Clinical diagnosis and treatment of refractory neuro-ischemic diabetic foot ulcer: A case report

Background Neuro-ischemic diabetic foot ulcers (DFUs) associated with advanced peripheral artery disease and severe neuropathy pose a considerable challenge for limb preservation, especially when repeated revascularization efforts are deemed ineffective due to insufficient distal perfusion and a high risk of restenosis. This report discusses the case of an elderly male patient in his 60s, who was admitted for a non-healing wound following the amputation of the right great toe. Clinical examination revealed a 4.5 cm × 2.5 cm × 2 cm deep cavity exposing the first metatarsal head, with 50% slough coverage and substantial exudate. The right ankle-brachial index was measured at 0.52, and duplex ultrasound confirmed near-occlusive multisegmental disease of the anterior and posterior tibial arteries. Electromyography indicated severe peripheral neuropathy. The clinical diagnosis was determined to be Wagner grade 4, WIfI stage W2, I2, Fi grade 2, neuro-ischemic diabetic foot with arteriosclerosis obliterans. Objectives This study aims to assess the effectiveness of a limb-salvage protocol that integrates traditional Chinese incremental debridement, known as "silkworm-feeding," with negative-pressure wound therapy (NPWT) and autologous platelet-rich plasma (PRP) gel in a patient with a refractory neuro-ischemic diabetic foot ulcer (DFU), for whom further revascularization was not feasible. Methods After a multidisciplinary evaluation, the limb-salvage protocol was initiated. Incremental debridement was conducted to excise necrotic tissue while preserving viable, well-perfused tissue margins. A herbal ointment, referred to as "Shangke Huangyou Gao," was applied post-debridement to sustain a moist wound environment. Once healthy granulation tissue developed, NPWT and autologous PRP gel were sequentially integrated into the treatment plan. Results The total treatment course from the first hospitalization to complete healing extended over approximately four months, with full epithelialization occurring 9 weeks after discharge. At the 12-month follow-up, the foot remained intact. Conclusions In patients with refractory neuro-ischemic diabetic foot ulcers (DFU) for whom further revascularization is not feasible, the integrated approach of incremental debridement, negative-pressure wound therapy (NPWT), and platelet-rich plasma (PRP) may represent a feasible adjuncitve limb-salvage option in selected patients. Additional cases and prospective stuides are warranted to verify its safety, cost-effectiveness, and reproducibility.