A 46-year-old Mexican-American man with diabetes, hypertension and hyperlipidemia presented to the emergency department with a 2-week history of acute progressive constitutional symptoms. These symptoms were the result of an infected plantar left foot ulcer that had been noted to have increased swelling, drainage, and foul odor along with the more recent development of an area of black, skin blistering. The underlying ulceration had been present for approximately 1 year and resulted from a skeletal malformation of the foot secondary to longstanding Charcot arthropathy of 9 years duration that left him with a collapsed arch and bony prominence on the bottom of the midfoot. Despite surgical reconstruction of the foot at the time of initial arch collapse and ulceration, the patient had suffered from chronic, intermittent wound breakdown, and repetitive infections requiring hospitalization and IV antibiotics. He did not have a weight bearing offloading device. For the last year, the patient had been unemployed and without health insurance and was therefore self-managing his wounds with a poultice recommended by a family doctor in Mexico. He had, however, just started a new job as a clerk in a deputy sheriff's office, but this position was probationary and he was not yet eligible for health benefits.\nUpon evaluation in the emergency room, the patient was febrile with an oral temperature of 39.1°C and otherwise normal vital signs. Laboratory studies were remarkable for a leukocytosis of 24,900/µl and markedly elevated inflammatory markers, with a CRP level of 31.1 mg/dl and ESR of 143 mm/h. The patient's comprehensive metabolic panel was significant for hyponatremia (128 mMol/l), elevated serum creatinine (3.2 mg/dl), blood urea nitrogen (60 mg/dl), and a serum glucose level of 228 mg/dl.\nPhysical evaluation of the affected lower extremity revealed palpable pedal pulses, severe foot and ankle edema, and a lack of protective sensation from the toes to the mid-calf. Dermatologic examination revealed a full thickness, 15 cm2 ulceration of the plantar central midfoot, extending to the bone. Frankly malodorous discharge and sinus tracking to well-circumscribed necrotic gas-filled bulla of the medial foot were also evident (A). Radiographic findings demonstrated gas in the dorsal and medial foot, significant soft tissue edema, and osseous breakdown of the midtarsal bones with osteolytic erosions at the level of the ulceration suggestive of osteomyelitis (B).\nFollowing fluid resuscitation and administration of broad spectrum antibiotics, the patient was promptly transferred to the operating room for surgical incision and drainage. The debridement extended from the area of ulceration down to the underlying bone including a portion of central cuneiform that was sent for culture and sensitivity to rule out osteomyelitis. From the area of plantar ulceration the incision was extended through the sinus track to the medial arch and area of necrotic tissue. All areas of obvious diseased tissue were removed with the assistance of high pressure water debridement. All compartments of the foot were explored for any residual abscess or gas formation. Once adequate debridement was achieved, the foot was irrigated with copious amounts of antibiotic treated saline solution (C). Necrotic soft issue was sent for Gram stain and culture and sensitivity in order to identify bacterial pathogens for proper antibiotic therapy. The wound was dressed with Dakin's 0.25% solution wet to dry dressing to be changed twice daily. The patient was placed on a broad spectrum course of antibiotics (vancomycin and ertapenem) pending results of tissue and bone cultures. Results of initial blood culture demonstrated Streptococcus anginosis-constellatus and the culture results of the bone and soft tissue infection were positive for mixed gram positive and gram negative flora including anaerobic bacteria; at this time antibiotic therapy of piperacillin/tazobactam was continued and other antibiotics discontinued. The patient was followed closely by the surgical team and did not undergo further soft tissue debridement because the open wound did not exhibit ongoing necrosis, the leukocytosis was improving with antibiotic therapy and subsequent blood cultures were negative.\nThe surgical team had extensive discussions with the patient. Mutually agreed goals of subsequent therapy were to enable the patient to ambulate; to prevent recurrence of this wound and infection that had been plaguing him for nearly a decade; and, to allow him to return to his current probationary position as a deputy sheriff so that he would have a means of support and health benefits. After weighing the limb salvage options including significant bone debridement to remove residual bone infection, external fixation, delayed soft tissue coverage, prolonged recovery phase and even if successful, the lifetime risk of re-ulceration, he elected to proceed with primary below the knee amputation in order to facilitate timely discharge and progression to a weight bearing status in a prosthesis that would permit him to return to his job. He also was concerned that prolonged treatment and convalescence that prevented early return to work could result in loss of his new-found employment.\nOne week after the initial surgical incision and drainage, the patient underwent a below the knee amputation. The patient was discharged on oral amoxicillin 4 days following surgery having been in the hospital a total of 10 days. He was sent home after working with physical therapy and able to ambulate with a walker and having been instructed on transferring abilities. Two weeks after the amputation, healing was unremarkable, and the skin sutures were removed (D). He returned to work within 4 weeks and was ambulatory with a prosthesis at 6 weeks postoperatively.
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.