Osteomyelitis And Heel Ulcers: What You Should Know

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Author(s): 
Eric J. Lullove, DPM, CWS

   In its online guidelines on refractory osteomyelitis treatment, the Undersea and Hyperbaric Medical Society (UHMS) notes that HBOT delivery ordinarily occurs with daily treatments of 90 to 120 minutes at 2.0 to 3.0 ATA, starting soon after surgical debridement and continuing for four to six weeks.16 The UHMS notes that this recommendation is based on best clinical practice and there are no randomized clinical trials to support it.16 However, the substantial majority of available animal data, human case series and non-randomized prospective trials suggest that adding HBOT therapy to routine surgical and antibiotic management of osteomyelitis is safe and improves the ultimate rate of infection resolution. As antibiotics and other traditional weapons against these worrisome microscopic invaders begin to weaken, HBOT provides a vital backstop.

Pertinent Insights On Surgical Management Of Calcaneal Osteomyelitis

When conservative management fails or the infection within the calcaneus is grossly beyond the point of conservative care, surgical management is necessary to resolve the infection and preserve the extremity. The partial calcanectomy with resection of all non-viable tissue and bone is necessary to ensure limb preservation.

   When doing perioperative planning for a partial calcanectomy, patient and family education are paramount. One should state that the procedure is a “salvage” procedure and that below-knee amputation may still occur in the future. Further debridements may also be necessary and one should explain this to the patient and/or the patient’s family.17

   Direct the surgical approach as a linear-posterior or posterior-medial orientation. Alternatives can include a hockey-stick, posterior-lateral approach, which gives extensive exposure. Ensure prone positioning of the patient for the procedure. If there are anesthesia concerns, the patient should be in a lateral recumbent position with vacuum beanbag positioning.18

   When planning the incision, make sure the flaps of skin are in full thickness. Do not undermine the subcutaneous tissues. Handle the skin gently with minimal use of retraction. Avoid using a tourniquet in these cases as the healthy bleeding tissue serves as a guide during the surgical resections. Detach the Achilles tendon and resect any non-viable portions. It is important to retain the length of the Achilles for the reattachment procedure.

   Remove the posterior calcaneus at an angle consistent with a posterior-proximal to plantar-distal axis, removing all non-bleeding bone. When performing a partial calcanectomy, it is useful to combine power and hand instrumentation.19 The total amount of bone removed is usually one-half to two-thirds of the calcaneal body but one will determine this by the extent of the clinical presentation and infectious process. Surgeons may apply antibiotic beads directly to the open medullary bone as local antibiosis after resecting the posterior calcaneus.

   In the past, polymethylmethacrylate (PMMA) beads were in use and had to be removed from patients. Additionally, while commercial formulations of PMMA beads are available outside the United States, they currently are not available within the United States, leaving the hospital pharmacies or podiatric surgeons to produce their own formulation.20 Clinicians may combine commercially available PMMA cements and antibiotic powder to form a liquid-like substance. Then they place this substance into molds or hand roll it in the operating room to form beads.

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