A 63-year-old male with long-term uncontrolled type 2 diabetes presented to our foot and ankle center facility with a 4-year history of DFU and associated episodes of purulent drainage with intermittent chills. The patient’s cardiologic history included three open revascularizations and five endovascular stents within the previous 6 years, and placement of an implantable cardioverter defibrillator (ICD). In addition, he reported an endovascular stent due to arterial stenosis in the affected limb 3 years ago.\nLower extremity physical examination revealed erythema and edema of a midfoot (Lisfranc’s) amputation stump with active purulent drainage from a DFU (). The patient’s left foot amputation stump was plantarflexed, grossly erythematous, and edematous. The associated DFU was actively draining purulent fluid and was associated with wound dehiscence. The wound was probed to bone readily and revealed necrosis of the cuneiforms and cuboid. Dorsalis pedis and posterior tibial pulses were palpable bilaterally, with as no overt signs of peripheral artery disease. After clinical, radiographic (), and ultrasound assessment, patient was diagnosed with a post-operative infection at the amputation stump of midfoot of a neuropathic diabetic foot. Panels 1 and 2 show radiological and clinical presentation of the infected foot over the course of treatment.\nBroad-spectrum antibiotic therapy—ertapenem and clindamycin—was initiated with the intention of narrowing based on culture results. Tight blood glucose control was initiated, with a combination of regular, intermediate-acting, and long-acting insulin. Desired levels were 70–130 mg/dL before meals and 180 mg/dL after meals.\nBacterial and fungal growth was only observed in pre-debridement tissue cultures. Right now, the patient’s antibiotic therapy was narrowed following the susceptibility tests. He was treated by the combination of levofloxacin, sulfamethoxazole-trimethoprim, and fluconazole.\nAll antibiotics therapy was discontinued.\nA staged approach to treatment was designed and performed based on clinical and imaging findings.\nSurgical irrigation and debridement of the distal stump wound—debridement of all devitalized and infected bones (cuneiforms, cuboid, and navicular) and soft tissue was performed. Pre- and post-debridement tissue samples were collected for cultures of aerobic and anaerobic bacteria, fungi, mycobacteria, and antibiotic susceptibility testing. Achilles tenotomy was performed percutaneously, the wound was primarily closed, and then provisional negative pressure wound therapy (PICO®, Smith & Nephew, London, UK) was installed (80 mm Hg) and set to continuous mode for 72 h ().\nA second-look irrigation and debridement were performed with additional tissue samples being sent for cultures. No evidence of progressive infection or necrosis was observed. Negative pressure wound therapy was applied (80 mm Hg) and set for the next 11 days. The result of cultures collected at second-look procedure from remnant tissues was negative.\nThe wounds were noted to be completely closed with no signs of active infection, blood inflammatory tests—erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP)—continued to fall. Based on these criteria and negative cultures at the second-look procedure, the decision was made to proceed with the next stage of treatment. We then performed a tibiotalocalcaneal fusion using lateral transfibular approach and a plantar approach ( and 2). A conventional dressing was maintained for 14 days.\nWe then performed a total contact casting (TCC_EZ®, Integra, 1100 Campus Road, Princeton – NJ08540) and the patient initiated a weight-bearing rehabilitation protocol (). The TCC was changed every 2 weeks.\nRadiographs revealed good bone healing (). Total contact cast was then discontinued. The patient was able to walk independently in a stiff sole shoe with a custom-made orthotic.\nThe patient was fully weight-bearing in stiff sole sneakers with no gross overt alteration of the gait pattern. During this period, he remained in complete remission and wounds remained completely healed with no signs of infection. Patient demonstrated full range of motion of the hip and knee joints, with a 5+/5+ muscle power for flexion, extension, adduction, and abduction. When assessed by the hindfoot American Orthopaedic Foot and Ankle Society (AOFAS) outcome score, patient reached 79 points ( and 2). We informed patient that the data concerning this case would be considered for publication, and he consented to it.
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.