gms | German Medical Science

Background: The heel plays a vital role in weight transmission and in the dynamics of walking. A major lower limb amputation is defined as a surgical removal of a part or whole limb by cutting through the bone or joint proximal to the ankle.

The management of heel ulcers for limb salvage is complex and needs multidisciplinary management for control of associated comorbidities, management of ischemia, control of infection, coverage and off-loading.

Aim of the work: To evaluate and compare clinical outcomes and ulcer healing between patients in whom angiosome target vessel revascularization was performed successfully [direct revascularization (DR)] and patients with indirect revascularization (IR) in whom the dilated vessels successfully were the nonangiosome target with presence or absence of blush sign.

Methods: It is a prospective study that included 42 patients having ischemic heel ulcers associated with isolated infragenicular arterial disease.

Patients were divided into Group I: patients having PTA revascularized (Direct heel revascularization) which included 22 patients and Group II: in which patients have anterior tibial artery (ATA) revascularized or peroneal artery (PA) revascularized with collateral(s) to pedal arch (Indirect heel revascularization) which included 20 patients.

Results: Complete ulcer healing was observed in 16 patients (72.7%) in group I, while healing was complete in 13 patients in group II (65%). The mean ulcer healing time for both groups was 17.07±4.79 weeks and the median was 18 weeks. The mean ulcer healing time for group I was 15.9±4.6 weeks and the median was 15 weeks, while for group 2 the mean ulcer healing time was 21.7±1.66 weeks and the median was 22 weeks. There was statistically significant difference between both groups healing time with a p value of 0.002.

Thirty-two limbs (76.19%) were salvaged during the study period, seventeen in group I (77.27%) and 15 in group II (75%). There was no statistically significant difference in overall limb salvage between both groups P= 0.826. All limb losses (n=10) occurred in 1^st follow-up month, seven of them (4 in group I and 3 in group II) due to inability to control infection even after revascularization, in spite of extensive repeated debridement. The other 3 cases (1 in group I and 2 in group II) had ongoing ischemia and gangrene even after successful revascularization, the 3 cases had type 3 pedal arch.

Direct blood flow to the heel ulcer had significantly shortened ulcer healing time but not significantly differs from obtaining indirect flow in limb salvage rate. Diabetes mellitus, cardiovascular diseases, delayed ulcer stage and higher grade of infection prolong ulcer healing time and decrease limb salvage rate. ESRD, ulcer depth and preoperative degree of ischemia are negatively affecting limb salvage while post revascularization multiple patent vessels and completeness of pedal arch are associated with higher limb salvage rate. We also noted that immediate post-operative PTA ABPI, PTA PSV are negatively correlated to healing time.

Conclusion: Multiple vessel revascularization should be the role – when possible – in revascularization of heel ulcers, the second strategy should be direct revascularization through PTA. In case of direct revascularization is not technically feasible, indirect revascularization should not be overlooked for a better result over time and limb salvage.Wound blush and pedal arch completeness are positive independent factors for limb salvage.