title: Large and deep diabetic heel ulcers need not lead to amputation.
abstract: 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.
  
  
  METHODS
  Level IV, retrospective case series.
authors: Surgery Department, Tehran University of Medical Sciences, Tehran, Iran.
authors: Abolfazl
authors: A
authors: Shojaiefard
authors: Zhamak
authors: Z
authors: Khorgami
authors: Mohammad Reza
authors: MR
authors: Mohajeri-Tehrani
authors: Bagher
authors: B
authors: Larijani
mesh_terms: D000671:Amputation, Surgical; D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D003430:Cross-Sectional Studies; D003646:Debridement; D017719:Diabetic Foot / Q000473:pathology / Q000628:therapy*; D003929:Diabetic Neuropathies / Q000150:complications; D004322:Drainage; D005260:Female; D006365:Heel / Q000098:blood supply; D006801:Humans; D007511:Ischemia / Q000150:complications; D023821:Limb Salvage / Q000379:methods*; D008297:Male; D008875:Middle Aged; D010019:Osteomyelitis / Q000628:therapy; D010348:Patient Care Team; D011446:Prospective Studies; D013524:Surgical Flaps; D058017:Vascular Grafting; D014945:Wound Healing
chemical_list: D000900:Anti-Bacterial Agents