Multimodal strategy allows diabetic heel ulcer limb salvage
MedWire News: A multimodal strategy, designed to encourage revascularization, can help patients with diabetes heal large heel ulcers and avoid limb loss, suggest findings published in the International Journal of Wound Care.
Over a 5-year period, the researchers tested an aggressive limb salvage algorithm in 21 diabetes patients, aged 39-84 years, with a mixed ischemic heel ulcer greater than 4 cm in diameter and a confirmed diagnosis of osteomyelitis. Seven patients had end-stage renal disease.
The patients underwent distal bypass surgery to achieve vascularization, followed by partial calcanectomy and intra-operative negative pressure wound therapy (NPWT) placement to the surface of the calcaneous. Patients were also given recombinant platelet-derived growth factor wound dressing for an average of 43 days.
The patients were followed-up at weekly intervals for wound closure and reperfusion. Although patients received an ankle immobilizing boot after surgery, most were nonambulatory during NPWT, which lasted an average of 52 days.
Wound closure took an average of 99 days. Twenty of the patients successfully healed their ulcer within 6 months of surgery, but one patient required below knee amputation (BKA) for sepsis within 30 days of surgery. Three patients subsequently underwent BKA within 12 months of healing their ulcer due to reopening of their wound.
After 2 years, 12 patients were ambulating without aid, four patients had intact limbs but were not ambulatory, and one patient had died. The total limb salvage rate at 2 years was 76%.
The average time to assisted and independent ambulation with the multimodal treatment was 54 and 99 days, respectively, which compares favorably with an average of 30 and 270 days following BKA at the same institution, say John Lantis II (St Luke's-Roosevelt Hospital, New York, USA) and co-authors.
Noting that the rate of independent ambulation with multimodal treatment compared well with historical data for patients undergoing BKA, the team say their findings provide "support for an aggressive policy of heel resection in patients who can be revascularized and their heel treated with this algorithm."
Acknowledging the long period of immobilization and healing, however, they add: "While effective, the time and resources spent following this algorithm must be carefully balanced with the needs and abilities of the patient."
By Lynda Williams