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Italian Journal of Vascular and Endovascular Surgery 2018 March;25(1):37-49

DOI: 10.23736/S1824-4777.17.01320-1


language: English

Tips and tricks for achieving healing and limb salvage in patients with ischemic heel ulcers and gangrene

Palma M. SHAW 1 , Jonathan LEE 2

1 Division of Vascular Surgery, Upstate Medical University, New York, NY, USA; 2 Upstate Medical University School of Medicine, New York, NY, USA


Management of an ischemic heel ulcer can be challenging due to difficulty with off-loading, malnutrition, neuropathy, and limitations of bony coverage at this location. Arterial revascularization is often not enough to salvage the limb. Specific steps to promote healing of heel ulcerations, particularly in the presence of diabetes, and prevent major amputation are discussed including assessment of the depth of ulceration and bone involvement, ways to evaluate and control infection, determination of degree of vascular disease, and role of angiography and method of revascularization (endovascular vs. open; direct vs. indirect). Aggressive debridement and bone resection for management of calcaneal osteomyelitis are frequently needed. These techniques are not commonly part of the armamentarium of vascular surgeons. Indications and methods to accomplish effective partial or total off-loading and specific contemporary wound care when there is bone and or tendon exposure will be discussed. There is a role for adjuncts, such as hyperbaric oxygen, but timely assessment of their effectiveness is critical.
A discussion regarding clinical aspects of managing heel ulcers is included as well as a review of the published literature from journals, text books and worldwide net. A PubMed search was performed using terms “heel ulcer, peripheral arterial disease, diabetes mellitus, gangrene, limb salvage, calcanectomy, angiosome and or wound care”.
Limb salvage in the presence of heel ulceration, particularly in diabetics, is a complex undertaking. Adequate evaluation, use of available adjuncts or revascularization alone are unlikely to save the extremity. A multidisciplinary team offers the most comprehensive approach for success.

KEY WORDS: Heel - Ulcer - Peripheral arterial disease - Angiosome

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