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  Discussion on Healing a stitched wound with a laser
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Posted on Wednesday, Oct 31, 2001 - 12:09 pm:

Hi Dr. O

I tried to post this earlier, but it didn't work. So I'll try again.

I have a 3 YO filly that cut her leg. It happened over night and was found the next morning. It is a 5-6 in laceration in an upside down V, on the back of her front leg, about 3 inches above the fetlock. It was very dirty and swollen when found.

The vet came out to stitch it up, at least 12 hours after the cut happened. He cleaned it and stitched it (15 stitches). The cut appears to run along the tendon sheath, but did not appear to have have involved it. He put her on antibiotics and bute. His biggest concern was infection.

He also recommended using a therapeutic laser directly over the stitches and the skin flap every other day for 10 days. He said the laser would help prevent infection and proudflesh.

The injury occured Sat night/Sunday morning. When I cleaned and rebandaged the wound last night it looked very good. The swelling and heat are dissipating. There is very little discharge, mostly reddish serous fluid, no pus or bad smells. She's getting SMZ-TMP, 12 pills 2 x a day and 1g Bute, 2x a day. I'm reducing her to 1g bute 1x a day today, since the swelling is down so much.

My question is, in your opinion will the laser help? The cost is rather high to have the treatments done, and if there isn't any evidence that it will help, I'd like to not use it. She had 1 treatment on Monday.

Any advice you can give would help.

Thanks,
Heidi

Posted on Thursday, Nov 1, 2001 - 6:03 am:

Hello Heidi,
This is not a simple question. First there is no "typical laser". They differ tremendously in their frequency, power, and focus. While some will provide little more than thermal warming to the skin others can cut rapidly through tissue.

I do not know of any work that shows that lasering the stitches and sutured skin flap would prevent infection or proud flesh forming under a stitched wound. Proud flesh should not be a problem under a stitched wound. I would be interested in any such information. About the only mechanisim that makes sense is warming the tissues resulting in increase circulation, but this could be done much cheaper and with far more control with other means and it is not clear that it would be helpful in all cases.

You should be aware Heidi, a laceration of this description, is very prone to complications, primarily wound dehiscense (break down of the sutures) secondary to the interrupted blood supply and/or infection. These would usually occur 3 to 11 days following suturing.
DrO

Posted on Thursday, Nov 1, 2001 - 6:12 am:

I just came across your other post that had one extra piece of information: a serosangunous discharge. Having a discharge of this type 4 days post repair is probably an indication this wound is going to dehisce.
DrO
PS, The probable reason your earlier post did not show up in your browser is that it is not refreshing (reloading) each time a page is updated, check your help section of your browser to adjust these settings.

Posted on Thursday, Nov 1, 2001 - 9:53 am:

Thanks for the information. The laser That was recommended appears to have only warmed the tissues, it doesn't cut through anything. I suspect the wound stays warmer all by itself, just by having a pressure wrap on it all the time. I don't believe I will be using the laser.

I understand your caution about dehiscense. I will watch for that. As of last night, there was no discharge, the sutures are all intact, and the flap of skin appears to be healthy. There doesn't appear to be any shrinking or drying out of the skin flap.

I think she was lucky in that the overall width of the bottom of the laceration is about 3 - 4 inches across. The wound looks almost like an upside down U instead of the V I initially described. Hopefully the blood supply stayed intact.

Thanks again for the infomation.

PS. I am looking into my browser settings.

Posted on Friday, Nov 2, 2001 - 11:48 am:

Hi again,

I think I spoke too soon about the skin flap not starting to shrink. Last night when I went to clean and re dress it, 1 of the stitches had pulled out and another looked like it was going to. There was an open area about the size of a dime along one side of the wound. The other side looked good. There was some discharge again from the open side of the wound, and some blood. But no puss.

I spoke to my vet, and the only thing he recommends is the laser. He says it increases blood supply and oxygenation. Can something like a laser restore blood supply? It doesn't sound right to me.

I'm wondering if there's anything else I should be doing? The wound is being kept clean and dry. I'm putting neosporin on it and putting a pressure wrap over it. I don't particularly care if she has a scar, but I am worried about proud flesh and infection.

Thanks again for your help.

Heidi

Posted on Saturday, Nov 3, 2001 - 6:28 am:

Reread my comments above about using the laser to warm the tissues. While you are attempting to get the sutures to hold and no puss is present, I do not recommend anything much more aggressive than what you are doing. This wound does sound like it is going to open back up and if it does check out the articles on wound care. You can get to them by clicking on the title above.
DrO

Posted on Monday, Nov 5, 2001 - 8:42 am:

Thanks again for your help.

I completely agree with your statement about the laser. Unfortunatly I get the feeling that my vet thinks the only reason I'm having any problems with this wound, is that I'm not using the laser. It's very frustrating.

I've been following your recommendations on wound care, and I think the wound will end up fairly clean, without too much scarring. So far only the one side of the wound seems to have opened up. The other side looks good. The skin seems to have reattached. I'll keep an eye on it though.

Thanks again

Heidi

Posted on Monday, Nov 5, 2001 - 9:54 am:

Hello Heidi,
If only there was a treatment that could guarantee such difficult wounds from dehisicing. I would certainly buy one. It sounds like you were seeing the beginnings of problems back on your first post after he had lasered. I almost suggested then to tell him he can use the laser if he guarantees the results. Then considered it a bit flippant, wish I had if he is going to make such statements.

I am afraid it may be unusual to get one side to heal primarily and one side to open, generally there is too much inflammation under the flap, even in wounds that look good. But it would not be a first. The key is the proper balance of aggressive / gentle cleaning of the open side and good bandaging. The cleaning must remove all exudate and purulence without disturbing areas of the wound that have healed primarily or with minimal granulation, it is a tricky balance. Keep us informed.
DrO

Posted on Monday, Nov 12, 2001 - 4:03 pm:

Well it's been 16 days now. The stitches were removed on Saturday. 1/2 of the wound seems to have closed up, with the other 1/2 open. The area that is open is about the size of a silver dollar and is filled with granulation tissue that bleeds readily. It is just above the pastern, just to the outside of the back of her leg.

The vet is still saying that I need to use the laser on the wound. I can't afford to use the laser, nor do I think it will do anything. So basically I'm ignoring his advice. I did ask if he made guarantees, and he didn't answer.

What I am doing is keeping the leg wrapped in a sturdy pressure wrap. I unwrap it and clean it with a diluted Nolvasan solution every other day, and then re wrap it with Nolvasan ointment. The horse is turned out in a small paddock with another horse to keep her company. If I keep her in a stall she kicks the wall all day, and I'm afraid she will injure herself worse. When she's turned out, she basically just walks around, but nothing too strenuous.

I was wondering though, will using expired Nolvasan ointment do any harm? The cream looks and smells OK, however it expired 11/00. I just found a supplier that has some, and it will be here this week, but will the older ointment do any harm?

Also, at what point should I worry about proud flesh? The granulation tissue has filled the wound, but doesn't "stick out". I'm thinking (after rereading the article) that I just need to keep an eye on it, and if it starts growing beyond the skin, I'll need to have the vet out again. Does that sound right?

Thanks again for your help.

Heidi

Posted on Tuesday, Nov 13, 2001 - 8:01 am:

Hello Heidi,
Excellent that is not a bad deal to get 1/2 a wound of this type healed primarily. He may be pushy with the laser but considering your intial description, he sounds like a pretty good surgeon.

A year out of date is a bit much and may indicate a lack of active chlorhexidine. Use at your own risk there. Are you actively hosing the wound (?)(see Long Term Wound Care) but other than that sounds about right.
DrO

Posted on Tuesday, Nov 13, 2001 - 8:22 am:

Thanks for all of your help Dr. O

Sorry I forgot to mention that after the wound is cleaned with the Nolvasan scrub it is hosed off with pressure. I agree the vet does seem to be a pretty good surgeon. The barn owner has used him for years. Except for vaccinations and coggins, I hadn't needed his services personally. I guess I just need to get to know him

Last night the wound looked really good, and I'm hopeful that the scarring will be minimal.
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