Cath Lab Digest

Diabetic heel ulcers are particularly challenging to treat as a wide range of factors can affect potential healing. With this in mind, this author discusses the challenges of wound bed preparation, key considerations with offloading and the possible impact of peripheral arterial disease.

   Despite a better understanding and the advent of preventive measures that have been developed to address heel ulcers, the problems we encounter due to complications of diabetes make treating this specific patient population more challenging.

   The problem of heel ulcers will increase in conjunction with our increasing diabetic and aging population. The prevalence of heel ulcers across settings is high and continues to increase. In hospitalized patients, it ranges between 10 to 18 percent. Heel ulcers continue to be prevalent after patients are discharged.¹

   Researchers have shown that diabetic foot ulcers correlate with multiple co-morbidities and an increased mortality. They often serve as a barometer of a patient’s health in general and correlate with a decrease in mobility and independence. Heel ulcers are often the precursor to hospitalization, osteomyelitis, lower extremity amputation and death. Diabetic patients with foot ulcers have a higher rate of surgical intervention (97 percent versus 85 percent) and amputation (71 percent versus 63 percent) than non-diabetic patients with heel ulcers.²

   Although heel ulcers are less frequent than forefoot ulcers, higher expenses and higher morbidity rates are associated with heel ulcers. Researchers have estimated that heel ulcers are one and one-half times more expensive to treat and are two to three times less likely to heal in comparison to metatarsal ulcers.²

   Also keep in mind that heel ulcers are not strictly the result of a deep tissue injury resulting from pressure alone. Peripheral arterial disease (PAD), lymphedema, neuropathy, connective tissue disorders and malignancies are just some of the complicating factors and etiologies we encounter when it comes to managing heel ulcers that can be exacerbated by the underlying presence of diabetes.

   The frustration of discovering the onset of a new heel ulcer reflects the understanding that an extensive and often complicated course of intensive treatment awaits the unfortunate patient. From a medicolegal perspective, heel ulcers are a nightmare for hospitals, extended care facilities and providers as the formation of a heel ulcer carries an implication of negligence, abuse or overall poor quality of care. The addition of diabetes puts a patient at a greater risk for developing a heel ulcer. Once a heel ulcer is present in a patient with diabetes, it can be an event that ultimately leads to amputation or death.

   While prevention is critical and diligence in the utilization of preventative measures must be ongoing, heel ulcers are still an unfortunate but permanent reality in healthcare.

   A working knowledge of pressure (decubitus) ulcer classification is all well and good, but understanding how to manage the Stage l through the Stage lV ulcer is critical.

   What do you do when you have been consulted to manage a heel ulcer? What happens when a heel ulcer develops in a patient who is already under your care? What should you know in order to achieve optimal treatment results and successful outcomes in a scenario that typically is already suboptimal with the proverbial deck being “stacked against you?” What can you do to protect yourself in the course of managing a patient with a diabetic heel ulcer?

   Accordingly, let us take a closer look at the treatment of heel ulcers complicated by diabetes and its complications.