Heel pressure ulcers can be particularly challenging for podiatric physicians, given the risk of complications, offloading challenges and the compromised vascular status of high-risk patients. Accordingly, our expert panelists share their perspectives in providing wound care for these patients.
Q: How do you dispense offloading devices for pressure ulcers of heels?
A: Kazu Suzuki, DPM, CWS, considers factors such as the patient’s weight, sensory perception (neuropathy), activity level and mobility level, as well as skin perfusion pressure (SPP). Richard Brietstein, DPM, CWS, also recommends checking the perfusion to the lower extremity. If the patent has been hospitalized recently, Dr. Suzuki checks the patient’s medical records for Braden Scale scores, which list the clinically validated risk level for developing pressure ulcers.
For example, if the patient is at low risk of developing such ulcers, is relatively light, mobile and has good protective sensation, this patient may do fine with a few pillows under the calf and verbal instructions on offloading, according to Dr. Suzuki. If a patient has good perfusion and some mobility, Dr. Brietstein dispenses a foam waffle boot or a L’Nard splint (LaMed). Caroline E. Fife, MD, says L’Nard splints are the only splints she uses because “they completely offload the heel.”
If patients are obese, immobile and bedridden, Dr. Suzuki notes they will require more rigid “ankle brace”-like offloading devices, such as a Pressure Relief Ankle Foot Orthosis (PRAFO), to suspend the heels completely off the bed. Alternately, a softer foam-based boot, like Heelift (Alimed) or a Rooke boot, may be more comfortable and acceptable to more patients, according to Dr. Suzuki.
When it comes to patients with poor perfusion and little or no mobility, Dr. Brietstein tends to stay away from dispensing any offloading device with straps, which may cause other areas of increased pressure that may lead to tissue breakdown. Accordingly, with these patients, he will most likely order pillows beneath the calves to offload the heels.
Q: How about the local wound care of heel pressure ulcers? Do you treat these ulcers any differently than wounds with other etiologies?
A: Dr. Fife says one should not debride a stable, uninfected eschar on the heel or anywhere on the foot until one has performed a vascular assessment to determine whether the patient is able to heal the wound. In this respect, heel ulcers are very different from wounds on other areas of the body, according to Dr. Fife. In other body areas, she says it is typical for a physician to see an eschar and start to debride it immediately. However, when it comes to heel pressure ulcers, she says it is common for physicians to leave eschars in place and even paint them with Betadine to keep them dry.
Dr. Brietstein advises that one should consider all of the parameters in the algorithm that contribute to good wound care outcomes. However, with this particular subset of patients, perfusion, nutritional status and the presence of infection play pivotal roles in the capacity to heal wounds. Accordingly, Dr. Brietstein says he “would temper (his) aggressiveness.” If an individual has poor nutrition and poor perfusion, Dr. Brietstein treats that patient conservatively via enzymatic debriding agents or possibly Betadine solution.
“I would not surgically debride these patients for fear of creating a larger non-healing wound, which could possibly lead to limb loss,” explains Dr. Brietstein. He says it is critical to facilitate appropriate consults to ensure optimal nutrition for these patients.
When it comes to the care of patients with pressure heel ulcers, Dr. Suzuki suggests establishing the therapeutic goal at the outset of treatment. Are you looking to provide curative/rehabilitative care or palliative/comfort care? On the other hand, if the patient is very old, very ill or has been non-ambulatory for a long time, Dr. Suzuki strives for pain relief rather than a clinical cure.
If the patient is ambulatory with good rehabilitation potential, Dr. Suzuki treats the wound aggressively. Once he has resolved the offloading issues, he performs an arterial perfusion study, a SPP and Pulse Volume Recording (PVR) test to rule out ischemia. He then aggressively debrides the wound, including the Achilles tendon or calcaneus if they appear necrotic. If the tendon or calcaneus is exposed, Dr. Suzuki uses negative pressure wound therapy (VAC therapy, KCI) to aid in the development of granulation tissue. Dr. Suzuki then applies a skin graft or skin substitute to facilitate final wound closure.
Dr. Suzuki does not believe in the concept of “auto-amputation,” which is leaving the gangrenous toes indefinitely, hoping the body will demarcate the necrotic toe and let the toe fall off. “I consider these gangrenous toes as open wounds, and I prefer swift toe/partial foot amputation to achieve wound closure, given the perfusion is adequate,” concludes Dr. Suzuki.
Q: How do you approach “palliative” wound care of heel pressure ulcers for terminally ill and bedridden patients?
A: Dr. Brietstein routinely orders albumin and prealbumin levels. He empirically starts the patient on zinc sulfate 220 mg daily, vitamin C 500 mg daily and a multivitamin with minerals, and routinely calls for a nutritional consult. For these patients, Dr. Brietstein says he is “extremely conservative,” using enzymatic debriding agents, hydrocolloids and Betadine solution in the presence of eschars.
For a patient who is truly terminal and non-ambulatory, or if the patient or family opts out of aggressive wound care, Dr. Suzuki may advocate palliative wound care. His palliative regimen consists of applying Betadine to “dry out” and temporize the heel eschar. Alternately, he says one may apply a hydrogel or hydrocolloid a few times a week to debride the heel eschar in a painless autolytic manner.
“Palliative care does not mean giving up on the patient,” clarifies Dr. Suzuki. “We would still provide offloading to minimize the pain and keep the pressure ulcers from becoming worse. We would also give adequate analgesics, even if the patient would not or could not verbalize his or her wound pain.”
Dr. Fife concurs. She discusses with the patient and family what the patient’s care will entail. As she notes, palliative care is directed at pain and infection control. With these patients, Dr. Fife says the goal is not necessarily healing per se but more of a focus on comfort and a reduction in the risk of infection. She usually uses topical antimicrobials to control infection. Dr. Fife says one must take an aggressive approach toward treating pain.
Q: Do you have any other pearls on heel pressure ulcers?
A: For any heel pressure ulcer patients, Dr. Suzuki ensures the patients undergo assessment, with the help of primary care physicians and wound/ostomy/ continence nurses, for pressure ulcers in other areas of the body (shoulders, hips, buttocks, etc.). If these patients have ulcers in other areas, Dr. Suzuki says they may need prescription wheelchair cushions, mattresses and/or bed overlays.
When patients with diabetes, particularly those with peripheral neuropathy or leg ischemia, are hospitalized, Dr. Suzuki takes extra caution to monitor their heels. He has found it may only take a few days of hospitalization for these high-risk patients to develop full-thickness ulcers.
As Dr. Fife notes, the key to caring for heel pressure ulcers is knowing the patient’s vascular status. If patients have adequate vascular status, she says they are candidates for any aggressive interventions in your armamentarium. In her clinical experience, Dr. Fife has found negative pressure wound therapy effective when one uses it after the debridement of heel pressure ulcers.
If patients do not have adequate vascular status, “then all your interventions are doomed to fail,” emphasizes Dr. Fife.
“You might end up just prolonging the inevitable (an amputation), creating unrealistic expectations for the family and increasing the likelihood of the development of osteomyelitis.”
She adds that heel pressure ulcers represent a significant litigation risk for wound care clinicians because they can result in amputation.
Dr. Fife emphasizes that one must assess vascular status early on in the evaluation of the patient. She says the patient and the family should have a clear understanding of the vascular situation and the likely outcome of the ulcer from the first visit.
When it comes to patients with heel ulcers, Dr. Brietstein’s philosophy consists of directing treatment conservatively unless the patient is well perfused, has osteomyelitis or advanced soft tissue infection, which could lead to sepsis.
Dr. Brietstein is a Clinical Professor in the Department of Geriatrics at Nova Southeastern College of Osteopathic Medicine in Davie, Fla. He is the Clinical Director of the University Hospital Wound Healing Center in Tamarac, Fla. He is a member of the Editorial Advisory Boards of WOUNDS and Ostomy/Wound Management.
Dr. Fife is an Associate Professor in the Department of Medicine, Division of Cardiology at the University of Texas Health Science Center in Houston. She is the Director of Clinical Research at the Memorial Hermann Center for Wound Healing and Hyperbaric Medicine.
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, Japan.