A 54-year-old female with uncontrolled type 2 diabetes mellitus presented to our emergency room facility with respiratory insufficiency and hemodynamic instability secondary to a progressive infected diabetic heel ulcer. Physical examination revealed a deep, necrotic, and infected plantar heel ulcer with exposure of the calcaneus bone, flexor hallucis longus, and flexor digitorum longus tendons, without any signs of peripheral arterial disease. The patient had been seen in the clinic 6 weeks earlier and at that point had only a small, non-infected heel wound that was treated with local debridement and dressing changes. shows the clinical presentation of the infected foot when the patient was seen in our emergency facility.\nDay 1: In the intensive care unit, medical support measures for patients in critical condition were performed, with intravenous fluid expansion, metabolic and blood glucose control, vasopressor medications, and invasive mechanical ventilation. Broad-spectrum antibiotic therapy was started with the intention of narrowing it after culture results []. Tight blood glucose control was initiated, with a combination of regular, intermediate-acting, and long-acting insulin. Desired blood glucose levels were 70–130 mg/dl before meals and 180 mg/dl after meals, with a hemoglobin A1c of 6%.\nDay 3: After significant clinical improvement, mechanical ventilation was interrupted and the patient was transferred to the inpatient ward unit.\nDay 7: Soft-tissue cultures and antibiotic susceptibility results are presented in and . The patient’s antibiotic therapy was narrowed following these results. She was treated with a combination of intravenous vancomycin, meropenem, and fluconazole.\nWeek 8: Her intravenous antibiotic therapy was discontinued.\nA staged surgical treatment protocol was performed based on the following procedures.\nDay 1: Irrigation and debridement of all devitalized and infected tissue was performed. Specimens were collected for culture and antibiotic susceptibility testing. Provisional negative pressure wound therapy (ActiV.A.C.®; KCI, San Antonio, TX, USA) was installed (125 mmHg) and set to be continuous for the first 24 h and intermittent in the next 48 h ( and ).\nDay 3: A second irrigation and surgical debridement was performed, with additional tissue sent for culture and antibiotic susceptibility testing. No macroscopic evidence of progressive infection or necrosis was observed. At that time, an external fixation was applied to maintain the ankle at 90° in the sagittal plane and a percutaneous fixation with Kirschner wire was used to maintain the correct relationship between lateral and medial columns of the foot (). A new negative pressure wound therapy was applied at 125 mmHg, set to be continuous for the first 24 h and intermittent in the following 3 days.\nDay 7: Forty grams of vancomycin-loaded polymethylmethacrylate bone cement (Surgical Simplex P®, Miami, FL, USA) was used to fill the void of the calcaneus bone removed in prior surgical debridements (). After that, a heel soft-tissue coverage procedure was performed. We used a free musculocutaneous latissimus dorsi flap () for soft-tissue coverage of the heel defect. The choice of this specific soft-tissue coverage was made secondary to characteristics of the injury, which included the large defect and location (plantar surface) that needed to be addressed, and also based on the unique features of this flap. This flap possesses excellent skin properties of the donor site (posterior surface of the trunk) with a thinner composition than other fasciocutaneous flaps, allowing plantar support and weight-bearing in the hindfoot and facilitating gait and proper fit in shoe-gear. End-to-end microanastomosis was performed between the thoracodorsal and posterior tibial arteries.\nDay 12: After adequate monitoring of the viability of the free musculocutaneous flap, and making certain that no venous insufficiency, venous stasis, or necrosis occurred in the flap, a split-thickness skin graft from the thigh to cover the free muscle and granulation tissue surfaces was performed ().\nWeek 12: The free flap and split-thickness skin graft had been fully integrated () and the external fixator and bone cement were then removed. We performed a reconstruction of the hindfoot with a femoral head bone allograft coated with bioactive synthetic bone graft (NovaBone®, Bangalore, India). The internal fixation was performed using three Acutrak headless compression screws (Acumed®, Hillsboro, OR, USA) (–).\nWeek 20: The patient initiated a progressive weight-bearing rehabilitation protocol in a long walking boot.\nMonth 36: The patient was able to walk independently in stiff-soled shoe-gear with an insole compensation for a 0.7 cm shortening in the affected lower extremity. Upon physical examination, a functional full range of motion of the ankle joint, with a 4+/5+ muscle power for dorsiflexion and plantarflexion, was noted ( and ). The patient had also reached 84 points when assessed by the American Orthopaedic Foot and Ankle Society (AOFAS) ankle–hindfoot outcome score.\nThe authors informed the patient that the data concerning this case would be submitted for publication, and she consented to this.
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.