This is a case report of a post-replantation infection treated with biologic debridement using maggots after failure of antibiotic therapy. The patient suffered amputation of his left arm at the level of the elbow in a machinery accident, with significant crush and destruction of the articular surfaces of the elbow joint. Standard replantation technique is described in the article, including operative debridement of non-viable tissue at the time of surgery. Vascularity of the distal part was restored, with no apparent ischemic changes in the early postoperative period. Infection was noted 72 hours after surgery, necessitating debridement and antibiotic therapy for Staph. aureus infection. After 7 days, no improvement was noted and maggot therapy was initiated. Maggots were introduced into the wound every other day for 6 days. There was no effect on vascularity of the distal part. The authors describe effective debridement of all infected and necrotic tissue without loss of viable tissue in the process. Cultures after maggot therapy were negative. The wound was closed with skin grafting without further complications at 2 month follow-up.
The authors review the available literature on maggot therapy, a technique largely abandoned with the advent of antibiotics and anesthetics allowing aggressive surgical debridement. The recent literature supports the effectiveness of maggot therapy in debridement of necrotic wounds, with favorable results when compared with surgical debridement alone. In this particular case, the treatment was made more palatable by the insensate nature of the infected part after limb replantation. In other wounds with intact sensation, pain and itching are apparently associated with the treatment. The authors cite the effective discrimination by maggots between viable and non-viable tissue, minimizing the loss of critical viable structures which may be seen with aggressive surgical debridement of large infected limb wounds. This does appear to be a useful, if psychologically difficult, practice in the treatment of these wounds.
Some questions remain unanswered by this report. Despite the elaborate "sterilization" procedure described by the authors, there is the possibility that maggots themselves may carry and transmit bacteria or other pathogens. This has certainly been seen with leeches, and studies have been published addressing the flora of the medicinal leech and the need for prophylactic antibiotic treatment during leech therapy. Are maggots alone enough to treat the infection present in large wounds, without antibiotics, or do they merely help debride the necrotic tissue resulting from the infection? This is not clear in this report. This is an important distinction in directing safe and effective treatment of necrotizing infections. Nonetheless, the use of maggots in debridement of necrotic wounds associated with replanted parts was effective in this case and warrants more thorough investigation. One wonders if the psychological implications will severely limit its utility in certain developed cultures, such as ours.
Replantation, Maggots, Debridement, Wounds, Infection
J of Reconstructive Microsurgery