remained safely in place until fullydistended (20–30 minutes). The leeches’ activity wasDO distended (20–30 minutes). The leeches’ activity wasmonitored over the entire duration of the procedure toDO monitored over the entire duration of the procedure toensure that each leech had not migrated or detached pre-DO ensure that each leech had not migrated or detached pre-maturely. The prophylactic regimen of antibiotic wasDO maturely. The prophylactic regimen of antibiotic was

NOT In an attempt to relieve the venous congestion and

NOT In an attempt to relieve the venous congestion andimprove blood flow to the distal digit, four sequential

NOT improve blood flow to the distal digit, four sequentialapplications of medical grade leeches were performed.

NOT applications of medical grade leeches were performed.Before each application the area was cleaned thoroughly

NOT Before each application the area was cleaned thoroughlywith warmed heparinized saline to enhance vasodilation

NOT with warmed heparinized saline to enhance vasodilationand promote ongoing bleeding. The area was not

NOT and promote ongoing bleeding. The area was notscrubbed with antiseptic agents that would impede the

NOT scrubbed with antiseptic agents that would impede theleech attachment. The skin surrounding the lesion wasNOT leech attachment. The skin surrounding the lesion waspricked with a hypodermic needle to encourage eachNOT pricked with a hypodermic needle to encourage eachleech to attach a targeted location. Each leech was gentlyNOT leech to attach a targeted location. Each leech was gentlypicked up using standard exam gloves and the leech’sNOT picked up using standard exam gloves and the leech’s

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2). Horizontal pattern stent sutures were placed in order

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2). Horizontal pattern stent sutures were placed in orderto relieve wound tension during the healing process.

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to relieve wound tension during the healing process.Twenty-four hours after the maggots were removed, the

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Twenty-four hours after the maggots were removed, thedistal portion of the digit was still significantly swollen

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distal portion of the digit was still significantly swollenand congested, most likely secondary to both the inflam-DUPLIC

ATE

and congested, most likely secondary to both the inflam-matory process and the inadequate venous return. DUPLIC

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matory process and the inadequate venous return.In an attempt to relieve the venous congestion andDUPLIC

ATE

In an attempt to relieve the venous congestion andimprove blood flow to the distal digit, four sequentialDUPLIC

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improve blood flow to the distal digit, four sequential

the re-checks in order to prevent excessive bleeding.

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the re-checks in order to prevent excessive bleeding.Packed cell volume and total solids were checked daily

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Packed cell volume and total solids were checked dailyfor the duration of leech therapy to monitor blood loss.

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for the duration of leech therapy to monitor blood loss.At the end of the treatment pain medications and

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At the end of the treatment pain medications andantibiotics were discontinued and the patient was dis-

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antibiotics were discontinued and the patient was dis-charged. Sutures were removed ten days after applica-

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charged. Sutures were removed ten days after applica-tion. At that time (4 days after the last leech treatment)

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tion. At that time (4 days after the last leech treatment)the wound was healed and completely re-epithelialized

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the wound was healed and completely re-epithelialized(Figure 4). The degree of weight bearing on each digit

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(Figure 4). The degree of weight bearing on each digitwas assessed with a pressure platform (Tek-ScanDUPLIC

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was assessed with a pressure platform (Tek-ScanBoston, MA) that allowed us to objectively measure limbDUPLIC

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Boston, MA) that allowed us to objectively measure limbDUPLICATEP

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0.80

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0.800.70

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0.700.15

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0.15+0.54

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+0.54-0.7

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-0.70.56

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0.56

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MA). Measurements are shown in percentage of body weight born by each digital pad of both front legs. The

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MA). Measurements are shown in percentage of body weight born by each digital pad of both front legs. Theresults showed that the percentage of weight borne by the pad of the right front fourth digit (injured digit) is not

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results showed that the percentage of weight borne by the pad of the right front fourth digit (injured digit) is not

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The successful outcome without complications suggestthat this combination of biotherapies may be beneficialin cases of complicated wounds unresponsive to surgi-cal debridement and dressing.

In this case, MDT was delayed until surgical debride-ment and dressing was attempted. We suspect that thecauses of failure of healing following the initial treatmentincluded insufficient necrotic debridement and insuffi-cient blood supply. Debridement of distal extremitieswounds is difficult because of the functional structuresthat need to be preserved. Additionally, poor blood sup-ply and scarce soft tissue predisposes these wounds toinfection and healing complications.5 The application ofmaggots in infected digital wounds may allow to debridetissue that cannot be otherwise removed surgically orwith other forms of wound therapy.22 The technique thatwe used to apply the maggot dressing is simple, readilyavailable, comfortable for the patient. Medicinal maggotshave multiple beneficial actions by secreting proteolyticenzymes and antimicrobial agents into the wound, andby raising the local pH to levels that inhibits bacteria.19

They produce a selective debridement of the necrotictissue in virtue of the fact that their secretions are inacti-vated by contact with healthy tissue.23 It has also beenshown that they directly stimulate wound healing pro-moting neutrophils activation and fibroblasts migra-tion.23–25 Minor complications of MDT occasionallyreported by human patients ranged from the emotionaldiscomfort of hosting larvae on the skin to the occur-rence of moderate pain.26,27 In the case reported here thedegree of pain associated with the wound, as assessed bythe dog’s response to digital pressure on the digit,decreased significantly early in the treatment. The larvaedid not appear to cause any irritation to the dog, whichseemed unaware of their presence. As for many othercomplex bandaging techniques, the application of thelarvae on veterinary patients requires sedation in orderto sufficiently restrain the animal during the placementof the “maggots cage.” A significant advantage of thistreatment compared to wet-to-dry dressing, is that a sin-gle sedation is needed for the initial application, whilewet-to-dry dressing requires daily treatments in mostcases.14 The maggot-cage remains in place until the endof treatment and then can be easily removed withoutsedation of the patient. Ammonia toxicity in animals nat-urally infested with very high numbers of fly larvae hasalso been reported.14 Therefore the size of the wound inrelation to the size of the animal may be a determinantfactor for the concentration of maggots per square cen-

timeter. Large size wounds in small patients may have tobe conservatively treated with a lower concentration oflarvae.14 Further studies should evaluate the correct num-ber of larvae necessary for application in animals.

The application of leeches for venous congestion inthe distal extremities has not been previously reportedin dogs but is commonly performed in people followingskin reconstruction procedures.11 Following digitalreconstructive surgery, skin-flap transposition, and freetissue transfer, there is often a critical need for adjuvanttherapy in order to restore sufficient venous drainage. Inconditions of limited or absent venous drainage, theblood must be removed and the pressure must bereduced in order to avoid tissue hypoxia and conse-quent necrosis.28,29 Venous congestion can be treated byrelieving tension on the suture site, applying heparin-soaked gauzes, or making small tension releasing-inci-sions.30 In our case, we elected to use medicinal leechesto treat the postoperative venous congenstion.31 Theleech is able to decrease venous congestion in virtue ofthe components of its saliva including anti-thrombotic,thrombolytic, hypotensive, anti-inflammatory, and bacte-riostatic agents.32–35 A single organism attached to theskin of a host will actively withdraw approximately 5mL (1 teaspoon) of blood.36 Further therapeutic benefitof leech therapy comes after the leech is removed, dur-ing which up to 50 mL of blood will continue to oozefor up to 48 hours.37 In human plastic surgery, leechtherapy commonly consists of multiple postoperativeleech applications to the area of interest over 3 to 6days. This is usually the period of time that it takes theveins to regenerate such that the blood is no longerpooling within the surgical site.38 The application ofleeches to the patient is relatively simple, but doesrequire care.39 The number of leeches needed for awound depends on its size and its clinical response tothe treatment. The patient’s skin must be cleaned thor-oughly with gentle soap and water, and then rinsed withdistilled, non-chlorinated water. A gauze barrier aroundthe intended site will prevent the leech from wanderingaway from the site where its attachment is desired. Itcan be carried to the site by hand, or it can be placedwithin a 5 cc plastic syringe (plunger removed) andthen applied to the wound site, containing the leechuntil it is attached.40 If the leech is reluctant to bite, itmight be necessary to entice it with a tiny droplet ofblood, drawn from the wound site with a needle prick.Once the leech is attached, it will likely remain safely inplace until fully distended.41 It is important that the site

Vigani et al

Vol. 23, No. 5 May 2011 E13


DO seemed unaware of their presence. As for many other

DO seemed unaware of their presence. As for many othercomplex bandaging techniques, the application of the

DO complex bandaging techniques, the application of thelarvae on veterinary patients requires sedation in order

DO larvae on veterinary patients requires sedation in orderto sufficiently restrain the animal during the placement

DO to sufficiently restrain the animal during the placementof the “maggots cage.” A significant advantage of this

DO of the “maggots cage.” A significant advantage of thistreatment compared to wet-to-dry dressing, is that a sin-DO treatment compared to wet-to-dry dressing, is that a sin-gle sedation is needed for the initial application, whileDO gle sedation is needed for the initial application, whilewet-to-dry dressing requires daily treatments in mostDO wet-to-dry dressing requires daily treatments in mostcases.DO cases.

NOT moting neutrophils activation and fibroblasts migra-

NOT moting neutrophils activation and fibroblasts migra-Minor complications of MDT occasionally

NOT Minor complications of MDT occasionallyreported by human patients ranged from the emotional

NOT reported by human patients ranged from the emotionaldiscomfort of hosting larvae on the skin to the occur-

NOT discomfort of hosting larvae on the skin to the occur-

26,27

NOT 26,27 In the case reported here the

NOT In the case reported here the

degree of pain associated with the wound, as assessed by

NOT degree of pain associated with the wound, as assessed bythe dog’s response to digital pressure on the digit,

NOT the dog’s response to digital pressure on the digit,decreased significantly early in the treatment. The larvaeNOT decreased significantly early in the treatment. The larvaedid not appear to cause any irritation to the dog, whichNOT did not appear to cause any irritation to the dog, whichseemed unaware of their presence. As for many otherNOT seemed unaware of their presence. As for many othercomplex bandaging techniques, the application of theNOT complex bandaging techniques, the application of the

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enzymes and antimicrobial agents into the wound, and

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enzymes and antimicrobial agents into the wound, andby raising the local pH to levels that inhibits bacteria.

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by raising the local pH to levels that inhibits bacteria.19

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19

They produce a selective debridement of the necrotic

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They produce a selective debridement of the necrotictissue in virtue of the fact that their secretions are inacti-

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tissue in virtue of the fact that their secretions are inacti-It has also beenDUPLIC

ATE

It has also beenshown that they directly stimulate wound healing pro-DUPLIC

ATE

shown that they directly stimulate wound healing pro-moting neutrophils activation and fibroblasts migra-DUPLIC

ATE

moting neutrophils activation and fibroblasts migra-Minor complications of MDT occasionallyDUPLIC

ATE

Minor complications of MDT occasionally

Further studies should evaluate the correct num-

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Further studies should evaluate the correct num-ber of larvae necessary for application in animals.

DUPLICATEber of larvae necessary for application in animals.

The application of leeches for venous congestion in

DUPLICATEThe application of leeches for venous congestion in

the distal extremities has not been previously reported

DUPLICATEthe distal extremities has not been previously reported

in dogs but is commonly performed in people following

DUPLICATEin dogs but is commonly performed in people following

skin reconstruction procedures.

DUPLICATEskin reconstruction procedures.11

DUPLICATE11 Following digital

DUPLICATEFollowing digital

reconstructive surgery, skin-flap transposition, and free

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reconstructive surgery, skin-flap transposition, and freetissue transfer, there is often a critical need for adjuvant

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tissue transfer, there is often a critical need for adjuvanttherapy in order to restore sufficient venous drainage. In

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therapy in order to restore sufficient venous drainage. Inconditions of limited or absent venous drainage, the

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conditions of limited or absent venous drainage, theblood must be removed and the pressure must be

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blood must be removed and the pressure must bereduced in order to avoid tissue hypoxia and conse-

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reduced in order to avoid tissue hypoxia and conse-quent necrosis.

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quent necrosis.28,29

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28,29 Venous congestion can be treated by

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Venous congestion can be treated byrelieving tension on the suture site, applying heparin-

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relieving tension on the suture site, applying heparin-soaked gauzes, or making small tension releasing-inci-

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soaked gauzes, or making small tension releasing-inci-sions.

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sions.30

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30 In our case, we elected to use medicinal leeches

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In our case, we elected to use medicinal leechesto treat the postoperative venous congenstion.

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to treat the postoperative venous congenstion.leech is able to decrease venous congestion in virtue of

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leech is able to decrease venous congestion in virtue ofthe components of its saliva including anti-thrombotic,

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the components of its saliva including anti-thrombotic,thrombolytic, hypotensive, anti-inflammatory, and bacte-

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thrombolytic, hypotensive, anti-inflammatory, and bacte-riostatic agents.

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riostatic agents.skin of a host will actively withdraw approximately 5DUPLIC

ATE

skin of a host will actively withdraw approximately 5mL (1 teaspoon) of blood.DUPLIC

ATE

mL (1 teaspoon) of blood.

be checked continuously to insure that the leech hasn'tmoved. The leech will let go of the patient (host) whenit is finished (usually within 30 minutes).

Complications following leech therapy are rare butworth attention.42 The most common complication fol-lowing leech therapy is persistent and prolonged bleed-ing at the site of detachment of the leech due to releaseof anticoagulants.37 Thus particular attention has to begiven to the blood loss in small sized patients. A well-padded, compressive bandage can be applied if bleedingis a concern. Infection by Aeromonas sp. is possibly themost worrisome complication of leech application inhuman medicine and prophylactic antibiotic therapy isrecommended.43,44 The cost of biotherapy in veterinarymedicine may represent a drawback to its use in veteri-nary practice. However, a study in human patients evalu-ated the cost of MDT compared with conventionalhydrogel bandages, for the treatment of nonhealingulcers.45 The cost of applying maggots was greater perday, yet the shorter hospitalization and smaller number ofdressing changes resulted in a reduced overall cost.46

ConclusionIn this report we presented the successful application

of MDT and leeches in a difficult wound managementcase. While it is impossible to know if other therapeuticapproaches would have given similar results, we con-cluded that this therapy was successful, inexpensive andwell tolerated by the patient. Although the literatureregarding biotherapy in veterinary medicine is severelylimited, the diffuse anecdotal evidence of its efficacy inanimals by both general practitioners and veterinary spe-cialists seems to be promising for the production of amore consistent, scientific literature base.

AcknowledgementWe thank Dr. Jonathan Dyce and Dr. Katy Townsend

from the Ohio State University for completing the Tek-Scan® analysis.

References1. Fowler D. Distal limb and paw injuries. Vet Clin North

Am Small Anim Pract. 2006;36(4):819-845.

2. Pavletic M. Basic principles of wound management. In:

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2010:31-49.

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Distribution of vertical forces in the pads of Greyhounds

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4. Liptak JM, Dernell WS, Rizzo SA, Withrow SJ. Partial foot

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ventional veterinary treatment of skin infections with

Vigani et al



DO Acknowledgement

DO AcknowledgementWe thank Dr. Jonathan Dyce and Dr. Katy Townsend

DO We thank Dr. Jonathan Dyce and Dr. Katy Townsendfrom the Ohio State University for completing the Tek-

DO from the Ohio State University for completing the Tek-Scan

DO Scan®

DO ® analysis.

DO analysis.

ReferencesDO References1. Fowler D. Distal limb and paw injuries. DO 1. Fowler D. Distal limb and paw injuries.

NOT case. While it is impossible to know if other therapeutic

NOT case. While it is impossible to know if other therapeuticapproaches would have given similar results, we con-

NOT approaches would have given similar results, we con-cluded that this therapy was successful, inexpensive and

NOT cluded that this therapy was successful, inexpensive andwell tolerated by the patient. Although the literature

NOT well tolerated by the patient. Although the literatureregarding biotherapy in veterinary medicine is severely

NOT regarding biotherapy in veterinary medicine is severelylimited, the diffuse anecdotal evidence of its efficacy in

NOT limited, the diffuse anecdotal evidence of its efficacy inanimals by both general practitioners and veterinary spe-

NOT animals by both general practitioners and veterinary spe-cialists seems to be promising for the production of aNOT cialists seems to be promising for the production of amore consistent, scientific literature base.NOT more consistent, scientific literature base.

AcknowledgementNOT Acknowledgement

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day, yet the shorter hospitalization and smaller number of

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day, yet the shorter hospitalization and smaller number of

In this report we presented the successful applicationDUPLICATE

In this report we presented the successful applicationof MDT and leeches in a difficult wound managementDUPLIC

ATE

of MDT and leeches in a difficult wound managementcase. While it is impossible to know if other therapeuticDUPLIC

ATE

case. While it is impossible to know if other therapeuticapproaches would have given similar results, we con-DUPLIC

ATE

approaches would have given similar results, we con-


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J Am Anim Hosp Assoc

DUPLICATEJ Am Anim Hosp Assoc.

DUPLICATE.

5. Pavletic M. Foot pad reconstruction. In: Sons JW, ed.

DUPLICATE5. Pavletic M. Foot pad reconstruction. In: Sons JW, ed. Atlas

DUPLICATEAtlasof Small Animal Wound Management & Reconstructive

DUPLICATEof Small Animal Wound Management & Reconstructive

. 3rd ed. Ames: Wiley-Blackwell; 2010:535-558.

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. 3rd ed. Ames: Wiley-Blackwell; 2010:535-558.


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ancient remedy for some contemporary afflictions.

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ancient remedy for some contemporary afflictions.

. 2000;45:55-81.

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. 2000;45:55-81.


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future potential.

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future potential. Postgrad Med J.

DUPLICATE

Postgrad Med J.


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tion.

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tion. Lancet

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Lancet. 2000;356(9236):1174.

DUPLICATE

. 2000;356(9236):1174.


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debridement therapy in chronic wound care.

DUPLICATE

debridement therapy in chronic wound care.

Med J.

DUPLICATE

Med J. 2007;13(5):382-386.

DUPLICATE

2007;13(5):382-386.


DUPLICATE


leech in head and neck reconstruction.

DUPLICATE

leech in head and neck reconstruction.

2000;29(5):327-332.

DUPLICATE

2000;29(5):327-332.

11. Shenfeld OZ. Successful use of the medicinal leechDUPLICATE

11. Shenfeld OZ. Successful use of the medicinal leech

blowfly larvae (Calliphoridae) in Slovakia. Bulletin of the

Veterinary Institute in Pulawy. 2003;47:487-490.

19. Chambers L, Woodrow S, Brown AP, et al. Degradation of

extracellular matrix components by defined proteinases

from the greenbottle larva Lucilia sericata used for the

clinical debridement of non-healing wounds. Br J

Dermatol. 2003;148(1):14-23.

20. Church JC. The traditional use of maggots in wound heal-

ing, and the development of larva therapy (biosurgery) in

modern medicine. J Altern Complement Med.

1996;2(4):525-527.

21. Gupta A. A review of the use of maggots in wound thera-

py. Ann Plast Surg. 2008;60(2):224-227.

22. Mumcuoglu KY, Ingber A, Gilead L, et al. Maggot therapy

for the treatment of intractable wounds. Int J Dermatol.

1999;38(8):623-627.

23. Horobin AJ, Shakesheff KM, Pritchard DI. Maggots and

wound healing: an investigation of the effects of secre-

tions from Lucilia sericata larvae upon the migration of

human dermal fibroblasts over a fibronectin-coated sur-

face. Wound Repair Regen. 2005;13(4):422-433.

24. van der Plas MJ, van der Does AM, Baldry M, et al. Maggot

excretions/secretions inhibit multiple neutrophil pro-

inflammatory responses. Microbes Infect. 2007;9(4):507-

514.

25. Nigam Y, Bexfield A, Thomas S, Ratcliffe NA. Maggot

Therapy: The Science and Implication for CAM Part II-

Maggots Combat Infection. Evid Based Complement

Alternat Med. 2006;3(3):303-308.

26. Steenvoorde P, Buddingh TJ, van Engeland A, Oskam J.

Maggot therapy and the "yuk" factor: an issue for the

patient? Wound Repair Regen. 2005;13(3):350-352.

27. Steenvoorde P, Budding T, Oskam J. Determining pain lev-

els in patients treated with maggot debridement therapy.

J Wound Care. 2005;14(10):485-488.

28. Chepeha DB, Nussenbaum B, Bradford CR, Teknos TN.

Leech therapy for patients with surgically unsalvageable

venous obstruction after revascularized free tissue trans-

fer. Arch Otolaryngol Head Neck Surg. 2002;128(8):960-

965.

29. Roch SP, Clements DN, Mitchell RA, et al. Complications

following tarsal arthrodesis using bone plate fixation in

dogs. J Small Anim Pract. 2008;49(3):117-126.

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venous congestion of free flaps: venous catheterization. J

Craniofac Surg. 2008;19(6):1645-1647.

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1994;93(5):1095-1098.

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N Z. 1998;4(11):21.

38. Movassaghi G. Re: The leech and the physician. World J

Surg. 2001;25(4):532-533.

39. Prentis T. Nursing care in leech therapy. Nurs N Z.

1998;4(11):19-20.

40. Tan O, Atik B, Koseoglu B. An easy and safe method to

apply leeches on flaps: the leech cage. Plast Reconstr

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2005;22(6):458-460.

43. Whitaker IS, Kamya C, Azzopardi EA, Graf J, Kon M,

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DO J Wound Care

DO J Wound Care

28. Chepeha DB, Nussenbaum B, Bradford CR, Teknos TN.

DO 28. Chepeha DB, Nussenbaum B, Bradford CR, Teknos TN.

Leech therapy for patients with surgically unsalvageable

DO Leech therapy for patients with surgically unsalvageable

venous obstruction after revascularized free tissue trans-

DO venous obstruction after revascularized free tissue trans-

fer.

DO fer. Arch Otolaryngol Head Neck Surg

DO Arch Otolaryngol Head Neck Surg

965.DO 965.

29. Roch SP, Clements DN, Mitchell RA, et al. ComplicationsDO 29. Roch SP, Clements DN, Mitchell RA, et al. Complications

following tarsal arthrodesis using bone plate fixation inDO following tarsal arthrodesis using bone plate fixation in

NOT 25. Nigam Y, Bexfield A, Thomas S, Ratcliffe NA. Maggot

NOT 25. Nigam Y, Bexfield A, Thomas S, Ratcliffe NA. Maggot


NOT Therapy: The Science and Implication for CAM Part II-

Evid Based Complement

NOT Evid Based Complement

2006;3(3):303-308.

NOT 2006;3(3):303-308.

26. Steenvoorde P, Buddingh TJ, van Engeland A, Oskam J.

NOT 26. Steenvoorde P, Buddingh TJ, van Engeland A, Oskam J.

Maggot therapy and the "yuk" factor: an issue for the

NOT Maggot therapy and the "yuk" factor: an issue for the

Wound Repair Regen

NOT Wound Repair Regen. 2005;13(3):350-352.

NOT . 2005;13(3):350-352.

27. Steenvoorde P, Budding T, Oskam J. Determining pain lev-NOT 27. Steenvoorde P, Budding T, Oskam J. Determining pain lev-

els in patients treated with maggot debridement therapy.NOT els in patients treated with maggot debridement therapy.

. 2005;14(10):485-488.NOT

. 2005;14(10):485-488.

28. Chepeha DB, Nussenbaum B, Bradford CR, Teknos TN.NOT 28. Chepeha DB, Nussenbaum B, Bradford CR, Teknos TN.

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. 2007;9(4):507-DUPLICATE

. 2007;9(4):507-

25. Nigam Y, Bexfield A, Thomas S, Ratcliffe NA. MaggotDUPLICATE

25. Nigam Y, Bexfield A, Thomas S, Ratcliffe NA. Maggot

Therapy: The Science and Implication for CAM Part II-DUPLICATE


Curr Pharm Des.

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Curr Pharm Des.

34. Baskova IP, Ferner Z, Balkina AS, Kozin S, Kharitonova OV,

DUPLICATE34. Baskova IP, Ferner Z, Balkina AS, Kozin S, Kharitonova OV,

Zavalova LL, et al. [Steroids, histamine and serotonin in

DUPLICATEZavalova LL, et al. [Steroids, histamine and serotonin in

medicinal leech salivary gland secretions].

DUPLICATEmedicinal leech salivary gland secretions]. Biomed

DUPLICATEBiomed

35. Hirudins: return of the leech?

DUPLICATE

35. Hirudins: return of the leech? Lancet

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Lancet

1992;340(8819):579-580.

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1992;340(8819):579-580.


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therapy: a better method.

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therapy: a better method. Plast Reconstr Surg

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Plast Reconstr Surg

1994;93(5):1095-1098.

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1994;93(5):1095-1098.

37. Prentis T. Caring for a patient having leech therapy.

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37. Prentis T. Caring for a patient having leech therapy.

. 1998;4(11):21.

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. 1998;4(11):21.

38. Movassaghi G. Re: The leech and the physician.

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38. Movassaghi G. Re: The leech and the physician.

Surg

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Surg. 2001;25(4):532-533.

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. 2001;25(4):532-533.

39. Prentis T. Nursing care in leech therapy.

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39. Prentis T. Nursing care in leech therapy.

1998;4(11):19-20.

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1998;4(11):19-20.


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apply leeches on flaps: the leech cage.

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apply leeches on flaps: the leech cage.

Surg

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Surg. 2004;113(1):466-467.

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. 2004;113(1):466-467.


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