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 52-year-old gentleman with diabetes and morbid obesity with a chief complaint of a right heel ulcer of 5-months duration presented to the clinic. The ulcer formed as a result of a burn that he received while walking barefoot outside on a hot wooden deck. He had a history of a total right hip replacement in which nerve damage as a result of the surgery caused a right-foot drop and loss of sensation to the right plantar foot. After months of both surgical and conservative care, his ulcer was superficial but unable to close fully (Fig ). At this point, a partial calcanectomy with hurricane incisional approach was done to obtain ulcer closure. The calcaneus was debrided and the incision was closed (Fig ). At the second postoperative visit, the central aspect of the incision had dehisced, most likely because of pressure or weight bearing as the patient admitted to resting his foot on the ground. However, the wound was still far smaller than preoperatively and responded well to local wound care.