Treating a Complex Heel Wound in a Patient with Diabetes and PAD Through a Multidisciplinary Approach

In an intriguing case involving a patient with a lower extremity burn wound and multiple comorbidities, these authors discuss the multidisciplinary care and targeted revascularization that facilitated healing of a large, complex wound.

A 37-year-old female with a past medical history notable for type 1 diabetes, neuropathy and gastroparesis presented with a third-degree scald burn to her left heel that occurred four days prior to presentation. The patient was showering and did not realize the temperature of the water at the time of the injury due to her severe neuropathy. She initially presented to a different emergency room on the day of the injury. The patient was discharged with topical sulfadiazine for local wound care and outpatient follow-up as the severity and depth of the injury were not immediately identified.

We admitted the patient to our hospital’s burn service, and she had subsequent debridement of her left heel.

At the time of presentation, the patient’s physical exam was notable for a palpable dorsalis pedis (DP) pulse and an absent posterior tibial (PT) pulse. Throughout her two-week course of treatment in the hospital, the patient had multiple debridements, but there was inadequate healing of the wound. Vascular surgery was consulted to assess blood flow, and an arterial duplex ultrasound revealed adequate distal flow to the extremity (see Figure 2). Given the non-healing nature of the wound on physical exam and an absent PT pulse, the decision was made to proceed with angiography to assess flow to the foot and heel. While angiography showed a normal anterior tibial (AT) artery, it also revealed occlusion of the distal posterior tibial artery (see Figure 3). Subsequent balloon angioplasty resulted in initial rapid and dramatic improvement of the heel wound.

The patient required multiple further debridements with both the burn care and podiatry teams to further facilitate healing. Endocrinology was also involved to help her poorly controlled diabetes. After two months, the wound healing progress began to slow and she was taken for re-angiography, which revealed re-occlusion of the distal PT artery. The patient was treated more aggressively with balloon angioplasty, orbital atherectomy and attempted reestablishment of the pedal loop, which again resulted in improved healing (see Figure 4).

After multiple interventions, we appreciated adequate granulation tissue in the wound bed, but the large defect was not expected to heal primarily in a timely fashion. The plastic and reconstructive surgery team was consulted and elected to perform a local free flap for wound coverage. During surgery, the recanalized PT artery was noted to have flow and an anterolateral thigh (ALT) free flap was performed. The plastics team created the arterial and venous anastomosis from the descending branch of the lateral femoral circumflex artery to the posterior tibial artery in an end-to-side fashion. Using the vena comitans, the surgeons performed the venous anastomosis with a 2.0 venous coupler. Approximately two months after the ALT free flap, the patient had a revisional procedure with a split-thickness skin graft to aid in wound coverage (see Figure 5). The patient has been stable and procedure-free for 13 months.

Final Notes

This case serves to elucidate the importance of a multidisciplinary team approach and the angiosome concept. A patient may have inadequate blood flow even in the presence of a palpable distal pulse. Up to 38 percent of ischemic wounds remain unhealed with bypass surgery via indirect revascularization compared to a nine percent failure rate after direct target bypass revascularization.^1,2

The angiosome concept, published by Taylor and Palmer in 1987, suggested that specific target vessel revascularization may facilitate improved wound healing and limb salvage over indirect revascularization based on the best available target vessel.¹ While this theory was introduced over 30 years ago, it only recently began to gain traction.^2,3 Open surgery is less dependent on the angiosome concept and patients appear to respond well with bypass surgery regardless of direct or indirect target revascularization. Bypass surgery is more dependent on adequate collateralization in the foot. With the increasing use of endovascular techniques and a high threshold to perform open surgery, direct target revascularization continues to gain traction as a method for improved outcomes, wound healing, and decreased amputation rates.^2,3

Dr. Chadnick is a Chief Resident in General Surgery at the Staten Island University Hospital.

Dr. Butler is a second-year resident in General Surgery at the Staten Island University Hospital.

Dr. Culliford is the Director of Plastic, Reconstructive and Hand Surgery at the Staten Island University Hospital.

Dr. Ng is an Assistant Professor at the Donald and Barbara Zucker School of Medicine at Hofstra University and Northwell Health.

Dr. Lopez is an attending podiatrist at the Staten Island University Hospital.

Dr. Singh is the Director of Limb Salvage Surgery and the Vascular Laboratory at the Staten Island University Hospital. He is an Associate Professor at the Donald and Barbara Zucker School of Medicine at Hofstra University and Northwell Health.

References

1. Taylor GI, Palmer JH. The vascular territories (angiosomes) of the body: experimental study and clinical applications. Br J Plast Surg. 1987;40(2):113–41.

2. Lejay A, Georg Y, Tartaglia E, et al. Long-term outcomes of direct and indirect below-the-knee open revascularization based on the angiosome concept in diabetic patients with critical limb ischemia. Ann Vasc Surg. 2014;28(4):983–9.

3. Jongsma H, Bekken JA, Akkersdijk GP, Hoeks SE, Verhagen HJ, Fioole B. Angiosome-directed revascularization in patients with critical limb ischemia. J Vasc Surg. 2017;65(4):1208-1219.e1.