Lower Extremity Wounds

Abstract

This chapter will review the management of chronic lower extremity wounds, including diabetic foot ulcers and chronic venous stasis ulcers. The reader will be able to identify the appropriate preoperative optimization and barriers to effective treatment of these wounds, and propose surgical management, as well as manage postoperative complications.

Keywords: lower extremity wounds, venous stasis ulcers

Six Key Points

• Wounds should be debrided and vasculature assessed.

• Chronic osteomyelitis may best be treated with a partial calcanectomy.

• One-half to two-thirds of the calcaneus can be removed surgically.

• Coverage can include local flaps with a partial calcanectomy or free flaps.

• Imaging should include plain films and MRI.

• Patients require orthotics.

Questions

1. What do you do with an open calcaneal wound (Fig. 20.1)?

Initially, the wound should be debrided. After that, a temporary dressing can be placed until the wound declares itself and full workup is completed.

2. What do you do next?

The vasculature should be assessed. If the patient is not renally impaired, and does not take metformin, an angiogram is appropriate. If no radiologic imaging can be done, then one should Doppler out the vessel. Noninvasive vascular studies should be performed, which can determine whether revascularization with vascular surgery should be performed first, or if the healing capacity is insufficient for salvage.

3. What next?

Once osteomyelitis has been treated, with either antibiotics or a partial calcanectomy, the wound should be covered.

4. How do you determine if a partial calcanectomy is an option?

Plain films will determine the amount of bony involvement, and MRI can be used as an adjunct to determine how much bone is involved. One-half to two-thirds of the calcaneus can be removed, but patients may require lifetime orthotics (Fig. 20.2).

5. How do you perform the partial calcanectomy?

Posterior or hockey stick incisions are used, and the skin flaps are dissected keeping their full thickness. Serpentine incisions can be used (the “hurricane” incision) if the surgeon wishes to avoid scarring of the posterior leg.¹ The Achilles tendon may be detached, and is preserved for reattachment later. The calcaneus is removed in a posterior-proximal/plantar distal with an oscillating saw or an osteotome. The remaining calcaneus is assessed for bleeding, and fluoroscopic appearance of sufficient bone. The Achilles tendon is reattached, with an anchor or with sutures.