From a small heel lesion to calcaneal exposure in diabetic heel salvage complicated by ischemia and infection: a case report

Abstract

Heel ulcers are among the most threatening manifestations of diabetic foot disease due to their lack of soft-tissue coverage, their critical location, which causes constant loading, and their reliance on distal perfusion. We report an unusual case of a woman who experienced rapid progression of a right heel lesion to necrosis with calcaneal exposure despite an assuring ankle-brachial index, highlighting the importance of distal perfusion assessment and a multimodality approach in the diagnostic workup. We report a case of a 54-year-old female who experienced rapid progression of a lesion in her right heel, eventually manifesting as necrosis with calcaneal exposure. Her ankle-brachial index was within normal limits (0.92), but her toe-brachial index was critically low (0.14). CT angiography confirmed severe peripheral arterial disease. As such, her treatment involved staged revascularization, debridement, and partial calcanectomy. Additionally, she received culture-directed antibiotics and negative-pressure wound therapy. She eventually recovered with improvement of her heel, and thus avoided the need for amputation. Management of diabetic heel ischemia and successful limb salvage requires multiple interventions, including revascularization, debridement, wound stabilization, and infection control through antibiotics. A normal ABI may be misleading; as such, other modalities should be used as part of the diagnostic workup.