Our expert panelists expound on the treatment of pressure ulcers, including the use of calcanectomies, nutritional supplements and negative pressure wound therapy (NPWT).
Do you routinely perform partial or subtotal calcanectomies for severe heel ulcers?
David Armstrong, DPM, PhD, MD, routinely performs calcanectomies, most often combining them with some element of vascular intervention. He has found that using indocyanine green angiography, such as the Spy Elite (Novadaq), is effective. Dr. Armstrong says the efficacy of this imaging technique is important because for some patients, even those with palpable pulses, there exists what he calls “orphan heel syndrome,” in which a localized island of ischemia can hamper healing. This is particularly true in people with renal disease. However, for many patients, he notes one should not consider a high-level amputation a failure if it helps to reduce complexity in care.
Kazu Suzuki, DPM, CWS, actively advocates using a partial calcanectomy as a limb-preserving procedure, an alternative to below-knee (BKA) and above-knee amputations (AKA), for a severe heel pressure ulcer (stage 3-4) with or without calcaneal osteomyelitis. After performing a partial or even a subtotal calcanectomy, he has found that patients can ambulate reasonably in most cases as long as they receive appropriate shoe gear and braces, such as a custom heel filler and/or custom ankle foot orthotics (AFOs). Dr. Suzuki believes that calcanectomy procedures are much less traumatic and disfiguring than major amputation procedures such as a BKA or AKA.
Ronald Sage, DPM, only performs a partial calcanectomy in cases of significantly exposed or infected bone. If the patient does not have the adequate circulation and nutritional status to support healing, he provides only local wound care and antibiotic suppression as needed. If he cannot control the infection in badly compromised patients, Dr. Sage will consult orthopedics or the peripheral vascular service for a possible transtibial or higher amputation.
Do you recommend any nutritional supplements (such as protein shakes)?
“I am a big believer in ‘you are what you eat,’ especially when it comes to wound care and pressure ulcer prevention,” says Dr. Suzuki.
As Dr. Suzuki notes, the most recent pressure ulcer guideline recommends that patients with pressure ulcers should be “offered high-protein mixed oral nutritional supplements and/or tube feeding, in addition to the usual diet.”1 He adds this recommendation has an “A” grade for strength of evidence, according to the 2009 National Pressure Ulcer Advisory Panel guidelines.1
Dr. Suzuki asked a local Abbott Nutrition rep to supply his wound care center with product samples and brochures with coupons so all of his patients get education on protein supplements. If a patient is anemic or hypoalbuminemic, Dr. Sage will obtain a nutrition support consultation.
“It may not be appropriate to simply load up a patient on supplements if diabetes is not well controlled or in cases of renal disease,” cautions Dr. Sage. “The nutrition support team or a qualified dietician will take all these factors into account before determining appropriate supplementation.”
Dr. Suzuki recommends his patients have three regular meals along with two protein supplemental drinks per day. He has found that some people like milkshake flavors (Ensure, Abbott Nutrition), while others may prefer Tang-like fruit drink flavors (Juven, Abbott Nutrition). For patients with diabetes, he recommends a low-sugar formula (Glucerna shake, Abbott Nutrition) or Juven. Dr. Suzuki will also routinely prescribe Juven twice a day for patients in the hospital recovering from surgeries.
Dr. Armstrong and his colleagues have just finished a large, multinational randomized study. He says the results seem to suggest that robust oral supplementation may help those who need it most: those with albumins less than 4 (which is the case with most of his admissions) and with ankle brachial indices less than 0.9.
Dr. Suzuki does not recommend vitamin supplements. He says the evidence is not clear enough that vitamin supplements help wound healing or pressure ulcer prevention although he wouldn’t make patients stop taking them. On the other hand, Dr. Suzuki does recommend probiotic supplements for all of his wound patients, especially if they are on antibiotics, as the supplements may help in boosting the immune functions while preventing C. difficile and other antibiotic-associated diarrhea.
What kind of dressing do you use for pressure ulcers?
Dr. Armstrong has a “vertical” and “horizontal” philosophy for wound healing. He and his colleagues will treat exposed bone or hardware (i.e. the vertical component) most frequently with NPWT. Dr. Armstrong says the next step is to resolve the horizontal component either with split thickness skin grafting, which is often his first option, or bioengineered tissue to facilitate healing by secondary intention.
Dr. Suzuki likes to use foam dressings (Mepilex, Molnlycke). He says they are soft and provide a little of bit of protection against friction and pressure. If his patients have a swollen limb along with pressure ulcers, Dr. Suzuki may apply a multilayer compression bandage (such as Comprifore, BSN Medical) to add more layers and cushioning to the wounded area while reducing the leg edema.
After cleansing the wound, Dr. Sage dresses pressure ulcers with simple gauze or alginates. He will also use protective offloading devices, such as a Prevalon boot (Sage Products).
In what kind of situations do you use NPWT?
For any deep wounds that need assistance in building up granulation tissue in the wound bed, Dr. Suzuki would order NPWT (Vacuum Assisted Closure, KCI) right away. He will also prescribe NPWT for exposed bones or tendons and fascia, noting that one will want to cover those structures with granulation tissue as soon as possible, granted that one has ruled out osteomyelitis or osteomyelitis is under appropriate treatment with antibiotics. Dr. Suzuki also uses NPWT in the operating room after applying split-thickness skin grafts or performing a complex flap procedure.
Dr. Sage uses NPWT after a calcanectomy when there is a large defect to fill.
Do you have any other pearls for the care of patients with pressure ulcers?
Dr. Sage emphasizes that offloading is the key to preventing and healing pressure wounds. “No amount of advanced wound care products, surgery or revascularization will work if the pressure is not relieved,” he advises.
When one sees multiple pressure ulcers on one patient, Dr. Suzuki says it is a clear sign that either patients’ nutrition intake is not catching up with their metabolism or that they are suffering from major organ failures.
“This does not mean you should give up on them but we should be aware of these frail patients and provide them with appropriate protection (heel boots and air bed) as well as appropriate palliation with palliative wound care, hydration and pain control,” says Dr. Suzuki.
For some patients who are unlikely to walk — even around the house — Dr. Armstrong suggests asking yourself, “What are our goals?” He notes that “a decided minority” of patients are better off not with an expensive therapy but often just with what he refers to as “wound hospice.” Additionally, he notes some patients may benefit from an amputation earlier rather than later.
“Much of this depends not on the surgeon and not on the technology,” emphasizes Dr. Armstrong. “It depends on listening to the patient.”
Dr. Armstrong is a Professor of Surgery and the Director of the Southern Arizona Limb Salvage Alliance (SALSA) at the University of Arizona College of Medicine in Tucson, Ariz.
Dr. Sage is a Professor and the Chief of the Section of Podiatry at the Department of Orthopaedic Surgery and Rehabilitation at the Loyola University Stritch School of Medicine in Maywood, Ill.
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. He can be reached via email at Kazu.Suzuki@CSHS.org .
1. National Pressure Ulcer Advisory Panel Guidelines, 2009. Available at http://www.npuap.org/ .