Management of ischemic heel ulceration and gangrene: An evaluation of factors associated with successful healing

The correlation between transcutaneous oxygen pressure (TcPO2 ) and forward-looking infrared (FLIR) thermography in the evaluation of lower extremity perfusion according to angiosome

The increased peripheral arterial disease (PAD) incidence associated with aging and increased incidence of cardiovascular conditions underscores the significance of assessing lower limb perfusion. This study aims to report on the correlation and utility of two novel non-invasive instruments: transcutaneous oxygen pressure (TcPO2 ) and forward-looking infrared (FLIR) thermography. A total of 68 patients diagnosed with diabetic foot ulcer and PAD who underwent vascular studies at a single institution between March 2022 and March 2023 were included. Cases with revascularization indications were treated by a cardiologist. Following the procedure, ambient TcPO2 and FLIR thermography were recorded on postoperative days 1, 7, 14, 21 and 28. In impaired limbs, TcPO2 was 12.3 ± 2 mmHg and FLIR thermography was 28.7 ± 0.9°C. TcPO2 (p = 0.002), FLIR thermography (p = 0.015) and ankle-brachial index (p = 0.047) values significantly reduced with greater vascular obstruction severity. Revascularization (n = 39) significantly improved TcPO2 (12.5 ± 1.7 to 19.1 ± 2.2 mmHg, p = 0.011) and FLIR (28.8 ± 1.8 to 32.6 ± 1.6°C; p = 0.018), especially in severe impaired angiosomes. TcPO2 significantly increased immediately post-procedure, then gradually, whereas the FLIR thermography values plateaued from day 1 to 28 post-procedure. In conclusion, FLIR thermography is a viable non-invasive tool for evaluating lower limb perfusion based on angiosomes, comparable with TcPO2 .

An novel and alternative treatment method for large heel ulceration in diabetic patients: Proximal tibial cortex transverse distraction

Heel ulceration in patients with diabetes mellitus (DM) is a major clinical challenge, manifesting with a protracted and uncertain healing process. The prefer treatment of heel ulceration is still controversial. This study aims at describing a newly alternative surgical method with the proximal transverse tibial bone transport technique, as an attempt to achieve wound healing in diabetic patients with large heel ulceration. Retrospective clinical study. A total of 21 diabetic patients with large heel ulceration were enrolled and followed up at least 6 months. The following parameters were assessed: Visual analogue scale (VAS), healing time, ulcer healing rate, ulcer recurrence rate and limb salvage rate. All patients got fully follow-up and achieved wound healing uneventfully. Eighteen patients returned to independent walking without any helper while three patients walked using a crutch. Limb salvage was achieved in all 21 patients (100%). The mean wound area was 67.43 ± 13.31 cm2 (range: 46-97 cm2 ). The mean healing time was 128.62 ± 16.76 days (range: 91-160 days). 16 out of 21 patients without calcaneal osteomyelitis achieved ulcer healing with a mean duration of 124.69 ± 14.42 days (range: 91-143 days), while the other five patients with calcaneal osteomyelitis were 141.20 ± 19.12 days (range: 110-160 days). 2 out of 21 patients got superficial rupture at the previous wounds and healed after outpatient dressing change combined with oral antibiotics. The novel technique described is particularly applicable for large heel ulceration in diabetic patients. It offers a better alternative for achieving wound healing with a favourable encouraging outcome.

Foot Osteomyelitis Location and Rates of Primary or Secondary Major Amputations in Patients With Diabetes

BACKGROUND

Diabetic foot osteomyelitis (DFO) often leads to amputations in the lower extremity. Data on the influence of the initial anatomical DFO localization on ultimate major amputation are limited.

METHODS

In this retrospective analysis, 583 amputation episodes in 344 patients (78 females, 266 males) were analyzed. All received a form of amputation in combination with antibiotic therapy. A multivariate logistic regression analysis with the primary outcome "major amputation" defined as an amputation above the ankle joint was performed. The association of risk factors including location of DFO, coronary artery disease, peripheral artery disease, neuropathy, nephropathy, and Charcot neuro-osteoarthropathy was analyzed.

RESULTS

Among 583 episodes, DFO was located in the forefoot in 512 (87.8%), in the midfoot in 43 (7.4%), and in the hindfoot in 28 episodes (4.8%). Overall, 53 of 63 (84.1%) major amputations were performed because of DFO in the setting of peripheral artery disease as primary indication. Overall, limb loss occurred in 6.1% (31/512) of forefoot, 20.9% (9/43) of midfoot, and 46.4% (13/28) of hindfoot DFO. Among these, 22 (41.5%) were performed as the primary treatment, whereas 31 (58.5%) followed previously failed minor amputations. Among this latter group of secondary major amputations, the DFO was localized to the forefoot in 23 of 583 (3.9%), the midfoot in 4 of 583 (0.7%) and the hindfoot in 4 of 583 (0.7%). In multivariate logistic regression analysis, initial hindfoot localization was a significant factor (P < .05), whereas peripheral artery disease, smoking, and a midfoot DFO were not found to be risk factors.

CONCLUSION

In our retrospective series, the frequency of limb loss in DFO increased with more proximal initial foot DFO lesions, with almost half of patients losing their limbs with a hindfoot DFO.

LEVEL OF EVIDENCE

Level IV, retrospective cohort study.

Evaluation of Peripheral Perfusion in the Presence of Plantar Heel Ulcerations Status After Transmetatarsal Amputation With Achilles Tendon Lengthening

The objective of this study is to evaluate peripheral perfusion in patients who developed plantar heel ulcerations status after transmetatarsal amputation and Achilles tendon lengthening. Peripheral perfusion was assessed via contrast angiography of the 3 crural vessels (anterior tibial, posterior tibial, and peroneal arteries), as well as intact heel blush and plantar arch. The secondary objective is to correlate the arterial flow to time to develop heel ulceration and incidence of minor and major lower-extremity amputation. Diagnostic angiography without intervention was performed on 40% of patients (4/10), and interventional angiography was performed on 60% of patients (6/10). In-line flow was present in 0% (0/10) of the peroneal arteries, 60% (6/10) of the anterior tibial arteries, and 70% (7/10) of the posterior tibial arteries. Heel angiographic contrast blush was present in 60% (6/10), and intact plantar arch was present in 60% (6/10). Patients developed heel ulcerations at a mean time of 7.6 months (range 0.7 to 41.2) postoperatively. The incidence of major lower-extremity amputation was 30% (3/10), with a mean time of 5.2 months (range 3.5 to 8.3) from time of heel wound development. No amputation occurred in 6 patients (60%). Among them, intact anterior tibial inline arterial flow was present in 3, intact posterior tibial inline arterial flow was present in 6, and heel blush was present in 5. Our results demonstrate that an open calcaneal branch of the posterior tibial artery is sufficient to heal plantar heel ulcerations to potentially increase rates of limb salvage.

Outcome after Hybrid Outflow Interventions for Chronic Limb-threatening Ischemia

BACKGROUND AND AIMS

Because chronic limb-threatening ischemia (CLTI) is often associated with multilevel arterial disease, it usually requires revascularization at different sites of the limb vasculature. We aim to assess the outcome of the hybrid interventions including open surgical revascularization together with outflow segment percutaneous transluminal angioplasty (PTA) in patients with chronic limb-threatening ischemia.

MATERIAL AND METHODS

This study included all hybrid outflow-PTA interventions (n = 80) on patients suffering from CLTI performed in Helsinki University Hospital between 2003 and 2015. Follow-up ended on 31 December 2019. Patient data were prospectively collected into our vascular registry and scrutinized retrospectively. Thirty-one patients (39%) suffered from rest pain (Rutherford category IV) and 49 patients (61%) had ischemic ulcers (Rutherford category V-VI). The most common open surgical procedure was femoral endarterectomy (n = 63, 79%) and the most common endovascular procedure was superficial femoral artery percutaneous transluminal angioplasty (n = 65, 81%). Mean follow-up time was 56 months (range: 4 days-183 months).

RESULTS

Limb salvage was at 30 days-92%, at 1 year-91%, and at 5 and 10 years-86%. Survival and amputation-free survival were at 30 days-93% and 86%, at 1 year-80% and 76%, at 5 years-51% and 48%, and at 10 years-21% and 21%. Wound healing at 3, 6, and 12 months was 48%, 71%, and 87%. Freedom from target lesion revascularization was at 30 days-97%, at 1 year-88%, at 5 years-72%, and at 10 years-66%.

CONCLUSION

Hybrid outflow revascularization is an important tool in the vascular surgeon's armamentarium for treatment of patients with multilevel arterial disease causing chronic limb-threatening ischemia.

Extent of heel ulceration influences the outcomes in patients with isolated infrapopliteal limb threatening critical ischemia

BACKGROUND

The aim of the present study was to assess the effects of the extent of heel ulceration on the outcomes of limb threatening critical ischemia due to isolated infrapopliteal disease.

METHODS

A retrospective review identified 989 patients with isolated infrapopliteal disease and heel ulceration treated from 2001 to 2018. The heel was defined as the back of the foot, extending from the Achilles tendon to around the plantar surface and covering the apex of the calcaneum bone. Heel ulceration was categorized into three groups by area: <5 cm², 5 to 10 cm², and >10 cm². The interventions were endovascular, open bypass, major amputation, and wound care. An intention-to-treat analysis by patient group was performed. The 30-day outcomes and amputation-free survival (AFS; survival without a major amputation) were evaluated.

RESULTS

Of the 989 patients, 384 (58% male; average age, 65 years; n = 768 vessels) had undergone isolated endovascular tibial intervention, 124 (45% male; average age, 59 years) had undergone popliteal tibial vein bypass for limb threatening critical ischemia, 219 (52% male; average age, 67 years) had undergone major amputation, and 242 (49% male; average age, 66 years) had received wound care. No difference was found in the 30-day major adverse cardiac events in the endovascular and open bypass groups, with significantly more events in the major amputation group (P = .03). The 30-day major adverse limb events and 30-day amputation rates were equivalent between the open bypass and endovascular groups. The 5-year AFS rate was superior in the open bypass group (37% ± 8%; mean ± standard error of the mean) compared with the endovascular group (27% ± 9%; P = .04). The wound care group had a 5-year AFS rate of 20% ± 9%, which was not significantly different from that of the endovascular group. Patients with heel ulcers of <5 cm² had better AFS (47% ± 8%) than those with 5- to 10- cm² heel ulceration (24% ± 9%). Heel ulcers >10 cm² were associated with markedly worse 5-year AFS outcomes (0% ± 0%). The presence of end-stage renal disease, osteomyelitis, uncontrolled diabetes (hemoglobin A_1c >10%), and/or frailty combined with a heel ulcer >10 cm² were predictive of poor AFS.

CONCLUSIONS

An increasing heel ulcer area combined with osteomyelitis and systemic comorbidities was associated with worsening 30-day outcomes and 5-year AFS, irrespective of the therapy chosen.

Heal or no heel: Outcomes of ischaemic heel ulcers following lower limb revascularization from a multi-ethnic Asian Cohort in Singapore

Ischaemic diabetic heel ulcers are difficult to treat and prognosis is often guarded. The aim was to document our outcome of treating heel ulcers following revascularization in a predominantly diabetic Asian cohort presenting with chronic limb threatening ischaemia from Singapore. Retrospective cohort study (n = 66, 66 limbs) over a 5‐year period. Data were collected from hospital electronic health records. Outcomes included time to healing, amputation free survival (AFS), and mortality. Minimum follow‐up period was 6 months. Multivariate regression analysis was performed to look for factors associated with poor outcome. Mean age was 67.4 ± 8.8 years. 62/66 (93.9%) were diabetics. Mean wound size at presentation was 3.6 ± 2.3 cm. Mean Wound, Ischaemia, Foot Infection (WIFI) score was 5 ± 1.6. 12/66 (18%) patients had a patent posterior tibial artery pre‐operatively. Straight line flow was restored in only 31/66 (46.9) patients but 47/66 (71.2%) had successful limb salvage. Median time to wound healing was 90.0 (IQR 60‐180) days. A median of 1 (IQR 0‐2) wound debridement was required. Patients who underwent negative pressure dressing (23/66; 34.8%) required a median of 26 (IQR 13‐33) cycles to achieve healing. Amputation free survival (AFS) was 72% and 68% at 6‐ and 12‐months, respectively. Mortality rate was 16.7% and 19.7% at 6‐ and 12‐months, respectively. Low albumin level and initial Rutherford class were independent predictors of worse 6‐month AFS. Outcomes of heel ulcers post revascularisation may not be as poor as previously described. Persistent attention to wound care with multidisciplinary effort is needed for optimal healing.

New Innovations and Devices in the Management of Chronic Limb-Threatening Ischemia

As the number of patients afflicted by chronic limb-threatening ischemia (CLTI) continues to grow, new solutions are necessary to provide effective, durable treatment options that will lead to improved outcomes. The diagnosis of CLTI remains mostly clinical, and endovascular revascularization remains mostly balloon-based. Multiple innovative techniques and technologies are in development or in early usage that may provide new solutions. This review categorizes areas of advancement, highlights recent developments in the management of CLTI and looks forward to novel devices that are currently under investigation.

Accurate Noninvasive Arterial Assessment of the Wounded Lower Limb: A Clinical Challenge for Wound Practitioners

Arterial investigations are an essential part of lower extremity wound assessment. The results of these investigations assist the wound clinician to determine the etiology of the wound, predict healing capacity, and inform further management. There are a number of noninvasive testing methods available to practitioners, all with varying levels of reliability and accuracy. Clinical wound assessment guidelines give varied recommendations when it comes to lower limb vascular assessment in the presence of a wound. This leaves clinicians with little guidance on how to choose the most appropriate test, and uncertainty remains about which tests provide the most accurate information in different patient-specific contexts. Conditions such as advanced age, diabetes, and renal disease are known to affect the accuracy of some commonly used lower limb arterial assessment methods, and alternate testing methods should be considered in these cases. This seminal review discusses the reliability and accuracy of lower limb vascular assessment methods used to guide lower limb arterial assessment in the presence of wounds.

A Case of Chronic Limb-Threatening Ischemia with Heel Ulcers Cured by Revascularization and Partial Calcanectomy

Ischemic limbs with infected heel ulcers are often difficult to salvage. We present a case of an 82-year-old woman who had bilateral heel ulcers owing to chronic limb-threatening ischemia. She underwent right femoral-terminal posterior tibial artery bypass surgery, but right calcaneus osteomyelitis occurred and inhibited wound healing. She underwent partial calcanectomy (PC), and her right heel healed six months after the bypass surgery. The ulcer on her left foot also healed after distal bypass and PC. We describe our experience with a patient who needed PC to cure her heel ulcers.

The Wound Healing Index for Predicting Venous Leg Ulcer Outcome

Objective: To develop a venous leg ulcer (VLU) risk stratification system for use in research and clinical practice. Approach: U.S. Wound Registry data were examined retrospectively and assigned an outcome. Bivariate analysis identified significant variables (p < 0.05) that were used to create a multivariable logistic regression model. Ulcers with data for wound area at the first visit before debridement were included in regression analysis, which was based on a 90% development sample. The model was validated on a hold-out 10% data sample. Results: The original dataset included 26,713 VLUs, of which 11,773 ulcers were eligible for preliminary analysis and 10,942 ulcers were eligible for regression analysis. The 90% development model included 9,898 ulcers, of which 7,498 healed (75.8%). The 10% validation sample included 1,044 ulcers, of which 809 healed (77.5%). The following variables significantly predicted healing: number of concurrent wounds of any etiology, wound size, wound age (in days), evidence of bioburden/infection, being nonambulatory, and hospitalization for any reason. Innovation: The VLU Wound Healing Index (WHI) is a comprehensive, validated risk stratification model for predicting VLU healing that incorporates patient- and wound-specific variables. Conclusions: The WHI can identify which VLUs most likely require adjunctive therapies to heal, prioritize referral to venous experts, risk-stratify ulcers to create more generalizable clinical trials and understand the impact of clinical interventions. The Centers for Medicare and Medicaid Services accepts this method for reporting VLU outcome under the Quality Payment Program.

Limb Salvage in Diabetic Patients With Ischemic Heel Ulcers

The purpose of this study is to investigate the outcomes of diabetic individuals with ischemic heel ulcers. The study group was composed of a consecutive sample of persons with diabetic ischemic foot ulcers managed by a preset multidisciplinary limb salvage protocol, including revascularization through endovascular technique. The outcome measures were healing, major amputation (above the ankle), and death at 1-year of follow-up. The outcomes between patients with heel ulcers (HUs) and without (NHUs) were compared. A total of 254 patients were recruited. There were 50/254 (19.7%) HUs and 204/254 (79.3%) NHUs. Overall, 190/254 (74.8%) patients healed. The rate of healing for HUs and NHUs was 30/50 (60%) and 160/204 (78.4%); P = .03, respectively. Major amputation occurred in 24/254 (9.4%) patients. The rates of major amputation for HUs and NHUs were 10/50 (20%) and 14/204 (6.9%; P = .002), respectively; 40/254 (15.7%) patients died, unhealed. The rates of mortality for HUs and NHUs were 10/50 (20%) and 30/204 (14.7%; P = .07), respectively. In HUs patients, absence of infection [95% CI = 3.1 (1.6-5.5); P = .002] and superficial ulcers [95% CI = 4.4 (2.2-9.3); P = .0001] were independent predictors of healing, whereas revascularization failure [95% CI = 8.1 (1.5.0-19.4); P = .0001], involvement of the plantar arch [95% CI = 6.3 (2.0-15.4); P = .0001], and dialysis [95% CI = 2.2 (1.3-4.5); P = .006] were independent predictors of major amputation. A multidisciplinary approach achieves good rate of limb salvage in people with diabetic ischemic heel ulcers.

Predictors of Wound Healing Following Revascularization for Chronic Limb-Threatening Ischemia

OBJECTIVES

After surgical or endovascular revascularization, some ischemic lesions will not heal, while some others will heal at a variable period of time from the intervention, indicating a multifactorial interaction between local and systematic "wound healing-promoting" factors. Our objective was to identify predictors of wound healing following revascularization for chronic limb-threatening ischemia (CLTI).

METHODS

A literature review was performed to identify published research concerning clinical, biochemical, and noninvasive methods as predictors of wound healing time and wound-free period after surgical and endovascular revascularization for CLTI.

RESULTS

Our review indicated that potential predictors included local wound factors, wound depth, patient's comorbidities, medications, smoking and alcohol abuse, poor vessel runoff, and direct versus indirect revascularization. Among the clinical biomarkers, platelet-derived growth factor, transforming growth factor β, basic fibroblast growth factor, tumor necrosis factor α, interleukin (IL) 1, and IL-6 have been proposed as potential predictors. Furthermore, the potential of noninvasive microcirculation assessment to predict proper wound healing has been the topic of extensive investigation. Among the novel methods, transcutaneous measurement of oxygen partial pressure, skin perfusion pressure, oxygen-to-see method, indocyanine green fluorescence imaging, and multispectral optoacoustic tomography have shown promising results.

CONCLUSIONS

The risk factor profile of an ischemic lesion in the lower extremities with a delayed/failed healing response, following a successful revascularization, is not fully clarified. Although many predictors have been assessed so far, further research needs to be done to identify the optimal clinical and biochemical indices and the noninvasive technique assessing the microcirculation that is associated with complete wound healing.

The Vertical Contour Calcanectomy: An Alternative Surgical Technique to the Conventional Partial Calcanectomy

Heel ulcers have a significant impact on lower extremity morbidity and confer a high risk for major amputations. Although there are many conservative treatment options, once calcaneal osteomyelitis occurs or a heel ulcer becomes chronic or recalcitrant, more invasive management is required. The partial calcanectomy is a surgical solution that can address both pathologies-the ulceration and the infected bone. The conventional partial calcanectomy, however, does not ensure complete soft tissue closure. Often, closure under tension is required for primary closure of the soft tissue deficit or the wound must be closed by secondary intention. This process occurs, in part, when the proportion of bone resected is insufficient in relation to the size of the wound. Closure under tension increases the possibility of dehiscence and subsequent postoperative surgical site complications that lead to the same risks for major amputation as the index heel ulcer. This article introduces and describes a novel modification to the conventional partial calcanectomy and addresses these aforementioned concerns. The vertical contour calcanectomy incorporates improvements to an already accepted limb salvage technique. The purpose of this article was to describe the indications, contraindications, intraoperative technique and postoperative management of the vertical contour calcanectomy for patients who present with heel ulcers in the limb salvage setting.

Functional prognosis of critical limb ischemia and efficacy of restoration of direct flow below the ankle

Objective

Patients with critical limb ischemia have serious systemic comorbidities and are at high risk of impairment of limb function. In this study, we assessed the prognostic factors of limbs after revascularization.

Methods

In this retrospective single-center cohort study, from April 2008 to December 2012, we treated 154 limbs of 121 patients with critical limb ischemia by the endovascular therapy-first approach based on the patients’ characteristics. The primary end point was amputation-free survival. Secondary end points were patency of a revascularized artery, major adverse limb events, or death. Furthermore, we investigated the ambulatory status one year after revascularization as prognosis of limb function.

Results

Endovascular therapy was performed in 85 limbs in 65 patients as the initial therapy (endovascular therapy group) and surgical reconstructive procedures (bypass group) were performed in 69 limbs in 56 patients. Early mortality within 30 days was not observed in either group. The primary patency rate was significantly better in the bypass group than in the endovascular therapy group ( p < 0.0001). Furthermore, the secondary patency rate was similar between the two groups ( p = 0.0096). There were no significant differences in amputation-free survival and major adverse limb event between the two groups. Univariate analysis showed that ulcer healing ( p < 0.0001), no hypoalbuminemia ( p = 0.0019), restoration of direct flow below the ankle ( p = 0.0219), no previous cerebrovascular disease ( p = 0.0389), and Rutherford 4 ( p = 0.0469) were predictive factors for preservation of ambulatory status one year after revascularization. In multivariate analysis, ulcer healing ( p < 0.0001) and restoration of direct flow below the ankle ( p = 0.0060) were significant predictors.

Conclusions

Ulcer healing and restoration of direct flow below the ankle are independently associated with prognosis of limb functions in patients who undergo infrainguinal arterial reconstruction.

Slow to heel: a literature review on the management of diabetic calcaneal ulceration

The diabetic heel ulcer (DHU) represents a reconstructive challenge to clinicians and the multidisciplinary team alike. It is traditionally viewed as a condition that is inherently difficult to treat due to the intrinsic anatomical vulnerabilities of the heel. In addition to this, several factors are associated with poorer end outcomes - namely, that of major amputation. These include peripheral vascular disease, infection/osteomyelitis and the size of the ulcer itself. In light of the significant morbidity, economic burden and mortality seen in this cohort of patients, this review aims to explore current treatment modalities that have been undertaken. Literature in this field has mostly been confined to a handful of small case studies, some of which reflect novel, multimodal approaches, and promising results. Management with osteotomy, flap reconstruction and acellular dermal matrices, amongst other options, is covered within this review.

Angiosome-directed revascularization in patients with critical limb ischemia

OBJECTIVE

Direct revascularization (DR), according to the angiosome concept, provides direct blood flow to the site of tissue loss in patients with critical limb ischemia (CLI). DR may lead to improved outcomes; however, evidence for this is controversial. This systematic review and meta-analysis investigated the outcomes of surgical and endovascular DR compared with indirect revascularization (IR) in patients with CLI.

METHODS

A systematic review was undertaken using the Cochrane Collaboration specified tool, and a meta-analysis was done according to the MOOSE (Meta-analysis of Observational Studies in Epidemiology) criteria. The electronic databases of MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials were systematically searched for studies of DR compared with IR in patients with CLI with tissue loss. All articles were critically assessed for relevance, validity, and availability of data regarding patient and lesion characteristics and outcomes. When possible, data were systematically pooled, and a meta-analysis was performed for wound healing, major amputation, amputation-free survival, and overall survival.

RESULTS

Of 306 screened abstracts, 19 cohort studies with 3932 patients were included. Nine scored 7 or higher on the Newcastle-Ottawa score. DR significantly improved wound healing (risk ratio [RR], 0.60; 95% confidence interval [CI], 0.51-0.71), major amputation (RR, 0.56; 95% CI, 0.47-0.67), and amputation-free survival rates (RR, 0.83; 95% CI, 0.69-1.00) compared with IR. This significance was lost in major amputation on sensitivity analysis for bypass studies. No significant difference was found in overall survival. In studies stratifying for collaterals, no differences between DR and IR were found in wound healing or major amputations in the presence of collaterals.

CONCLUSIONS

DR significantly improves wound healing and major amputation rates after endovascular treatment in patients with CLI, supporting the angiosome theory. In the presence of collaterals, outcomes after IR are similar to outcomes after DR. Alternatively, patients without collaterals may benefit even more from DR as a primary treatment strategy. The angiosome theory is less applicable in bypass surgery, because bypasses are generally anastomosed to the least affected artery, with runoff passing the ankle to maintain bypass patency.

Orthopaedic biofilm infections

Many infections of the musculoskeletal system are biofilm infections that develop on non-living surfaces. Microorganisms adhere either on dead bone (sequesters) or implants. As a rule for a curative concept, chronic osteomyelitis or implant-associated bone infection must be treated with a combination of surgery and antimicrobial therapy. If an implant is kept in place, or a new device is implanted before complete healing of infection, a biofilm-active antibiotic should be used. Rifamycins are active against biofilms of staphylococci, and fluoroquinolones against those of Gram-negative bacilli. In this review, the management of chronic osteomyelitis, periprosthetic joint infection and implant-associated osteomyelitis of long bones is presented.

Wound healing of critical limb ischemia with tissue loss in patients on hemodialysis

We assessed wound healing in patients on hemodialysis (HD) with critical limb ischemia (CLI). This study enrolled 267 patients (including 120 patients on HD and 147 patients not on HD) who underwent endovascular therapy (EVT) for CLI. The primary endpoint was wound-healing rate at two years. Secondary endpoints were time to wound healing, wound recurrence rate, and limb salvage at two years. The percentage of male and young patients was higher in the HD patients ( p < 0.01). A lower patency of the pedal arch after EVT was observed frequently in HD patients ( p < 0.01). The wound-healing rate was significantly lower in HD patients (79.5% vs. 92.4%, p < 0.001). Time to wound healing was significantly longer in HD patients (median 132 days vs. 82 days, p = 0.005). Wound recurrence was observed more frequently in HD patients (25.0% vs. 10.2%, p = 0.007). Limb salvage (72.8% vs. 86.4%, p = 0.002) was significantly lower in HD patients. In a cox proportional hazard model, HD was an independent predictor of wound healing (risk ratio (RR), 0.46; 95% confidence interval (CI), 0.33-0.62; p < 0.001) and wound recurrence (RR, 1.58; 95% CI, 1.11-2.22; p = 0.01). HD was independently associated with lower and delayed wound healing, and wound recurrence.

Combination of Open Subtotal Calcanectomy and Stabilization With External Fixation as Limb Salvage Procedure in Hindfoot-Infected Diabetic Foot Ulcers

Diabetic hindfoot ulcers, complicated by osteomyelitis, are associated with a high risk of major amputation. Partial calcanectomy, preceded by an effective management of the infection and of the eventual peripheral artery disease, can be considered as valid therapeutic option. We have evaluated a therapeutic protocol for diabetic hindfoot ulcers complicated by osteomyelitis, which, besides an adequate surgical debridement, considers a reconstructive pathway assisted by the positioning of a circular external fixator. We made a prospective study of a cohort of diabetic patients affected by heel ulcer complicated by osteomyelitis. All patients underwent open partial calcanectomy associated with the positioning of a circular external frame specifically designed for hindfoot stabilization and offloading. A reconstructive procedure was implemented starting with the application of negative pressure wound therapy and coverage with dermal substitute and split thickness skin grafting. From November 2014 to November 2015, 18 consecutive patients were enrolled. Mean follow-up period was 212.3 ± 64.0 days. Healing was achieved in 18 (100%) patients. The mean healing time was 69.0 ± 64.0 days. No major amputation had to be performed during the follow-up. Open partial calcanectomy associated with external fixation and skin reconstruction was as efficient as limb salvage in patients with infected lesions of the hindfoot complicated by calcaneal osteomyelitis.

Heel ulcers do heal in patients with diabetes

A heel ulcer is considered to be a serious complication in patients with diabetes, and there is limited information regarding outcome. In most of the literature, a poor prognosis is described. The aim of this study was to investigate a large cohort of ulcers located in the heel in patients with diabetes. Seven hundred and sixty-eight patients [median age 73 (17-98)], presenting with a heel ulcer at a multidisciplinary diabetes foot clinic, fulfilled the inclusion criteria and were followed-up until final outcome. Fifty-eight per cent of the patients healed primarily; 7% healed after major debridement; 9% healed after amputation and 25% died unhealed. Median healing time was 17 weeks. Ulcer progression was seen in 19% of patients. Thirty-one percent of patients had severe peripheral vascular disease. A creatinine level below 91 µmol/l was related to a higher probability for healing without major debridement or amputation, whereas vascular surgery, nephropathy and oedema were related to a lower probability for healing without major debridement or amputation. Two thirds of heel ulcers do heal in patients with diabetes despite patients being elderly and with extensive comorbidity. The extent of peripheral vascular disease, nephropathy, oedema and decreased renal function are important factors influencing outcome.

Development and validation of a new scoring system to predict wound healing after endovascular therapy in critical limb ischemia with tissue loss

PURPOSE

To develop a scoring system to predict wound healing in critical limb ischemia (CLI) patients treated with endovascular therapy (EVT).

METHODS

Between July 2007 and January 2013, 184 patients (118 men; mean age 73.0 years) with CLI (217 limbs) and tissue loss underwent EVT. From this cohort 236 separate wounds were divided into development (n = 118) and validation (n = 118) groups. Predictors of wound healing were identified using multivariable analysis. Each predictor was assigned a score based on its regression coefficient, and total scores were calculated, ranging from 0 to 1 for low risk up to ≥ 4 for high risk of a nonhealing wound. The performance of the scoring system in the prediction of wound healing was evaluated by calculating the area under the receiver operating characteristics (ROC) curve.

RESULTS

By multivariable analysis, a University of Texas grade ≥ 2 (HR 0.524, 95% CI 0.288-0.951, p = 0.034), an infected wound (HR 0.497, 95% CI 0.276-0.894, p = 0.020), dependence on hemodialysis (HR 0.459, 95% CI 0.259-0.814, p = 0.008), no visible blood flow to the wound (HR 0.343, 95% CI 0.146-0.802, p = 0.014), and major tissue loss (HR 0.322, 95% CI 0.165-0.630, p = 0.001) predicted a non-healing wound. The 1-year rates of wound healing in the low-, intermediate-, and high-risk groups were 94.6%, 67.6%, and 9.1%, respectively, in the development group (p < 0.001) and 92.3%, 70.5%, and 31.3%, respectively, in the validation sample (p < 0.001). The area under the ROC curve was 0.922 in the development group and 0.808 in the validation sample.

CONCLUSION

This scoring system reliably predicts wound healing in CLI patients after endovascular revascularization and is potentially helpful in deciding if additional adjuncts or revascularization should be considered.

A Novel and Alternative Treatment Method for Diabetic Heel Ulceration Exposing the Calcaneus Which Is Not Suitable for Flap Surgery: Vacuum Assisted Sandwich Dermal Matrix

Background. Currently, free flaps and pedicled flaps are the first treatment choices for large heel ulcer reconstruction. However, flap reconstruction of heel ulcerations cannot be performed in all diabetics especially with concurrent severe peripheral vascular disease because of higher flap failure rate. In recent years, the use of acellular dermal matrix (ADM) has emerged as an alternative treatment option for extremity ulcers. Methods. We present 13 diabetic patients with a large heel ulceration exposing the calcaneus, who were not eligible for flap surgery due to the presence of only one patent artery of trifurcation. These cases were treated with the vacuum assisted sandwich dermal matrix (VASDEM) method. Results. None of the patients required amputation. Skin grafting was successful in ten patients. Although partial losses were observed in three patients, they were healed spontaneously without surgical interventions. During the follow-up period none of the patients developed ulceration on the treatment area. All patients maintained their preoperative ambulatory ability. Conclusion. VASDEM is a novel method offering opportunity for treatment before proceeding to amputation in diabetic heel ulceration exposing the calcaneus which is not suitable for flap surgery. It also has the potential to close wounds of all sizes independent of the vessel status and wound size in selected diabetic patients.

Lower-extremity arterial revascularization: Is there any evidence for diabetic foot ulcer-healing?

The presence of peripheral arterial disease (PAD) is an important consideration in the management of diabetic foot ulcers. Indeed, arteriopathy is a major factor in delayed healing and the increased risk of amputation. Revascularization is commonly performed in patients with critical limb ischaemia (CLI) and diabetic foot ulcer (DFU), but also in patients with less severe arteriopathy. The ulcer-healing rate obtained after revascularization ranges from 46% to 91% at 1 year and appears to be improved compared to patients without revascularization. However, in those studies, healing was often a secondary criterion, and there was no description of the initial wound or its management. Furthermore, specific alterations associated with diabetes, such as microcirculation disorders, abnormal angiogenesis and glycation of proteins, can alter healing and the benefits of revascularization. In this review, critical assessment of data from the literature was performed on the relationship between PAD, revascularization and healing of DFUs. Also, the impact of diabetes on the effectiveness of revascularization was analyzed and potential new therapeutic targets described.

An Endovascular-First Approach to the Treatment of Critical Limb Ischemia Results in Superior Limb Salvage Rates

PURPOSE

To evaluate the effect of a shift to a primary endovascular revascularization (ER) strategy for patients presenting with critical limb ischemia (CLI) after a change in staff at our center in 2008 altered our revascularization strategy.

METHODS

Between 2004 and 2012, 344 critically ischemic limbs were treated in 279 patients (mean age 74.0±11.4 years; 179 men) during 546 separate hospital admissions. Limbs were analyzed according to (1) their principal revascularization strategy and (2) their date of presentation [early (2004-2008) or late (2008-2012)].

RESULTS

Compared with the open revascularization (OR) and no revascularization (NR) groups, the ER group had an increased freedom from major amputation (92.3% vs 80.0% OR vs 69.3% NR, p<0.001), reduced hospital stay (15.2 vs OR 31.6 vs NR 25.9 days, p<0.001), intensive care unit (ICU) stay (2.3 vs OR 23.7 vs NR 7.2 hours, p=0.033), and operating time for ER vs OR (157.9 vs 316.8 minutes, respectively; p<0.0001). There was also a significant decrease in limbs requiring minor amputations (23.2% vs OR 29.3% vs NR 37.6%, p=0.041) and mean number of admissions/limb compared to OR (1.5 vs OR 1.9 vs NR 1.5, p=0.007). The late era saw the treatment of a larger number of limbs (223 vs 121) compared with the earlier time period. This institutional shift resulted in increased freedom from major amputation (87.4% vs 74.4%, p<0.01), reduced ICU stay (3.45 vs 16.98 hours, p<0.01), and shorter length of stay (20.9 vs 31.5 days, p<0.01) between the 2 eras, respectively.

CONCLUSION

A shift to an endovascular-first treatment strategy is associated with fewer major amputations and shorter length of stay.

A review of the surgical management of heel pressure ulcers in the 21st century

Heel ulceration, most frequently the result of prolonged pressure because of patient immobility, can range from the trivial to the life threatening. Whilst the vast majority of heel pressure ulcers (PUs) are superficial and involve the skin (stages I and II) or underlying fat (stage III), between 10% and 20% will involve deeper tissues, either muscle, tendon or bone (stage IV). These stage IV heel PUs represent a major health and economic burden and can be difficult to treat. The worst outcomes are seen in those with large ulcers, compromised peripheral arterial supply, osteomyelitis and associated comorbidities. Whilst the mainstay of management of stage I-III heel pressure ulceration centres on offloading and appropriate wound care, successful healing in stage IV PUs is often only possible with surgical intervention. Such intervention includes simple debridement, partial or total calcanectomy, arterial revascularisation in the context of coexisting peripheral vascular disease or using free tissue flaps. Amputation may be required for failed surgical intervention, or as a definitive first-line procedure in certain high-risk or poor prognosis patient groups. This review provides an overview of heel PUs, alongside a comprehensive literature review detailing the surgical interventions available when managing such patients.

The contralateral extremity has also benefit from the locally administered bone marrow-derived mononuclear cells and cord blood serum in diabetic ischemic wound healing

OBJECTIVE

Impaired wound healing could be a disaster especially in diabetes and amputation is the major risk. The aim of this study was to evaluate the benefit of BMMCs and CBS on wound healing.

METHODS

Diabetic rats were underwent bilateral limb ischemia and wounding of skin defects on both extremities. The groups were formed as BMMCs (group A), BMMCs and CBS (group B), only CBS (group C), and phosphate buffer solution (group D) that were injected into wounds on right legs.

RESULTS

The complete recovery of right legs was established as a mean of 21.4 ± 1.1 days, 12.9 ± 1.5 days, 30.0 ± 0.0 days and 38.1 ± 1.5 days according to Groups A, B, C, and D (p < 0.05). The recovery of left legs were calculated as a mean of 27.0 ± 0.0 days, 24.0 ± 0.0 days, 35.6 ± 1.1 days and 37.3 ± 1.6 days according to Groups A, B, C and D (p < 0.05). At the end of the recovery, the HE staining showed that vascularity was increased in groups A and B.

CONCLUSION

Transplantation of BMMCs and CBS to the ischemic wounds of the diabetic rats accelerate the repair. The recovery was also superior in the same group although the treatment was not applied to the left extremity directly.

Outcomes of hospitalized diabetic foot patients in a multi-disciplinary team setting: Thailand's experience

Aims

The aims of this study were to evaluate the outcomes of treatment among hospitalized patients with diabetic foot ulcers, the risk factors for non-healing ulcers, and the rate of major amputation among Thai patients.

Methods

A retrospective study of hospitalized diabetic foot patients treated at Theptarin Hospital during the period of 2009–2013. The complete healing rate was assessed at 12 months after admission.

Results

During the study period, 232 patients (123 males and 109 females) with 262 admissions were included (mean age 65.6 ± 11.9 years, mean duration of diabetes 17.2 ± 9.9 years) with a mean follow-up of 17.5 ± 16.7 months. Major amputations were performed in 4.2% of the patients and peripheral vascular disease (PVD) was a predictive factor (OR 5.25; 95% CI [1.43–19.29]; p-value 0.006). Complete healing (including minor amputations) was achieved in 82.1% of the admissions. Only DFU of the heel was a statistically significant (OR 3.34; 95% CI [1.11–10.24]; p-value 0.041) predictor of non-healing ulcers. Three patients (1.1%) died during hospitalization.

Conclusions

Management of diabetes-related foot ulcers with a multidisciplinary approach resulted in a limb salvage rate that was greater than 90% and a complete healing rate that was greater than 80%. Successful management of diabetic foot ulcers might be possible in Thailand utilizing this approach.

Intraarterial injection of indocyanine green for evaluation of peripheral blood circulation in patients with peripheral arterial disease

BACKGROUND

To assess the peripheral blood flow of patients with peripheral arterial disease (PAD) by indocyanine green (ICG) arteriography (ICGA) with intraarterial injection of ICG and evaluate the efficacy of the ICGA tests.

METHODS

This study was undertaken from a retrospective review of patients with PAD who underwent ICGA tests during digital subtraction angiography (DSA) between November 2012 and June 2013. We defined some ICGA parameters as the magnitude of intensity of ICG, the time to maximum intensity, and the time from fluorescence onset to half the maximum intensity (T1/2). The ICGA parameters were evaluated in 2 regions, named regions of interest (ROIs). ROI 1 was part of the dorsum of the foot from the Chopart joint to the Lisfranc joint. ROI 2 was in the distal region of the first metatarsal bone and compared with the ankle-brachial pressure index (ABI), ankle pressure, toe-brachial pressure index, and toe pressure.

RESULTS

A total of 22 limbs in 16 patients with PAD underwent ICGA tests during DSA. The T1/2 on ROI 2 was the most correlated with the ABI (ρ=-0.622, P=0.003). A value of T1/2 for ROI 2>10 sec was significantly correlated with an ABI value of <0.7 (sensitivity: 0.85, specificity: 1.0).

CONCLUSIONS

By measuring the value of T1/2 in ROI 2, ICGA tests can be performed to assess the peripheral blood circulation during DSA. ICGA tests might help to promptly assess the peripheral blood flow during endovascular treatment procedures.

Results of infrapopliteal endovascular procedures performed in diabetic patients with critical limb ischemia and tissue loss from the perspective of an angiosome-oriented revascularization strategy

Our aim was to describe our experience with infrapopliteal endovascular procedures performed in diabetic patients with ischemic ulcers and critical ischemia (CLI). A retrospective study of 101 procedures was performed. Our cohort was divided into groups according to the number of tibial vessels attempted and the number of patent tibial vessels achieved to the foot. An angiosome anatomical classification of ulcers were used to describe the local perfusion obtained after revascularization. Ischemic ulcer healing and limb salvage rates were measured. Ischemic ulcer healing at 12 months and limb salvage at 24 months was similar between a single revascularization and multiple revascularization attempts. The group in whom none patent tibial vessel to the foot was obtained presented lower healing and limb salvage rates. No differences were observed between obtaining a single patent tibial vessel versus more than one tibial vessel. Indirect revascularization of the ulcer through arterial-arterial connections provided similar results than those obtained after direct revascularization via its specific angiosome tibial artery. Our results suggest that, in CLI diabetic patients with ischemic ulcers that undergo infrapopliteal endovascular procedures, better results are expected if at least one patent vessel is obtained and flow is restored to the local ischemic area of the foot.

Report on a clinical evaluation of the KerraPro Heel silicone heel pad

Heels are at increased risk of injury due to the posterior prominence and lack of padding over the calcaneus. Pressure injuries, once established, are extremely costly, both in terms of the detrimental effect on psychosocial wellbeing and threat to life, as well as financially due to length of hospital stay and resources used to heal the wounds. A new and inexpensive silicone heel pad has been designed to simplify the necessary decisions and to address the problems associated with pressure injuries to the heels. This article will describe an observational evaluation of the product. KerraPro Heel pads were evaluated in two separate cohorts of 17 participants over a 4-week period with the primary aim to evaluate the efficacy of the product in preventing and alleviating pressure injuries on the heels. All participants had been reported as 'at risk' or 'at high risk' of pressure injury to the heels and had a history of developing such lesions. The KerraPro heel pads were compared with the participant's standard protocol. The outcome of the evaluation demonstrated the effectiveness of the KerraPro Heel pads in the prevention and treatment of heel pressure injuries.

Heel Ulcer and Blood Flow

A young female diabetic patient is reported, who presented with a double foot lesion. She presented with a first metatarsal head exposure concomitant with a heel wet gangrene. Magnetic resonance demonstrated osteomyelitis of the rear portion of the calcaneus. Transmetatarsal amputation was performed and a wide debridement was required to remove all gangrenous tissue from the heel wound. The pedal artery was palpable; the posterior tibial pulse was present, but weak.Transcutaneous oximetry (TcPO2) at the dorsum of the foot was TcPO2 = 56 mmHg despite significant oedema. Nevertheless, TcPO2 on the perilesional area of the heel ulcer (TcPO2 = 24mmHg) was suggestive for critical chronic ischemia. At angiographic examination, anterior tibial and peroneal arteries were patent, but the posterior tibial artery that showed severe stenosis then percutaneous angioplasty (PTA) was performed. Just the day after PTA, values of TcPO2 at the perilesional area of the heel ulcer increased to 41 mmHg. Heel osteomyelitis was subsequently treated by partial calcanectomy. The patient was discharged after a 21-day hospital stay. In the treatment of heel ulcers, it is clinically useful to use the angiosomic concept. The majority of the blood supply to the heel is provided by the posterior tibial artery, and only to a small extent by the posterior branch of peroneal artery. If the decrease in blood flow to this region is not detected, and direct flow based on the angiosome concept is not obtained, the healing of a heel ulcer may be delayed or impaired.

Influence of osteomyelitis location in the foot of diabetic patients with transtibial amputation

BACKGROUND

To evaluate the prevalence of osteomyelitis in different areas of the foot and the possible correlation between localization and outcome of major amputation.

METHODS

From January 2008 to December 2010, a total of 350 diabetic patients were admitted to our diabetic foot unit for the surgical treatment of osteomyelitis. Osteomyelitis was diagnosed when both the probe-to-bone maneuver and plain radiography were positive. In all of these patients, osteomyelitis was confirmed by histological examination.

RESULTS

Osteomyelitis was localized to the forefoot in 300 (85.7%) patients, to the midfoot in 27 (7.7%) patients, and to the hindfoot in the remaining 23 (6.75) patients. On average, foot lesions had developed 6.6 ± 5.6 months before admission to our unit. Transtibial amputation was performed in 1 (0.33%) patient with forefoot osteomyelitis, in 5 (18.5%) patients with midfoot osteomyelitis, and in 12 (52.2%) patients with osteomyelitis of the heel (χ(2) = 128.4, P < .001). Multivariate analysis showed the independent role that osteomyelitis in the heel region had in major amputation outcome (odds ratio 15.3; P < .001; confidence interval, 17.4-5336.0), dialysis treatment (odds ratio 6.3; P = .012; confidence interval, 2.5-1667.2), and leukocyte count greater than 10(3) mm(3) (odds ratio 2.25; P = .036; confidence interval, 1.1-76.6).

CONCLUSIONS

We found a higher rate of transtibial amputation when osteomyelitis involved the heel instead of the midfoot or forefoot in diabetic patients.

LEVEL OF EVIDENCE

Level III, retrospective comparative series.

Large and deep diabetic heel ulcers need not lead to amputation

BACKGROUND

Management of large and deep heel ulcers (LDHUs) is a challenge in patients with diabetic foot lesions. We assessed outcomes of a treatment protocol to save feet with LDHUs from amputation.

METHODS

We managed LDHUs (larger than 3 cm(2)) in diabetic feet using a multidisciplinary approach consisting of medical and surgical management, including revascularization and amputation, if necessary. For deep heel infection and/or gangrene, we frequently debrided and drained the deep spaces of the heel, as needed. In patients with non-ischemic feet, we made a flap from the heel pad with a broad pedicle. When satisfactory granulation tissue covered the base of the heel and the inner surface of the flap, we sutured the heel flap to its base.

RESULTS

We managed 37 feet with LDHUs among 384 patients. Twenty-nine patients (78.4%) had neuropathy, 6 (16.2%) had ischemic diabetic feet, and 2 (5.4%) had both neuropathy and ischemia. Twelve (32.4%) had septic diabetic feet. We performed two femoropopliteal bypasses, 2 infrapopliteal bypasses, and 1 distal bypass (crural) for ischemic heel ulcers. Thirty-three of the 37 feet with heel lesions (89.2%) were salvaged using this multidisciplinary approach. These 33 LDHUs healed after 4 to 7 months (median, 6 months). Transtibial amputation was performed for 4 feet (10.8%; 2 ischemic and 2 neuropathic cases).

CONCLUSIONS

Diabetic patients with LDHUs can be managed with a multidisciplinary approach to prevent amputation. If necessary, deep spaces of the heel can be debrided by elevating the heel pad like a flap and then performing satisfactory reconstruction.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Near total calcanectomy with rotational flap closure of large decubitus heel ulcerations complicated by calcaneal osteomyelitis

Osteomyelitis is a common late-stage sequela of deep heel ulceration and frequently results in leg amputation, because few options exist to effectively treat this challenging problem. A technique that has been successful at our institution is near total calcanectomy with rotational flap closure of large decubitus heel ulcers complicated by calcaneal osteomyelitis. A case series is presented of 3 patients with differing locations or "zones" of heel decubitus ulceration with acute osteomyelitis. A description of our preferred flap choice, given the zone of the ulceration, is demonstrated, as are the surgical principles for the treatment approach. This procedure is an effective option, provided specific principles are followed to achieve complete wound coverage and minimize pressure points both when in bed and when walking.

miR-210: the master hypoxamir

MicroRNAs are small non-coding RNAs implicated mainly in post-transcriptional gene silencing by interacting with the untranslated region of the transcript. miR-210 represents major hypoxia-inducible miRs, also known as hypoxamirs, which is ubiquitously expressed in a wide range of cells, serving versatile functions. This review article summarizes the current progress on biogenesis of miR-210 and its physiological roles including arrest of cell proliferation, repression of mitochondrial respiration, arrest of DNA repair, vascular biology, and angiogenesis. Given the fact that miR-210 is aberrantly expressed in a number of diseases such as tumor progression, myocardial infarction and cutaneous ischemic wounds, miR-210 could serve as an excellent candidate for prognostic purposes and therapeutic intervention. With the advancement of computational prediction, high-throughput target validation methodology, sequencing, proteomic analysis, and microarray, it is anticipated that more down-stream targets of miR-210 and its associated biological consequences under hypoxia will be unveiled establishing miR-210 as a major hub in the biology of hypoxia-response.

Multimodal therapy as an algorithm to limb salvage in diabetic patients with large heel ulcers

In many series of diabetic foot ulcer care, heel ulcers greater than 4 cm across have been identified as an independent predictor of limb loss. Therefore, we set out to pursue the most aggressive limb salvage algorithm in patients with heel ulcers greater than 4 cm in diameter. Over 5 years, we identified 21 patients, 39-84 years of age, all with diabetes mellitus, with heel ulcers greater than 4 cm in diameter and had magnetic resonance imaging or bone scan evidence of osteomyelitis. Seven of the 21 patients had end-stage renal disease defined as being haemodialysis dependent. All patients had ankle brachial indices <0·4 or monophasic pulse volume recordings. All patients underwent distal bypass surgery with vein. After adequate perfusion was obtained, all patients underwent partial calcanectomy and intra-operative negative pressure wound therapy (NPWT) placement. This was followed by treatment with recombinant platelet-derived growth factor (PDGF). One patient underwent amputation during the healing process secondary to ongoing sepsis. Twenty of 21 patients healed acutely (within 6 months). Three of 20 patients went on to subsequent below knee amputation within 12 months of healing primarily. At 2 years, 12 of 21 (57%) were ambulating independently, 1 of 21 was dead, 4 of 21 had undergone amputation, 4 (19%) had limbs that were intact but were not ambulating. A total limb salvage rate of 76% at 2 years mirrored the secondary patency rates, with 100% follow up. Heel ulcers require multimodality therapy if they are going to have any chance to heal. We believe the algorithm presented allows for the required revascularisation and a modulation of the heel ulcer microenvironment by augmenting the microcirculation through NPWT, and improving the proliferative capacity with PDGF.