Heal or no heel: Outcomes of ischaemic heel ulcers following lower limb revascularization from a multi-ethnic Asian Cohort in Singapore

Yun Le Linn, Sze Ling Chan, Shereen Xue Yun Soon, Charyl Jia Qi Yap, Mervin Nathan Han Hui Lim, Qing Wei Shaun Lee, Tze Tec Chong, Tjun Yip Tang, Yun Le Linn, Sze Ling Chan, Shereen Xue Yun Soon, Charyl Jia Qi Yap, Mervin Nathan Han Hui Lim, Qing Wei Shaun Lee, Tze Tec Chong, Tjun Yip Tang

Abstract

Ischaemic diabetic heel ulcers are difficult to treat and prognosis is often guarded. The aim was to document our outcome of treating heel ulcers following revascularization in a predominantly diabetic Asian cohort presenting with chronic limb threatening ischaemia from Singapore. Retrospective cohort study (n = 66, 66 limbs) over a 5-year period. Data were collected from hospital electronic health records. Outcomes included time to healing, amputation free survival (AFS), and mortality. Minimum follow-up period was 6 months. Multivariate regression analysis was performed to look for factors associated with poor outcome. Mean age was 67.4 ± 8.8 years. 62/66 (93.9%) were diabetics. Mean wound size at presentation was 3.6 ± 2.3 cm. Mean Wound, Ischaemia, Foot Infection (WIFI) score was 5 ± 1.6. 12/66 (18%) patients had a patent posterior tibial artery pre-operatively. Straight line flow was restored in only 31/66 (46.9) patients but 47/66 (71.2%) had successful limb salvage. Median time to wound healing was 90.0 (IQR 60-180) days. A median of 1 (IQR 0-2) wound debridement was required. Patients who underwent negative pressure dressing (23/66; 34.8%) required a median of 26 (IQR 13-33) cycles to achieve healing. Amputation free survival (AFS) was 72% and 68% at 6- and 12-months, respectively. Mortality rate was 16.7% and 19.7% at 6- and 12-months, respectively. Low albumin level and initial Rutherford class were independent predictors of worse 6-month AFS. Outcomes of heel ulcers post revascularisation may not be as poor as previously described. Persistent attention to wound care with multidisciplinary effort is needed for optimal healing.

Keywords: diabetic; endovascular; heel ulcer; outcome; posterior tibial artery; revascularization.

Conflict of interest statement

The authors declare no conflict of interest.

© 2020 The Authors. International Wound Journal published by Medicalhelplines.com Inc and John Wiley & Sons Ltd.

Figures

FIGURE 1
FIGURE 1
Competing analysis graph (wound healing/amputation/death)
FIGURE 2
FIGURE 2
Change in proportion of Rutherford 5 and 6 post revascularisation
FIGURE 3
FIGURE 3
Multivariate regression showing variables associated with outcome

References

    1. Younes NA, Albsoul AM, Awad H. Diabetic heel ulcers: a major risk factor for lower extremity amputation. Ostomy Wound Manage. 2004;50(6):50‐60.
    1. Goudie EB, Gendics C, Lantis JC. Multimodal therapy as an algorithm to limb salvage in diabetic patients with large heel ulcers. Int Wound J. 2012;9:132‐138.
    1. Lehmann S, Murphy RD, Hodor L. Partial calcanectomy in the treatment of chronic heel ulceration. J Am Podiatr Med Assoc. 2001;91(7):369‐372.
    1. Meloni M, Izzo V, Giurato L, Brocco E, Gandini R, Uccioli L. Limb salvage in diabetic patients with ischemic heel ulcers. Int J Low Extrem Wounds. 2019;19:1‐7. 10.1177/1534734619884438.
    1. Faglia E, Clerici G, Caminiti M, Vincenzo C, Cetta F. Heel ulcer and blood flow: the importance of the angiosome concept. Int J Low Extrem Wounds. 2013;12(3):226‐230.
    1. Treiman GS, Oderich GS, Ashrafi A, Schneider PA. Management of ischemic heel ulceration and gangrene: an evaluation of factors associated with successful healing. J Vasc Surg. 2000;31(6):1110‐1118.
    1. Khoo R, Jansen S. Slow to heel: a literature review on the management of diabetic calcaneal ulceration. Int Wound J. 2018;15:205‐211.
    1. Örneholm H, Apelqvist J, Larsson J, Eneroth M. Heel ulcers do heal in patients with diabetes. Int Wound J. 2017;14:629‐635.
    1. Mohapatra A, Henry JC, Avgerinos ED, et al. Heel wounds predict mortality but not amputation after infrapopliteal revascularization. Ann Vasc Surg. 2018;51:78‐85.
    1. Azuma N, Uchida H, Kokubo T, Koya A, Akasaka N, Sasajima T. Factors influencing wound healing of critical ischaemic foot after bypass surgery: is the angiosome important in selecting bypass target artery? Eur J Vasc Endovasc Surg. 2012;43(3):322‐328.
    1. Karr J. Utilization of living bilayered cell therapy (Apligraf) for heel ulcers. Adv Skin Wound Care. 2008;21(6):270‐274.
    1. Kammerlander G, Eberlein T. Use of Allevyn heel in the management of heel ulcers. J Wound Care. 2003;12(8):313‐315.
    1. Bavarian B, Menendez MM, Weinheimer DJ, Lowery C, Kosanovich R, Vidt L. Subtotal calcanectomy for the treatment of large heel ulceration and calcaneal osteomyelitis in the diabetic patient. J Foot Ankle Surg. 1999;38(3):194‐202.
    1. Butt T, Lilja E, Örneholm H, et al. Amputation‐free survival in patients with diabetes mellitus and peripheral arterial disease with heel ulcer: open versus endovascular surgery. Vasc Endovasc Surg. 2019;53(2):118‐125.
    1. Berceli SA, Chan AK, Pomposelli FB Jr, et al. Efficacy of dorsal pedal artery bypass in limb salvage for ischemic heel ulcers. J Vasc Surg. 1999;30(3):499‐508.
    1. Daabiss M. American Society of Anaesthesiologists physical status classification. Indian J Anaesth. 2011;55(2):111‐115.
    1. Kim SH, Amber B, Groban L. Preoperative assessment of the older surgical patient: honing in on geriatric syndromes. Clin Interv Aging. 2015;10:13‐27.
    1. Hardman RL, Jazaeri O, Yi J, Smith M, Gupta R. Overview of classification systems in peripheral artery disease. Semin Intervent Radiol. 2014;31(4):378‐388.
    1. Norgren L, Hiatt WR, Dormandy JA, et al. Inter‐society consensus for the Management of Peripheral Arterial Disease (TASC II). J Vasc Surg. 2007;45(Suppl S):S5‐S67.
    1. Mills JL, Conte MS, Armstrong DG, et al. The society for vascular surgery lower extremity threatened limb classification system: risk stratification based on wound, ischemia, and foot infection (WIfI) on behalf of the society for vascular surgery lower extremity guidelines. J Vasc Surg. 2014;59:220‐34.e2.
    1. Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004;240(2):205‐213.
    1. Cacua M. Experience in the management of patients with chronic vascular ulcers of the lower limbs using negatively charged polystyrene microspheres. J Vasc Med. 2020;2020:3673657.
    1. Sardari K, Kakhki E, Mohri M. Evaluation of wound contraction and epithelialization after subcutaneous administration of Theranekron in cows. Comp Clin Pathol. 2007;16:197‐200.
    1. R Core Team . R: A language and environment for statistical computing. R Foundation for Statistical Computing, Vienna, Austria. 2018; Available from:. .
    1. Conte MS, Bradbury AW, Kolh P, et al. Global vascular guidelines on the management of chronic limb‐threatening ischemia. Eur J Vasc Endovasc Surg. 2019;58(1):s1‐s109.
    1. Tay WL, Chong TT, Chan SL, et al. Two‐year clinical outcomes following lower limb endovascular revascularisation for chronic limb threatening ischaemia at a tertiary Asian vascular Centre in Singapore. Singapore Med J. 2020. 10.11622/smedj.2020104. [Epub ahead of print].
    1. Gibbs J, Cull W, Henderson W, Daley J, Hur K, Khuri SF. Preoperative serum albumin level as a predictor of operative mortality and morbidity: results from the national VA surgical risk study. Arch Surg. 1999;134(1):36‐42.
    1. Peacock MR, Farber A, Eslami MH, et al. Hypoalbuminemia predicts perioperative morbidity and mortality after Infrainguinal lower extremity bypass for critical limb ischemia. Ann Vasc Surg. 2017;41:169‐175.e4.
    1. Furuyama T, Onohara T, Yamashita S, et al. Prognostic factors of ulcer healing and amputation‐free survival in patients with critical limb ischemia. Vascular. 2018;26(6):626‐633.
    1. Furuyama T, Yamashita S, Yoshiya K, et al. The controlling nutritional status score is significantly associated with complete ulcer healing in patients with critical limb ischemia. Ann Vasc Surg. 2020;66:510‐517.

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