A 42-year-old Mexican-American man with diabetes presented to the emergency room with a 3-day history of left foot swelling, redness, and pain associated with nausea, fever, and chills. He reported having stepped on a nail 1 month prior. The patient was initially managed with oral analgesics and antibiotics and referral to a wound care center for debridement and dressing changes. His condition failed to improve. The patient was a non-smoker with history of hypertension, and myasthenia gravis. He denied any history of previous ulceration in either foot.\nPhysical examination revealed that his foot was exquisitely tender, with copious, fetid purulent discharge. The popliteal pulse and the digital capillary refill time were normal. Pedal pulses were not readily palpable due to edema and exquisite tenderness, which transcended his neuropathy. Nonetheless, he had normal Doppler signals on the dorsum of his foot. He had loss of protective sensation to his feet based on the Ipswich Touch Test (). An open ulceration of the plantar lateral fifth metatarsal probing to the capsular tissue with a tunneling track toward the proximal porta pedis was noticed. A malodorous purulent draining and deep tunneling lesion at the level of the distal medial arch with fluctuance encompassed the surrounding area. The entire forefoot was erythematous to the level of the midfoot. There were no palpable regional lymph nodes or lymphangitic streaking. The overall musculoskeletal appearance of the foot did not demonstrate any significant abnormalities or structural deformities (A).\nPertinent admission laboratory tests demonstrated a profound leukocytosis, with a white blood cell count greater than 36,000/µl and elevated segmented neutrophils. C-reactive protein (CRP) levels were greater than 25 mg/dl and the erythrocyte sedimentation rate (ESR) was 129 mm/h. The patient's comprehensive metabolic panel was remarkable for severe hyponatremia (122 mMol/l), elevated serum creatinine (2.0 mg/dl) and blood urea nitrogen (43 mg/dl), and serum glucose of 225 mg/dl. Radiographic imaging of the foot revealed peri-articular osteopenia about the fifth metatarsophalangeal joint, with subtle periosteal reaction, adjacent soft tissue swelling, and soft tissue gas, compatible with severe infection (B).\nAfter hospital admission and intravenous (IV) rehydration, the patient was taken to the operating room for urgent incision and drainage of deep space abscess in order to control the infection. Immediately upon making the incision, over 20 ml of frank pus was expressed from the wound. An extensive open debridement of the foot was performed extending proximally to the deep plantar tissues and superficial compartments with complete removal of necrotic debris involving cutaneous and subcutaneous tissue as well as muscle and tendon. The incision also required extension to the lateral aspect of the forefoot to the level of the fifth metatarsal head. Sharp debridement of all non-viable and grossly infected tissue was carried out utilizing hydro-surgical instrumentation. Once adequate debridement of all compartments of the foot was complete, the underlying bone was investigated for possible infectious involvement. It did not appear intra-operatively that there was violation of the capsular tissue of the fifth metatarsal phalangeal joint necessitating resection. The surgical field was irrigated with pulse lavage of 6 l of antibiotic-laden sterile saline. Perfusion to the soft tissue appeared more than adequate with hemostasis achieved utilizing cauterization and ligation. A soft tissue sample was sent to microbiology for Gram stain as well as culture and sensitivity in order to guide proper antibiotic therapy. The wound was dressed with a moist to dry dressing using 0.25% Dakin's solution. The patient was placed on IV ertapenem 1 g daily. Tissue culture ultimately yielded Prevotella bivia.\nIn the inpatient setting the wound was assessed daily and repeat surgical debridement was performed in the operating room twice more over the following week to remove nonviable tissue and evacuate any remaining abscess formation. The overall debridement involved much of the plantar medial and plantar forefoot area tissue but did not involve removal of bone (C). Once signs of infection abated and the wound ceased to exhibit tissue necrosis, negative pressure wound therapy (NPWT) was begun in preparation for split-thickness skin grafting (STSG). The patient was discharged from the hospital to a rehabilitation center with a peripherally inserted central catheter for continued antibiotic therapy and routine wound care in the form of NPWT dressing changes every 48 h. He was instructed to remain totally non-weight bearing during this time. The patient was evaluated in the outpatient clinic on a weekly basis to monitor the progression of the granulation tissue. Overall, the time from commencement of the NPWT to adequate depth reduction allowing for STSG was 26 days. After surgical application of a STSG taken from the ipsilateral thigh, NPWT was applied over the graft at a reduced pressure setting of 75 mm Hg for 5 days as a bolster to promote graft adherence. NPWT was removed on the fifth day in the outpatient clinic and nonadherent petroleum gauze and dry gauze dressing was placed over the graft site. The patient was able to return home and receive dressing changes every other day as well as weekly clinic visits with the surgical team. This continued until complete healing was observed at 8 weeks (D). The patient was then cleared to return to weight bearing status in a diabetic boot. The total time from initial debridement of the foot to complete healing and return to weight bearing activities was approximately 3 months. The patient was employed as a tile specialist at new home construction which required walking up and down stairs and kneeling on a daily basis.
A 49-year-old woman with diabetes with a history of a plantar right-foot heel ulcer of 4-month duration initially presented to the SALSA clinics at the University of Arizona College of Medicine, Tucson. She had a history of Charcot changes to her midfoot and rearfoot making the calcaneus prominent to the plantar aspect (Fig ). She had undergone a previous surgical debridement of the ulcer, but it was unable to heal. After presenting to our clinic, she was managed with aggressive offloading, consisting of a CROW boot as well as standard ulcer care. With this combination, the ulcer became very superficial and was on the verge of being healed. She then went on vacation and returned with an increase in ulcer size and depth, probing the calcaneus (Fig ). To address this misadventure, surgical intervention was performed using the hurricane incision approach. The calcaneus was debrided and the incision was closed. Bolster sutures were used to the central aspect of the incision to reduce any potential tension. A Jackson-Pratt drain was placed, and the patient was placed in a posterior splint with strict non–weight-bearing orders. On her first postoperative visit (Fig ), the incision was well approximated with no signs of dehiscence or infection. The sutures were removed at 3 weeks.