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Clinical Research
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Multimodal therapy for the successful closure of large heel ulcers John Lantis, MD, Cindy Gendics, RN, George Todd, MD Introduction: In many series of diabetic foot ulcer care, heel ulcers greater than 4 cm across have been identified as an independent predictor of limb loss. Therefore, we set out to pursue the most aggressive limb salvage algorithm in patients with heel ulcers greater than 4 cm in diameter. .Methods: Over 5 years we identified 21 patients ages 39 to 84 years, all with diabetes mellitus, all with heel ulcers greater than 4 cm in diameter, all had MRI or bone scan evidence of osteomyelitis. Seven of the 21 had ESRD and were hemodialysis dependent. All patients had ABI < 0.4 or monophasic pulse volume recordings (PVRs). All patients underwent distal bypass surgery with vein. After adequate perfusion was obtained all patients underwent partial calcanectomy, and intra-operative negative pressure wound therapy (NPWT) placement. Upon determination of a good granulation bed the first 5 patients underwent STSG with NPWT overlay. The next two patients underwent placement of three layered living cell skin substitute. All seven of these patients had failure of their grafts. All seven of these patients had rescue of their poorly healing wounds with platelet-derived growth factor. Therefore, the ensuing fourteen patients were treated with platelet derived growth factor as soon as their heel ulcers became smaller than 4cm in diameter. Results: One patient underwent amputation during the healing process secondary to ongoing sepsis. Twenty of 21 patients healed acutely (within 6 months). Three of twenty patients went on to subsequent below knee amputation within 12 months of healing primarily. At two years 12 of 21 (57%) are ambulating independently, 1 of 21 is dead, 4 of 21 have undergone amputation, 4 (19%) have limbs that are intact but are not ambulating. A total limb salvage rate of 76% at 2 years, with 100% follow up. Randall DB, Phillips J, Ianiro G. Partial calcanectomy for the treatment of recalcitrant heel ulceration. J Am Podiatr Med Assoc. 2005;95(4):335Ð341..Chipchase SY, Treece KA, Pound N, Game FL, Jeffcoate WJ. Heel ulcers don't heal in diabetes. Or do they? Diabet Med. 2005;22(9):1258Ð1262 Younes NA, Albsoul AM, Awad H. Diabetic heel ulcers: a major risk factor for lower extremity amputation. Ostomy Wound Manage. 2004;50(6):50Ð60. |
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