Surgery Department, Tehran University of Medical Sciences, Tehran, Iran.
Foot Ankle Int. 2013 Feb;34(2):215-21. doi: 10.1177/1071100712460228. Epub 2013 Jan 10.
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.
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.
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).
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 IV, retrospective case series.
糖尿病患者足部病变中，大而深的足跟溃疡（LDHU）的治疗是一个挑战。我们评估了一种治疗方案，以避免 LDHU 导致足部截肢。
我们采用多学科方法治疗糖尿病足的 LDHU（大于 3cm2），包括医学和手术治疗，必要时包括血运重建和截肢。对于足跟深部感染和/或坏疽，我们经常清创和引流足跟深部。对于非缺血性足部，我们从足跟垫上切取带宽蒂的皮瓣。当足跟底部和皮瓣内面有满意的肉芽组织覆盖时，我们将足跟皮瓣缝合到其基底。
我们共治疗了 384 例患者中的 37 例 LDHU。29 例患者（78.4%）有神经病变，6 例（16.2%）有缺血性糖尿病足，2 例（5.4%）同时有神经病变和缺血。12 例（32.4%）有感染性糖尿病足。我们为缺血性足跟溃疡实施了 2 例股腘旁路、2 例腘下旁路和 1 例小腿（胫）旁路。通过这种多学科方法，37 例足跟病变中有 33 例（89.2%）得以挽救。这些 LDHU 在 4 至 7 个月（中位数 6 个月）后愈合。4 例（10.8%；2 例缺血性，2 例神经病变）进行了胫骨截肢。
对于 LDHU 的糖尿病患者，可以采用多学科方法进行管理，以预防截肢。如果需要，可以通过抬起足跟垫形成皮瓣，然后进行满意的重建来清创足跟深部。
IV 级，回顾性病例系列。
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