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Keys To Addressing Posterior Heel Ulceration
How do you achieve optimal offloading? How do you address deeper ulcers with exposed bone and tendon? What are the best preventive strategies? Answering these questions and more, this author shares pearls from her clinical experience and emerging insights from the literature on managing posterior heel ulcerations.
Posterior heel ulcerations are commonly associated with prolonged bed rest but can also be secondary to wound complications after Achilles or posterior calcaneal surgery.1,2 Pressure ulcers at the posterior heel may be due to prolonged pressure, friction or shear. Distortion of tissues will result in ischemia and subsequent skin breakdown if the ulcer does not get relief.3
Pressure ulceration at the heel is very common and several studies have looked at the possible reasons for this. Arao and colleagues theorized that tissues at the posterior heel may be susceptible to ischemia due to high metabolic demand for oxygen by the epidermis and the arrangement of adipose tissue in an elliptical fashion, which is perpendicular to the skin, causing deep lesions if excessive force is concentrated there.4 Sopher and coworkers found that strain and stress on the fat pad of the posterior heel were reduced if the foot was positioned at 90 degrees to the bed in comparison with 60 degrees, the normal resting position when a patient is laying in a supine position.5 With the foot at 90 degrees, the majority of cushion at the posterior heel is against the bed, which could result in less risk for posterior heel ulceration.
Physicians can prevent ulceration in hospitalized patients first by determining pressure ulcer risk and then implementing simple strategies to reduce pressure on the heels of those at risk. The Braden Scale traditionally determines pressure ulcer risk but does have some limitations.6,7 It looks at six risk factors associated with pressure ulceration, including immobility, activity, friction/shear, moisture, nutrition and sensation. The most important risk factors may be neuropathy and reduced mobility. However, comorbidities such as peripheral arterial disease (PAD) and diabetes could be additional risk factors specific to posterior heel ulceration.8-9
Preventive strategies for posterior heel ulceration include:
• specialty mattresses;
• regular turning of patients unable to turn themselves;
• heel offloading with pillows or heel offloading boots;
• education of patients on self-mobilization in and out of bed if patients are capable; and
• reduction of friction/shear and moisture control.10-13
There is no consensus on what heel offloading boots might be more effective than others for pressure ulcer prevention/treatment. Junkin and Gray recommended that the boots keep the heel elevated while reducing friction and shear, avoiding dropfoot and abduction, and that they remain in place without causing undue pressure to other parts of the foot.13 In a pilot study, Hosking and colleagues noted that offloading boots contoured to the heel and made of polyurethane foam, rather than the use of planar surfaces for offloading, were the most beneficial for alleviating pressure at the posterior heel.14
Getting A Full Picture Of Patient Comorbidities And Ulcer Severity
There are conservative and surgical options for treatment of posterior heel ulceration dependent on the severity of the ulcer as well as patient comorbidities. We can stage ulcers based on depth with Stage I and II ulcers involving the skin, Stage III ulcers entering the fat layer and Stage IV ulcers exposing muscle, tendon or bone.15
It is important to assess the patient fully to identify any contributing factors such as poor diabetes control, nutritional deficiency or PAD, which might contribute to delayed healing or non-healing of the ulcer.16 Evaluate serum albumin and pre-albumin to determine nutritional status in patients with ulcers. Adequate nutrition including protein, vitamin C, vitamin A and zinc is required to aid wound healing.3
The posterior tibial artery is the main arterial supply to the posterior heel with the posterior branch of the peroneal artery providing a minor component.17 Despite this, researchers have demonstrated that revascularization via bypass to the dorsalis pedis artery leads to improved circulation at the posterior heel and improved healing rates independent of an intact pedal arch.18
Non-invasive vascular studies are appropriate if one suspects PAD. Radiological studies such as X-ray to rule out osteomyelitis and possibly magnetic resonance imaging (MRI) may be required in the initial assessment of the ulcer. Aerobic and possibly anaerobic cultures are indicated if signs of infection are present. The involvement of other specialties including internal medicine, endocrinology, nephrology, vascular surgery, infectious disease and dietetics, as required, can be helpful in managing comorbidities that could affect healing.
What You Should Know About Conservative Treatment Of Heel Ulcers
Conservative management of posterior heel ulcers (usually Stages I to III) without the presence of osteomyelitis involves: good local wound care including sharp and/or enzymatic debridement of necrotic or fibrous tissue to help achieve a granular base; use of appropriate wound care products to promote healing by keeping the wound moist; and possibly adding collagen or skin equivalents as indicated to speed the healing process.19
A healthy, granular base must be present before attempting the use of skin equivalents. Do not perform sharp debridement more than once weekly and possibly only once every two weeks. In larger wounds, one may utilize negative pressure wound therapy (NPWT), which generally requires a dressing change every 48 hours.
Generally, clinicians should emphasize weekly dressing changes unless heavy drainage is present, which would require more frequent changes. It is necessary to control swelling in the extremity with compression and/or elevation to reduce drainage from the wound and subsequent time to healing.3,20 A Jones compression dressing is a good option for edema control. I use this modality on most of the lower extremity wounds in my practice. Compression may be contraindicated in patients with PAD.
Offloading of the area is critically important in bed or during leg elevation. Pair offloading with frequent turning, specialty mattresses, pillows under calves, allowing the posterior heel to hang free, heel offloading boots and/or felt to foam offloading within a dressing.
When There Are Deeper Wounds Or Osteomyelitis
With deeper wounds exposing tendon or bone, and when osteomyelitis is present (Stage IV), other surgical options may be indicated. In acute cases of osteomyelitis, treatment with intravenous antibiotics may be successful. However, for chronic bone infection or osteomyelitis refractory to antibiotic therapy, a partial calcanectomy may be an option. Patients with PAD will require revascularization, preferably prior to surgical intervention, unless there is severe infection, which would require surgical debridement before revascularization. The MRI studies prior to surgery that identify the extent of osteomyelitis are helpful for determining the amount of bone resection necessary.
One should surgically excise the wound with a margin of good skin. Remove the infected bone and soft tissue, and then flush the area using pulse lavage irrigation. Take cultures at this stage to identify any bacteria that might be left. Antibiotic bead placement may be appropriate. If the surgeon utilizes antibiotic beads, leave the wound open and perform repeat debridement approximately three days later. If cultures taken at the initial surgery are negative, one may perform wound closure over a drain. Repeat irrigation and debridement with antibiotic bead placement may be required to achieve negative cultures. Afterward, wound closure would be appropriate. I take a new culture prior to wound closure and ensure no bacteria are left.
Administer IV antibiotics perioperatively. One can switch to oral antibiotics after the excision of all infected tissue, final cultures are negative and the wound has been closed. Oral antibiotics may be indicated for a time after surgical wound closure even if final culture results from surgery are negative. If complete excision of infected tissue does not happen, IV antibiotics may be required for a longer period and an infectious disease specialist can help in determining appropriate antibiotic treatment.
Pertinent Post-Op Offloading Considerations
Some surgeons utilize external fixation for offloading and/or gradual repositioning of the foot from a plantarflexed to neutral position.21-22 Babiak and colleagues had good long-term functional results in treating diffuse calcaneal osteomyelitis with drilling and implantation of collagen sponges containing gentamicin into the calcaneus, allowing maintenance of the entire bone.23
Depending on the amount of bone resection required, the Achilles tendon insertion might be compromised. Many patients will require bracing after healing of the surgical site to prevent plantar heel ulceration due to loss of the plantarflexory function of the gastrocnemius muscle and subsequent overload at the plantar heel in gait. Patellar tendon bearing braces could be indicated in these patients and these braces can offload up to 85 percent of body weight, in my prosthetist’s clinical experience. An ankle foot orthotic (AFO) or orthotics with an extra-depth shoe may be appropriate in some cases.
When considering surgical options, the surgeon should discuss the final functional result with patients to ensure they have realistic expectations. If the salvaged extremity will not be able to provide the required support for the patient, one may need to consider a higher-level amputation.
A Guide To Wound Closure And Management
Surgical wound closure techniques such as skin grafts or flaps may be options in the absence of bone infection or after partial calcanectomy if there is inadequate skin for primary wound closure. Multiple authors have reported on flap options for coverage of the posterior heel including proximally based sural adipose cutaneous flaps, reverse sural fasciocutaneous flaps, lateral calcaneal V-Y advancement flaps and free flaps.24-28 Adequate circulation is required if one attempts flaps. Consider plastic surgery consultation when flap coverage is indicated unless the primary surgeon has experience with these techniques. Patients with limbs unable to have revascularization or those with more severe infection that could require total calcanectomy may do better with a below-knee amputation for a more functional extremity at a level where they have greater potential to heal.29
When considering wound management, utilize the reconstructive ladder to help determine appropriate options for the patient. The lowest rung would be closure by secondary intention followed by primary closure, delayed primary closure, split-thickness skin grafting, full-thickness skin grafting, tissue expansion, random flaps, axial flaps and free flaps.30
As the level of complexity goes up for wound closure, consider patient factors to help determine the best form of treatment. Sandberg has recommended the use of a plastic surgery compass to help in this determination.31 The four patient factors making up the compass include complexity of the procedure, risk factors specific to the patient, the anatomical problem and personal factors of the patient.
When looking at procedure complexity, identify different options for wound closure appropriate to the condition and compare them to determine if one would provide a better quality or more complete result than another, and if any procedure might prevent utilization of another procedure in the future if required.31 These factors could lead to the choice of one method of treatment on the reconstructive ladder over others.
Identify risk factors intrinsic to the patient including cardiovascular conditions, smoking and mobility restrictions that might affect outcomes of one treatment option over others. Anatomical factors such as the level of complexity and anatomical structures involved may translate into specific preferred procedures on the reconstructive ladder. Patient factors such as adherence, expectations, emotional stability and family support could impact the likelihood of success of one form of treatment over others, and may alter the treatment choices made by the surgeon/provider.
In Conclusion
As with any ulcer, posterior heel ulcerations require a comprehensive approach to treatment. Due to the high incidence of posterior heel pressure ulcers, it is critically important to emphasize prevention so all members of the hospital staff can identify risk factors associated with this form of ulceration as well as methods to prevent it during patient hospitalization. Patients and their families should also receive education on preventive measures to use at home.
Once an ulcer occurs, one must fully evaluate the patient to ensure the identification and treatment of comorbidities that might reduce the ability to achieve wound closure and healing. Order indicated testing to ensure adequate nutrition, ensure necessary circulation available to the area and identify the presence or absence of bone infection. Institute offloading and local wound care immediately. One should involve specialty services as appropriate to manage associated comorbidities. Surgical treatment may be indicated if deep infection exists or surgical wound closure options are available. When patient factors dictate, certain procedures may not be feasible and in some cases, limb salvage is not possible.
Dr. Schweinberger is affiliated with the Veterans Affairs Medical Center in Cheyenne, WY. She is a Fellow of the American College of Foot and Ankle Surgeons.
References
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