Leg Amputations Among Texans Remote From Experienced Surgical Care.

BACKGROUND: Surgical outcomes may differ between low-volume and experienced hospitals. We sought to identify characteristics of remote patients-those living more than 50 miles from an experienced center-who underwent leg amputations for peripheral artery disease (PAD) and foot complications at low-volume and experienced hospitals and identify regions of Texas where such patients live. MATERIALS AND METHODS: Publicly available Texas hospitalization data from 2004 through 2009 were used to identify patients with PAD who underwent leg amputation for foot complications, including foot ulcers, foot infections, and gangrene. Geocoding was used to further identify a subset of remote patients and to estimate distances from zip code of residence to hospital in which care was received. RESULTS: Among all leg amputations, 850 (18.6%) were performed on patients classified as remote, and 3723 (81.4%) were performed on patients classified as nonremote. Compared with nonremote patients, remote patients were more often categorized as white and more frequently received Medicare and/or Medicaid. Of the subset of remote patients, those at low-volume hospitals were older, were less often categorized as Hispanic, more often had Medicaid coverage, were also more frequently admitted through the emergency department, and often had a foot infection compared with those at experienced centers. Geospatial analysis identified five concentrated geographic areas of remote patients who live more than 50 miles from an experienced center. CONCLUSIONS: These findings suggest travel distance may at least influence, if not constrain, the choice of hospital for patients with PAD and foot complications. Efforts to decrease leg amputations among remote patients should be focused on five specific geographic areas of Texas.

Laser therapy for onychomycosis in patients with diabetes at risk for foot ulcers: a randomized, quadruple-blind, sham-controlled trial (LASER-1).

BACKGROUND: Patients with diabetes mellitus are at high risk for onychomycosis, which is related to the development of foot ulcers. OBJECTIVE: The aim of this study was to evaluate the safety and efficacy of the treatment of onychomycosis with local laser therapy. METHODS: In a single-centre, randomized (1:1), quadruple-blind, sham-controlled trial, patients and microbiological confirmation with diabetes mellitus, at risk for developing diabetic foot ulcers (Sims classification score 1, 2) and a clinical suspicion on onychomycosis, were randomized to either four sessions neodymium-doped yttrium aluminium garnet (Nd-YAG) 1064 nm laser or sham treatment. The primary outcome was clinical and microbiological cure of onychomycosis after 1-year follow-up. RESULTS: From March 2015 to July 2016, 64 patients were randomized; 63 could be analysed. Trichophyton rubrum was the most detected pathogen. There was no difference in the primary outcome between laser and sham treatment. With the exception of a subungual haematoma in the fifth toenail occurring 2 weeks after laser treatment, the results suggested that treatment with Nd-YAG 1064 nm laser is safe. CONCLUSION: At this moment, there is no evidence of any effect of laser treatment for onychomycosis in patients with diabetes at increased risk for foot ulcers, at least not within 1 year after treatment.

Comparison of arthroscopic to open tibiotalocalcaneal arthrodesis in high-risk patients.

BACKGROUND: Open tibiotalocalcaneal arthrodesis (TTCA) is associated to high complication rates, which led to the development of arthroscopic techniques. Aim was to compare complication rates of open to arthroscopic TTCA in high-risk patients. METHODS: Single-center, retrospective case-control study. Patients were selected from the authors' TTCA database. Eligible were high-risk patients receiving arthroscopic-, or open TTCA retrospectively suitable for arthroscopic TTCA. Primary outcome were major complications. RESULTS: Eight open and 15 arthroscopic TTCAs were included. Three open and 4 arthroscopic TTCAs presented preoperative plantar ulceration. Fusion rates were similar (75% vs. 67%; p=0.679). Major complications occurred in 63% of open (80% surgical-site-infections (SSI)) and 33% of arthroscopic (100% non-unions) TTCA. Preoperative plantar ulceration did not affect major SSI in open TTCA (67% vs. 60%) but resulted in a significant increase of non-union rates for arthroscopic TTCA (75% vs. 18%; p=0.039). In patients without plantar ulceration the union-rate was 80% for both, open and arthroscopic TTCA. CONCLUSION: Arthroscopic TTCA drastically reduced major SSI. Patients without preexisting ulceration had excellent union-rates for open and arthroscopic TTCA.

Social deprivation modifies the association between incident foot ulceration and mortality in type 1 and type 2 diabetes: a longitudinal study of a primary-care cohort.

AIMS/HYPOTHESIS: The aim of this study was to determine whether social deprivation in the presence of diabetes is an independent predictor of developing a foot ulcer and separately of mortality. METHODS: This was a primary-care-based retrospective analysis of 13,955 adults with type 1 (n = 1370) or type 2 (n = 12,585) diabetes after a median follow-up of 10.5 years. Demographic characteristics, indices of social deprivation and clinical variables were assessed at baseline. The primary outcomes were new foot ulceration (in those without a previous history of foot ulcers) and all-cause mortality. Cox proportional hazard models were used to describe the associations among foot ulceration, social deprivation and mortality. RESULTS: The mean age of the population was 69.4 (range: 16-89) years. The incidence of foot ulceration was greater in individuals with type 2 (8.6%) compared with type 1 diabetes (4.8%). Occurrence was similar by sex, but increased with age and deprivation index. Individuals in the highest quintile of deprivation were 77% more likely to develop a foot ulcer compared with those in the lowest quintile (OR 1.77 [95% CI 1.45, 2.14], p < 0.0001). Overall, 2946 (21.1%) deaths were recorded. Compared with individuals without a foot ulcer, the development of a foot ulcer was associated with a higher age- and sex-adjusted mortality rate (25.9% vs 14.0%), and a 72% (HR 1.72 [95% CI 1.56, 1.90], p < 0.001) increased risk of mortality in those with type 2 diabetes. Risk of death increased by 14% per quintile of deprivation in a univariable analysis (HR 1.14 [95% CI 1.10, 1.17]). In multivariable Cox regression analyses, there was a 48% increased risk of mortality in individuals with a foot ulcer (HR 1.48 [95% CI 1.33, 1.66]) independent of the Townsend index score (HR 1.13 [95% CI 1.10, 1.17], per quintile), baseline age, sex, diabetes type, smoking status, hypertension, statin use, ß-blocker use, metformin use, HbA1c levels and insulin use. CONCLUSIONS/INTERPRETATION: This study confirms the high mortality rate in individuals with diabetes-related foot ulcers. In addition, socioeconomic disadvantage was found to be an independent effect modifier, contributing to an increased burden of mortality in people with diabetes who develop foot ulceration. In light of this, and as diabetes service configurations are orientated for the next 5-10 years, modelling of foot ulceration risk needs to take socioeconomic disadvantage into account.

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 story of a deformed leprous foot.

Eccrine syringofibroadenoma (ESFA) is a rare adnexal tumour of eccrine ductal proliferation. A 50 year old treated case of leprosy presented with a chronic non healing ulcer of 5 years duration on the deformity laden right foot. Multiple verrucous papules and plaques were seen surrounding the ulcer which showed histopathological findings consistent with ESFA. Although ESFA constitutes a rare association with leprosy, considering the load of treated cases in our country and elsewhere, it may represent an under-reported entity which requires more attention in the post elimination era.

Nodular melanoma in trophic ulceration of a leprosy patient: a case study.

UNLABELLED: Non-healing chronic trophic ulceration is very common in leprosy patients. Marjolin's ulcer consists of the malignant transformation of a chronic ulcerative lesion. Nodular melanoma developing from Marjolin's ulcer, caused by a trophic ulceration of a leprosy patient, is very rare with only a few cases reported in the literature. Due to the disguised presentation of these malignancies within trophic ulceration lesions in leprosy, neoplastic transformation is frequently overlooked, leading to misdiagnosed and delayed treatment. This paper reports a case of an 83-year-old man with lepromatous leprosy and chronic ulceration on the foot for 22 years. Over a period of 2 months, the ulcer enlarged, turned black, and became more painful. The patient underwent regional excision and immunotherapy after the diagnosis of malignant nodular melanoma. After 9 months follow-up, no metastasis was found. DECLARATION OF INTEREST: There were no external sources of funding for this study. The authors have no conflicts of interest to declare.

Infectious endocarditis caused by Helcococcus kunzii in a vascular patient: a case report and literature review.

BACKGROUND: Helcococcus kunzii is a facultative anaerobic bacterium that was first described by Collins et al. in 1993, and was initially considered as a commensal of the human skin, in particular of lower extremities. Human infections caused by H. kunzii remain rare with only a few cases published in the pubmed database. Nevertheless recent reports indicate that this microorganism has to be considered as an opportunistic pathogen that can be involved in severe infections in human. To the best of our knowledge, we describe here the first known case of infectious endocarditis caused by H. kunzii. CASE PRESENTATION: A 79 year-old man reporting severe polyvascular medical history attended the emergency ward for rapid deterioration of his general state of health. After physical examination and paraclinical investigations, the diagnosis of infectious endocarditis on native mitral valve caused by Helcococcus kunzii was established based on Dukes criteria. MALDI-TOF mass spectrometry and 16S rDNA sequencing allowed an accurate identification to the species level of Helcococcus kunzii. The patient was successfully treated by a medico-surgical approach. The treatment consisted in intravenous amoxicillin during four weeks and mitral valve replacement with a bioprosthestic valve. After an in depth review of patient's medical file, the origin of infection remained unknown. However, a cutaneous portal of entry cannot be excluded as the patient and his General Practitioner reported chronic ulcerations of both feet. CONCLUSIONS: We describe here the first case of endocarditis caused by H. kunzii in an elderly patient with polyvascular disease. This report along with previous data found in the literature emphasizes the invasive potential of this bacterial species as an opportunistic pathogen, in particular for patient with polyvascular diseases. MALDI-TOF mass spectrometry and 16S rDNA sequencing are reliable tools for H. kunzii identification. We also sequenced in this work H.kunzii type strain 103932T CIP and deposited in the Genbank under accession number KM403387. We noticed a 14 base difference between our sequence and the original sequence deposited by Collins et al. under Genbank accession number X69837. Hopefully, the spread of next generation sequencing tools would lead to a more accurate classification of clinical strains.

Health beliefs surrounding leprosy induced foot ulceration; an exploratory qualitative study from South Nepal.

UNLABELLED: Leprosy is a complex and multi-faceted disease responsible for significant disability in several endemic countries. Physical impairments caused by leprosy are often amplified by local sociocultural phenomena in many parts of the world. In Nepal, sociocultural phenomena such as stigmatisation and health beliefs affecting treatment compliance and health seeking behaviours are known to play an important role in the acquisition of disability. Foot-ulceration is reported to be a common sequelae of leprosy, however, presently little research has been published investigating the potential influence of patient beliefs on management of foot ulceration in leprosy affected persons. OBJECTIVE: In light of this we conducted an exploratory qualitative study to investigate the health beliefs held by patients with foot ulceration at a Leprosy hospital in Nepal. METHODS: A mixture of open-ended interviews (n = 21), three focus groups and a series of field observations were used to explore the explanatory models of foot ulceration thought to be used by leprosy affected people to understand and explain this specific comorbidity. RESULTS: Our findings indicated that a wide range of health beliefs were present in our sample, many of which lie outside of the biomedical understanding of illness. This included a range of non-biomedical beliefs regarding wounds and widespread application of the traditional 'hot-cold' model of illness used to explain foot ulceration. DISCUSSION: The findings of this study appear to suggest many beliefs held by leprosy affected persons concerning foot ulceration are highly complex, with some expressed beliefs potentially having a negative impact on self-management of ulceration.

Chronic neuropathic ulcer is not the most common antecedent of lower limb infection or amputation among diabetics admitted to a regional hospital in Jamaica: results from a prospective cohort study.

BACKGROUND: Guidelines of the International Consensus on the Diabetic Foot state that "Amputation of the lower extremity or part of it is usually preceded by a foot ulcer". The authors' impression has been that this statement might not be applicable among patients treated in our institution. A prospective cohort study was designed to determine the frequency distribution of antecedents of lower limb infection or gangrene and amputation among adult diabetics admitted to a Regional Hospital in western Jamaica. METHODS: Adult diabetics admitted to Hospital with a primary diagnosis of lower limb infection and/or gangrene were eligible for recruitment for a target sample size of 126. Thirty five variables were assessed for each patient-episode of infection and/or gangrene, main outcome variable being amputation during admission or 6-months follow-up. Primary statistical output is the frequency distribution of antecedents/precipitants of lower limb infection and/or gangrene. The data is interrogated by univariate and multivariable logistic regression for variables statistically associated with the main antecedent/precipitant events. RESULTS: Data for 128 patient-episodes were recorded. Most common antecedents/precipitants, in order of decreasing frequency, were idiopathic acute soft tissue infection/ulceration (30.5%, CI; 22.6-39.2%), chronic neuropathic ulcer (23.4%, CI; 16.4-31.7%), closed puncture wounds (19.5%, CI; 13.1-27.5%) and critical limb ischemia (7.8%, CI; 3.8-13.9%). Variables positively associated with non-traumatic antecedents/precipitants at the 5% level of significance were male gender and non-ulcerative foot deformity for idiopathic acute soft tissue infection/ulcer; diabetes >5 years, previous infection either limb, insulin dependence and peripheral sensory neuropathy for chronic neuropathic ulcer and older age, diabetes >5 years, hypertension, non-palpable distal pulses and ankle-brachial index ≤0.4 for critical limb ischemia. CONCLUSIONS: Chronic neuropathic ulcer accounted for only 23.4 % of lower limb infections and 27.7% of amputations in this population of diabetics, making it the second most common antecedent of either after acute idiopathic soft tissue infection/ulcer at 30.5 and 34.7% respectively. Trauma as a group (defined as closed puncture wounds, lacerations, contusion/blunt trauma and burns) also accounted for a greater number of lower limb infections but fewer amputations than chronic neuropathic ulcer, at 32 and 19.5% respectively.

Influence of foot ulceration on cause-specific mortality in patients with diabetes mellitus.

OBJECTIVE: The purpose of this study was to assess the odds of all-cause mortality in individuals with diabetic foot ulceration (DFU) compared with those with diabetes and no history of DFU. In addition, we sought to determine the strength of association of DFU with cardiovascular and nonvascular mortality. METHODS: We obtained data for a cohort of patients who attended a secondary care diabetic foot clinic or a general diabetes clinic between 2009 and 2010. A clinic cohort of patients with diabetes and no history of DFU provided a control group. Cause-specific mortality was recorded during a median follow-up duration of 3.6 years (interquartile range, 3.3-4.2 years). The association between DFU and all-cause mortality was evaluated by Cox regression. The association between DFU and cardiovascular mortality was determined by competing risk modeling. RESULTS: We recorded 145 events of all-cause mortality and 27 events of cardiovascular mortality among 869 patients with diabetes. After adjustment for potential confounders, DFU was associated with both cardiovascular disease (hazard ratio, 2.53; 95% confidence interval, 0.98-6.49; P = .05) and all-cause mortality (hazard ratio, 3.98; 95% confidence interval, 2.55-6.21; P < .001). The proportion of deaths attributable to cardiovascular disease was similar between the groups (18% with diabetes only and 19% with DFU; P = .91). CONCLUSIONS: DFU is associated with premature death from vascular and nonvascular causes.

Establishing a multidisciplinary diabetic foot team in a large tertiary hospital: a workshop.

Every year, over 1 million people with diabetes lose a leg due to diabetic foot disease. Most amputations are preceded by a foot ulcer. Causes for the development of foot ulcers are generally multifactorial and may include neuropathy, peripheral vasculopathy, abnormal foot mechanics and infection. Multidisciplinary approach to the patient with acute diabetic foot is mandatory and has been shown to reduce amputation rate. In our article we describe the establishment of a multidisciplinary diabetic foot team in a large tertiary hospital and its outcomes.

High Mortality in Patients With an Ischemic Foot Ulcer Following Revascularization.

Critical limb ischemia (CLI) is the advanced stage of peripheral arterial disease, which impairs blood flow to the extremities due to occlusion of arteries, in which patients suffer from ischemic pain at rest and gangrene or ulcers. It is frequently accompanied by major adverse cardiac events, resulting in exceedingly high mortality from a cardiac or cerebrovascular event in this population. Although there have been considerable amounts of novel and costly revascularization and wound dressing technology, mortality is still high. Therefore, the risk factors for such high mortality need to be addressed. This review aimed to summarize the potential risk factors for mortality in patients with CLI of the lower extremities. There are several such risk factors, including modifiable and nonmodifiable risk factors. This review further discusses some highlighted major modified risk factors, including renal failure, cardiovascular, and diabetes. The strategy of regular surveillance and modification of such risk factors in any patients with CLI should be developed.

Biological maintenance of distal vein arterialization.

Eleven weeks after surgery, a fine microvessel network was seen in the feet of patients with arteriosclerosis obliterans treated by distal vein arterialization. A possible mechanism for establishment of blood flow to, and biological maintenance of, the graft in the foot, in relation to oxygen consumption rate during walking was investigated, using Krogh's tissue cylinder model. Our calculations showed that the increase in oxygen consumption rate of the muscle when patients walked would reduce the size of the oxygen front in the tissue cylinder, thus producing small, transient hypoxic regions in skeletal foot muscle. Such muscle hypoxia, although localized, could stimulate synthesis of vascular endothelial growth factor and facilitate angiogenesis in the grafted tissue. The architecture of fine microvessel networks observed in the foot by angiography seems consistent with this supposition and, moreover, suggests that the reinstatement of blood vessel networks in the foot tissues after grafting is supported by "normal" biological mechanisms.

Melanoma arising in chronic ulceration associated with lymphoedema.

Chronic ulceration can be complicated by development of a malignancy. The most frequent associated malignances are squamous cell carcinoma and basal cell carcinoma, although melanoma, leiomyosarcoma and adenocarcinoma are less commonly seen. Chronic lymphoedema may also predispose to development of some malignancies, including lymphangiosarcoma, squamous cell carcinoma and Kaposi's sarcoma. Here, we report the case of a 77-year-old man with primary lymphoedema, who developed melanoma in a chronic foot ulcer of 60 years' duration. The patient underwent wide excision for the melanoma, and remains free from metastases at 1-year follow up.

Predictive risk assessment for major amputation after tibiotalocalcaneal arthrodesis.

BACKGROUND: Tibiotalocalcaneal (TTC) arthrodesis using a nail has been shown to be an effective salvage technique; however, there is a risk of major amputation. A better understanding of the relative risk of amputation after TTC fusion and the factors that influence this could help the preoperative consultation and guide discussion on the economics of limb salvage. METHODS: One hundred seventy-nine limbs were treated with TTC fusion with an intramedullary nail. A comprehensive chart and radiographic review was pulled from our intramedullary nail database. Patients were divided into those who went on to eventual amputation and those with successful salvage of their limb. Variables from the database were used to build a statistical model with a biostatistician. Final results were presented, and a formula to determine probability of amputation was created. RESULTS: There were 21 limbs that were eventually treated with major amputation. This represents an overall salvage rate of 88.2% (158/179 patients). Age was a factor in amputation risk, and the highest risk factor for amputation was diabetes with an odds ratio of 7.01 and 95% confidence, P = .0019. The odds of amputation were 6.2 times and 3 times greater for patients undergoing revisions and those with preoperative ulcers, respectively. The probability of amputation could be found preoperatively by using the derived equation: e(x) /(1 + e(x) ) where x is a factor of age, diabetes, revision, and ulceration. CONCLUSION: TTC arthrodesis with a retrograde intramedullary nail has a high rate of limb salvage across a wide range of indications and medical comorbidities. In this patient cohort, diabetes was the most notable risk for amputation, followed by revision surgery, preoperative ulceration, and age. A model has been built to help predict the risk of amputation. LEVEL OF EVIDENCE: Level II, prognostic.

Ewing sarcoma in a diabetic male with history of foot ulceration.

Ewing sarcoma is a rare diagnosis, with as few as 225 new cases diagnosed in North America annually, and only 3% occurring in the foot. They generally present in the second decade of life and are very infrequently found in patients older than 40 years. The diagnosis of Ewing sarcoma can be difficult, especially in older patients with diabetes and a history of ulceration, because it can have an appearance on radiography similar to that of osteomyelitis. We present a case of Ewing sarcoma of the foot in a patient with type 2 diabetes in his sixth decade of life.

Fragile Feet and Trivial Trauma: Communicating the Etiology of Diabetic Foot Ulcers to Patients.

People at risk for diabetic foot ulcer (DFU) often misunderstand why foot ulcers develop and what self-care strategies may help prevent them. The etiology of DFU is complex and difficult to communicate to patients, which may hinder effective self-care. Thus, we propose a simplified model of DFU etiology and prevention to aid communication with patients. The Fragile Feet & Trivial Trauma model focuses on two broad sets of risk factors: predisposing and precipitating. Predisposing risk factors (eg, neuropathy, angiopathy, and foot deformity) are usually lifelong and result in "fragile feet." Precipitating risk factors are usually different forms of everyday trauma (eg, mechanical, thermal, and chemical) and can be summarized as "trivial trauma." We suggest that the clinician consider discussing this model with their patient in three steps: 1) explain how a patient's specific predisposing risk factors result in fragile feet for the rest of life, 2) explain how specific risk factors in a patient's environment can be the trivial trauma that triggers development of a DFU, and 3) discuss and agree on with the patient measures to reduce the fragility of the feet (eg, vascular surgery) and prevent trivial trauma (eg, wear therapeutic footwear). By this, the model supports the communication of two essential messages: that patients may have a lifelong risk of ulceration but that there are health-care interventions and self-care practices that can reduce these risks. The Fragile Feet & Trivial Trauma model is a promising tool for aiding communication of foot ulcer etiology to patients. Future studies should investigate whether using the model results in improved patient understanding and self-care and, in turn, contributes to lower ulceration rates.

Health Literacy predicts incident foot ulcers after 4 years - the SHELLED cohort study.

AIMS/HYPOTHESIS: To determine whether health literacy is associated with an index diabetes-related foot ulcer (DFU). METHODS: The SHELLED Study is a 4-year prospective study of people with diabetes aged over 40 with no history of DFU. The primary outcome was development of a first foot ulcer. Health Literacy was measured using the short form Test of Functional Health Literacy in Adults (s-TOFHLA) and nine domains of the Health Literacy Questionnaire (HLQ). RESULTS: Of 222 participants, 191 (86.0%) completed the study, of whom 13 (5.9%) developed an incident ulcer. In multivariable models, every unit increase in S-TOFHLA was associated with a reduced odds of foot ulcer development by 6% (OR 0.94, 95% CI 0.88 to 0.99). Better scores on two HLQ domains reduced the odds of foot ulcer (actively managing my health (OR 0.23, 95% CI 0.08 to 0.65) and understanding health information well enough to know what to do (OR 0.39, 95% CI 0.19 to 0.78). This was independent of baseline risk for foot disease. CONCLUSIONS/INTERPRETATION: These data provide novel evidence that health literacy is an important clinical risk factor for index foot ulceration. This is an area of potential focus for research and development of educational programs or policy aimed at reducing development of incident foot ulceration.

Acupuncture for rheumatoid vasculitis complicated by refractory foot ulcer: A case report.

INTRODUCTION: Rheumatoid vasculitis (RV) is a frequently encountered complication of rheumatoid arthritis (RA), wherein skin vasculitis lesions are observed as a common clinical manifestation, encompassing skin purpura, erythema, vascular occlusion, ulcers, and gangrene. As a matter of fact, it marks the most severe extra-articular manifestation of RA. And the resultant ulcers tend to pose a greater challenge with regard to therapeutic interventions. We report a case of RV complicated by refractory foot ulcer that was successfully treated with puncture. CASE PRESENTATION: A 62-year-old man with RV caused by RA developed refractory foot ulcers. Despite the application of topical antibiotics, the wound gradually expanded and remained unhealed for 7 months. Consequently, the patient sought an integrated therapeutic approach involving Traditional Chinese Medicine and was subsequently treated with acupuncture. After 12 weeks of acupuncture, the foot ulcers healed completely. CONCLUSION: Acupuncture has the potential to facilitate wound healing and may serve as a viable alternative treatment modality for wounds unresponsive to traditional therapeutic interventions.