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 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.