Osteomyelitis And Heel Ulcers: What You Should Know

Eric J. Lullove, DPM, CWS

   More recently, there has been expanding use of calcium sulfate-antibiotic impregnated beads for local use in bone. There have been reports in the literature of packing calcium sulfate beads as an antibiotic delivery system within bony defects with good success.21 The use of calcium sulfate beads is off-label and without FDA approval. As with PMMA, the surgeon must mix the antibiotic with the calcium sulfate mixture to create the antibiotic beads. Complete resorption of the beads occurs at six months or sooner, and one can use serial radiographs to follow the progress clinically.

   Sulfate-antibiotic impregnated beads also have the advantage of a more reliable elution profile of antibiotics than traditional PMMA as there is more delivery of the antibiotic in the postoperative period. The antibiotic releases completely over a two- to three-month period with high concentrations detectable for at least four weeks.21

   Reattachment of the Achilles tendon needs to occur under physiological tension. Modalities for reattachment include suture anchors, plain sutures, locking bridge sutures or plating. Closure of the wound can be difficult if tension is present. Primary closure is preferable but in cases in which tension on the tissues is an issue, one may use bolster sutures. Otherwise, the use of negative pressure wound therapy may assist with closure.22

A Guide To Postoperative Care

For initial post-op management, one should apply a Jones compression cast with a posterior splint applied in plantarflexion. Non-weightbearing lasts for a period of six to eight weeks. Inspect the incision and wound weekly and reduce the amount of plantarflexion to more dorsiflexion on a week-to-week basis. Physical therapy is beneficial when the wounds have fully healed. Then the patient can transfer to a pneumatic walking boot.

   Coordinate IV antibiotics with the infectious disease specialist as well as other medical providers for a continual multidisciplinary approach. One should leave grossly infected wounds open or treat them with negative pressure wound therapy, routinely re-debriding them as necessary. Vascular surgery consultations are critically important for these patients given the need to heal rapidly. These patients are in high-risk populations and have multiple comorbidities that can derail your surgery, and prospectively place the patients in less tenable positions that may require higher level amputation, further debridement or longer-term antibiotic coverage.

In Conclusion

Understanding the complex nature of calcaneal osteomyelitis and its effect on the outcome of care in patients are of profound importance. A team approach is absolutely necessary in order to have positive outcomes for patients. These patients are high risk and require substantial perioperative evaluations regarding their history. There is no current medical literature that determines when it is appropriate to treat osteomyelitis alone medically and when to initiate surgical treatment. A comprehensive patient-oriented approach will help to determine the course of treatment. Acting decisively, whether through medical or surgical means, can facilitate beneficial outcomes in these difficult to treat patients.

   Dr. Lullove is in private practice in Boca Raton, Fla. He is a Fellow of the American College of Clinical Wound Specialists.

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