The functional repair of heel ulcerations is one of the most important challenges faced by surgeons in the treatment of diabetic patients with heel ulcerations exposing the calcaneus and accompanying vascular disorders. Currently, free flaps and pedicled flaps are the first choices of treatment in the repair of large heel ulcerations [
In recent years, the use of acellular dermal matrix (ADM) has emerged as an alternative option in the treatment of selected cases with extremity ulcerations [
The medical records of 13 patients, who underwent heel reconstruction surgery using the VASDEM method between December 2010 and December 2014, were retrospectively reviewed after the patients had provided written informed consent. The study was approved by the Institutional Review Board. All patients had large heel ulcerations exposing the calcaneus that could not be repaired by local skin flaps. The study group consisted of patients who had severe peripheral vascular disease and only one patent vessel among the three vessels that establish the infrapopliteal trifurcation. The patients with uncontrolled systemic infection originating from the wound were not included in the study until the infection was controlled. However, the presence of local soft tissue infection or osteomyelitis was not considered an exclusion criterion for the study. All patients had type 2 diabetes and were using insulin injections, and all patients were male.
The mean age was 50.6 years (range: 39–59 years). The etiology of the wound was neuropathic heel ulceration associated with diabetes mellitus in 11 patients (84.6%), acute arterial insufficiency in one patient (7.7%), and burn in one patient (7.7%). The mean wound diameter was 5.07 cm (range: 4–8 cm). The mean duration of negative pressure wound therapy was 32.76 days (range: 24–57 days). The mean duration of follow-up was 28.69 months (range: 10–42 months). The blood glucose levels were regulated in all patients before performing reconstruction with ADM. In all patients, vascular patency in the lower extremity was examined by a vascular surgeon, and all patients were evaluated for the indication of bypass grafting, stenting, or balloon dilation using MR angiography. Vascular surgical procedures were performed before the therapy as indicated. All patients included in the study received antiplatelet therapy before and after surgery (Table
Characteristics of patients with heel defects managed with VASDEM.
Number | Sex | Age | Type of wound/ulcer | Defect size/cm | Follow-up/month | NPWT/days | Special shoe | Vascular procedures | ||
---|---|---|---|---|---|---|---|---|---|---|
Bypass graft | Vascular stent | Balloon dilatation | ||||||||
1 | M | 39 | Acute arterial insufficiency | 8 | 42 | 57 | Yes | No | Yes | Yes |
2 | M | 48 | Neuropathic | 4 | 36 | 27 | No | No | Yes | No |
3 | M | 46 | Neuropathic | 5 | 34 | 29 | No | No | Yes | Yes |
4 | M | 47 | Neuropathic | 5 | 40 | 31 | Yes | No | Yes | Yes |
5 | M | 48 | Burn | 4 | 26 | 30 | No | No | Yes | No |
6 | M | 59 | Neuropathic | 6 | 34 | 36 | No | No | Yes | Yes |
7 | M | 54 | Neuropathic | 5 | 26 | 29 | No | No | Yes | Yes |
8 | M | 47 | Neuropathic | 4 | 32 | 24 | No | No | Yes | No |
9 | M | 51 | Neuropathic | 6 | 23 | 35 | Yes | No | Yes | Yes |
10 | M | 55 | Neuropathic | 4 | 17 | 33 | No | No | Yes | No |
11 | M | 53 | Neuropathic | 5 | 31 | 35 | No | No | Yes | No |
12 | M | 56 | Neuropathic | 6 | 22 | 34 | Yes | No | Yes | Yes |
13 | M | 55 | Neuropathic | 4 | 10 | 26 | No | No | Yes | No |
A deep wound tissue biopsy culture was performed to determine wound infection before the procedure, and appropriate antibiotherapy was initiated as guided by the culture results. When osteomyelitis was diagnosed, bone debridement was performed in addition to soft tissue debridement (Figures
Full thickness necrosis due to acute limb ischemia (patient 1 in Table
After serial wound debridements appearance of peripheral granulation tissue. Medial view.
After serial wound debridements appearance of peripheral granulation tissue. Lateral view.
After serial wound debridements appearance of peripheral granulation tissue. Oblique view.
Most of the wound filled with healthy granulation tissue.
Immediate view after ADM application.
Immediate view after ADM application.
Granulation tissue formation over ADM.
Granulation tissue formation over the second layer of ADM.
The foot at 42 months.
The foot at 42 months
None of the patients treated with ADM required amputation. None of the patients developed a wound site infection in the postoperative period. The mean duration for the formation of granulation tissue was 12 days for the wound floor (range: 9–18 days) and nine days for the first and second layers of ADM (range: 6–12 days). None of the patients experienced loss of ADM. None of the patients developed a hematoma or seroma. Skin grafting was successful in ten patients (77%) and partial losses were observed in three patients (23%). However, these losses showed recovery with dressings without requiring additional interventions. None of the patients developed ulceration at the skin site grafted with ADM. Four patients (30.77%) developed several wounds at the junction of the ADM and normal skin, and all recovered spontaneously with local wound care. This complication did not prevent mobilization of the patients. Of the 13 patients, four (30.8%) required orthopedic shoes, whereas the remaining nine (69.2%) patients maintained their lives with normal shoes. One of the patients who required orthopedic shoes developed a plantar flexion deformity associated with the shortening of the Achilles tendon. This patient was also using orthotics. One patient sustained a burn injury at the operation site seven months after the operation due to contact with a hot object. The superficial second-degree burn injury showed spontaneous epithelialization with wound dressing within ten days (Figures
The view of the wound caused by thermal injury seven months after the operation. ADM exposure (patient 8 in Table
After the epithelialization.
Foot ulcers are observed in 85% of diabetic patients and are the most important causes of lower extremity amputations [
“Replacing like with like” is one of the most important principles in reconstructive surgery. A thinner tissue that is similar to the heel is found in the palms of the hands; however, the hand is so precious that it cannot be used as a donor site for the repair of heel defects. Local flaps, island flaps, and local muscle flaps are the most appropriate options for the repair of small defects in the heel (<3 cm) [
There is still debate over the use of free flaps or pedicled flaps in the reconstruction of large heel ulcerations occurring in diabetic patients with concurrent peripheral vessel disease. Sacrificing a vessel that supplies the entire leg for the sake of closing the wound or stealing from the flow of this vessel (steal phenomenon) can result in critical ischemia distal to the anastomosis [
The selection of a recipient vessel, the presence of appropriate anastomosis segments, and vessel perfusion are the most important factors affecting the success of free flaps in diabetic patients [
The diabetic patient group in the present study consisted of patients with severe peripheral vascular disease and large heel ulceration. These patients were not eligible for free or pedicled flaps because only one of the three vessels that constitute the trifurcation was patent.
Most importantly an ideal tissue or material for use in the repair of large heel defects is thin and stable enough to allow shoes to be worn. The tissue or material must resist trauma and shearing forces and should not easily become ulcerated; it must be resistant to ischemia and must be large enough to cover wounds of all sizes. However, donor site morbidity must also be minimal. Because ADM is traditionally used in the treatment of burn injuries, there is limited data on the use of ADM in the treatment of chronic wounds. BellaDerm is a human-derived ADM. The most prominent advantage of human-derived ADM over animal-derived ADM is that it elicits a weaker immune response and offers a safer profile for potential infections by prions. ADM integrates with the neighboring tissues and becomes a part of the host. The ADM is resistant to trauma, and it can be sutured, folded, cut, and easily shaped into rolls, similar to normal tissues. Donor site morbidity is not applicable for ADM.
The integration of ADM into the recipient site is gradual, as in other grafts involving imbibition, fibroblast migration, neovascularization, and maturation [
The loss of ADM is inevitable as it is not sufficiently attached to the recipient zone. It is not a new practice to apply NPWT dressing with dermal matrices instead of classical bolster dressing [
The use of NPWT dressing alone is known to have favorable effects in the treatment of diabetic foot ulcers [
Under normal conditions, the thickness of heel skin varies between 0.9 and 1.3 mm [
Although it theoretically seems intuitive that plantar sensation is required for the prevention of ulcers, this subject remains controversial. In most cases, a deep protective sensation seems sufficient for the protection of flaps [
Another advantage of this method is that complex reconstruction can be postponed to a later date in trauma patients who are not eligible for free or pedicled flaps in the acute phase, independent of the conditions of the vessels.
The current series of patients constitutes a homogeneous group in terms of location and extent of the wound site and vascular status. This is the first series in the literature in which two layers of ADMs were used.
The most important drawbacks associated with this method include the high costs of NPWT and ADMs, the dependence of the patient on NPWT dressing, even for a short period of time, and the duration of the therapy. These methods are currently under development and available data are not sufficient to calculate the costs.
Diabetic patients with severe peripheral vascular disease and heel ulceration face the risk of amputation. VASDEM is a new method offering an opportunity for treatment before resorting to amputation that has the potential to close wounds of all sizes independent of the vessel status and wound size in selected diabetic patients who require complex reconstruction of the diabetic heel ulcerations.
The authors have no financial interest to declare in relation to the content of this paper. The authors have no conflict of interests related to any of the products, devices, and drugs mentioned in this paper.