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dear all,
i have been treating a 65 years old female with diabetic foot ulcer for 3 months period. forefoot part of the wound in web space healed well. there is no bony involvement.but wound over the heel both medial side and lateral side communicating each other with osteomyelitic calcneum showing no response to
regular dressing.some times bleeding was more while doing dressing.
how can i proceed?

dr.suresh

 

Re: diabetic foot

Antibiotics and offloading done?
how ischaemic is she?
Orthopaedic / podiatric surgery for Osteomyelitis?

Just a few suggestions

Cheers

Joe

 

An MRI and white blood cell scan should have been performed to evaluate the extent of the osteomyelitis in the calcaneus. Next, the vascular status of the patient should be addressed. If adequate, you may consider attempting a fish-mouth type incision to the heel with partial calcanectomy and flap closure if the remaining bone and soft tissues appear viable. You may also consider implantation of antiobiotic beads with a drain if closure is performed. If the wound cannot be closed, consider seqquential debridements until the heel is free from infection in conjunction with negative pressure wound dressings if available. Delayed primary closure can then be performed when "ready". The patient will require specialized shoegaer and bracing post-operatively but at least she will have a functional limb. If MRI show extensive osteomyelitis of the calcaneus, then BKA may be the only option. Hope this helps and good luck.

 

quality pathway advised by hstam, and i would concur with almost all. If the limb is viable arterally then the surgical debridement offers an excellent avenue. We had a patient last year spina bifida with massive fat pad creating allsorts of tissue stress problems. developed an extensive ulcer following a thermal burn and managed to persuade the trauma surgeon to debride, prior to BKA. (+++ OM of calcaheum)
On last imaging (plain film about 10% of calcaneum remains from memory, i will try and dig out the film to attach) Post op placed him in a modified DH walker boot with an extended rear foot rocker and rapid progess once weight nearing. The purpose of the extended rear foot rocker is to move ground reaction force away from the heel contact (essentially attempts to make the rearfoot act as the mid foot, again will try and attach an image if interested).

regards

Mark