Calcaneal Ulcer Research Articles

Long-term limb salvage and functional outcomes for patients undergoing partial calcanectomy.

Partial calcanectomy (PC) can be performed to treat chronic heel ulcers in patients with calcaneal osteomyelitis. Patients undergoing PC often have multiple comorbidities, limited mobility, and face high risk of major limb amputation. This study examined the extent of vascular diagnostic testing and interventions as well as long-term outcomes in patients undergoing PC. A retrospective analysis was performed on patients who underwent PC for non-healing calcaneal ulcer over a ten-year period. Demographics, comorbidities, vascular testing, and procedural data were recorded. Additional subgroup analysis was performed according to presence or absence of peripheral arterial disease (PAD). Primary outcomes were major limb amputation (above or below the knee) and mortality. Secondary outcomes included successful wound healing, time to complete wound healing, re-interventions, and change in ambulatory status. A total of 157 patients underwent partial calcanectomies on 162 limbs. 78.3% of patients had diabetes mellitus and 47.8% were diagnosed with PAD. Ankle brachial index with pulse volume recording (ABI/PVR) was performed for 46.5% (73/157) of patients, arterial duplex in 44.6% (70/157), and 19.7% (31/157) had a computed tomography angiogram. Lower extremity revascularization was performed in 28.4% of limbs (46/162). Independent ambulatory status was reported in 40.1% prior to PC and decreased to 17.9% by the time of last recorded follow-up (p < .00001). Long-term amputation-free survival was significantly higher in patients without PAD at 7 years (78.4% vs 57.1%, p = .02). Multivariate logistic regression analysis demonstrated that PAD and end-stage renal disease (ESRD) increased the odds of major limb amputation (OR 3.5 and 2.8, respectively), whereas ESRD and adjuvant podiatric procedures were associated with increased mortality (OR 4.8 and 4.8, respectively). Non-invasive vascular testing should be obtained in all patients undergoing PC, in order to stratify risk of amputation and identify candidates for revascularization. Over the long-term, patients undergoing PC face significant risk of prolonged wound healing, decline in ambulatory status, and major limb amputation.

Soft Tissue Reconstruction Strategy of Spontaneous Calcaneal Fracture in a Patient with Diabetic Penetrating Foot Ulcer

Background: Spontaneous pathologic fractures of the calcaneum in diabetic patients are rarely described in the literature. The pathologic fractures following osteomyelitis represent a possibly limb-threatening condition and if associated with a concomitant calcaneal ulcer, they present defiance for the surgeon and furthermore an outstandingly challenging condition to handle. Methods: A 61-year-old diabetic female patient on insulin therapy has been treated for a penetrating foot ulcer. In sequence the following procedures were carried out: Negative pressure wound therapy with instillation and dwell time (NPWTi-d), Negative Pressure Wound Therapy (NPWT), arterial percutaneous angioplasty (PTA), calcanectomy and temporary arthrodesis, application of Dermal Regeneration Template (DRT) and transplantation of microfractured autologous adipose graft (LIPOGEMS®), treatment of residual dehiscence with physical cold plasma (kINPen®MED). Results: The patient completely healed within 20 months and was able to walk without further aids. Conclusion: The authors point to the promptness within the treatment of pathologic calcaneal fractures, whether throughout the usage of technical devices targeting the reduction of the bacterial load and stimulation of healthy tissue, like in NPWTi-d and kINPen®MED. The use of a dermal regeneration template followed by skin grafting enriched with autologous microfractured adipose tissue (LIPOGEMS®), therefore represents today the most advanced regenerative surgical procedures.

Long-term Outcomes of Patients Undergoing Partial Calcanectomy

Long-term Outcomes of Patients Undergoing Partial Calcanectomy

Ischemic diabetic foot ulcer when treated in association with photobiomodulation: Case report

Introduction: Because ischemic diabetic foot has arterial lesions with micro and macroangiopathies, it is challenging successfully treat ulcers even now. This becomes especially true if limb revascularization is impossible due to the particularities of systemic pathology and/or local arterial disease. Case Report: A 61-year-old male patient with type II Diabetes mellitus, arterial hypertension, chronic arterial insufficiency, single limb, with ischemic calcaneal ulcer and posterior tibial artery occlusion that irrigates the angiosome of the lesion, but unfavorable to revascularization. Defined by conventional treatment with platelet antiaggregant, statin and vasodilator associated with laser photobiomodulation (PBM). Red laser, 660 nm, 108 mW, 2.7 W/cm2, was used to irradiate the ulcer point by point, since the area of the laser beam was smaller than the area of the ulcer (laser beam = 0.04 cm2), in contact mode, 108 J/cm2, 4.32 J, and 10 s per point once a week for 33 weeks. Arterial Doppler ultrasound examinations were performed twice, i.e., after three and six months of treatment. Results: Gradual improvement of blood flow in the ulcer bed with postocclusive flow after three months, and after six months, triphasic flow toward the calcaneus. Conclusion: Photobiomodulation proved to be effective for the formation of collateral circulation in the occluded vascular bed studied here, despite only partial ulcer healing. Randomized controlled trials should be performed to better understand the effects of PBM.

Combined Intramedullary Nail Coated With Antibiotic-Containing Cement and Ring Fixation for Limb Salvage in the Severely Deformed, Infected, Neuroarthropathic Ankle.

The severely deformed, infected, and unstable neuroarthropathic ankle is challenging to treat. We evaluated our preliminary experience and results of combined internal and external ring fixation for a complex neuropathic population. We retrospectively reviewed medical records and radiographs for 8 patients with unilateral severely deformed ankle neuroarthropathy associated with infection and ulceration. Treatment included single-stage reconstruction arthrodesis with an interlocked intramedullary nail coated with antibiotic-containing cement combined with ring fixation. Taylor Spatial Frame™ technology was used when the deformity was not amenable to acute correction (5 patients). Protected postoperative weightbearing was permitted. Their mean age averaged 55.6 (range, 42-66) years with an average body mass index of 38.4 (range, 28.7-49.6) kg/m2. Seven patients achieved limb preservation. Average time for fusion healing was 15.2 (range, 12.2-22.2) weeks, frame time was 17.7 (range, 12.2-23.0) weeks, and follow-up was 34.1 (range, 24.1-68.8) months. All presenting wounds and infection successfully resolved. Reinker and Carpenter scale was excellent for 2 patients, good for 2 patients, and fair for 3 patients. Foot and Ankle Ability Measure averaged 59.0% (range, 39.3%-87.5%). One patient developed a recalcitrant calcaneal ulcer with osteomyelitis that required a transtibial amputation 17 months after successful ankle arthrodesis. Combined use of interlocked intramedullary nail and ring external fixation for neuroarthropathic ankle arthrodesis achieved a functional and clinically stable salvaged lower limb for most patients. Level IV, retrospective case series.

Myroides odoratimimus Forms Structurally Complex and Inherently Antibiotic-Resistant Biofilm in a Wound-Like in vitro Model.

Myroides odoratimimus is an aerobic, non-fermenting Gram-negative multidrug-resistant bacterium widely distributed in nature that rarely causes infections in immunocompromised patients. We recently described in a diabetic patient a case of recurrent calcaneal ulcer infection caused by a M. odoratimimus strain showing potential for biofilm formation. For the first time, we therefore evaluated the ability of M. odoratimimus to form biofilm under different pH values and glucose concentrations using an in vitro “skin-like” model, and its susceptibility to levofloxacin, meropenem, and tigecycline. The expression of some antibiotic-resistance related genes was also monitored by RT-PCR during planktonic-to-biofilm transition. Our results indicated that M. odoratimimus can produce relevant amounts of biofilm biomass, in a time-dependent manner, especially at acidic pH and regardless of glucose concentration tested. The comparative analysis of MIC and MBC values between planktonic and sessile cells showed that resistance to antibiotics increased during the planktonic-to-biofilm transition. Viable cell count indicated that none of the tested antibiotics were able to completely eradicate preformed biofilms, although meropenem and levofloxacin were the most active causing a significant, dose-independent, reduction of biofilm's viability, as also confirmed by microscopic analysis. RT-PCR showed that antibiotic-resistance related gyrA and acrB genes are over-expressed during the transition from planktonic to sessile (biofilm) lifestyle. Overall, our findings showed that M. odoratimimus can form relevant amounts of inherently antibiotic-resistant biofilm under conditions relevant to wound site, therefore suggesting a role in the pathogenesis of chronic ulcer infections.

PROSPECTIVE ASSESSMENT OF THE CLINICAL, RADIOGRAPHIC AND FUNCTIONAL EVOLUTION OF TREATMENT FOR UNSTABLE TROCHANTERIC FRACTURES OF THE FEMUR USING A CEPHALOMEDULLARY NAIL

To assess the clinical, radiological and functional evolution of osteosynthesis using a cephalomedullary nail, in unstable trochanteric fractures of the femur, over a one-year postoperative follow-up. Methods: Fourteen men and 23 women of mean age 77.7 years were evaluated. Twenty-seven of them had fractures classified as AO/ASIF 31A2 and ten as 31A3. The patients were evaluated clinically, radiologically and functionally one week, two weeks, one month, two months, six months and one year after the operation. Results: The clinical complications comprised five cases of death, one case of calcaneal ulcer, one case of acute arterial obstruction and two cases of deep vein thrombosis. The radiographic evaluation showed that the mean cervicodiaphyseal angle in the immediate postoperative period was 132.5°. The mean tip-apex index was 22.8 mm. After one year, the mean cervicodiaphyseal angle was 131.7°. Fracture consolidation was seen in all the patients six months after the operation, except in one case that presented cut-out. There were no cases of fracture below the implant. The functional evaluation using the Harris score after one year showed a mean of 69.3 points. The evaluation of walking progress showed that after one year, 40.6% of the patients had the same ability to walk that they had before the fracture. The visual analogue pain scale showed that a significant decrease in pain complaints occurred, going from 5.19 in the first week to 2.25 after 1 year. Conclusion: Osteosynthesis using a cephalomedullary nail resulted in low rates of clinical and mechanical complications and adequate functional outcomes.

Use of non-conventional coverage in ischemic wound treatment in patients with sickle cell anemia: case study

This study aims to report the case of a patient with sickle cell anemia, that had right calcaneal ulcer , treated topically with coverage based on collagen and aloe vera. Clinical case study, developed in a public hospital in Joao Pessoa-PB, which is part of an experimental research project for the development of new technologies for wound treatment. History was taken and physical examination was performed, and the information was recorded in the evaluation form of the client. Bandages were applied, evaluations and daily logs of the lesion were made and photographs were taken to assist in monitoring the response of the lesion to the applied coverage. During the appointments, guidelines were given on systematic medical follow-up, on the diet, on the abstention from alcohol, to rest and to prevent new injuries on the wound. The client reported gradual reduction of pain, attendance to hematologist appointments, caution to prevent trauma on the injury, abandonment of alcoholism and diet was followed within their economic possibilities, The treatment lasted approximately five weeks, showing rapid healing process, without discomfort or complications arising from the use of coverage. The coverage showed good tolerability and therapeutic efficacy in the given case.

Calcaneal ulcer in a child with congenital insensitivity to pain syndrome

Congenital insensitivity to pain with anhidrosis (CIPA) is a rare hereditary sensory neuropathy, comprising congenital insensitivity to pain, anhidrosis, and mental retardation. We present a 4-year-old child with CIPA and a calcaneal ulcer who was treated with double opposing rotation flaps, which eventually healed.

Chronic Foot Ulcers in a Patient with Hepatitis C

The warty lesions (figure 1) and ulcers (figure 2) were consistent with a chronic, indolent infectious process. Biopsy of the heel ulcer revealed marked verrucuform hyperplasia and occasional microabscesses in the epidermis. The biopsy showed spherules with mixed inflammatory infiltrates and granulomas characteristic of Coccidioides immitis in the dermis (figure 3). Fungal culture of a deep swab of the calcaneal ulcer grew C. immitis. Routine culture grew mixed gram-negative species, including Pseudomonas aeruginosa. Serologic tests showed a highly elevated Coccidioides complement-fixation antibody titer of 1:256. Results of a total coccidioidal IgG EIA were positive. Findings of a chest radiograph were normal. Plain films of the foot showed no bone destruction, but a bone scan of the affected foot revealed uptake consistent with osteomyelitis. The case we report illustrates disseminated coccidioidomycosis in a patient with classic risk factors. He was of Filipino descent, lived for an extended time in the southwest corner of the United States, and worked outdoors. All of these factors, in addition to his sex, increased the risk for the development of active disease caused by this endemic fungus [1]. Coccidiomycosis has also been reported in patients with end-stage liver disease who live in an area where Coccidioides species are endemic [2]. The stage of this patient's liver disease, which resulted from hepatitis C infection, was not known at the time this report was prepared. Despite the localized presentation of his coccidioidal infection, this patient most likely had an initial pulmonary infection with subsequent dissemination. Disseminated coccidioidal infection is thought to result from hematogenous spread from the lungs after inhalation of arthroconidial spores, which can survive in soil [1, 3]. At least two-thirds of primary pulmonary infections are benign and self-limited [3, 4]. A recent, large