Key Pearls On Treating Pressure Ulcers
These expert panelists discuss how to offload pressure ulcers in the heel and ankle, which patients are at high risk for pressure ulcers and whether one should debride dry heel eschar.
What is your offloading device of choice for heel and ankle pressure ulcers?
Nicholas Giovinco, DPM, emphasizes that offloading an ambulatory patient poses a great challenge. While total contact casts work well, Dr. Giovinco says they require regular maintenance and replacements. In addition, he notes that sturdy, removable devices designed for offloading in ambulatory patients can sometimes cause new ulcers on other parts of the foot due to the hard nature of the construct (such as steel or carbon fiber).
Both Kazu Suzuki, DPM, CWS and Desmond Bell, DPM, CWS emphasize the importance of determining whether the patient is ambulatory. If the patient is ambulatory, Dr. Suzuki says he or she would benefit from a rigid PRAFO boot (Anatomical Concepts) that enables some extent of ambulation. If the patient is completely or mostly bedridden, he always prefers soft heel floating boots. Dr. Suzuki says they are more comfortable than the standard PRAFO boots and one can expect better patient adherence.
Dr. Suzuki’s institution uses Prevalon boots (Sage Products), giving a pair to every admitted patient with heel pressure ulcers or high-risk patients. He says the boots are washable if they get soiled.
In addition, Dr. Suzuki notes a new kind of “hybrid” boot combines rigid PRAFO boots and soft heel offloading boots, citing the development of soft heel offloading boots with sole traction pads. He says Heelift boots (DM Systems) are an example.
“It may be a nice alternative to having a pair of both rigid and soft boots,” suggests Dr. Suzuki.
Dr. Bell also prefers using devices such as the Heelift for the patients who are at the greatest risk for developing pressure ulcers or as part of the offloading protocol in patients with existing heel and ankle ulcers. Ideally, he says the ulcers should “float” within the selected device and the device should be soft with material construction that will prevent additional shearing.
When offloading pressure ulcers of the heel and/or ankle, Dr. Bell also considers the status of the wounds (as far as showing clinical improvement) as well as vascular status, condition of the surrounding skin, the presence of infection and nutritional status.
While splint devices that are characterized by a rigid outer frame and a soft inner lining may be appropriate for more ambulatory patients, Dr. Bell says the hard material of the frame can create new areas of pressure in the minimally or non-ambulatory patient.
Dr. Suzuki cautions that using a regular pillow to elevate the heels is “just not good enough” with the current standard of care in pressure ulcer treatment. He says the pillows often do not stay in place longer than a few hours.
For Dr. Giovinco, applying padded heel protection appliances over the dressings works well. He notes these devices are characteristically “oversized” in appearance and Velcro often holds them in place. Although there are several devices that work suitably, Dr. Giovinco says not many of them offload ambulatory patients without increasing their risk of falling.
Noting that some of the newer devices show promise in diverting pressure, he says they can require custom fitting. The success of that application depends upon the workmanship of the orthotist and other factors, according to Dr. Giovinco.
Who are the patients at high risk of pressure ulcers in the foot and ankle?
Dr. Bell advises that patients with diabetes, peripheral vascular disease, poor nutrition, a history of vasculitic disease, prior ulceration, geriatric structural deformity of the foot or ankle, or immobility from virtually any cause are at risk for developing pressure ulcers. Patients with a neurological condition such as paralysis, spasticity, foot drop, flaccidity or contracture deformity are also at risk.
For Dr. Suzuki, any patient who is temporarily immobilized or weakened can be at high risk for pressure ulcers. He finds the major risk factor to watch for is Parkinson’s disease as patients with the disease often cannot initiate the motion to reposition themselves.
“I have seen the worst case of heel pressure ulcers in such a patient,” recalls Dr. Suzuki.
In addition, Dr. Suzuki considers as high risk any post-surgical patients, intensive care unit patients, comatose patients or post-dialysis patients. He also watches patients of extreme age (90 and over) as they tend to have fragile skin with a small amount of lean muscle mass to protect themselves from pressure ulcers.
Dr. Giovinco says both extremes of patient activity lead to the highest risk for developing pressure ulcers. He notes that patients who work in manual labor or have a particularly active lifestyle will sustain wounds related to repetitive moderate stress while patients who are bed- or chairbound will often develop pressure sores on the posterior heel and malleoli.
“The patients who have the worse prognosis are unfortunately the ones that are neglected,” argues Dr. Giovinco. “Many nursing homes and care facilities are either not trained or staffed to perform regular surveillance of high-risk areas and these wounds are discovered after development.” To that end, he and his colleagues are working to develop inexpensive technologies that can monitor and prevent those problems in the future.
How do you determine if you should debride dry heel eschars (unstageable heel ulcer)?
“This is a huge point of debate within the wound care community,” notes Dr. Suzuki.
Knowing the etiology of the unstageable ulcer is the first thing to consider, advises Dr. Bell. He adds that the presence of peripheral arterial disease is extremely important. If the posterior tibial artery is occluded, Dr. Bell notes the blood supply to the heel is compromised as the calcaneal branch off the posterior tibial artery is unable to supply the skin at the heel adequately. As he points out, this is based not only on anatomy but the angiosome concept.
Dr. Suzuki advocates defining a clear goal of therapy as in curative versus palliative therapy. If the patient is truly debilitated with minimal chance of returning to ambulation, he may decide to go with palliative care. By painting the heel eschar with a Betadine swab and letting it dry, one would simplify wound care for the patient and the caregivers, notes Dr. Suzuki. He also uses a medical-grade honey dressing (Medihoney, Derma Sciences), which gently debrides most wounds.
If the patient is unlikely to return to any level of function or is terminal, Dr. Bell says the goal is protection of the site to prevent further breakdown or infection. As he points out, eschar is really the body’s response to injury and is a protective dressing in a sense. If demarcation of the eschar is present, especially at the periphery of the eschar, Dr. Bell says serial debridement can be beneficial. When eschar is no longer dry and any fluctuance or underlying infection is visible, Dr. Bell says one should consider more aggressive debridement.
On the other hand, if he expects the patient to recover fully with a fair amount of ambulation, Dr. Suzuki will debride the eschar aggressively in the operating room and be prepared to repair the tissue defect, most likely with negative pressure wound therapy, a muscle flap or a partial calcanectomy.
Dr. Giovinco notes blood flow is the most important factor when performing elective debridement. Even with good blood flow to the posterior tibial and peroneal arteries, he says the angiosome distribution to the posterior heel may be “orphaned” nonetheless. As Dr. Giovinco notes, recent imaging technology, such as the SPY indocyanine green angiography (Novadaq) have provided impressive visualization of the perfusion to areas of the foot and ankle.
If the wound is unstageable and closed, Dr. Giovinco would favor allowing the wound to resolve independently with padding protection for as long as possible. If one decides to intervene physically, he has found regular debridement and subsequent application of enzymatic collagenase dressings produce good results.
“Something to remember with pressure sores is that they take a longer time to resolve than many other types of wounds. It is not at all unusual to be working with these patients for many months,” says Dr. Giovinco.
Dr. Bell is a board-certified wound specialist of the American Board of Wound Management and a Fellow of the American College of Certified Wound Specialists. He is the founder of the “Save a Leg, Save a Life” Foundation, a multidisciplinary, non-profit organization dedicated to the reduction of lower extremity amputations and improving wound healing outcomes through evidence-based methodology and community outreach.
Dr. Giovinco is an Assistant Professor in the Department of Surgery at the University of Arizona. He is the Director of Education with the Southern Arizona Limb Salvage Alliance.
Dr. Suzuki is the Medical Director of the Tower Wound Care Center at the Cedars-Sinai Medical Towers. He is also on the medical staff of the Cedars-Sinai Medical Center in Los Angeles and is a Visiting Professor at the Tokyo Medical and Dental University in Tokyo. Dr. Suzuki can be reached via e-mail at Kazu.Suzuki@CSHS.org .