|Year : 2015 | Volume
| Issue : 2 | Page : 74-78
Preserve the lower limb in a patient with calcaneal osteomyelitis and severe occlusive peripheral vascular disease by partial calcanectomy
Chin-Ta Lin, Chi-Yu Chen, Shyi-Gen Chen, Tim-Mo Chen, Shun-Cheng Chang
Department of Surgery, Division of Plastic and Reconstructive Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, Republic of China
|Date of Submission||26-Nov-2013|
|Date of Decision||22-May-2014|
|Date of Acceptance||25-Jun-2014|
|Date of Web Publication||29-Apr-2015|
Dr. Shun-Cheng Chang
Department of Surgery, Division of Plastic and Reconstructive Surgery, Tri-Service General Hospital, National Defense Medical Center, No. 325, Section 2, Cheng-Gung Road, Taipei 11490, Taiwan
Republic of China
Source of Support: None, Conflict of Interest: None
Heel ulcers in patients with severe peripheral artery occlusive disease represent a challenge to the treating physician. They become more difficult to treat with underlying medical comorbidities. We report a case of 76-year-old man with hypertension, diabetes mellitus, and end-stage renal disease in uremia status presented to our hospital with a 3-month history of a diabetic foot ulcer on his right heel. He was diagnosed with near total artery occlusion below the knee at the local hospital, and vascular reconstruction failed. After admission, surgical debridement was performed with subsequent partial calcanectomy facilitating wound closure without tension. After surgery, the foot was immobilized with a short-leg splint for 2 weeks. Thereafter, ankle immobilization was accomplished using a thermal protective plastic splint and cast shoes with a posterior window for wound care. The wound healed well with no recurrence during the 12-month follow-up period, and the patient may return to an ambulatory status, including a normal gait pattern. In this case, we demonstrate that the partial calcanectomy is practical for the treatment of plantar heel ulcers in a patient with severe comorbidities. With proper surgical planning and postoperative care, partial calcanectomy is a viable alternative to below-the-knee amputation and may better serve the patient who would otherwise be restricted to a sedentary lifestyle.
Keywords: Heel ulcer, partial calcanectomy, occlusive peripheral vascular disease
|How to cite this article:|
Lin CT, Chen CY, Chen SG, Chen TM, Chang SC. Preserve the lower limb in a patient with calcaneal osteomyelitis and severe occlusive peripheral vascular disease by partial calcanectomy. J Med Sci 2015;35:74-8
|How to cite this URL:|
Lin CT, Chen CY, Chen SG, Chen TM, Chang SC. Preserve the lower limb in a patient with calcaneal osteomyelitis and severe occlusive peripheral vascular disease by partial calcanectomy. J Med Sci [serial online] 2015 [cited 2019 Aug 19];35:74-8. Available from: http://www.jmedscindmc.com/text.asp?2015/35/2/74/156016
| Introduction|| |
The management of patients with diabetic ulcers and calcaneal osteomyelitis of the heel remains a challenge for reconstructive surgeons because of the lack of locally available tissues for transposition, relatively poor skin circulation, and weight-bearing requirement of the region.  Diabetic foot ulcers are difficult to treat because of the range of pathogenic abnormalities in patients with diabetes, which includes ischemia, intrinsic defects in angiogenesis, and impaired immunity against infection.  The lifetime incidence of developing a diabetic foot ulcer is as high as 25%.  Moreover, osteomyelitis is a common late-stage sequela of deep heel ulceration that frequently complicates wound management.
When contemplating treatment options, the goals to consider include removing the infected bone, healing the wound with durable soft tissue, maintaining limb function for walking or transfer, and avoiding leg amputation.  Patients who develop heel ulcers often have several medical comorbidities such as diabetes mellitus, peripheral vascular disease, and chronic renal failure. It poses a life-threatening risk for patients undergoing long operations and anesthesia.  In addition, documented near total occlusive peripheral vascular disease and failed vascular reconstruction preclude the employment of a pedicle or free-flap reconstruction. 
Partial calcanectomy is a simple procedure for the treatment of chronic heel ulcers with limited calcaneal involvement. ,,,, This procedure is an effective option provided specific principles are followed to achieve complete wound coverage and minimize pressure points when the patient is in bed and walking. Here, we present a case with heel ulceration and calcaneal osteomyelitis using partial calcanectomy to facilitate wound closure as an alternative to below-the-knee amputation.
| Case Reports|| |
A 76-year-old man with hypertension, diabetes mellitus, and end-stage renal disease in uremia status presented to our hospital with a 3-month history of a diabetic foot ulcer on his right heel. He was diagnosed with near total artery occlusion below the knee at the local hospital, and vascular reconstruction failed. A below-knee amputation was recommended, and he was referred to our section because he did not want to amputate his leg. The patient had a 30 years history of smoking but quit 20 years previously. Preoperative ankle-brachial index was measured about 0.4 and a serum albumin level was 2.5 g/dL. Physical examination showed an 8 cm × 4 cm-sized wound of the right heel with calcaneal bone exposure [Figure 1]a. After admission, local wound care using wet-gauze dressings with saline-diluted iodine was performed twice daily to condition the wound bed. At operation, we partially removed the calcaneus about 3 cm ×5 cm in size and 3 cm in height [Figure 1]b leaving the Achilles tendon in position, and the wound was closed primarily without tension [Figure 1]c. Pathology indicated calcaneal osteomyelitis, and wound culture was positive for methicillin-resistant Staphylococcus aureus. Subacillin was prescribed initially as 1.5 g/time in every 8 h for 1 week and then changed to vancomycin as 1.0 g/time in every 12 h a day for 4 weeks according to the suggestion of the infection specialist. After surgery, the foot was immobilized with a short-leg splint for 2 weeks. Thereafter, ankle immobilization was accomplished using a thermal protective plastic splint and cast shoes with a posterior window for wound care. Full weight-bearing was permitted approximately 4 weeks after surgery after good wound healing was noted. The wound healed well [Figure 1]d with no recurrence during the 12-month follow-up period, and a plain film of the foot was taken for comparison [Figure 2]. Finally, the patient may return to an ambulatory status, including a normal gait pattern.
|Figure 1: A diabetic ulcer of the heel region in a 76-year-old man. (a) Physical examination shows an 8 cm × 4 cm-sized wound of the right heel with calcaneal bone exposure. (b) During the operation, the calcaneus was partially removed. (c) The heel region wound was closed primarily without tension. (d) The wound healed well without recurrence during the 12-month follow-up period|
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|Figure 2: A plain film of the foot of patient 6 (a) before and (b) after the operation|
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| Discussion|| |
Chronic ulcers located on the weight-bearing surface of the foot limit a patient's activities and increase the load on the contralateral foot. Plantar defects may progress to advanced stages in patients with neurological deficits or diabetes, which frequently results in osteomyelitis of the calcaneus. Soft tissue loss at the heel, often accompanied by exposure of the calcaneus and Achilles tendon, represents a challenge for reconstructive surgeons because of the lack of locally available tissues for transposition, relatively poor skin circulation, and weight-bearing requirement of the region.  Tissues that provide adequate coverage, stability, and sufficient blood supply to prevent osteomyelitis are preferred for reconstruction of these defects.
With each carrying its own relative benefits and disadvantages, various local and free-flap alternatives have been used for heel reconstruction. Reversed island flaps such as the peroneal artery flap, anterior tibial artery flap, and posterior artery flap have the disadvantage of major leg artery sacrifice. ,, Fasciocutaneous flaps based on the dorsalis pedis island flap, sural pedicle, the lateral calcaneal artery, medial and lateral plantar arteries or peroneal artery perforators and their various modifications have also been used. ,,,, Flaps that provide inherent skin coverage and sensation do not necessitate sacrifice of major vessels or nerves. However, structural instability and vulnerability to infection are disadvantages of all fasciocutaneous flaps.
Several proximally based muscle flaps from the foot have been developed, including the abductor hallucis muscle, abductor digiti minimi muscle, extensor digitorum brevis muscle, and flexor digitorum brevis muscle island pedicle flaps. ,, Limited effective range, lack of significant dimensions, and insufficient padding because of their thin nature are the main disadvantages of these muscle flaps, which are used to reconstruct sole defects. Free-tissue transfer for coverage of foot defects also shows promising results in achieving coverage because bone and tendon exposure results in a chronic intractable wound. ,,,,,,,, Hallock indicated that even a small defect in this region might justify the need for a microsurgical tissue transfer.  However, morbidity and operative time are increased in technically demanding microvascular reconstruction.
Occasionally, peripheral vascular disease precludes the employment of pedicle or free-flap reconstruction. Major limb amputation has been suggested in the past in some subgroups such as patients with ischemic heel ulcers and gangrene accompanied by end-stage renal failure and diabetes as well as those with large (>6 cm) wounds. , Reports of vascular reconstruction interventions have revolutionized the treatment of patients with critical limb ischemia in recent years, and a decrease in major amputations with the use of this approach in high-risk patients has been evident. , Several studies using various bypass procedures with additional free-flap repairs on patients with heel ulcers and gangrene have been reported. ,,
However, severe occlusion with peripheral vascular disease could occur in some patients and failed vascular reconstruction complicates heel ulceration. Adequate preoperative testing of the patient's vascular perfusion and degree of ulceration is important. Moreover, when combined with several medical comorbidities, it poses a life-threatening risk to patients undergoing long operations and anesthesia. In this condition, vacuum-assisted closure device (VAC) therapy has been useful in preparing diabetic ulcers for closure via split-skin grafting. However, prolonged VAC therapy application (3-8 weeks) is sometimes not affordable for patients. 
Partial calcanectomy is an excellent alternative for the treatment of calcaneal ulceration with or without osteomyelitis. Partial calcanectomy, first described by Gaenslen in 1931, is simple to perform and clears infected bone, tissue, and ulceration.  Generally 1 cm of dorsal-proximal and 2-3 cm of distal-plantar calcaneus are left intact following the calcaneal resection and the Achilles tendon was reattached to the residual calcaneal bone.  Occasionally, the Achilles tendon may not be violated and can remain attached to its insertion in the calcaneus. With proper postoperative protection, the patient may return to an ambulatory status, including a normal gait pattern. Primary reapproximation of the skin edges prevents scar tissue formation that results from secondary intention, which could produce a less supple and immobile skin region. Salvaging the limb of patients with calcaneal symptomatology could decrease morbidity and mortality and increase the quality of life of these patients.
| Conclusion|| |
This report illustrates that the partial calcanectomy is practical for the treatment of plantar heel ulcers with underlying osteomyelitis in patients with severe comorbidities. Morbidity and operative time are increased in technically demanding pedicle flap harvest and microvascular reconstruction. VAC therapy is useful, but prolonged application is sometimes not affordable. With proper surgical planning and postoperative care, partial calcanectomy is a viable alternative to below-the-knee amputation and may better serve the patient who would otherwise be restricted to a sedentary lifestyle.
| Disclosure|| |
None of the contributing authors have any conflicts of interest, including specific financial interests and relationships and affiliations relevant to the subject matter or materials discussed in the manuscript.
| References|| |
Chen SL, Chen TM, Chou TD, Chen SG, Wang HJ. The distally based lesser saphenous venofasciocutaneous flap for ankle and heel reconstruction. Plast Reconstr Surg 2002;110:1664-72.
Brem H, Sheehan P, Rosenberg HJ, Schneider JS, Boulton AJ. Evidence-based protocol for diabetic foot ulcers. Plast Reconstr Surg 2006;117:193S-209.
Singh N, Armstrong DG, Lipsky BA. Preventing foot ulcers in patients with diabetes. JAMA 2005;293:217-28.
Baumhauer JF, Fraga CJ, Gould JS, Johnson JE. Total calcanectomy for the treatment of chronic calcaneal osteomyelitis. Foot Ankle Int 1998;19:849-55.
Treiman GS, Oderich GS, Ashrafi A, Schneider PA. Management of ischemic heel ulceration and gangrene: An evaluation of factors associated with successful healing. J Vasc Surg 2000;31:1110-8.
Fraccalvieri M, Bogetti P, Verna G, Carlucci S, Fava R, Bruschi S. Distally based fasciocutaneous sural flap for foot reconstruction: A retrospective review of 10 years experience. Foot Ankle Int 2008;29:191-8.
Randall DB, Phillips J, Ianiro G. Partial calcanectomy for the treatment of recalcitrant heel ulcerations. J Am Podiatr Med Assoc 2005;95:335-41.
Smith DG, Stuck RM, Ketner L, Sage RM, Pinzur MS. Partial calcanectomy for the treatment of large ulcerations of the heel and calcaneal osteomyelitis. An amputation of the back of the foot. J Bone Joint Surg Am 1992;74:571-6.
Bollinger M, Thordarson DB. Partial calcanectomy: An alternative to below knee amputation. Foot Ankle Int 2002;23:927-32.
Lehmann S, Murphy RD, Hodor L. Partial calcanectomy in the treatment of chronic heel ulceration. J Am Podiatr Med Assoc 2001;91:369-72.
Geertzen JH, Jutte P, Rompen C, Salvans M. Calcanectomy, an alternative amputation? Two case reports. Prosthet Orthot Int 2009;33:78-81.
Gu YD, Wu MM, Li HR. Lateral lower leg skin flap. Ann Plast Surg 1985;15:319-24.
Wee JT. Reconstruction of the lower leg and foot with the reverse-pedicled anterior tibial flap: Preliminary report of a new fasciocutaneous flap. Br J Plast Surg 1986;39:327-37.
Liu K, Li Z, Lin Y, Cao Y. The reverse-flow posterior tibial artery island flap: Anatomic study and 72 clinical cases. Plast Reconstr Surg 1990;86:312-6.
McCraw JB, Furlow LT Jr. The dorsalis pedis arterialized flap. A clinical study. Plast Reconstr Surg 1975;55:177-85.
Morrison WA, Crabb DM, O'Brien BM, Jenkins A. The instep of the foot as a fasciocutaneous island and as a free flap for heel defects. Plast Reconstr Surg 1983;72:56-65.
Grabb WC, Argenta LC. The lateral calcaneal artery skin flap (the lateral calcaneal artery, lesser saphenous vein, and sural nerve skin flap). Plast Reconstr Surg 1981;68:723-30.
Masquelet AC, Beveridge J, Romana C, Gerber C. The lateral supramalleolar flap. Plast Reconstr Surg 1988;81:74-81.
Masquelet AC, Romana MC, Wolf G. Skin island flaps supplied by the vascular axis of the sensitive superficial nerves: Anatomic study and clinical experience in the leg. Plast Reconstr Surg 1992;89:1115-21.
Attinger CE, Ducic I, Cooper P, Zelen CM. The role of intrinsic muscle flaps of the foot for bone coverage in foot and ankle defects in diabetic and nondiabetic patients. Plast Reconstr Surg 2002;110:1047-54.
Furukawa M, Nakagawa K, Hamada T. Long-term complications of reconstruction of the heel using a digitorum brevis muscle flap. Ann Plast Surg 1993;30:354-8.
Lin SD, Chou CK, Yang CC, Lai CS. Reconstruction of plantar heel defect using reinnervated, skin-grafted flexor digitorum brevis flap. Br J Plast Surg 1991;44:109-12.
Kuran I, Turgut G, Bas L, Ozkan T, Bayri O, Gulgonen A. Comparison between sensitive and nonsensitive free flaps in reconstruction of the heel and plantar area. Plast Reconstr Surg 2000;105:574-80.
Germann G, Wieczorek D. Combined pedicle and free-tissue transfer to improve functional restoration of the foot: The "backpack principle". J Reconstr Microsurg 1999;15:409-13.
Rautio J, Asko-Seljavaara S, Laasonen L, Härmä M. Suitability of the scapular flap for reconstructions of the foot. Plast Reconstr Surg 1990;85:922-8.
Stevenson TR, Greene TL, Kling TF Jr. Heel reconstruction with the deep circumflex iliac artery osteocutaneous flap. Plast Reconstr Surg 1987;79:982-6.
Noever G, Brüser P, Köhler L. Reconstruction of heel and sole defects by free flaps. Plast Reconstr Surg 1986;78:345-52.
Musharafieh R, Osmani O, Musharafieh U, Saghieh S, Atiyeh B. Efficacy of microsurgical free-tissue transfer in chronic osteomyelitis of the leg and foot: Review of 22 cases. J Reconstr Microsurg 1999;15:239-44.
Chen D, Jupiter JB, Lipton HA, Li SQ. The parascapular flap for treatment of lower extremity disorders. Plast Reconstr Surg 1989;84:108-16.
Gulyás G, Máté F, Kartik I. A neurovascular island flap from the first web space of the foot to repair a defect over the heel: Case report. Br J Plast Surg 1984;37:398-401.
Hallock GG. Distally based flaps for skin coverage of the foot and ankle. Foot Ankle Int 1996;17:343-8.
Carsten CG 3 rd
, Taylor SM, Langan EM 3 rd
, Crane MM. Factors associated with limb loss despite a patent infrainguinal bypass graft. Am Surg 1998;64:33-7.
Edwards JM, Taylor LM Jr, Porter JM. Limb salvage in end-stage renal disease (ESRD). Comparison of modern results in patients with and without ESRD. Arch Surg 1988;123:1164-8.
Adam DJ, Beard JD, Cleveland T, Bell J, Bradbury AW, Forbes JF, et al.
Bypass versus angioplasty in severe ischaemia of the leg (BASIL): Multicentre, randomised controlled trial. Lancet 2005;366:1925-34.
Faglia E, Dalla Paola L, Clerici G, Clerissi J, Graziani L, Fusaro M, et al.
Peripheral angioplasty as the first-choice revascularization procedure in diabetic patients with critical limb ischemia: Prospective study of 993 consecutive patients hospitalized and followed between 1999 and 2003. Eur J Vasc Endovasc Surg 2005;29:620-7.
Serletti JM, Hurwitz SR, Jones JA, Herrera HR, Reading GP, Ouriel K, et al.
Extension of limb salvage by combined vascular reconstruction and adjunctive free-tissue transfer. J Vasc Surg 1993;18:972-8.
Ciresi KF, Anthony JP, Hoffman WY, Bowersox JC, Reilly LM, Rapp JH. Limb salvage and wound coverage in patients with large ischemic ulcers: A multidisciplinary approach with revascularization and free tissue transfer. J Vasc Surg 1993;18:648-53.
Tukiainen E, Kallio M, Lepäntalo M. Advanced leg salvage of the critically ischemic leg with major tissue loss by vascular and plastic surgeon teamwork: Long-term outcome. Ann Surg 2006;244:949-57.
Nather A, Chionh SB, Han AY, Chan PP, Nambiar A. Effectiveness of vacuum-assisted closure (VAC) therapy in the healing of chronic diabetic foot ulcers. Ann Acad Med Singapore 2010;39:353-8.
Gaenslen FJ. Split-heel approach in osteomyelitis of the os calcis. J Bone Joint Surg 1931;13:759-72.
Baravarian B, Menendez MM, Weinheimer DJ, Lowery C, Kosanovich R, Vidt L. Subtotal calcanectomy for the treatment of large heel ulceration and calcaneal osteomyelitis in the diabetic patient. J Foot Ankle Surg 1999;38:194-202.
[Figure 1], [Figure 2]