Heel Ulcers Research Articles

Evaluating Iatrogenic Complications of the Total-Contact Cast: An 8-Year Retrospective Review at Cleveland Clinic.

Total-contact casting is an effective method to treat various pathologic abnormalities in patients with diabetic neuropathy, but its use is frequently associated with iatrogenic complications. The largest retrospective review to date of iatrogenic complications of total-contact casts was conducted over an 8-year period at Cleveland Clinic. In the past 8 years, 23% of patients developed complications, and the most common complication was a new heel ulcer formation. Of these complications, 92.1% resolved, 6.4% were lost to follow-up, and 1.4% resulted in a partial foot amputation. Mean cast duration was 10.3 days for patients who developed a total-contact cast iatrogenic complication. The most common indication for the use of a total-contact cast was a neuropathic foot ulceration. The results of this study support the use of total-contact casting in the insensate patient with diabetes. However, adequate staff training in total-contact cast application is recommended to reduce complications.

Characteristics of calcaneal osteomyelitis: an unusual and severe form of diabetic foot disease

Background: Osteomyelitis of the calcaneus is an uncommon type of diabetic foot infection considered to have a poor outcome. Little is known about predisposing and prognostic factors, or optimum treatment regimens. Methods: Case records were reviewed of the eight patients with diabetes who presented to our centre during 2011–13 with calcaneal osteomyelitis and a complementary group of 19 patients who presented with heel ulcers but without osteomyelitis. Results: Male sex (6/8 vs. 4/19; p 2 cm2 (8/8 vs. 3/19; p<0.0001) and depth (probing to bone) (6/8 vs. 0/19; p<0.0001) were associated with calcaneal osteomyelitis. We were unable to identify any patient or treatment characteristics in the osteomyelitis group that conferred improved outcome. Outcomes at 30 weeks after presentation were significantly poorer in the osteomyelitis group (ongoing osteomyelitis or amputation 4/8, and death 2/8) than in the ulcer only group (1/19 and 2/19). Conclusions: In patients with diabetes and heel ulcers, calcaneal osteomyelitis is associated with gender, neuro-pathy and large deep ulcers. It is uncommon and has a poor prognosis. We were unable to identify any factors associated with improved prognosis.

Diabetic neuropathic forefoot and heel ulcers: management, clinical presentation and outcomes

The two most common sites for diabetic neuropathic foot ulcers are the forefoot and the heel. Each site has special characteristics that determines its course. The aim of this study is to compare clinical presentation, management and outcome of diabetic neuropathic forefoot ulcers to diabetic neuropathic heel ulcers. This was a prospective cross-sectional comparative study carried in Jabir Abu Eliz Diabetic Centre (JADC), Khartoum, Sudan. A hundred patients with neuropathic diabetic ulcer were included, half were forefoot ulcers and the other half were hindfoot ulcers, two patients were lost on follow-up from each group. Neuropathy was graded using 10g monofilament nylon. Patients with vascular ischaemia, ankle brachial index pressure (ABPI) <0.9 and >1.1 were excluded. Other patient's data included demographic, foot and ulcer characteristics, comorbidities and outcomes. Foot ulcers were categorised according to Wagner classification, site and size of ulcer and presence of infection. Comorbidities evaluated included hypertension, ischaemic heart disease and renal impairment. All patients received standard wound care and regular follow-up. The age of the studied patients was 54.3 ± 11 years (mean ± standard deviation (SD 11)) and 52.9 ± 11 years for forefoot and heel ulcer respectively. The mean duration of diabetes was 12.4 ± 6 years for forefoot ulcers and 13.3 ± 7 years for heel ulcer. The mean duration of foot ulcer was 21 and 26 days for forefoot and heel respectively. Forefoot ulcers healed within 12 week in 45% of patients and by 20 weeks in 63%, while 35% of heel ulcers healed by 12 weeks and 54% healed by 20 weeks (p=0.058). Based on Wagner classification, healing was best in class 1 among both forefoot and heel ulcers, 22.4% and 12.2% respectively (p=0.003 for forefoot and 0.002 for heel). First and second metatarsal heads were the common site of forefoot ulcer. Heel ulcers >3cm dimension had longer duration of healing compared to forefoot ulcers at both 12 and 20 weeks (p<0.02). Healing in diabetic neuropathic forefoot ulcer was better than heel ulcer, though not reaching statistically significant value. Wagner class 1 had the best healing among both ulcers and a heel ulcer >3cm had a significantly longer healing time. The authors have no conflict of interest to declare.

Strategies for Free Flap Transfer and Revascularisation with Long-term Outcome in the Treatment of Large Diabetic Foot Lesions

To analyse the impact of ischaemia and revascularisation strategies on the long-term outcome of patients undergoing free flap transfer (FFT) for large diabetic foot lesions penetrating to the tendon, bone, or joint. Foot lesions of 63 patients with diabetes (median age 56 years; 70% male) were covered with a FTT in 1991-2003. Three groups were formed and followed until 2009: patients with a native in line artery to the ulcer area (n=19; group A), patients with correctable ischaemia requiring vascular bypass (n=32; group B), and patients with uncorrectable ischaemia lacking a recipient vessel in the ulcer area (n=12; group C). The respective 1, 5, and 10 year amputation free survival rates were 90%, 79%, and 63% in group A; 66%, 25%, and 18% in group B; and 50%, 42%, and 17%, in group C. The respective 1, 5, and 10 year leg salvage rates were 94%, 94%, and 87% in group A; 71%, 65%, and 65% in group B; and 50%, 50%, and 50% in group C. In 1 year, 43%, 45%, and 18% of the patients in groups A, B, and C, respectively, achieved stable epithelisation for at least 6 months. The overall amputation rate was associated with smoking (relative risk [RR] 3.09, 95% confidence interval [CI] 1.8-5.3), heel ulceration (RR 2.25, 95% CI 1.1-4.7), nephropathy (RR 2.24, 95% CI 1.04-4.82), and an ulcer diameter of >10cm (RR 2.08, 95% CI 1.03-4.48). Despite diabetic comorbidities, complicated foot defects may be covered by means of an FFT with excellent long-term amputation free survival, provided that a patent native artery feeds the ulcer area. Ischaemic limbs may also be salvaged with combined FFT and vascular reconstruction in non-smokers and in the absence of very extensive heel ulcers. Occasionally, amputation is avoidable with FFT, even without the possibility of direct revascularisation.

The prevention and management of pressure ulcers: summary of updated NICE guidance.

Journal of Wound CareVol. 24, No. 4 EducationThe prevention and management of pressure ulcers: summary of updated NICE guidanceL. Cooper, C. Vellodi, G. Stansby, L. AvitalL. Cooper1Department of Plastic Surgery, Royal Free HospitalSearch for more papers by this author, C. Vellodi2Department of Acute Medicine and Medicine for the Elderly, Barnet and Chase Farm Hospitals NHS Trust, LondonSearch for more papers by this author, G. Stansby3Department of Vascular Surgery, Freeman Hospital, Newcastle upon Tyne. On behalf of the Guideline Development GroupSearch for more papers by this author, L. Avital4National Clinical Guideline Centre, Royal College of Physicians London.Search for more papers by this authorL. Cooper; C. Vellodi; G. Stansby; L. AvitalPublished Online:8 Apr 2015https://doi.org/10.12968/jowc.2015.24.4.179AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article References 1 Dealey, C., Posnett, J., Walker, A. The cost of pressure ulcers in the United Kingdom. J Wound Care 2012; 21: 6, 261–262. Link, Google Scholar2 Moore, Z., Johanssen, E., Van Etten, M. A review of PU prevalence and incidence across Scandinavia, Iceland and Ireland (Part I). J Wound Care 2013; 22: 7, 364–368 Link, Google Scholar3 Grey, J.E., Harding, K.G., Enoch, S. Pressure Ulcers. Br Med J 2006; 332: 472–425. Crossref, Medline, Google Scholar4 Graves, N., Birrell, F,. Whitby, M. Effect of Pressure Ulcers on Length of Hospital Stay. Infect Control Hosp Epidemiol 2005; 26: 3, 293–297. Crossref, Medline, Google Scholar5 Bennett, G., Dealey, C., Posnett, J. The cost of pressure ulcers in the UK. Age Ageing 2004; 33: 3, 230–235. Crossref, Medline, Google Scholar6 The NHS Outcomes Framework 2014/15, Department of Health 2013. www.gov.uk/government/publications/nhs-outcomes-framework-2014-to-2015 (Accessed June 2014). Google Scholar7 Johansen, E., Moore, Z,. van Etten, M., Strapp, H. Pressure ulcer risk assessment and prevention: what difference does a risk scale make? A comparison between Norway and Ireland. J Wound Care 2014; 23: 7, 369–370. Link, Google Scholar8 Pressure ulcers: prevention and management of pressure ulcers. (2014) National Institute for Health and Care Excellence. www.guidance.nice.org.uk/CG179 (accessed 22/06/2014). Google Scholar9 European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel. Treatment of pressure ulcers: Quick Reference Guide. Washington DC: National Pressure Ulcer Advisory Panel; 2009. www.epuap.org/guidelines/Final_Quick_Treatment.pdf. (accessed 19/1/2015). Google Scholar10 NICE Guidelines Manual. (2012) www.nice.org.uk/article/pmg6/chapter/1%20introduction (accessed 31/10/2014). Google Scholar11 Pressure ulcers overview. NICE Pathways 2014. pathways.nice.org.uk/pathways/pressure-ulcers (accessed 22/06/2014). Google Scholar12 Pressure ulcer prevention, treatment and care. NICE Information for the public 2014. www.publications.nice.org.uk/pressure-ulcer-prevention-treatment-and-care-ifp179 (Accessed June 2014). Google Scholar FiguresReferencesRelatedDetailsCited ByDevelopment of customized support for the prevention of Pressure Ulcer (PU) using multi-materials printingJournal of Physics: Conference Series, Vol. 1969, No. 1Pressure injury prevalence and predictors among older adults in the first 36 hours of hospitalisation8 August 2019 | Journal of Clinical Nursing, Vol. 28, No. 21-22Development and validation of the pressure ulcer management self‐efficacy scale for nurses21 April 2019 | Journal of Clinical Nursing, Vol. 28, No. 17-18Pressure heel ulcers in patients with type 2 diabetes: Is it T.I.M.E. to customise wound bed preparation according to different heel areas?17 April 2018 | International Wound Journal, Vol. 15, No. 5Support surfaces for treating pressure ulcers11 October 2018 | Cochrane Database of Systematic Reviews, Vol. 2018, No. 10References and Further Reading3 September 2018Large‐Scale Hospital Mattress Switch‐Out Leads to Reduction Hospital‐Acquired Pressure Ulcers: Operationalization of a Multidisciplinary Task Force8 March 2018 | Worldviews on Evidence-Based Nursing, Vol. 15, No. 3Pressure injuries in intensive care: What is new?Intensive and Critical Care Nursing, Vol. 45Pressure ulcers in critically ill patients – Preventable by non-sedation? A substudy of the NONSEDA-trialIntensive and Critical Care Nursing, Vol. 44Secondary Assessment of Life-Threatening Conditions of Older Patients9 September 2017Cicatrização de úlceras por pressão com extrato Plenusdermax® de Calendula officinalis L.Revista Brasileira de Enfermagem, Vol. 69, No. 2Spinal cord injury5 March 2016Spinal cord injury5 March 2016 2 April 2015Volume 24Issue 4ISSN (print): 0969-0700ISSN (online): 2052-2916 Metrics History Published online 8 April 2015 Published in print 2 April 2015 Information© MA Healthcare LimitedPDF download

Pressure-ulcer reduction using low-friction fabric bootees.

At St Helens and Knowsley Teaching Hospitals NHS Trust, implementation of pressure management measures has reduced the incidence of hospital-acquired pressure ulcers. There is now a focus on those pressure ulcers still occurring despite these measures, particularly grade 2 ulcers on the heel, which are often attributed to friction and shear. During 2012 and 2013 low friction fabric bootees (Parafricta®) were used on at-risk patients (where possible) to attempt to address this issue. The bootees were first introduced in 2012. There was a decline in heel ulcers of 78% in the 2 years, which accounted for a sizeable portion of the overall decline in all grade 2 pressure ulcers. There was also a substantial change in the ratio of heel to all other grade 2 pressure ulcers, which fell from 0.67 to 0.24. On the basis of heel pressure ulcers avoided, there is an implied net saving to the NHS. The trust concluded that routine use of low-friction fabric bootees made a significant further contribution towards achieving zero harm targets and had done so while providing substantial cost benefits.

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

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.

Changes in classifications of chronic lower-limb wound codes in patients with diabetes: ICD-9-CM versus ICD-10-CM.

To enhance the learner's competence with knowledge of changes in classifications of chronic lower limb wound codes from ICD-9-CM to ICD-10-CM in patients with diabetes. This continuing education activity is intended for physicians and nurses with an interest in skin and wound care. After participating in this educational activity, the participant should be better able to:1. Identify the upcoming transition date and coding differences of ICD-9-CM and ICD-10-CM coding.2. Interpret the author's study population, methods, and design.3. Summarize the author's study findings comparing ICD-9-CM coding to ICD-10-CM coding. To determine the sensitivity and specificity of International Classification of Diseases, Ninth Edition, Clinical Modification (ICD-9-CM) and ICD-10-CM codes for individuals with diabetes and foot ulcers. Wound care providers and researchers are concerned about the potential impacts when the United States transitions from ICD-9-CM to ICD-10-CM. To identify the impact on diabetic foot ulcers, health history and wound variables were prospectively assessed with criterion-standard data from a prospective study of 49 patients with 65 foot ulcer episodes representing 81 incident foot ulcers. The ICD-9-CM and ICD-10-CM code sets were mapped to correctly classify individuals with diabetes and foot ulcers. Frequencies for health history variables were similar in both systems. The ICD-9 code did not capture any data on laterality (left or right) or ulcer depth/severity. The ICD-9 captured 69 of 81 incident ulcers (85%) and 94% of heel and midfoot ulcers, whereas the ICD-10 code captured 78 of 81 incident ulcers (96%) and all incident heel or midfoot ulcers. Sensitivity and specificity for ulcer characteristics were consistently lower in ICD-9 than in ICD-10. The ICD-9 and ICD-10 are similar for data capture on health history variables, but wound variables are captured more accurately using ICD-10. The increased specificity of ICD-10 for ulcer location and severity improves identification and tracking ulcers during an episode of care.

The effects of heel-elevated total contact insole on rearfoot pressure reduction in heel injury patients who had neurosensory impairment after receiving reconstructive flap operations

To evaluate the effects of a custom-molded heel-elevated total contact insole (TCI) on rearfoot pressure reduction and heel cushion for patients with heel-reconstruction. Eleven patients with unilateral heel-reconstruction were recruited in this study. Maximal force and plantar pressures (peak pressure and pressure-time integral) at three different areas (heel Midfoot and forefoot) were measured under 3 randomized conditions (shoe-only flat insole and heel- elevated TCI) after wearing a heel-elevated TCI for 3 months. Ulceration inspection and pain intensity were evaluated before and 3 months after wearing a heel-elevated TCI Results: Pain intensity was decreased and walking velocity was improved in all patients (p<0.01), and ulcerations were completely healed in all of the five patients who had heel ulcers 3 months after wearing heel-elevated TCIs. Compared to shoe-only condition, the heel-elevated TCI was effectively reduced maximal force and plantar pressures in heel area (p<0.01) while part of the body weight was shifted from heel to midfoot and forefoot. Plantar pressures in heel area were more effectively reduced in the heel-elevated TCI than in the flat insole (p<0.05). These findings suggested that heel-elevated TCI provided more effective heel pressure reduction and shock absorption, and resulted in improvement of clinical symptoms.

The biomechanical efficacy of dressings in preventing heel ulcers

The heels are the most common site for facility-acquired pressure ulcers (PUs), and are also the most susceptible location for deep tissue injuries. The use of multilayer prophylactic dressings to prevent heel PUs is a relatively new prevention concept, generally aimed at minimizing the risk for heel ulcers (HUs) through mechanical cushioning and reduction of friction at the dressing-support interface. We used 9 finite element model variants of the posterior heel in order to evaluate the biomechanical performance of a multilayer dressing in prevention of HUs during supine lying. We compared volumetric exposures of the loaded soft tissues to effective and maximal shear strains, as well as peak stresses in the Achilles tendon, without any dressing and with a single-layer or a multilayer dressing (Mepilex® Border Heel-type), on supports with different stiffnesses. The use of the multilayer dressing consistently and considerably reduced soft tissue exposures to elevated strains at the posterior heel, on all of the tested support surfaces and when loaded with either pure compression or combined compression and shear. The aforementioned multilayer design showed (i) clear benefit over a single-layer dressing in terms of dissipating tissue strains, by promoting internal shear in the dressing which diverts loads from tissues; (ii) a protective effect that was consistent on supports with different stiffnesses. Recent randomized controlled trials confirmed the efficacy of the simulated multilayer dressing, and so, taken together with this modeling work, the use of a prophylactic multilayer dressing indicates a great promise in taking this route for prevention.

A Novel and Alternative Treatment Method for Diabetic Heel Ulceration Exposing the Calcaneus Which Is Not Suitable for Flap Surgery: Vacuum Assisted Sandwich Dermal Matrix.

Background. Currently, free flaps and pedicled flaps are the first treatment choices for large heel ulcer reconstruction. However, flap reconstruction of heel ulcerations cannot be performed in all diabetics especially with concurrent severe peripheral vascular disease because of higher flap failure rate. In recent years, the use of acellular dermal matrix (ADM) has emerged as an alternative treatment option for extremity ulcers. Methods. We present 13 diabetic patients with a large heel ulceration exposing the calcaneus, who were not eligible for flap surgery due to the presence of only one patent artery of trifurcation. These cases were treated with the vacuum assisted sandwich dermal matrix (VASDEM) method. Results. None of the patients required amputation. Skin grafting was successful in ten patients. Although partial losses were observed in three patients, they were healed spontaneously without surgical interventions. During the follow-up period none of the patients developed ulceration on the treatment area. All patients maintained their preoperative ambulatory ability. Conclusion. VASDEM is a novel method offering opportunity for treatment before proceeding to amputation in diabetic heel ulceration exposing the calcaneus which is not suitable for flap surgery. It also has the potential to close wounds of all sizes independent of the vessel status and wound size in selected diabetic patients.

Preserve the lower limb in a patient with calcaneal osteomyelitis and severe occlusive peripheral vascular disease by partial calcanectomy

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. We report a case of 76-year-old man with hypertension, diabetes mellitus, and end-stage renal disease in uremia status presented to our hospital with a 3-month history of a diabetic foot ulcer on his right heel. He was diagnosed with near total artery occlusion below the knee at the local hospital, and vascular reconstruction failed. After admission, surgical debridement was performed with subsequent partial calcanectomy facilitating wound closure without tension. After surgery, the foot was immobilized with a short-leg splint for 2 weeks. Thereafter, ankle immobilization was accomplished using a thermal protective plastic splint and cast shoes with a posterior window for wound care. The wound healed well with no recurrence during the 12-month follow-up period, and the patient may return to an ambulatory status, including a normal gait pattern. In this case, we demonstrate that the partial calcanectomy is practical for the treatment of plantar heel ulcers in a patient 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.

Lower extremity function following partial calcanectomy in high-risk limb salvage patients.

Partial calcanectomy (PC) is an established limb salvage procedure for treatment of deep heel ulceration with concomitant calcaneal osteomyelitis. The purpose of this study is to determine if a relationship exists between the amount of calcaneus removed during PC and the resulting lower extremity function and limb salvage outcomes. Consecutive PC patients were retrospectively divided into two cohorts defined by the amount of calcaneus resected before wound closure: patients in cohort 1 retained = 50% of calcaneus, while patients in cohort 2 underwent resection of >50% of the calcaneus. The Lower Extremity Function Scale (LEFS) was used to assess postoperative lower extremity function. The average amount of calcaneus resected was 13% ± 9.2 (1–39%) and 74% ± 19.5 (51–100) in cohorts 1 and 2, respectively (P < 0.0001). Below knee amputation was performed in 7 (28%) and 5 (29%) of subjects in cohorts 1 and 2, respectively (P = 1.0). The average LEFS score was 33.9 ± 15.0 for subjects in cohort 1 and 36.2 ± 19.9 for the subjects cohort 2 (P = 0.8257) which correlates to “moderate to quite a bit of difficulty.” Our study suggests that regardless of the amount of calcaneus resected, PC provides a viable treatment option for high-risk patients with calcaneal osteomyelitis.

Evaluation of lightweight fibreglass heel casts in the management of ulcers of the heel in diabetes: study protocol for a randomised controlled trial.

BackgroundUlcers of the heel in diabetes are the source of considerable suffering and cost. In the absence of specific treatments, it has been suggested that removable, lightweight fibreglass heel casts may both promote healing and reduce discomfort and pain. The aim of the study is to assess the effectiveness and cost-effectiveness of fibreglass heel casts in the management of heel ulcers.Methods/DesignThis is an observer-blind, randomised controlled trial in which participants with diabetes and heel ulcers (NPUAP/EPUAP grades 2, 3 or 4 and present for 2 or more weeks) are randomised to receive either usual care plus lightweight fibreglass heel casts or usual care alone. Randomisation is undertaken by random number sequence generation incorporated as part of the electronic case record form, and is stratified by both ulcer area (less than versus equal to or greater than 1 cm2) and NPUAP/EPUAP grade. Participants are followed every two weeks until healing or for 24 weeks. The primary outcome measure is healing at or before 24 weeks and maintained for 4 weeks. Secondary outcomes include (i) ulcer-related outcomes: time to healing, change in ulcer area, minor and major amputation, secondary infection and (ii) patient-related outcomes: local pain, mood and function (EQ-5D), impact of the ulcer (Cardiff Wound Impact Schedule) and survival. Cost-effectiveness will be assessed using a decision analytic model to estimate costs from the perspective of the UK NHS and personal social services and health outcomes, including percent healing and Quality Adjusted Life Years gained.Safety will be documented as adverse and serious adverse device effects.DiscussionIf it is possible to confirm significant clinical benefit and/or cost-effectiveness, this would have direct implications for the management of this distressing and costly complication of diabetesTrial registration numberISRCTN62524796 Registered 29 March 2011

Influence of the calcaneus shape on the risk of posterior heel ulcer using 3D patient-specific biomechanical modeling.

Most posterior heel ulcers are the consequence of inactivity and prolonged time lying down on the back. They appear when pressures applied on the heel create high internal strains and the soft tissues are compressed by the calcaneus. It is therefore important to monitor those strains to prevent heel pressure ulcers. Using a biomechanical lower leg model, we propose to estimate the influence of the patient-specific calcaneus shape on the strains within the foot and to determine if the risk of pressure ulceration is related to the variability of this shape. The biomechanical model is discretized using a 3D Finite Element mesh representing the soft tissues, separated into four domains implementing Neo Hookean materials with different elasticities: skin, fat, Achilles' tendon, and muscles. Bones are modelled as rigid bodies attached to the tissues. Simulations show that the shape of the calcaneus has an influence on the formation of pressure ulcers with a mean variation of the maximum strain over 6.0 percentage points over 18 distinct morphologies. Furthermore, the models confirm the influence of the cushion on which the leg is resting: a softer cushion leading to lower strains, it has less chances of creating a pressure ulcer. The methodology used for patient-specific strain estimation could be used for the prevention of heel ulcer when coupled with a pressure sensor.

Addition of a kickstand to unilateral external fixators

Traumatic fractures, ligamentous injuries, and dislocations of the lower extremities often require two-staged protocols with initial external fixation and delayed internal fixation. Bone stability, joint congruency, and decreased swelling of the surrounding soft tissue are achieved prior to definite fixation. Unilateral (also known as monolateral) or bilateral external fixators can be used for temporary fixation depending on the character and stability of the fracture. The heel is vulnerable to pressure. Patients in intensive care units who have multiple fractures with severe traumatic head and brain injury, including compromised protective reflexes as well as diabetic trauma patients are at risk for pressure-related heel ulcers. Here we describe a modification of a unilateral external fixator for lower extremity injuries by adding a kickstand to prevent heel ulcers. This modification not only reduces ulcers, their complications, and related treatment costs but also improves the outcome for the patient.

Malignant Melanoma Presenting as a Nonhealing Heel Ulceration

Malignant melanoma is responsible for more than three-fourths of skin cancer deaths in the United States. Melanomas presenting on acral surfaces are frequently misdiagnosed initially, leading to progression of disease and worse prognosis. This case is presented to reinforce the significance of careful physical examination and early biopsy of atypical ulcerations of the foot.

Commentary on “‘Real Angiosome’ Assessment from Peripheral Tissue Perfusion Using Tissue Oxygen Saturation (StO2) Foot-mapping in Patients with Critical Limb Ischemia”

When choosing the target vessel for revascularization of an ischaemic foot, common clinical practice and recent guidelines, for example TASC-II, favour grafting of the “best vessel” that crosses the ankle. Although this strategy will most often offer the best run off for the graft or the endovascular reconstruction, it may not offer the best perfusion of the ischaemic area or the best chance of wound healing or limb salvage. As an example, 15% of heel ulcers do not heal even in the presence of a patent bypass graft to the dorsal pedal artery. In common with the rest of the body, the foot can be divided into a number of three-dimensional blocks of tissue, each with its own feeding artery and venous drainage, the so-called “angiosomes”. Plastic surgeons have identified small calibre vessels (“choke vessels”) between the angiosomes. Ligation of a feeding artery to an angiosome induces hyperplasia and dilatation of “choke vessels” from the neighbouring angiosomes to form functional collaterals. In this way, larger reconstruction flaps can be harvested in a later operation. In the ischemic foot, however, “choke vessels” are not recruited in a reproducible manner and the collaterals formed between the angiosomes are not always reliable. A number of recent retrospective comparisons have documented faster wound healing and better limb preservation after direct revascularization of the relevant angiosome than is the case after indirect revascularization of another angiosome. Particularly in patients with microangiopathy due to diabetes or nephropathy, connections between neighbouring angiosomes of the foot are sparse. Even in the absence of randomized trials, it seems fair to argue that current evidence leans towards the position that, when possible, the angiosome-specific artery should be chosen for revascularization rather than just the “best vessel”. This would also bring the practice of peripheral vascular surgery into line with that of other surgical specialities, for example coronary bypass surgery and plastic surgery.

A study of prognostic factors in Chinese patients with diabetic foot ulcers.

ObjectiveFew studies have identified factors as predictors of clinical prognosis of patients with diabetic foot ulcers (DFUs), especially of Chinese patients. In this study, we assessed the prognostic factors of Chinese patients with DFUs.Methods and materialsThis was a retrospective study (January 2009–January 2011) of 194 DFUs conducted in an inpatient population at PLA 454 Hospital in Nanjing, China, to determine the prognostic influential factors of DFUs in Chinese patients. All of the studied patients were grouped into an amputation group, a non-healing group, and a cured group, according to the clinical prognosis. Patient parameters, including gender, age, smoking habits, education level, family history of diabetes mellitus, medical history, duration of foot lesions and complications, ankle-brachial index (ABI), transcutaneous oxygen pressure (TcPO2), urinary albumin/creatinine ratio (Alb/Cr), fundus oculi, electrocardiogram, DFU characteristics, bacterial nature, and neuropathy, were cross-studied among the three groups.ResultsCompared with the other two groups, the amputation group showed a higher number of males, older in age, lower ABI and TcPO2 levels, higher Wagner wound grading and size, and significantly higher urinary Alb/Cr ratio, blood urea nitrogen, serum creatinine, white blood cell count, and erythrocyte sedimentation rate. Compared to the cured group (162 patients), more patients with an older age, smoking, family history of diabetes mellitus, medical history of foot ulcerations, lower ABI and TcPO2 levels, higher urine Alb/Cr ratio, and serum creatinine were found in the non-healing group. Regression analysis was used to study the correlation between various factors and clinical prognosis, and the results were as follows: age, Wagner wound classification, and heel ulcerations were negatively correlated to the DFU prognosis, whereas the female population, ABI, and TcPO2 were positively correlated with DFU prognosis.ConclusionIn this retrospective study, we conclude that the DFU prognosis may be related to age, gender, wound location (heel), Wagner wound classification, ABI, and TcPO2 levels in the Chinese population.

Older adults with heel ulcers in the acute care setting: frequency of noninvasive vascular assessment, surgical intervention, and 1-year mortality.

To examine how often hospitalized older adults with a diagnosis of heel ulcers are evaluated with noninvasive vascular tests and to determine the impact of invasive vascular or surgical procedures on 1-year mortality. Retrospective review using an electronic database and chart review of all patients discharged with a diagnosis of heel ulcer between 2006 and 2009. Urban teaching hospital. A total of 506 participants aged 65 years and older. Data collected included resident characteristics (demographics, medical history, and severity of illness using the Charlson comorbidity index), staging of heel ulcers, rates of noninvasive vascular assessments, vascular and surgical procedures, length of stay, and 1-year mortality. Thirty-one percent (155/506) of patients with a heel ulcer underwent noninvasive vascular testing and of these 83% (129/155) were found to have underlying ischemia. Twenty-six percent (130/506) of patients underwent at least 1 vascular or surgical procedure. The 1-year mortality rate for patients with stage 1 or 2 disease was 55%; this rose to 70% for patients with stage 3 or 4 ulcers (P = .01), and could not be explained by differences in the Charlson comorbidity index. Patients who underwent a vascular or surgical procedure had a significantly lower mortality compared with those who did not (59% vs 68% P = .04). Older adults with a heel ulcer in the acute care setting are frequently not assessed for underlying ischemia of the lower extremities. The diagnosis carries high 1-year mortality rates. Evidence-based protocols need to be developed to determine which older adults should have a vascular assessment and then undergo an invasive procedure.