Managing The Recalcitrant Calcaneal Wound

Guy R. Pupp, DPM, FACFAS, and Anthony LaLama, DPM

Although calcaneal ulcers complicated by osteomyelitis can seem destined for amputation, judicious multidisciplinary management can save a limb. These authors review key risk factors and potential complications, assess treatment options including the subtotal calcanectomy, and emphasize the merits of multidisciplinary care with a compelling limb salvage case study.

Recurrent ulcerations of the heel with osteomyelitis, diabetes and neuropathy present a challenge to the wound care specialist. Due to the poor nature of the soft tissue envelope with prolonged soft tissue inflammation and fibrosis complicated many times by neuropathy, osteomyelitis is often present in these patients.

   Our patient population consists of many patients suffering from obesity with motor and sensory neuropathy, which allows quick transitions from a superficial dermal lesion to a deep tissue, limb-threatening infection. It has been our observation that wound care specialists do not refer these challenging patients to an experienced limb salvage surgeon in a timely manner. We feel that many times in spite of the best wound care, the plantar calcaneal ulcer will progress to an “emergency situation” consisting of septicemia and/or major amputations. The outlook for amputation of the contralateral limb and decreased survival rates as well as the increased energy requirements and inability to ambulate without the aid of assistive devices makes amputation an undesirable option for many patients.

   Heel ulcers in patients with diabetes are usually difficult to treat and are a clinical challenge. Pressure in the heel area combined with neuropathy in patients with diabetes favors the development of extensive wounds. Weightbearing pressure and the paucity of vessels in the heel pad area delay the healing process when ulcers develop.

   There are multiple studies that claim heel ulcers in diabetic feet often lead to amputations.1-3

   The heel is the greatest weightbearing part of the foot and if one does not manage heel lesions properly, they can lead to sepsis, osteomyelitis, amputation and significant disability.

   Recent studies have shown a lower amputation rate in patients with infected diabetic foot lesions by using multidisciplinary team approaches.4-5 There are few studies focused on the management of heel ulcers leading to limb preservation.6-7
The eventual goal is to preserve a limb that enables a patient to walk with or without a brace, and to live without imposing on caregivers.

What You Should Know About Heel Ulcer Complications

The incidence of heel ulcers is quite prevalent within the healthcare system. An estimated one in five patients who are hospitalized will develop decubitus heel ulcers.8-9 In fact, pressure ulcers of the heel are the second most common type of pressure ulcer behind the sacral decubitus ulcer and these decubitus heel ulcers comprise 19 to 32 percent of pressure ulcers. Sixty percent of these heel ulcers develop in an acute setting such as a hospital ICU. Detection of these heel ulcers is somewhat delayed with 54 percent detected at stage 2.8

   The staging of these ulcers, along with any other type of ulcer, is critically important for the treatment regimen and in communication with other specialties that are incorporated in the team approach of healing the ulcers. Staging of ulcers helps guide the podiatric physician on the initial presentation as well as the progression or regression of the ulcers. The classification system currently recognized by the National Pressure Ulcer Advisory Panel (NPUAP) is below at left.

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