Patient history

An adult male dog called Django was presented to the on-call service with a gunshot wound on the right hind limb. The dog was not known to have an owner and therefore had an unknown medical history. An X-Ray and ultrasound was performed. The X-Ray scan revealed several pellets from a hunting firearm largely spread around the abdominal wall and the knee joint (figure 1). Because of the severity of the gunshot wound, amputation was necessary and performed after three days of admittance. One week later, the patient was again presented to the on-call service with a highly exudative, necrotic wound underneath the pelvis.  

Methods

On initial presentation, the patient was lavaged and bandaged. The initial treatment (before surgery) consisted of fluid therapy (Ringer´s lactate), antibiotics (Enrofloxacin, Amoxicillin, Clavulanic acid), NSAID (Meloxicam), an antihemorrhagic agent (Ethamsylate) and pain medication (Buprenorphine). This treatment continued until the amputation surgery three days later.

One week after the surgery, the patient was again presented with the wound showing signs of dehiscence. The wound was mechanically and surgically debrided of necrotic tissue. A lavage with Ringers Lactate was performed until the wound was visually free of necrotic tissue and macroscopic foreign bodies. After which L-Mesitran Soft (containing Medical Grade Honey (MGH)) was applied to the wound for the first and last week of treatment, (with L-Mesitran Tulle and Foam being applied in between), covered by non-woven gauze, cast padding, and cohesive elastic wrap. 

Results

The dehiscent amputation site showed signs of infection, for which antibiotics were administered. The wound received topical treatment with MGH, but showed no signs of healing. After opening the suture and applying MGH in the amputation cavity (Figure 2, day 5), the  wound started to contract in a short time frame (figure 2, day 10, 15 and 28) before closing completely (figure 2, day 28 and 35). Partial epithelialization was observed, and the wound edges contracted after application with MGH.

Discussion

In this case, we present the patient as having suffered a gunshot wound in the right hind limb and as a result, had to have the limb amputated. A wound with an origin like a gunshot or multiple gunshots being treated with MGH is rare but has been published before. In white rhinos, poaching led to gunshot wounds in a sub-adult calf and bull which were left for dead after their horns had been cut out. Both rhinos recovered after the application of MGH and further antibiotics to prevent infection were not needed (1). The use of MGH is known to be effective in amputee cases. In amputation cases where polymicrobial infections were present, MGH was shown to be effective against ampicillin-and penicillin-resistant bacteria and removed malodour from the wound site (2). Infection in this case was likely the result of the dehiscence of the wound and not the result of the amputation surgery itself.. Contraction was observed to be the main factor in the healing of the wound, with epithelialization being observed to be less apparent compared to epithelium formation. In an earlier case, the same effect was observed on full-thickness burn wound healing application of MGH. Contraction was the main mechanism and healed the full-thickness burn in 26 days, which usually takes longer to heal (3). Furthermore, no complications arose from this decreased wound healing time (3). Antibiotics were administered, with no improvement to the wound healing process. MGH has antibacterial properties and is effective on multi-resistant bacteria, even when present in a biofilm (4, 5).

Conclusion

The use of MGH in the treatment of a wound of surgical origin is safe and effective, even after the wound has been present for an extended period of time. In amputation wounds, it is effective in reducing bacteria colonization and malodour, which it exerts through its antimicrobial action.