Case Study: Healing A Chronic Wound In A Patient With Charcot Foot And PAD

Author(s): 
Stephanie C. Wu, DPM, MSc

This author provides an intriguing case study detailing the diagnostic workup and treatment of a chronic wound complicated by Charcot foot and peripheral arterial disease (PAD).

A 60-year-old male presented to the clinic complaining of a recurrent ulcer on the bottom of his foot for the past six months. The patient states his ulcer heals when he does not put weight on his foot but the ulcer opens up again once he starts walking. The patient denies pain to the area and notes that he washes his foot with 1% betadine solution everyday.

   He says he previously received treatment for the ulcer that included the use of VAC therapy (KCI) and a skin graft, which did not incorporate into his skin. The patient also notes a previous bone biopsy that was taken when the wound was deeper and it was negative for osteomyelitis.

   The patient’s past medical history includes diabetes for the past 25 years, atrial fibrillation since 2007, congestive heart failure, hypertension, hypercholesterolemia and bilateral lower extremity edema. The patient also had Charcot neuroarthropathy of the left foot 15 years ago that is now inactive. He currently has Charcot neuroarthropathy of the right foot.

   The patient’s past surgical history include coronary artery bypass graft (CABG) in 2002, cataract surgery for both eyes and surgery for a detached retina approximately eight years ago.

   The patient’s medications include carvedilol (Coreg CR) 12.5 mg twice a day; 60 units of insulin during the day and 40 units at night; lisinopril 20 mg daily; gabapentin 600 mg twice daily; ezetimibe 10mg q PM; simvastatin (Zocor, Merck) 40 mg qhs; lansoprazole (Prevacid, Novartis) 30 mg qam; and furosemide 40mg daily.

   The patient has no known drug allergies. He denies tobacco, alcohol and illicit drug use. The patient works as a Realtor and lives alone. He also has a family history of heart disease, diabetes and stroke.

   Aside from the aforementioned findings from the past medical history, the remaining review of systems was unremarkable.

Reviewing The Physical Exam Findings

The patient had no hair growth bilaterally on the foot and ankle but there was hair growth present proximal to the ankle.

Comments

We frequently see such patients with diabetes with renal insufficiency and a baseline creatinine well over 2. What is your opinion regarding the approach and management of such patients given that the vascular surgeon may be reluctant to revascularize as the dye load may push the patient to hemodialysis. My background is general surgery and hyperbaric medicine. Although I do perform arterial revascularization and would like to do more, we also routinely get healing of wounds in patients with an ABI of as low as 0.4 (albeit without the benefit of foot reconstruction).

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