Staged management of a large ischemic heel ulcer in a diabetes patient: a case report

Abstract

Heel ulcer is one of the severe complications of patients with diabetes mellitus, which poses a high risk for foot infection and amputation, especially in patients with peripheral arterial disease and neuropathy. Researchers have searched for new treatments for treating diabetic foot ulcers in recent years. In this case report, we demonstrated the treatment of large ischemic ulcers for the first time in a diabetic patient. The overall treatment goal of this patient was designed to improve blood supply to her diseased lower extremities and close the ulcer. This two-stage reconstruction approach resulted in an ulcer-free, stable, plantigrade foot at postoperative follow-up.

Keywords: heel ulcer; ischemic; peroneal artery perforator flap; staged; vascular reconstruction.

Figure 1

Physical examination of the wound, preoperative CTA examination of lower limb vessels, and angiography after lower limb arterial reconstruction. It was a round ulcer of approximately 5 cm × 5 cm in diameter, which was covered with large black scabs, and the tissue around it was cool, dark red, and swollen (A). Long segment occlusion of the inferior segment of the right superficial femoral artery with segmentary severe stenosis (B). The vascular lumen of the superficial femoral artery, popliteal artery, anterior tibial artery, peroneal artery, and some arterial arches of the foot were unobstructed in the affected limb after lower limb arterial reconstruction (C). CTA, computed tomography angiography.

Figure 2

The repair of the wound and postoperative follow-up. After the blood supply improved, the wound repair procedure began. Wound debridement began approximately 4 weeks after the vascular intervention, with fresh granulation tissue hyperplasia at the base of the wound and bleeding after scraping (A). The location of perforating artery of peroneal artery perforator flap (B). Peroneal artery perforator flap design during operation (C, D). The wound condition after the operation (E) and dressing change of the wound post-operation (F). At the postoperative follow-up, the patient’s wound healed completely approximately 7 weeks after the operation (G).

Figure 3

Treatment procedures for heel ulcers. For ischemic diabetic heel ulcer, treatment procedures were implemented in four stages: i) revascularize the occluded large vessels of the affected lower limb, ii) improve the local blood supply of the ulcer, iii) debride and repair the ulcer, and iv) remodel the closed ulcer.

Figure 4

A schematic representation of the surgical management of ischemic diabetic heel ulcer. Assessment of the lower limb blood supply (A). Reconstruction of the target artery vessels (B). Design and operation of peroneal artery perforator flap transfer surgery (C, D).