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

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Author(s): 
Stephanie C. Wu, DPM, MSc

Keys To Closing The Wound And Achieving A Plantigrade Foot

The patient’s left arterial findings were suggestive of moderate arterial occlusive disease with hemodynamically significant iliofemoral and tibioperoneal disease. His right arterial test showed moderate to severe right lower extremity arterial occlusive disease with multilevel disease by segmental limb pressure gradients. I referred the patient for a vascular consult.

   I explained to the patient that his Charcot foot deformity had created a bony prominence that significantly increased the pressure on the plantar aspect of his foot in the location of his ulcer breakdown. While the patient was very interested in having Charcot reconstruction, I explained that he will most likely need bypass surgery to increase blood flow to the foot or he will likely not heal from the reconstructive surgery.

   The patient received stenting of the bilateral thigh after an angiogram procedure and was scheduled for femoral popliteal bypass surgery following a cardiac stress test.

   Following the patient’s bypass procedure, the dorsalis pedis/posterior tibial pulses show biphasic waveforms with the Doppler exam. Transcutaneous oximetry (tcPO2) testing showed 58 mmHg on the medial aspect of the right midfoot and 66 mmHg with the right medial ankle.

   The patient subsequently underwent Charcot foot reconstruction on the right foot (see Figure 4a) with an external fixator (see Figure 4b). We dispensed an external bone stimulator and educated the patient on use of the device.

   Four weeks after Charcot foot reconstruction, the patient developed a blood blister on the plantar forefoot that later progressed to an eschar. Subsequent debridement of the eschar revealed a full thickness ulcer, which was 10.5 cm x 5.6 cm in diameter and 0.5 cm in width (see Figure 5a). I subsequently applied a bioengineered skin equivalent to the wound on a weekly basis for eight weeks to facilitate wound closure. For a view of the wound five weeks after application of the bioengineered skin equivalent, see Figure 5b.

   After wound closure, the patient’s radiographs (see figures 6a and 6b) and plantar pressures (see figure 6c) show a more plantigrade foot with a heel toe gait.

   Dr. Wu is an Associate Professor of Surgery at the Dr. William M. Scholl College of Podiatric Medicine and Associate Professor of Stem Cell and Regenerative Medicine at the School of Graduate Medical Sciences at the Rosalind Franklin University of Medicine and Science in Chicago. She is also the Director for Educational Affairs and Outreach at the Center for Lower Extremity Ambulatory Research (CLEAR) in Chicago.

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John Hovorkasays: April 15, 2012 at 10:47 pm

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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