Surgical management of non-ischemic diabetic heel ulcers and the role of magnetic resonance imaging [MRI] in these cases

ABSTRACT

Amputations distal to the heel are minor foot amputations while proximal amputations to the heel are major. Heel ulcers may be superficial but may send infection deep to bone [calcaneus] and/or-Achilles tendon .In the start of the treatment the anticipated outcome is not well known. The Aim of the work is to report our results of management of chronic non-ischemic diabetic heel ulcers including surgical management in the form of debridement, partial calcnectomy and partial excision of Achilles tendon plus off-loading, edema management and wound management. Role of medical management of diabetes mellitus [DM] and comorbid conditions and to report the role of MRI in diagnosis and management these cases. This retrospective study involved Sixty patients [33 female, and 27 male], mean age 55.87 [range 26-78 years, mode 60 years] with 66 heel ulcers in the 4 year period from January 2002 to January 2006. Diagnosis of neuropathy and vascular state were done. Photographic documentation of the ulcers, Plain-x-ray and MRI were used to diagnose osteomyelitis. In twelve cases partial calcanectomy and in 5 Achilles tendon was partially excised. Regular debridement, wound care and control, management of infection, hyperglycemia, comorbid conditions was performed in all patients plus post-operative off-loading, patient and relatives education. Follow up of the patients. End points of the study were ambulation and independency of the patient, healing of the ulcers, proximal amputation, or death of the patient. All of the Ulcers were >2 cm[2] surface area with duration > 8 weeks. Most of them were in the right side in the planter aspect. MRI showed osteomyelitis in 12 cases of the calcaneus and they were managed by partial calcanectomy. Foot stability and patient independence was achieved after partial excision of Achilles tendon. Complete healing of the ulcers after one year of management was in 68% of the ulcers. Blow knee amputations were done in 5 cases and above knee in two. Seven patients died within 4 year period due to metabolic, cardiac and cerebral causes. Multidisciplinary approach including vascular surgery, radiological imaging and internal medicine is crucial to successful treatment through integration of knowledge and experience. Debridement of chronic or infected tissues even if Achilles tendon or calcanei are involved is essential for ulcer healing. MRI has a role in accurate detection of precise area of osteomyelitis allowing proper debridement and partial calcanectomy with little morbidity and major impact on patient and limb outcome: