Essential Insights On Treating Pressure Ulcers

Author(s): 
Clinical Editor: Kazu Suzuki, DPM, CWS

Our expert panelists expound on the treatment of pressure ulcers, including the use of calcanectomies, nutritional supplements and negative pressure wound therapy (NPWT).

Q:

Do you routinely perform partial or subtotal calcanectomies for severe heel ulcers?

A:

David Armstrong, DPM, PhD, MD, routinely performs calcanectomies, most often combining them with some element of vascular intervention. He has found that using indocyanine green angiography, such as the Spy Elite (Novadaq), is effective. Dr. Armstrong says the efficacy of this imaging technique is important because for some patients, even those with palpable pulses, there exists what he calls “orphan heel syndrome,” in which a localized island of ischemia can hamper healing. This is particularly true in people with renal disease. However, for many patients, he notes one should not consider a high-level amputation a failure if it helps to reduce complexity in care.

   Kazu Suzuki, DPM, CWS, actively advocates using a partial calcanectomy as a limb-preserving procedure, an alternative to below-knee (BKA) and above-knee amputations (AKA), for a severe heel pressure ulcer (stage 3-4) with or without calcaneal osteomyelitis. After performing a partial or even a subtotal calcanectomy, he has found that patients can ambulate reasonably in most cases as long as they receive appropriate shoe gear and braces, such as a custom heel filler and/or custom ankle foot orthotics (AFOs). Dr. Suzuki believes that calcanectomy procedures are much less traumatic and disfiguring than major amputation procedures such as a BKA or AKA.

   Ronald Sage, DPM, only performs a partial calcanectomy in cases of significantly exposed or infected bone. If the patient does not have the adequate circulation and nutritional status to support healing, he provides only local wound care and antibiotic suppression as needed. If he cannot control the infection in badly compromised patients, Dr. Sage will consult orthopedics or the peripheral vascular service for a possible transtibial or higher amputation.

Q:

Do you recommend any nutritional supplements (such as protein shakes)?

A:

“I am a big believer in ‘you are what you eat,’ especially when it comes to wound care and pressure ulcer prevention,” says Dr. Suzuki.

   As Dr. Suzuki notes, the most recent pressure ulcer guideline recommends that patients with pressure ulcers should be “offered high-protein mixed oral nutritional supplements and/or tube feeding, in addition to the usual diet.”1 He adds this recommendation has an “A” grade for strength of evidence, according to the 2009 National Pressure Ulcer Advisory Panel guidelines.1

   Dr. Suzuki asked a local Abbott Nutrition rep to supply his wound care center with product samples and brochures with coupons so all of his patients get education on protein supplements. If a patient is anemic or hypoalbuminemic, Dr. Sage will obtain a nutrition support consultation.

   “It may not be appropriate to simply load up a patient on supplements if diabetes is not well controlled or in cases of renal disease,” cautions Dr. Sage. “The nutrition support team or a qualified dietician will take all these factors into account before determining appropriate supplementation.”

   Dr. Suzuki recommends his patients have three regular meals along with two protein supplemental drinks per day. He has found that some people like milkshake flavors (Ensure, Abbott Nutrition), while others may prefer Tang-like fruit drink flavors (Juven, Abbott Nutrition). For patients with diabetes, he recommends a low-sugar formula (Glucerna shake, Abbott Nutrition) or Juven. Dr. Suzuki will also routinely prescribe Juven twice a day for patients in the hospital recovering from surgeries.

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