الفهرس 
Surgical Anatomy of the Heel
Blood Supply of the Heel:Only 14 pages are availabe for public view
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Abstract
The heel is the last station before major amputation which is a burden for person, family and society. Heel ulcers are a significant healthcare problem resulting from a combination of several problems including neuropathy, inadequate blood supply, infection and abnormal pressure on the heal bones. The management of patients with ischemic heel ulcers and gangrene is one of the most challenging tasks for a practicing vascular surgeon because of lack of adequate tissue for coverage over exposed bone and tendons, difficulty avoiding local pressure and impaired wound healing because of associated comorbidities. In this study, we tried to evaluate the clinical outcome of ischemic heel ulcers after infragenicular endovascular revascularization in a prospective manner. Our management protocol for patients with heel ulcers summarized in Figure 55 This study included 42 patients with ischemic heel ulcers that were revascularized through endovascular surgery during the period from October 2016 to June 2019 in a prospective manner. After full history taking, thorough general and local examination including assessment of the heel ulcer and degree of ischemia including ABPI, then duplex study of lower limb arteries and x-ray of the foot was done for all patients and CT angiogram was done if needed. After that, endovascular revascularization of the heel ulcers was done. Post-operative reevaluation of ABPI, post-operative duplex scan were done. Summary and conclusions 168 According to whether PTA was successfully revascularized or not, our patients were divided into; group I: patients having PTA revascularized (Direct revascularization) included 22 patients and group II: patients have ATA or PA revascularized (Indirect revascularization) included 20 patients. Dressing of the heel ulcers and offloading was individualized for each patient. The following data were collected and registered for each patient at time of admission, immediate post-operative, at 1 month follow up, at 3 months follow up and at 6 months follow up: Ulcer surface area, ABPI at anterior and posterior tibial arteries, PSV at anterior and posterior tibial arteries. These data were compared between both groups and between different follow up periods, the collected data were correlated to limb salvage and ulcer healing time using SPSS v.25. The age of the studied patients ranged between 48y and 83 years, 64.3% were males and 35.7% were females. Diabetes mellitus was the most common risk factor in the patients (83.33%) and was negatively affecting both healing time and limb salvage, smoking was another prevalent risk factor (47.6%) and was associated with lower limb salvage rate, hyperlipidemia was also in 54.7% but had no statistically significant correlation to neither healing time nor limb salvage. Preoperative application of WIFi score revealed that 42.86% of the studied patients were at high risk for amputation and the remaining patients were at moderate risk for amputation. Either complete occlusion or stenosis of the posterior tibial artery (PTA) was noticed in all patients, and PTA immediate ABPI and PSV in Summary and conclusions 169 duplex scan were negatively correlated to healing time. While preoperative grade of ischemia was negatively correlated to limb salvage. There was no significant difference between mean ulcer size for both groups on admission but there was statistically significant difference between both group in third follow up month in favor of direct revascularization group P = 0.034 In this study, successful revascularization of either ATA or PTA improve the other one’s ABPI and PSV. Healing time was significantly better with direct revascularization p=0.002 while limb salvage rate difference did not reach statistical significance p=0.826 Healing time increased with Diabetes mellitus, CVS diseases, increased wound size and depth and presence of infection at time of admission and it decreased with higher PTA ABPI and PSV immediately postoperative. Older age, DM, ESRD, ulcer stage and depth, degree of preoperative ischemia and presence of infection were associated with low limb salvage rate. While multiple patent vessels and complete pedal arch were associated with higher limb salvage rate.