A review of the surgical management of heel pressure ulcers in the 21st century

Abstract

Heel ulceration, most frequently the result of prolonged pressure because of patient immobility, can range from the trivial to the life threatening. Whilst the vast majority of heel pressure ulcers (PUs) are superficial and involve the skin (stages I and II) or underlying fat (stage III), between 10% and 20% will involve deeper tissues, either muscle, tendon or bone (stage IV). These stage IV heel PUs represent a major health and economic burden and can be difficult to treat. The worst outcomes are seen in those with large ulcers, compromised peripheral arterial supply, osteomyelitis and associated comorbidities. Whilst the mainstay of management of stage I-III heel pressure ulceration centres on offloading and appropriate wound care, successful healing in stage IV PUs is often only possible with surgical intervention. Such intervention includes simple debridement, partial or total calcanectomy, arterial revascularisation in the context of coexisting peripheral vascular disease or using free tissue flaps. Amputation may be required for failed surgical intervention, or as a definitive first-line procedure in certain high-risk or poor prognosis patient groups. This review provides an overview of heel PUs, alongside a comprehensive literature review detailing the surgical interventions available when managing such patients.

Slow to heel: a literature review on the management of diabetic calcaneal ulceration

“…• a standard of care should be carried out for all diabetic heel ulcer patients; this includes assessment of peripheral vasculature, screening for infection and offloading of the heel • the application of acellular dermal matrices should be considered in patients where flap reconstruction may not be suitable • patients with normal ankle-brachial pressure indices are less likely to demonstrate postoperative complications, for example, wound dehiscence • recent comparative studies have shown no significant differences in the success of free or pedicled flaps between the diabetic and non-diabetic population; all patients had 'adequate vascular supply' prior to flap surgery • partial to complete calcanectomies with concurrent external foot fixation and hindfoot offloading may result in limb salvage this, the close proximity of skin to bone in the heel presents a considerable risk of osteomyelitis when a communicating ulcer lays in situ (5). While the abovementioned factors may be at play against the adequate healing of an ulcer, PVD in particular has been shown to be an important predictive factor for limb loss (14,15).…”

“…Complications commonly seen in diabetic populations include peripheral neuropathy, peripheral vascular disease (PVD), arthropathy, altered biomechanics of the foot and poor wound healing . These risk factors, coupled with intrinsic anatomical vulnerabilities and the pressure‐loading nature of the heel, are accountable for the unique challenges faced in the management of this condition . In addition to this, the close proximity of skin to bone in the heel presents a considerable risk of osteomyelitis when a communicating ulcer lays in situ .…”

“…These risk factors, coupled with intrinsic anatomical vulnerabilities and the pressure‐loading nature of the heel, are accountable for the unique challenges faced in the management of this condition . In addition to this, the close proximity of skin to bone in the heel presents a considerable risk of osteomyelitis when a communicating ulcer lays in situ .…”

“…Ultimately, limb salvage and restoration of baseline mobility and independence are the desired outcomes. Major amputations in diabetic patients have been associated with poor 5‐year survival of between 22% and 50% and are usually considered in cases of acute DHU sepsis with extensive tissue involvement where debridement and antimicrobial therapy have failed .…”

Lower Limb Amputation in Germany

“…Thus, in the period 2008 to 2011 around every fifth patient with a major amputation had a secondary diagnosis of dementia (26). In bedridden demented patients with advanced tissue destruction, primary major amputation makes more sense than revascularization (27,28).…”