SLR - August 2014 - Jason Mendivil

The Diagnostic Triad of Orphan Heel Syndrome: Posterior Tibial and Peroneal Artery Occlusive Disease, Poorly Controlled Diabetes and Renal Failure

Reference: Taylor Z. The Diagnostic Triad of Orphan Heel Syndrome: Posterior Tibial and Peroneal Artery Occlusive Disease, Poorly Controlled Diabetes and Renal Failure. Journal of Vascular Surgery. 2013; 32.

Scientific Literature Review

Reviewed By: Jason Mendivil, DPM
Residency Program: Southern Arizona VA Health Care System

Podiatric Relevance: In a wound care setting, large heel ulcers pose a challenge for the podiatric surgeon. In patients presenting with uncontrolled diabetes mellitus, renal failure and arterial occlusive disease below the knee, limb salvage can be a difficult task. In some cases, non-invasive vascular studies may not be a reliable indicator for wound healing potential. It is pertinent that the podiatric surgeon acknowledges this clinical triad when attempting to treat a chronic heel wound. The heel angiosome is unique because its main arterial inflow is from two sources. The chief investigator of this study challenges the value of non-invasive studies and looks at healing rates of patients with a full thickness, heel ulcer.

Methods: Twenty-one consecutive patients with a full thickness heel ulcer requiring surgical debridement were evaluated. These patients presented with uncontrolled diabetes mellitus and renal insufficiency. The amount of time to heal the wound and limb salvage rates were determined.

Results: Of the twenty one patients analyzed, ten (48 percent) had chronic kidney disease (seven on dialysis; three stage 3/4 CKD). All the patients had an HgbA1c that was greater than nine (eight patients with an HgbA1c greater than 11). Sixty-six and seventh tenths percent of the patients had normal ABI values (ranging from 0.8 to 1.2). Twenty-three and eight tenths percent of the patients had ABIs that showed non-compressible vessels. Two patients presented with ABIs of 0.28 and 0.39, respectively. Thirteen patients healed their wounds over a range of 42-540 days (average 251 days). Three patients had a major amputation. Eight patients with good perfusion to their forefoot based on normal ABI and TP values had occlusive disease to the arterial inflow to the heel (diagnosed by angiography). Seven patients underwent a revascularization procedure.

Conclusions: The patients in this study presented with an ischemic heel, despite the clinical presentation of a palpable dorsalis pedis pulse and normal ABIs and TPs. The orphan heel triad depicted in this investigation involved occlusive disease of the posterior tibial and pedal arch

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