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

Abstract

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.

Surgical Treatment and Outcomes of Calcaneal Osteomyelitis in Adults: A Systematic Review

“…In two studies 15,16, Ilizarov circular frames were used to off-load and maintain the foot in equinus position to decrease the plantar soft tissue defect. In the study by Akurtt et al (2017), they assessed the outcome of 23 patients treated with an Ilizarov frame.…”

“…Two studies 15,26 reported the use of dermal substitute layers without infection recurrence. However, 20% of the patients needed a skin graft or a second dermal layer implantation due to wound healing disorders.…”

“…Negative pressure wound therapy (NPWT) was used in combination with other techniques in 6 studies 12, 13, 15,19, 25, 26. Specific details (duration of use, sponge changes, complications) of NPWT were generally not reported, but Fraccalvieri et al(2012) used it for 14 days prior to skin grafting.…”

Topical 5% potassium permanganate solution accelerates the healing process in chronic diabetic foot ulcers

“…Despite recent advances in antimicrobial therapy ( 6 , 7 ), diabetic foot lesions continue to be a serious problem. Foot ulcer treatments are lengthy, costly and require intensive care ( 8 , 9 ).…”

Guidelines on multidisciplinary approaches for the prevention and management of diabetic foot disease (2020 edition)

“…Heel ulcers, a common manifestation in people with diabetes, are often associated with infection or Charcot’s joint disease. When calcaneal ulcers are complicated by osteomyelitis, pressure ankle ulcers or joint deformities and pain caused by Charcot to avoid below-knee amputations, partial calcaneal resection should be considered to remove all necrotic and infected tissue, deformed bone or osteophytes (note that no infected tissue or plantar bone protrusions should be left behind) [ 127 ]. Bone biological materials (BBMs) include bone conduction materials, such as bone grafts, calcium ceramics, hydroxyapatite and collagen and osteoinductive materials, such as platelet gel concentrates, demineralized bone matrix and bone morphogenetic proteins.…”