Regional skeletal muscle perfusion distribution in diabetic feet may differentiate short-term healed foot ulcers from non-healed ulcers.

OBJECTIVES: The purpose of this study was to leverage a magnetic resonance imaging (MRI) approach to characterize foot perfusion distribution in patients with diabetes, with or without foot ulcers, and determine the ability of the regional perfusion measurements to identify ulcer-healing status. METHODS: Three groups of participants (n = 15 / group) were recruited: controls (without diabetes), type II diabetes, and type II diabetes with foot ulcers. All participants underwent MRI evaluating foot perfusion in three muscle layers (from plantar to dorsal) at rest and during a standardized toe-flexion exercise. The exercise perfusion and perfusion reserve values were analyzed around and away from ulcers. Participants with foot ulcers were followed up 3 months after the MRI exams to determine the foot healing status. RESULTS: Foot plantar muscle perfusion reserves were progressively lower from controls to diabetes, and to diabetes with foot ulcers (e.g., 2.58 ± 0.67, 1.48 ± 0.71, 1.12 ± 0.35, p < 0.001). In controls, the plantar layer had significantly higher perfusion reserve than the dorsal layer, whereas in either diabetes group, there was no significant difference in perfusion reserve among muscle layers. Using the ratio of total exercise perfusion around ulcers to that away from ulcers, the sensitivity and specificity to differentiate healing from non-healed ulcers were 100% and 86%, respectively. CONCLUSIONS: Our study reveals significantly different foot perfusion distribution among controls, diabetes, and diabetes with foot ulcers. The prognostic value of MRI regional perfusion assessments has the potential to monitor interventions to improve ulcer healing outcomes. KEY POINTS: • Contrast-free MRI permits quantitative assessment of regional foot muscle perfusion at rest and during isometric exercise. • Patients with diabetes and foot ulcers, without clinical evidence of peripheral arterial disease, had significantly impaired foot muscle perfusion and perfusion reserve. • Regional foot perfusion distribution may be used to predict the short-term healing status of foot ulcers in diabetes.

Intravascular Ultrasound-Guided Revascularization of Chronic Juxtarenal Aortoiliac Occlusion.

Chronic juxtarenal aortoiliac occlusion (JRO) represents the most severe form of aortoiliac occlusive disease, classified under Trans-Atlantic Inter-Society Consensus (TASC II) as a TASC II D lesion with surgical treatment as the main recommendation. Although endovascular revascularization of other TASC II D lesions are routinely performed, JRO is often considered a contraindication for endovascular treatment due to the extensive nature, extending from the level of the renal arteries down to the iliac arteries. We hereby illustrate an intravascular ultrasound-guided re-entry based technique to facilitate endovascular reconstruction of a JRO. A 58-year-old man with JRO presented with an infected nonhealing forefoot ulcer. A transradial pigtail catheter was positioned at the level of the occlusion as an imaging catheter and landmark for re-entry. Subintimal wiring was performed through bilateral groin accesses to the level of the pigtail catheter. Intravascular-guided re-entry catheter was used to identify the true lumen guide firing of the needle catheter, allowing passage for a guidewire into the true lumen of the suprarenal aorta. The intimal fenestration was dilated using a 4-mm angioplasty balloon which allowed passage of the contralateral guidewire. Kissing stent grafts were deployed bilaterally, extending from the level of the infrarenal aorta down to the level of the distal external iliac arteries in overlapping fashion. Completion angiography showed brisk flow from the aorta through the stented portion into the femoral arteries. The patient underwent forefoot amputation 2 days later with successful wound healing and limb salvage at 6 months.

Vein Harvest Wound Healing after Bypass Surgery for Critical Limb Ischemia.

BACKGROUND: Lower-limb revascularization surgery, especially when performed using the great saphenous vein, predisposes patients to major surgical trauma on initially ischemic tissue. Vein harvest wounds (VHWs) after infrainguinal revascularization heal slowly. This study's aim was to assess the factors associated with VHW healing after infrainquinal bypass surgery for critical limb ischemia (CLI). METHODS: A retrospective patient record study was conducted. All patients with CLI who underwent infrainguinal bypass surgery with autologous vein graft between January 1, 2015, and December 31, 2017, in the Turku University Hospital, were included. Follow-up data were collected until February 28, 2018. The following data was collected from the patient files; risk factors, ankle-brachial indices (ABIs), systolic toe pressures (STPs), the presence of an ischemic ulcer, VHW dehiscence, and the time when the VHW was completely healed. Procedures with outflow vessels at either popliteal or tibial artery were analyzed separately. Descriptive and univariate statistical analyses were performed. RESULTS: Altogether, 195 patients were operated on for CLI, of whom 133 (68.2%) patients had ischemic ulcers. The mean follow-up time was 535.0 days (range 3.0-1143.0 days). The mean ABI improvement was 0.49 (P = 0.00), and STP improvement, 39.9 mm Hg (P = 0.00). The median time taken when VHW was healed was 48.0 days (95% confidence interval [CI], 39.4-56.6) in patients without ischemic ulcers and 82.0 days (95% CI, 59.7-104.3) in patients with ischemic ulcers, P = 0.03. VHW in patients who underwent popliteal artery bypass (62 days, 95% CI, 12.9-93.0) healed faster than VHW in those who underwent tibial artery bypass (132 days, 95% CI, 48.0-93.0), P = 0.02. Risk factors and the preoperative or postoperative ABIs or STPs had no effect on VHW healing time. CONCLUSIONS: VHW healing was remarkably slower after revascularization surgery in patients with an ischemic foot ulcer than in those without ischemic ulcers.

Competing Risk Analysis of the Impact of Pedal Arch Status and Angiosome-Targeted Revascularization in Chronic Limb-Threatening Ischemia.

BACKGROUND: In the context of chronic limb-threatening ischemia, the prognostic impact of angiosome-targeted revascularization and of the status of the pedal arch are debated. METHODS: This series includes 580 patients who underwent endovascular (n = 407) and surgical revascularization (n = 173) of the infrapopliteal arteries for chronic limb-threatening ischemia associated with foot ulcer or gangrene. The risk of major amputation after infrapopliteal revascularization was assessed by a competing risk approach. A subanalysis was made separately for patients who underwent endovascular or open surgical revascularization. RESULTS: At 2 years, survival was 65.1% and leg salvage was 76.1%. Multivariable competing risk analysis showed that C-reactive protein ≥10 mg/dL, diabetes, rheumatoid arthritis, increased number of affected angiosomes, and the incomplete or total absence of pedal arch compared with complete pedal arch (CPA) were independent predictors of major amputation after infrapopliteal revascularization. Multivariable analysis showed increasing risk estimates of major amputation in patients with incomplete (subdistribution hazard ratio [SHR], 2.131; 95% confidence interval [95% CI], 1.282-3.543) and no visualized pedal arch (SHR, 3.022; 95% CI, 1.553-5.883) compared with CPA. Pedal arch was important even if angiosome-targeted revascularization was achieved: Angiosome-directed revascularization in presence of CPA had a lower risk of major amputation (adjusted SHR, 0.463; 95% CI, 0.240-0.894) compared with angiosome-directed revascularization without CPA. In the subanalysis, among patients who underwent endovascular revascularization, CPA (SHR, 0.509; 95% CI, 0.286-0.905) and angiosome-targeted revascularization (SHR, 0.613; 95% CI, 0.394-0.956) were associated with a lower risk of major amputation. CONCLUSIONS: Competing risk analysis showed that a patent pedal arch had significant impact on leg salvage and that the subset of patients undergoing endovascular procedure may most benefit of an angiosome-targeted revascularization.

Use of a bacterial fluorescence imaging system to target wound debridement and accelerate healing: a pilot study.

OBJECTIVE: Optimal wound-bed preparation consists of regular debridement to remove devitalised tissues, reduce bacterial load, and to establish an environment that promotes healing. However, lack of diagnostic information at point-of-care limits effectiveness of debridement. METHOD: This observational case series investigated use of point-of-care fluorescence imaging to detect bacteria (loads >104CFU/g) and guide wound bed preparation. Lower extremity hard-to-heal wounds were imaged over a 12-week period for bacterial fluorescence and wound area. RESULTS: A total of 11 wounds were included in the study. Bacterial fluorescence was present in 10 wounds and persisted, on average, for 3.7 weeks over the course of the study. The presence of red or cyan fluorescent signatures from bacteria correlated with an average increase in wound area of 6.5% per week, indicating stalled or delayed wound healing. Fluorescence imaging information assisted in determining the location and extent of wound debridement, and the selection of dressings and/or antimicrobials. Elimination of bacterial fluorescence signature with targeted debridement and other treatments correlated with an average reduction in wound area of 27.7% per week (p<0.05), indicative of a healing trajectory. CONCLUSION: These results demonstrate that use of fluorescence imaging as part of routine wound care enhances assessment and treatment selection, thus facilitating improved wound healing.

Evaluation of Peripheral Perfusion in the Presence of Plantar Heel Ulcerations Status After Transmetatarsal Amputation With Achilles Tendon Lengthening.

The objective of this study is to evaluate peripheral perfusion in patients who developed plantar heel ulcerations status after transmetatarsal amputation and Achilles tendon lengthening. Peripheral perfusion was assessed via contrast angiography of the 3 crural vessels (anterior tibial, posterior tibial, and peroneal arteries), as well as intact heel blush and plantar arch. The secondary objective is to correlate the arterial flow to time to develop heel ulceration and incidence of minor and major lower-extremity amputation. Diagnostic angiography without intervention was performed on 40% of patients (4/10), and interventional angiography was performed on 60% of patients (6/10). In-line flow was present in 0% (0/10) of the peroneal arteries, 60% (6/10) of the anterior tibial arteries, and 70% (7/10) of the posterior tibial arteries. Heel angiographic contrast blush was present in 60% (6/10), and intact plantar arch was present in 60% (6/10). Patients developed heel ulcerations at a mean time of 7.6 months (range 0.7 to 41.2) postoperatively. The incidence of major lower-extremity amputation was 30% (3/10), with a mean time of 5.2 months (range 3.5 to 8.3) from time of heel wound development. No amputation occurred in 6 patients (60%). Among them, intact anterior tibial inline arterial flow was present in 3, intact posterior tibial inline arterial flow was present in 6, and heel blush was present in 5. Our results demonstrate that an open calcaneal branch of the posterior tibial artery is sufficient to heal plantar heel ulcerations to potentially increase rates of limb salvage.

Intravenous contrast-free standardized exercise perfusion imaging in diabetic feet with ulcers.

BACKGROUND: Impaired foot perfusion is a primary contributor to foot ulcer formation. There is no existing device nor method that can be used to measure local foot perfusion during standardized foot muscle exercise in an MRI environment. PURPOSE: To develop a new MRI-compatible foot dynamometer and MRI methods to characterize local perfusion in diabetic feet with ulcers. STUDY TYPE: Prospective. POPULATION/SUBJECTS: Seven participants without diabetes and 10 participants with diabetic foot ulcers. FIELD STRENGTH/SEQUENCE: 3.0T, arterial spin labeling (ASL). ASSESSMENTS: Using a new MRI-compatible foot dynamometer, all participants underwent MRI ASL perfusion assessment at rest and during a standardized toe-flexion exercise. The participants without diabetes were scanned twice to assess the reproducibility of perfusion measurements. The absolute perfusion and perfusion reserve values were compared between two groups and between regions near ulcers (peri-ulcer) and away from ulcers (away-ulcer). STATISTICAL TESTS: Bland-Altman methods for the calculation of coefficient of repeatability (CR) and two-sided and unpaired Student's t-test to compare multiple differences. RESULTS: The perfusion reserves measured had the best reproducibility (CR in medial region: 1.6, lateral region: 0.9). The foot perfusion reserve was significantly lower in the participants with diabetes compared with the participants without diabetes (1.34 ± 0.32, 95% confidence interval [CI]: 1.1, 1.58 vs. 1.76 ± 0.31, 95% CI: 1.53, 1.98, P = 0.02). Both peri-ulcer exercise perfusion (8.7 ± 3.9 ml/min/100g) and perfusion reserve (1.07 ± 0.39, 95% CI: 0.78, 1.35) were significantly lower than away-ulcer exercise perfusion (12.7 ± 3.8 ml/min/100g, P = 0.02) and perfusion reserve (1.39 ± 0.37, 95% CI: 1.11, 1.66, P = 0.03), respectively. DATA CONCLUSION: This study demonstrates intravenous contrast-free methods for local perfusion in feet with ulcers by standardized exercise-based MRI. Ischemia regions around foot ulcers can be quantitatively distinguished from normal perfused muscle regions. LEVEL OF EVIDENCE: 2 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2019;50:474-480.

Indocyanine Green Angiography to Prognosticate Healing of Foot Ulcer in Critical Limb Ischemia: A Novel Technique.

BACKGROUND: To predict wound healing in patients with critical limb ischemia (CLI) is an ongoing issue. Current methods such as ankle-brachial index (ABI), color Doppler and transcutaneous oxygen pressure (TCPO2), and computed tomography angiography are lacking in demonstrating regional perfusion. Indocyanine green angiography (ICGA) has the potential to provide regional perfusion information lacking in other methods. This study was conducted to demonstrate successes of revascularization procedure in CLI patients based on ICGA data. METHODS: A total of 47 patients with grade 2 or grade 3 University of Texas Wound Classification System ischemic foot ulcer undergoing lower limb revascularization procedure were included in this study, from July 2014 to May 2016. ICGA with intravenous 0.1 mg/kg of 0.1% indocyanine green dye was performed before and after revascularization procedure. ICGA data maximum unit, blush time, and blush rate were compared between prerevascularization and postrevascularization data, along with ABI and TCPO2. RESULTS: Out of 47 patients (45 males and 2 females), 43 underwent endovascular revascularization and 4 underwent open procedure. Of all, 76.6% of patients were diabetic and 46.8% were hypertensive. Also, 31.9% had coronary artery disease, 21.2% had history of cerebrovascular disease, 23% had chronic kidney disease, and 74.4% were chronic smokers. A total of 37 patients' ulcer healed completely on follow-up with significant improvement (P < 0.05) in preoperative and postoperative ABI, TCPO2, and ICGA data. Ten patients' ulcer did not heal in the follow-up period. In those 10 patients, preoperative and postoperative ABI and TCPO2 improved, but ICGA data were not improved postoperatively (P > 0.05). CONCLUSIONS: ICGA is an evolving tool to quantify regional perfusion in CLI. ICGA parameters provide qualitative real-time visual images of perfusion in area of interest as well as quantitative information of perfusion.

Peripheral Blood Mononuclear Cells Therapy for Treatment of Lower Limb Ischemia in Diabetic Patients: A Single-Center Experience.

BACKGROUND: The aim of this study is to analyze the effects of peripheral blood mononuclear cells (PBMNCs) therapy in diabetic patients with critical limb ischemia (CLI), with particular regard to its application, as adjuvant therapy in patients underwent endovascular revascularization. METHODS: Fifty diabetic patients affected by CLI were enrolled. All patients underwent PBMNCs therapy. Thirty-two patients underwent PBMNCs therapy associated with endovascular revascularization (adjuvant therapy group). In 18 patients, who were considered nonrevascularizable or underwent unsuccessful revascularization, regenerative therapy with PBMNCs was performed as the therapeutic choice (PBMNCs therapy group). RESULTS: The median follow-up period was 10 months. The baseline and end point results in adjuvant group were as follows. The mean transcutaneous partial pressure of oxygen (TcPO2) improved from 25 ± 9.2 mmHg to 45.6 ± 19.1 mmHg (P < 0.001), and visual analogue scale (VAS) score means decreased from 8.6 ± 2.1 to 3.8 ± 3.5 (P = 0.001). In PBMNCs therapy group, the mean TcPO2 improved from 16.2 ± 7.2 mmHg to 23.5 ± 8.4 mmHg (P < 0.001), and VAS score means decreased from 9 ± 1.1 to 4.1 ± 3.3 (P = 0.001). Major amputation was observed in 3 cases (9.4%), both in adjuvant therapy group and in PBMNCs therapy one (16.7%) (P = 0.6). CONCLUSIONS: The role of cellular therapy with PBMNCs is decisive in the patients that are not susceptible to revascularization. In diabetic patients with CLI and healing resistant ulcers, the adjuvant PBMNCs therapy could represent a valid therapeutic option.

Relationship of Cuboid Height to Plantar Ulceration and Other Radiographic Parameters in Midfoot Charcot Neuroarthropathy.

The objective of the present investigation was to examine the effect of cuboid height on the presence of plantar midfoot ulceration and the relationship of cuboid height to other commonly performed radiographic parameters during evaluation of midfoot Charcot neuroarthropathy. A retrospective analysis was performed of 68 feet in 60 subjects who met the inclusion criteria. We did not observe statistically significant differences in the presence of a plantar midfoot ulceration when considering a cuboid height threshold of 0.0 mm, 2.0 mm, -2.0 mm, or -5.0 mm nor was the cuboid height a robust predictor for the presence of plantar midfoot ulceration when considering the positive predictive value, negative predictive value, sensitivity, or specificity. We observed a significant negative association between a negative cuboid height and the presence of Sanders Type 2 deformities (76.2% of those with negative height versus 50.0% of those with positive height had type 2 deformities; p = .0036), the absence of radiographic visualization of the lateral tarsometatarsal joint (71.4% of those with negative height versus 26.9% of those with positive height had an absence of radiographic visualization; p = .005), and lower calcaneal inclination angles (6.06° versus 15.08°; p < .001). We further observed significant positive correlations between the cuboid height and the calcaneal-fifth metatarsal angle (0.655; p < .000), calcaneal inclination angle (0.591; p < .001), calcaneal-cuboid angle (0.254; p = .038), medial column height (0.264; p = .029), and first metatarsal inclination angle (0.245; p = .047). We also observed negative correlations with Meary's angle (-0.475; p < .001) and the talar declination angle (-0.387; p < .001). These findings showed a general trend toward a decreasing cuboid height and increasing sagittal plane deformity involving both the medial and the lateral columns. The results of the present investigation provide evidence against a single radiographic parameter being associated with the presence of plantar midfoot ulceration.

The Feasibility of Angiosome-Targeted Endovascular Treatment in Patients with Critical Limb Ischemia and Foot Ulcer.

BACKGROUND: To determine wound location according to the angiosome concept and to investigate the feasibility and success of angiosome-based revascularization in below-the-knee (BTK) arteries. METHODS: This was a retrospective study of 161 patients (67.5 ± 25.5 years, 66.5% diabetics) with critical limb ischemia and a foot ulcer, stage Rutherford 5-6, who underwent percutaneous transluminal angioplasty on BTK arteries in 2012. We evaluated feasibility of angiosome-targeted revascularization and the number of angiosomes affected by a wound in each patient. Patients were divided into 3 groups depending on how many BTK vessels were suitable for revascularization. The feasibility was analyzed in each group and in relation to number of affected angiosomes. RESULTS: The wound(s) interfered with one angiosome in only 39 (24.0%) cases. Direct flow into affected angiosome was successfully achieved in 98 (60.9%) cases. If ulceration was limited in one angiosome, the targeted revascularisation was possible in 27 cases (69.2%), if ulceration was extended over 2 angiosomes it was possible in 65 cases (86.7%), if 3 angiosomes were affected it was possible in 36 cases (85.7%), when 4 angiosomes were affected the rate dropped to 25.0% and ulceration extended over 5 angiosomes had no possibility of revascularization. CONCLUSIONS: In critical limb ischemia, the tissue lesion affects several angiosomes in majority of the cases. In thus far published literature, there is existence of more approaches of angiosome-targeted revascularization when more than one angiosome is clinically involved and therefore consensus needs to be achieved for the accurate definition.

Selective intra-arterial dual-energy CT angiography (s-CTA) in lower extremity arterial occlusive disease.

OBJECTIVE: In patients with peripheral arterial occlusive disease, renal impairment is a common contraindication to iodine and gadolinium contrast media, which limits the utility of conventional computed tomography angiography (CTA) and magnetic resonance angiography (MRA). It is proposed that selective intra-arterial dual-energy CT-angiography (s-CTA), that is CTA with intra-arterial injection of an ultra-low dose iodine contrast media, is a feasible, safe and accurate alternative imaging method to conventional non-invasive contrast enhanced vascular imaging in this patient group. The aim of this study was to report a preliminary experience of s-CTA in patients with critical limb ischemia and renal insufficiency with respect to safety, feasibility, and diagnostic accuracy. MATERIALS AND METHODS: Ten non-consecutive patients with ischemic foot ulcers underwent s-CTA of one leg. Procedure related complications were recorded and imaging results were compared with conventional digital subtraction angiography (DSA). RESULTS: A median 17 mL (range 10-19 mL) contrast media (400 mg I/mL) was used. The median baseline plasma creatinine was 163 µmol/L (range 105-569) pre s-CTA versus 153 µmol/L (range 105-562) post s-CTA (p = .24). There was no puncture site complication. Among the patients selected for intervention (n = 6 with 30 arterial segments) the s-CTA findings correlated well with the DSA findings; the diagnostic sensitivity was 100%, the specificity 89%, and the accuracy 93%. CONCLUSION: In this pilot study, a novel imaging method (s-CTA) is presented that provides high-quality arterial phase images with ultra-low dose iodine contrast media useful also for patients unsuitable for conventional contrast enhanced imaging methods because of renal insufficiency.

Radiographic Abnormalities in the Feet of Diabetic Patients with Neuropathy and Foot Ulceration.

OBJECTIVE: People with diabetic neuropathy are frequently prone to several bone and joint abnormalities. Simple radiographic findings have been proven to be quite useful in the detection of such abnormalities, which might be helpful not only for early diagnosis but also in following the course of diabetes through stages of reconstruction of the ulcerated foot.The present study was designed to identify the common foot abnormalities in south Indian diabetic subjects with and without neuropathy using radiographic imaging. METHODS: About 150 (M:F 94:56) subjects with type 2 diabetes were categorised into three groups: Group I (50 diabetic patients), Group II (50 patients with neuropathy), and Group III (50 diabetic patients with both neuropathy and foot ulceration). Demographic details, duration of diabetes and HbA1c values were recorded. Vibration perception threshold was measured for assessment of neuropathy. Bone and joint abnormalities in the feet and legs of the study subjects were identified using standardised dorsi-plantar and lateral weight-bearing radiographs. RESULTS: Radiographic findings of the study subjects revealed that those with both neuropathy and foot ulceration and a longer duration of diabetes had more number of bone and joint abnormalities. Subjects with neuropathy alone also showed presence of several abnormalities, including periosteal reaction, osteopenia, and Charcot changes. CONCLUSIONS: The present findings highlight the impact of neuropathy and duration of diabetes on the development of foot abnormalities in subjects with diabetes. Using radiographic imaging can help in early identification of abnormalities and better management of the diabetic foot.

Outcomes of angiosome and non-angiosome targeted revascularization in critical lower limb ischemia.

OBJECTIVE: Blood supply to the foot is from the posterior tibial, anterior tibial, and the peroneal arteries. Ischemic ulceration of the foot is the most common cause for major amputations in vascular surgical patients. It can be presumed that revascularization of the artery directly supplying the ischemic angiosome may be superior to indirect revascularization of the concerned ischemic angiosome. METHODS: This was a prospective study of 64 patients with continuous single crural vessel runoff to the foot presenting with critical limb ischemia from January 2007 to September 2008. Direct revascularization (DR) of the ischemic angiosome was performed in 61% (n=39), indirect revascularization (IR) in 39% (n=25). Open surgery was performed in 60.9% and endovascular interventions in 39.1%. All patients were evaluated for the status of the wound and limb salvage at 1, 3, and 6 months. The study end points were major amputation or death, limb salvage, and wound epithelialization at 6 months. RESULTS: In the study, 81.2% of patients had forefoot ischemia, 17.2% had ischemic heel, whereas 1.6% had midfoot nonhealing ischemic ulceration. The runoff involved the anterior tibial artery in 42.2% (27/64), posterior tibial artery in 34.4% (22/64), and the peroneal artery in 23.4% (15/64). All patients were followed at 1, 3, and 6 months postoperatively for ulcer healing, major amputation, or death. At the end of 6 months, nine patients expired, and six were lost to follow-up. Of 49 patients who completed 6 months, nine underwent major amputation, and 40 had limb salvage. Ulcer healing at 1, 3, and 6 months for DR vs IR were 7.9% vs 5%, 57.6% vs 12.5%, and 96.4% vs 83.3%, respectively. This difference in the rates of ulcer healing between the DR and IR groups was statistically significant (P=.021). The limb salvage in the DR group (84%) and IR group (75%) was not statistically significant (P=.06). The mortality was 10.2% for DR and 20% for IR at 6 months. CONCLUSIONS: To attain better ulcer healing rates combined with higher limb salvage, direct revascularization of the ischemic angiosome should be considered whenever possible. Revascularization should not be denied to patients with indirect perfusion of the ischemic angiosome as acceptable rates of limb salvage are obtained.

Report on a clinical evaluation of the KerraPro Heel silicone heel pad.

Heels are at increased risk of injury due to the posterior prominence and lack of padding over the calcaneus. Pressure injuries, once established, are extremely costly, both in terms of the detrimental effect on psychosocial wellbeing and threat to life, as well as financially due to length of hospital stay and resources used to heal the wounds. A new and inexpensive silicone heel pad has been designed to simplify the necessary decisions and to address the problems associated with pressure injuries to the heels. This article will describe an observational evaluation of the product. KerraPro Heel pads were evaluated in two separate cohorts of 17 participants over a 4-week period with the primary aim to evaluate the efficacy of the product in preventing and alleviating pressure injuries on the heels. All participants had been reported as 'at risk' or 'at high risk' of pressure injury to the heels and had a history of developing such lesions. The KerraPro heel pads were compared with the participant's standard protocol. The outcome of the evaluation demonstrated the effectiveness of the KerraPro Heel pads in the prevention and treatment of heel pressure injuries.

Solitary erythematous, tender plaque of the heel in a young infant.

Calcinosis cutis is a rare disorder resulting from the precipitation and deposition of insoluble calcium and phosphate salts (hydroxyapatite crystals) in the dermis and subcutaneous tissue. It is generally divided into four main groups on the basis of etiology and pathogenesis. Clinical presentation of cutaneous calcinosis cutis varies according to the diagnosis and the underlying process. We report a case of calcinosis cutis of the heel in which both the extravasation of a calcium gluconate infusion and renal failure could have promoted the development of calcinosis cutis.

Use of high-frequency ultrasound to detect heel pressure injury in elders.

PURPOSE: To examine the usefulness of high-frequency ultrasound (HFU) to detect heel pressure injury in geriatric medical patients, to compare the prevalence rates of visualized pressure ulcers with the prevalence of hidden injury, and to determine whether HFU could assist in predicting the development of heel pressure injury. SUBJECTS AND SETTING: The sample comprised 100 medical patients who were aged 65 years or older, had a Braden Scale score of 10 to 17, and remained hospitalized 28 days or less. Participants had at least 1 heel free of visible pressure injury. The study setting was a 528-bed urban hospital in the northeastern United States. METHODS: The study used a prospective, descriptive, observational design for data collection. At the initial visit, chart review and physical examination were used to obtain data about pressure ulcer risk factors, and heels were assessed visually and with HFU. Subsequent visits included visual and scan evaluations for pressure injury. Patients in the study were seen at least twice; 82 were assessed 3 times and 43 were assessed 4 times. RESULTS: The prevalence rate of visible heel pressure ulcers was 7.3% for 520 patients who met inclusion criteria. Slightly more than one-tenth (10.1%) of subjects without heel ulcers had 2 normal heels scans upon entry into the study. Age, Braden Scale score, foot temperature, edema, and turgor were not statistically significant predictors of abnormal heel scans. However, there was a statistically significant relationship between low friction/shear scores and abnormal heel scans, particularly in relation to the right foot. CONCLUSIONS: High-frequency ultrasound detected occult injury more than visual assessment, but scans are not easy to interpret in heels due to calluses and other skin changes. It appears that patients have a greater tendency for pressure injury on the right heel than on the left heel and risk may be predicted by low friction/shear scores.