Heel Ulcers Research Articles

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

The diabetic heel ulcer (DHU) represents a reconstructive challenge to clinicians and the multidisciplinary team alike. It is traditionally viewed as a condition that is inherently difficult to treat due to the intrinsic anatomical vulnerabilities of the heel. In addition to this, several factors are associated with poorer end outcomes-namely, that of major amputation. These include peripheral vascular disease, infection/osteomyelitis and the size of the ulcer itself. In light of the significant morbidity, economic burden and mortality seen in this cohort of patients, this review aims to explore current treatment modalities that have been undertaken. Literature in this field has mostly been confined to a handful of small case studies, some of which reflect novel, multimodal approaches, and promising results. Management with osteotomy, flap reconstruction and acellular dermal matrices, amongst other options, is covered within this review.

Tips and tricks for achieving healing and limb salvage in patients with ischemic heel ulcers and gangrene

Tips and tricks for achieving healing and limb salvage in patients with ischemic heel ulcers and gangrene

Single stage treatment of diabetic calcaneal osteomyelitis with an absorbable gentamicin-loaded calcium sulphate/hydroxyapatite biocomposite: The Silo technique

BackgroundChronic osteomyelitis necessities appropriate infected bone and soft tissue excision. The authors describe the Silo surgical technique for the treatment of calcaneal osteomyelitis using a new antibiotic-loaded absorbable calcium sulphate/hydroxyapatite biocomposite. MethodsThe Silo method involves debridement of the dead bone and local delivery of antibiotic in drilled tunnels using the biocomposite. It is combined with multiple sampling and culture-specific systemic antibiotic treatment guided by a multidisciplinary team.Twelve consecutive diabetic patients with heel ulcers and calcaneal osteomyelitis were treated with the above method. All had comorbidities (Cierny–Mader (C–M) Class B hosts). The mean age was 68 years (range 50–85). A retrospective review of radiographs and electronic medical records was conducted. ResultsPatients were followed up until clinical cure of the ulcer for a mean of 16 weeks (range 12–18). Infection was eradicated in all 12 patients with a single stage procedure following a bone preserving technique. One patient required a subsequent flap operation and six vacuum-assisted closure (V.A.C.). There was also one case of prolonged wound leakage and no calcaneal fractures. ConclusionsThe Silo technique is an effective method of local delivery of antibiotics and can be effectively implemented into the single-stage treatment of calcaneal osteomyelitis offering increased bone preservation and local delivery of antibiotic, decreasing the need for a major amputation. Level of evidenceLevel IV- case series.

Why is the heel particularly vulnerable to pressure ulcers?

In this article, the vulnerability of the soft tissues of the heel to pressure ulcers (injuries) is explained from a biomechanical engineering perspective, and emerging technologies for protecting the heel, particularly low-friction garments, are reviewed. Sustained deformations in the soft tissue of the weight-bearing posterior heel cause progressive cell and tissue damage due to loss of homeostasis in the cells, as the cytoskeleton and plasma membranes of the affected cells lose integrity and functionality. This deformation damage onsets and evolves rapidly when there is no relief of the tissue distortion (e.g. in supine motionless lying). Hence, prevention should be timely and be applied across all patient populations that are at risk. In particular there is a need to protect tissues from the action of frictional forces that are shearing not only the skin but also the deep tissue structures of the heel. The internal anatomy and physiology of the posterior heel, the common hospital conditions (lying supine, head of the bed elevated) and medical conditions involving neuropathy and perfusion impairments may impose specific risk for heel (pressure) ulcers. There is growing evidence that low-friction-fabric garments may provide added benefits in preventing heel ulcers when used in addition to standard clinical and technology-supported pressure ulcer prevention strategies, as the low-friction fabric structures absorb frictional forces before these are able to considerably distort the susceptible heel tissues.

Evidence-Based Interventions for Diabetic Heel Ulcers

Diabetes can increase a patient's risk for the development of a pressure ulcer. Specifically, diabetic heel ulcers require an interprofessional approach that includes nutritional care provided by a dietitian. Assessment of malnutrition risk, along with a review of macro- and micronutrient deficiencies, assists the dietitian in determining the most appropriate intervention for a diabetic patient with a heel ulcer. Standardized nutrition recommendations exist for the management of pressure ulcers; however, a need exists for further evidence to support these guidelines. This case report presents a patient with a diabetic heel ulcer and explores evidence-based nutrition management.

<i>Pasteurella</i><i> </i><i>multocida</i><i> </i>Bacteremia and Osteomyelitis from a Diabetic Foot Ulcer

Pasteurella multocida is a gram-negative coccobacillus that causes a spectrum of illnesses. P multocida lives as commensal bacteria in the upper respiratory tracts of fowl and mammals. Infections most commonly result from cat or dog bites; however, direct inoculation via saliva has been reported. Although the majority of P. multocida infections manifest in skin and soft tissue, it may cause bacteremia with disseminated infection in an immunocompromised host. Dissemination is responsive to treatment but carries a significant mortality risk of about 30%. We present a case of a 46 year old male with type 2 diabetes mellitus, coronary artery disease and chronic kidney disease with stage 4 neuropathic heel ulcer who presented with hypothermia and chills. One day into admission, 4/4 blood culture bottles were positive for Pasteurella multocida. MRI of the foot was concerning for osteomyelitis which was confirmed via I&D. The patient did report having a dog and a cat at home, but adamantly denied any bites from either animal. Examination of his boot used for support with his foot containing the ulcer revealed extensive animal hair stuck to the boot. It was deemed likely that the route of inoculation occurred from contamination of his neuropathic ulcer from his dog’s saliva, likely from a lick, for which his diabetic neuropathy may have impaired initial sensation of the contamination. The patient was treated with ampicillin-sulbactam while admitted and discharged with oral levofloxacin 6 week course for residual osteomyelitis.

Evaluation of the effectiveness and cost-effectiveness of lightweight fibreglass heel casts in the management of ulcers of the heel in diabetes: a randomised controlled trial.

Ulcers of the foot in people with diabetes mellitus are slow to heal and result in considerable cost and patient suffering. The prognosis is worst for ulcers of the heel. To assess both the clinical effectiveness and the cost-effectiveness of lightweight fibreglass casts in the management of heel ulcers. A pragmatic, multicentre, parallel, observer-blinded randomised controlled trial. A central randomisation centre used a computer-generated random number sequence to allocate participants to groups. Thirty-five specialist diabetic foot secondary care centres in the UK. Those recruited were aged ≥ 18 years and had diabetes mellitus complicated by ulcers of the heel of grades 2-4 on the National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel scale. In total, 509 participants [68% male, 15% with type 1 diabetes mellitus, mean age 67.5 years (standard deviation 12.4 years)] were randomised 1 : 1 to the intervention (n = 256) or the control (n = 253) arm. The primary outcome data were available for 425 participants (212 from the intervention arm and 213 from the control arm) and exceeded the total required; attrition was 16.5%. The median ulcer area at baseline was 275 mm2 [interquartile range (IQR) 104-683 mm2] in the intervention group and 206 mm2 (IQR 77-649 mm2) in the control group. There were no differences between the two groups at baseline in any parameter, neither in relation to the participant nor in relation to their ulcer. The intervention group received usual care supplemented by the addition of an individually moulded, lightweight, fibreglass heel cast. The control group received usual care alone. The intervention phase continued either until the participant's ulcer had healed (maintained for 28 days) or for 24 weeks, whichever occurred first. During this intervention phase, the participants were reviewed every 2 weeks, and the fibreglass casts were replaced when they were no longer usable. The primary outcome measure was ulcer healing (confirmed by a blinded observer and maintained for 4 weeks) within 24 weeks. Other outcome measures included the time taken for the ulcer to heal, the percentage reduction in the cross-sectional area, the reduction in local pain, amputation, survival and health economic analysis. The study was powered to define a difference in healing of 15% (55% intervention vs. 40% control). Forty-four per cent (n = 94) of the intervention group healed within 24 weeks, compared with 37% (n = 80) of the control participants (odds ratio 1.42, 95% confidence interval 0.95 to 2.14; p = 0.088), using an intention-to-treat analysis. No differences were observed between the two groups for any secondary outcome. Although the component items of care were standardised, because this was a pragmatic trial, usual care was not uniform. There was some evidence of a small excess of adverse events in the intervention group; however, non-blinded observers documented these events. There was no excess of adverse device effects. There may be a small increase in healing with the use of a heel cast, but the estimate was not sufficiently precise to provide strong evidence of an effect. There was no evidence of any subgroup in which the intervention appeared to be particularly effective. A health economic analysis suggested that it is unlikely that the intervention represents good value for money. The provision of a lightweight heel cast may be of benefit to some individuals, but we have found no evidence to justify the routine adoption of this in clinical practice. It is unlikely that further study of this intervention will have an impact on usual clinical care, and so future efforts should be directed towards other interventions designed to improve the healing of ulcers in this population. Current Controlled Trials ISRCTN62524796. This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 34. See the NIHR Journals Library website for further project information.

Risk factors associated with poor outcome in diabetic foot ulcer patients.

Diabetic foot ulcers and related complications are a major cause of morbidity and hospital admissions. Our aim was to evaluate the risk factors associated with poor outcome in diabetic foot ulcers. A prospective study was conducted on patients with diabetic foot ulceration attending the Madinah Teaching Hospital from June 2014 to December 2015. Potential risk factors and laboratory test results at presentation were recorded and their association with outcome (healing vs. amputation) was analyzed using IBM SPSS Statistics for Windows, Version 22.0. In total, 112 patients were studied during our study period. The majority of the patients were male (60.7%) and aged 50 years and older (62.5%). Regarding the outcome, 68% healed completely, 27.7% underwent amputation, and 4.5% died during this period. Patient age of 50 and older, long duration of diabetes (>10 years), rural origin, and heel ulcers were significantly associated with poor outcome (P < 0.05). Patients with diabetes should have a detailed annual foot examination; those having risk factors for poor outcome require more frequent foot care, patient education, and early referral to tertiary care centers.

Combination of Open Subtotal Calcanectomy and Stabilization With External Fixation as Limb Salvage Procedure in Hindfoot-Infected Diabetic Foot Ulcers.

Diabetic hindfoot ulcers, complicated by osteomyelitis, are associated with a high risk of major amputation. Partial calcanectomy, preceded by an effective management of the infection and of the eventual peripheral artery disease, can be considered as valid therapeutic option. We have evaluated a therapeutic protocol for diabetic hindfoot ulcers complicated by osteomyelitis, which, besides an adequate surgical debridement, considers a reconstructive pathway assisted by the positioning of a circular external fixator. We made a prospective study of a cohort of diabetic patients affected by heel ulcer complicated by osteomyelitis. All patients underwent open partial calcanectomy associated with the positioning of a circular external frame specifically designed for hindfoot stabilization and offloading. A reconstructive procedure was implemented starting with the application of negative pressure wound therapy and coverage with dermal substitute and split thickness skin grafting. From November 2014 to November 2015, 18 consecutive patients were enrolled. Mean follow-up period was 212.3 ± 64.0 days. Healing was achieved in 18 (100%) patients. The mean healing time was 69.0 ± 64.0 days. No major amputation had to be performed during the follow-up. Open partial calcanectomy associated with external fixation and skin reconstruction was as efficient as limb salvage in patients with infected lesions of the hindfoot complicated by calcaneal osteomyelitis.

老年糖尿病患者足跟溃疡护理的临床报道*

目的 评价老年糖尿病足跟溃疡的临床护理效果。方法 选择我院整合门诊收治的老年糖尿病足跟溃疡患者6例，采用创面处理、适宜的抗菌敷料、减压技术和全身支持治疗，观察治疗护理效果。结果 6例足跟溃疡全部愈合，创面愈合时间为63～448天，159±62.56天。结论 创面减压、活性炭纤维含银敷料的应用及全身治疗能够促进糖尿病患者足跟溃疡的愈合。

Heel ulcers do heal in patients with diabetes

A heel ulcer is considered to be a serious complication in patients with diabetes, and there is limited information regarding outcome. In most of the literature, a poor prognosis is described. The aim of this study was to investigate a large cohort of ulcers located in the heel in patients with diabetes. Seven hundred and sixty-eight patients [median age 73 (17-98)], presenting with a heel ulcer at a multidisciplinary diabetes foot clinic, fulfilled the inclusion criteria and were followed-up until final outcome. Fifty-eight per cent of the patients healed primarily; 7% healed after major debridement; 9% healed after amputation and 25% died unhealed. Median healing time was 17 weeks. Ulcer progression was seen in 19% of patients. Thirty-one percent of patients had severe peripheral vascular disease. A creatinine level below 91 µmol/l was related to a higher probability for healing without major debridement or amputation, whereas vascular surgery, nephropathy and oedema were related to a lower probability for healing without major debridement or amputation. Two thirds of heel ulcers do heal in patients with diabetes despite patients being elderly and with extensive comorbidity. The extent of peripheral vascular disease, nephropathy, oedema and decreased renal function are important factors influencing outcome.

Rearfoot Transcutaneous Oximetry is a Useful Tool to Highlight Ischemia of the Heel.

To demonstrate the usefulness of rearfoot transcutaneous oximetry to assess the peripheral arterial disease in diabetic patients with heel ulcer. From our database of 550 critical limb ischemia diabetic patients followed after a percutaneous transluminal angioplasty, we have selected patients with below the knee arterial disease. Patients were grouped according to the dorsal transcutaneous oximetry value (Group A<30mmHg; Group B≥30mmHg). Patients of Group B had a second oximetry performed at the rearfoot, close to the lesion localized in all cases at the heel. Finally, the analysis of the arterial pattern disease has been done. We selected 191 patients: Group A (151 patients), dorsal transcutaneous oximetry of 11.8±0.7mmHg; Group B (40 patients), dorsal transcutaneous oximetry of 44.2±10.1mmHg. In Group B, rearfoot oximetry was 20.5±5mmHg, significantly lower than dorsal oximetry (p=0.0179). The anterior tibial artery was involved in all patients of Group A. In Group B, the anterior tibial artery was involved in 15 subjects and never alone; the posterior tibial artery was involved in 20 subjects and in 11 cases alone. The peroneal artery was affected in 20 subjects and in 14 patients alone. When a heel lesion is present and the transcutaneous oximetry recorded on the dorsum of the foot does not confirm the presence of critical limb ischemia (not ≤30mmHg), a second oximetry recorded on the rearfoot is useful to point out ischemia of the peroneal artery and/or of the posterior tibial artery.

Partial Calcanectomy for Heel Ulcers Revisited – a Possible Solution to a Difficult Problem

Category: Diabetes Introduction/Purpose: Diabetic heel ulcers are a major problem, often leading to amputations. Partial or total calcanectomy has been described as a possible salvage procedure, by allowing soft tissue coverage after debridement of necrotic and infected tissue, and possibly allowing walking. We report on our experience with this technique which is not commonly used Methods: Fourteen patients, who presented with diabetic heel ulcers between 2010-15, and who were BKA candidates, underwent debridement and partial calcanectomy. Average age was 67.8 ±12.7 years, M:F ratio was 6:1 Extent of procedures, need for additional procedures and complications were noted. Outcome assessment included wound closure and walking status. No patients were lost to follow up. Results: Nine patients underwent partial calcanectomy as the initial procedure while others underwent prior debridement. Calcanectomies were subtotal (1), wedge (5) or partial (8). Primary closure was mostly achieved (11), the remainder requiring local skin graft (2) or myocutaneous flap (1). Ten patients underwent re-vascularization prior to calcanectomy, either angiographic (8) or bypass (2). Most calcanectomies (9/14) healed successfully, while five subsequently required amputations. Most failures were noticed within 24 days, with similar prevalence in wedge and partial calcanectomies. One patient had wound complications requiring BKA. At one year, the nine patients had full wound closure and could bear weight. Five patients regained full ambulatory status wearing specially modified shoes with custom fillers. Conclusion: Partial calcanectomy is a little-known procedure, that is a viable alternative to BKA. We present our positive experience with this procedure, which in a majority of cases not only prevented BKA, but also allowed weight bearing. Poor vascular supply is not necessarily a contraindication, as re-vascularization prior to calcanectomy is a viable option.

Marjolin's ulcer. A 10 year experience in a diabetic foot unit

Abstract Background Marjolin's ulcer is defined as the appearance of a neoplasm within a chronic wound. The most common histological type is squamous. A total of 2 cases treated in our hospital are presented. Clinical cases Case 1 . A 71 year old man who presented with redness and suppuration from the wounds he had in his right foot after an electric shock 40 years earlier. The radiology showed involvement of the 4° and 5° metatarsal. Supracondylar amputation was performed, showing a well-differentiated invasive squamous cell carcinoma. Case 2. A 56 year old male, paraplegic for 20 years. He was treated due to an infected right heel ulcer, with partial improvement, but the ulcers persisted. Biopsy was performed, reporting as epidermoid carcinoma. Infracondylar amputation was performed. The diagnosis was a well-differentiated squamous cell carcinoma infiltrating the dermis. Conclusion The prevalence of Marjolin's ulcer is 1.3–2.2% of all ulcers. Diagnosis is difficult, so biopsy is recommended on any suspicious lesion or ulcer that has received conservative treatment for one month without improvement, although this time limit is not clear. The treatment is the surgery. Local excision with a margin of an inch is enough. If the ulcer is extensive, amputation is required. Survival is estimated between 66 and 80% at 2 years, with recurrence rates of 23%. Unfavourable factors are poor tumour differentiation and metastasis, appearing in 20% of cases.

Partial Calcanectomy Facilitates Wound Closure of Heel Defects in High-Risk Patients

Heel ulcers in patients with severe peripheral artery occlusive disease represent a challenge to the treating physician. They become more difficult to treat with underlying medical comorbidities. The purpose of this report is to document evidence that partial calcanectomy is simple to perform and clears infected bone, tissue, and ulceration. Between July 2011 and August 2013, 30 consecutive patients presented to our department with heel wounds caused by diabetes mellitus and pressure. After evaluation by a vascular surgeon, 12 patients diagnosed with near total occlusive peripheral vascular disease were included in this report. Of the 12 patients, 7 were women. Their ages ranged from 65 to 79 years (mean, 73.3 years). After admission, surgical debridement was performed emergently with subsequent partial calcanectomy and wound closure. Eight heel wounds (75%) healed completely with no further surgery to achieve defect coverage. Wound dehiscence developed in 4 patients (25%). The mean number of debridements was 1.75 (range, 1-3) with a total operation time of 71.5 minutes (range, 45-114 min). One patient died of acute myocardial infarction 2 weeks after discharge. The mean length of hospital stay was 8.3 days (range, 5-16 days). In this study, we demonstrate that partial calcanectomy is practical for the treatment of plantar heel ulcers in patients with severe comorbidities. With proper surgical planning and postoperative care, partial calcanectomy is a viable alternative to below-the-knee amputation and may better serve the patient who would otherwise be restricted to a sedentary lifestyle.

TCTAP C-192 Below-the-knee Angioplasty by Calcification Cracking Technique with Stiff Guidewire

### Patient initials or identifier number Y. N ### Relevant clinical history and physical exam We report a case of a 72-year-old woman who presented with left leg rest pain and small heel ulceration, a Rutherford classification of grade 5. She had past histories of old myocardial infarction,

Predicting Pressure Ulcer Development in Clinical Practice: Evaluation of Braden Scale Scores and Nutrition Parameters.

Accurate patient assessment and screening for pressure ulcer (PU) is difficult in the clinical setting, and evaluation of nutritional status is especially problematic. The aim of this retrospective study was to determine the extent to which Braden Scale scores and other nutrition screening parameters (body mass index, poor intake, and weight loss) predict PU development in general and heel and sacral ulcers specifically. Records of 230 hospitalized patients who developed PU were compared to a matched control group without PU. Logistic regression was used to determine the association of total Braden scores, Braden nutrition subscale scores, and nutrition factors with PU development at any time, within week 1, or within week 2 of hospitalization; and development of sacral and heel ulcers at these same periods. Braden Scale scores on hospital admission were predictive of hospital-acquired pressure ulcer development at some point during the hospital stay; and more specifically Braden scores on day 7 were predictive of PU development within week 2 of hospitalization. Among nutrition screening factors and PU development, a low body mass index showed a statistically significant relationship with sacral ulcer development. Findings indicate that the overall Braden score is a valid predictor of PU development. Implications for clinical practice to decrease the risk for PU development include appropriate use of reliable and valid scales by nurses along with careful evaluation of nutrition parameters.

Diabetes and temperature

Diabetes and temperature

Diabetic hindfoot problems

Diabetes prevalence is reaching pandemic proportions in the 21st century. Since the discovery of insulin physicians and surgeons have been challenged by the long term complications of diabetes. Foot and ankle complications consume a great proportion of healthcare resources. In recent times there have been great advances in understanding the basic science behind the aetiology of diabetic foot and ankle complications. The combination of abnormal biomechanics, neuropathy and vascularity is integral to the pathogenesis of ulceration and Charcot arthropathy. The article discusses the unique biomechanical properties of a diabetic neuropathic lower limb.Hindfoot and ankle ulcerations have a greater association with major lower limb amputation. Conservative treatment includes prescription of off-loading orthotics and local ulcer treatment. However heel ulcers can also be the result of overzealous surgical intervention.Mirroring the increased prevalence of diabetes, Charcot arthropathy incidence is rising. We discuss the conservative and surgical management of this devastating complication of a neuropathic hindfoot and ankle. Conservative management is the mainstay of the initial phase of this disease though evidence is appearing of the benefits of early surgical intervention. Surgical interventions aim at preserving the lower limb and producing a stable plantigrade foot.

Wound Healing Society 2015 update on guidelines for pressure ulcers.

Wound Healing Society 2015 update on guidelines for pressure ulcers.