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A Function-Based Algorithm for Hindfoot Ulcer Reconstruction: Clinical Outcomes From a Tertiary Limb Salvage Center
Kishan S. Shah
1, Christopher M. Ply
1, Luke J. Llaurado
1, Hannah Soltani
1, Rachel N. Rohrich
1, Parker Buck
1,Jayson Atves
1, John Steinberg
1, Cameron Akbari
1, Richard C. Youn
1, Karen K. Evans
1, Christopher E. Attinger
1, Stephen Baker
1
1. Department of Plastic & Reconstructive Surgery, Georgetown University School of Medicine, San Diego, CA, United States.
Background: Hindfoot ulceration presents a unique reconstructive challenge. This study proposes a novel function-first treatment algorithm for the surgical treatment of heel ulcers.
Methods: A retrospective review of 124 patients undergoing surgical management of heel ulceration was performed. Patients were managed according to a multidisciplinary algorithm incorporating infection control, vascular optimization, soft tissue reconstruction, biomechanical correction. Patients were stratified by anatomical ulcer location. Outcomes assessed included demographics, comorbidities, vascular details, ulceration and long-term functional outcomes.
Results: The cohort consisted of 71 plantar (57.3%) and 53 posterior (42.7%) heel ulcers. Posterior ulcers occurred in older, less ambulatory patients (39.6% ambulatory vs 88.7% plantar,
p=0.016), Plantar ulcers demonstrated larger wound area (40 vs 20 cm
2,
p=0.020) and a higher rate of re-ulceration (49.3% vs 18.9%,
p=0.003), compared to posterior ulcers. Reconstruction strategy differed significantly by ulcer location (
p=0.004), with plantar ulcers more frequently requiring local or free flap reconstruction, and posterior ulcers more commonly managed with split-thickness skin grafting. Both groups underwent calcanectomy at comparable frequencies. Rates of dehiscence, necrosis, and infection before 4 weeks post-op were comparable between groups. 23 (32.4%) of plantar ulcer patients and 10 (18.9%) of posterior ulcer patients underwent ipsilateral major amputation (
p=0.092). Among preoperatively ambulatory patients, 75.0% remained ambulatory at final follow-up. Overall mortality was 21.8% with a median 22.6-month follow-up.
Conclusions: We propose an algorithm for hindfoot ulcer reconstruction that utilizes ulcer location to inform the cause, reconstruction, and then make corrections to prevent recurrence. In posterior ulcers, offloading is key. In plantar, correcting gait is paramount to prevent re-ulceration. Our findings support a shift from limb-salvage-at-all-costs toward individualized, function-driven reconstruction.
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