01 · The Patient
A 57-year-old man with a significant medical history and severe psychiatric fragility was admitted to our care on February 26, 2025, three months after a forefoot trauma that had led to amputation of the distal portion of the right big toe.
The traumatic injury had rapidly become chronic because of the patient’s underlying diabetes and arteriopathy. From an anamnestic standpoint, the patient suffered from severe anxiety-depressive syndrome in addition to several comorbidities: type II diabetes controlled since the age of 34, psoriatic arthritis under treatment, hypertension and hypercholesterolemia.
His past medical history also included acute lymphoblastic leukemia treated with autologous stem cell transplantation at the age of 17, and hepatitis C at the age of 25, subsequently treated until the virus became undetectable.
Pharmacological therapy included empagliflozin, metformin, candesartan, escitalopram, rosuvastatin, ixekizumab, metoprolol tartrate, fenofibrate, lecardipine and insulin degludec.
02 · The Wound
At presentation on February 26, 2025, the lesion involved the right big toe and had an area of 1.71 cm².
The wound showed signs of critical colonization, poorly controlled pain and apparent exposure of the extensor tendon. Pain was severe, with an NRS score of 7.
The clinical picture was particularly concerning because the lesion was located in a diabetic foot, following trauma and partial toe amputation, with exposed deep structures and an underlying vascular impairment. Oximetry performed at the base of the big toe showed an O₂ saturation value of 12.
Arterial Doppler ultrasound revealed no proximal lesions, with a sclerotic but well-preserved peripheral circulation. The right anterior tibial artery was occluded just below its origin, but collateral circulation was well developed.
03 · Prior treatment history
Before regenerative therapy was considered, topical treatment with silver sulfadiazine and antibiotic therapy based on an antibiogram were initiated.
Despite conventional management, the wound remained open and clinically serious. The option of amputation of the big toe was proposed, but the patient categorically refused it.
This proposal triggered a worsening of the patient’s severe anxiety-depressive syndrome, which became one of the central issues in the case. Cooperation was difficult in the initial phase, and the psychological dimension had to be considered alongside the wound itself.
The case therefore required an alternative strategy capable of addressing both the biological complexity of the wound and the patient’s strong refusal of further amputation.
04 · Decision and protocol
On March 25, 2025, the lesion had cleaned up, with the previously exposed deep areas covered and effective granulation tissue present. The area had decreased slightly to 1.32 cm², but pain remained unchanged at NRS 7.
Because oximetry remained poor and the patient’s psychological condition was worsening, treatment with mononuclear cells was indicated.
The decision was made to proceed with combined E-PRP and CGF therapy using the High Q Cell® All-In-One procedural kit. The aim was to support wound healing, modulate inflammation, stimulate local vascular response and preserve the big toe.
The E-PRP component was injected according to the angiosome criterion of the anterior tibial artery, while CGF was applied locally as a patch to cover the lesion.
05 · Clinical response
On April 15, 2025, the first mononuclear cell treatment was performed with both injectable E-PRP and local CGF patch application. The post-treatment course was uneventful.
By June 5, 2025, the lesion had already significantly reduced to 0.4 cm², corresponding to a reduction of nearly 70%. Pain also decreased drastically, from NRS 7 to NRS 1.
This rapid improvement had an important clinical and psychological impact. The patient reported feeling well, and the marked pain reduction helped restore trust in the healthcare team, making the therapeutic relationship easier to manage.
A second mononuclear cell treatment was performed on the same day, again using the High Q Cell® procedural kit. E-PRP was injected into the anterior tibial angiosome and CGF gel was used to cover the lesion, with the aim of achieving complete resolution.
06 · Outcome and follow-up
On June 19, 2025, the patient did not attend the scheduled follow-up appointment, which was not unexpected given his psychiatric history. However, he reported that the condition had resolved.
On September 3, 2025, he returned for follow-up with a fully healed wound and a well-managed local condition.
Oximetric reevaluation showed an O₂ saturation of 31% at the base of the big toe in the supine position, exceeding expectations compared with the initial value.
The wound therefore resolved within approximately six weeks from the beginning of E-PRP and CGF therapy, with disappearance of pain and preservation of the big toe. No post-treatment complications were reported.
07 · Discussion
This case illustrates the potential role of combined E-PRP and CGF therapy in a post-traumatic diabetic foot wound at high risk of amputation.
The case was clinically complex for several reasons. The wound developed after a crush-related forefoot injury in a diabetic patient with underlying arteriopathy, critical colonization and exposed tendon. At the same time, the patient’s severe anxiety-depressive syndrome made the proposed amputation psychologically unacceptable and reduced cooperation in the initial phase.
In this context, the first treatment produced a rapid reduction in pain and wound area. This was clinically important not only for tissue repair, but also because pain relief helped restore patient trust and improved the manageability of the entire case.
The result suggests that E-PRP and CGF may have acted through complementary mechanisms: injectable E-PRP supported local vascular and cellular regeneration along the relevant angiosome, while CGF provided a fibrin-based biological matrix over the lesion.
The most meaningful outcome was not simply wound closure, but the preservation of the big toe in a patient who had refused amputation and who presented significant systemic and psychological fragility.
This case supports the use of PBMNC therapy as a minimally invasive regenerative option in selected diabetic foot wounds where conventional management is insufficient and tissue preservation remains a priority.