Pertinent Treatment Insights On Heel Ulcers

In a discussion of treating heel ulcers, these expert panelists expound on factors that influence treatment, offer insights on offloading and appropriate debridement, and review possible surgical options.

Q:

What are the key patient characteristics to weigh when considering the best treatment option for heel ulcers?

A:

Heel ulcers are most common in patients with limited mobility and significant medical comorbidities, notes John S. Steinberg, DPM. He says the focus should first be on determining the cause of the wound and this is likely followed by a need for offloading of pressure. Similarly, Kazu Suzuki, DPM, CWS, focuses on the heel ulcer’s history and the patient’s ability to adhere with heel offloading measures, which he calls the most important component in healing heel ulcers.

When dealing with heel ulcers, Lawrence Karlock, DPM, advises considering patient characteristics such as whether the ulcer is infected or just contaminated. He also suggests evaluating the appearance of the wound, if necrotic eschar is present and how the patient’s lower limb contractures, if any, play a role in the cause of the ulceration.

Barbara Aung, DPM, first determines the goal of treatment. She questions if the case is one for palliative care, maintenance and prevention of infection. She notes this is something physicians often consider for patients who may be in hospice or in a long-term care facility. In these cases, Dr. Aung says one may not be expecting to heal the wound due to extenuating circumstances of the patient’s health status and/or the patient’s personal medical directives.  

However, if the goal is complete healing, then Dr. Aung says clinicians should consider a variety of factors before making the final decision in concert with the patient for the plan of care. She notes these factors include family or social support if patients are home and taking care of their own wound. She advises considering if the patient will actually be able to adhere to the treatment plan or offloading plan. Dr. Aung also suggests considering if the patient will be able to afford supplies or if the insurance plan will cover the cost of supplies or provide home health nursing services.

Dr. Steinberg very often will take patients with heel ulcers to the operating room for surgical debridement, exploration and deep cultures, or possible bone biopsy. Once he really knows what he is dealing with, Dr. Steinberg will consider conservative care versus a partial calcanectomy. As he notes, the advantage of a partial calcanectomy is that one can often create local flaps, which can have primary closure at the time of surgery.

Of utmost importance is the arterial vascular inflow, according to Dr. Karlock.

“The question becomes: does this patient have enough vascular inflow to heal this ulcer with conservative treatment?” he notes.

Dr. Suzuki does not modify his treatment plan for heel ulcers from any other wounds. He still recommends a routine wound check and debridement (either weekly or every two weeks) along with non-adherent dressings to maintain the moist wound environment.  

Q:

What are the most effective methods of offloading heel ulcers and how does one encourage adherence?

A:

Adherence is the key to effective offloading, according to Dr. Aung. As she notes, one may give the patient an offloading option with instructions to follow, but if the patient does not have the ability to adhere or cannot follow this method of care for financial reasons, then adherence will be compromised.  

Dr. Suzuki also cites the importance of adherence and says patient education is the key.

“When I see my patients with heel ulcers, I make it abundantly clear to the patient (and to his or her caregiver as well) that the heel ulcer will never heal if (he or she) cannot ‘float’ and offload the heel effectively,” says Dr. Suzuki. He also informs patients they will require surgical interventions (either partial calcanectomy or below-the-knee amputation) if the infection reaches the heel bone and the wound infection is becoming a life-threatening situation.  

Dr. Steinberg uses Prevalon Heel Protectors (Sage Products), foam/cushion boots that fasten to the leg/foot with Velcro. Dr. Karlock also cites the efficacy of Prafo ankle-foot orthoses (Anatomical Concepts) and the Prevalon boots. In his experience, Dr. Karlock has found the Prevalon boots more effective in adherence in comparison with some other offloading devices.

Dr. Suzuki notes the Prafo boot has a solid sole and a metal brace so patients can walk on it with the boot on, but it may be more uncomfortable due to the rigidity of the device. He says Prevalon boots or related devices are much softer and patients tolerate them better, but they are not appropriate for ambulation as they do not have any sole grippers. Dr. Suzuki often prescribes both boots, noting that his patients need Prafo boots for transfer and in-house ambulation purposes, but Prafo boots may be too uncomfortable to wear during sleep.

Often, Dr. Aung will suggest offloading heel ulcers by placing pillows under the ankles to “float the heels.” If patients can’t sleep this way, Dr. Aung says another approach is for patients to keep their heels off the end of the bed, again floating the heels. The basics, she notes, are to prevent any pressure on the skin when sleeping, sitting or even sitting in a wheelchair — let alone walking — to prevent further tissue damage. Not all offloading methods work well for every patient, says Dr. Aung. Dr. Karlock agrees, noting the importance of judicious nursing care. He concurs that floating of the feet under pillows in a bedridden patient is effective.

In contrast, Dr. Steinberg has found elevation on pillows to be a very unreliable form of offloading. Dr. Suzuki concurs, saying the “pillow under calf” method is not generally recommended as it is very easy for the pillow to become displaced as the patient tosses and turns. As a caveat to using pillows to offload, Dr. Aung has to remind patients and their caregivers that in the middle of the night, things may shift and patients have to readjust as soon as they realize there is excessive pressure building up.

In ambulatory patients, Dr. Karlock encourages the use of walker crutches, wheelchairs or walker boots as well as Charcot restraint orthotic walkers (CROW) to encourage offloading of the plantar ulcers. Dr. Aung advises considering a knee walker or roller device if the patient is physically capable of using this device. She says there are also ankle foot orthotic (AFO)-type devices that may assist the patient in offloading the heel when walking but Dr. Aung notes the patient may need a walker for balance when using this type of device.  

Dr. Steinberg notes one can consider surgical offloading with a kickstand-type external fixator in severe cases.

Ultimately, the majority of heel ulcers are preventable and Dr. Karlock says it can only take up to four hours for an ischemic limb to develop skin breakdown.

Q:

In your experience, what are the most effective treatment strategies for heel ulcers?

A:

The most important factor in treating heel ulcers is offloading, according to Dr. Suzuki. He interviews the patient, caregivers and the family to ensure the patient is indeed wearing the offloading boots 24/7 (except for bathing) without fail.

As Dr. Aung says, often it is difficult to allow the patient’s own body to heal the ulcer. Offloading is the key to preventing further tissue breakdown and she says one should remove necrotic tissue to prevent infection.

Dr. Aung advises against aggressive debridement of heel wounds. If there is eschar that tightly adheres to the wound surface, she recommends leaving the eschar in place. Dr. Aung says one can score the eschar and apply collagenase (Santyl, Smith and Nephew) to help break down the eschar with local normal saline. She also advocates the use of foam or gauze type dressings, changing daily or every two days, depending on the setting for care.  

“The main goal for me is to cover any exposed viable deeper structures, such as fascia, tendon and bone, as quickly as possible,” says Dr. Aung.

Dr. Karlock has found debridement of the overlying eschar is effective with either topical collagenase-type products or surgical debridement. He thinks moist wound healing in the majority of heel ulcers is appropriate to help promote granulation. If the wound is stagnant but not infected, Dr. Karlock will apply a skin graft substitute to try to expedite closure of these wounds.

If the eschar is fluctuant and/or there is purulent material present, and/or the patient is showing signs of sepsis, Dr. Aung says immediate “aggressive” debridement is necessary to remove necrotic tissue. If the bone is exposed after debridement, she will often apply Omnigraft (Integra LifeSciences) to cover the bone and prevent further invasion of contamination, and continue to offload. Dr. Aung says clinicians may use other products, such as cadaver dermal matrices, to accomplish this.

“The quicker these wounds can be closed, the better chance of the wound being saved,” says Dr. Karlock.

After making a proper diagnosis, debridement and offloading, Dr. Steinberg considers conservative care versus a partial calcanectomy. Dr. Suzuki would consider a partial calcanectomy if the patient has a large heel eschar or calcaneal osteomyelitis due to a chronic heel ulcer. He would excise the heel ulcer with an elliptical incision, removing one-half to one-third of the posterior aspect of the calcaneus, and close the wound using the flap closure technique.

Dr. Suzuki may consider major leg amputation if the patient is developing sepsis and the infected heel is becoming a life-threatening situation. If the patient is severely ischemic with no means of further vascular intervention or, more simply, if the affected limb is severely painful, he notes a possible indication for leg amputation.

However, Dr. Suzuki cautions surgeons not to rush into surgical intervention. He cites a study by Marston and colleagues on palliative care, noting that 50 percent of patients who had palliative wound care actually healed within one year.¹ Dr. Suzuki emphasizes that physicians should not give up on palliative wound patients and be diligent in local care, but have a long-term perspective as well.

“As many of our wound patients with heel wounds tend to be old, frail or otherwise chronically ill, we need to have an understanding that the wound healing process may take many months or years, or sometimes it could become a lifetime condition that requires meticulous and palliative local wound care,” says Dr. Suzuki.

Dr. Aung is in private practice in Tucson, Ariz. She is a Certified Professional Medical Auditor and member of the American Academy of Professional Coders. She is also a panel doctor at Carondelet St. Mary’s Advanced Wound and Hyperbaric Center in Tucson. Dr. Aung serves on the examination committees for both the American Board of Wound Management and the American Board of Podiatric Medicine. Dr. Aung is a member of the APMA Coding Committee.   

Dr. Karlock practices in Austintown, Ohio. He is a Clinical Instructor with the Ohio Podiatric Residency Program of the ValleyCare Health System of Ohio in Youngstown, Ohio.

Dr. Steinberg is a Professor at the Georgetown University School of Medicine and is the Podiatric Residency Program Director at MedStar Washington Hospital Center.

Dr. Suzuki is the Medical Director of the Tower Wound Care Centers 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 at Kazu.Suzuki@cshs.org.

Reference

1.    Marston WA, Davies SW, Armstrong B, et al. Natural history of limbs with arterial insufficiency and chronic ulceration treated without revascularization. J Vasc Surg. 2006; 44(1):108-14.