Heel ulcers / Calc osteo discussion

[janV88]

This has been on my mind for a while and I figured it's a good topic to discuss on here.

From my limited experience, it seems like heel ulcers almost never have good outcomes. What do you guys do in your respective institutions? What have you seen that works? And what have you all seen surgically/non surgically for calc osteo?

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[ldsrmdude]

This has been on my mind for a while and I figured it's a good topic to discuss on here.

From my limited experience, it seems like heel ulcers almost never have good outcomes. What do you guys do in your respective institutions? What have you seen that works? And what have you all seen surgically/non surgically for calc osteo?

Yeah, heel ulcers are problematic from what I've seen as well. It's tough to generalize all heel ulcers, but depending on the patient, we've done calcanectomies with primary closure, total contact casting, BKA. Obviously a partial or total calcanectomy with primary closure isn't a great choice for a lot of patients, but we've done it for bedbound patients with decubitus heels ulcers +osteo. On the right patient, I think a debridement of the calc with some sort of a flap like a reverse sural artery flap is a reasonable choice if there's osteo. We do quite a few total contact casts and have had some decent success with heel ulcers, but the biggest issue, I think, isn't healing the ulcer but preventing it from recurring. Depending on what caused the ulcer, it's tough to offload the patients long-term.

 

[janV88]

My program treats these similarly to what you guys have mentioned. Pretty much local wound care/offloading. Once calc osteo sets in we recommend BKA if the wound doesn't heal. We've tried a partial calcanectomy once recently. Pretty much told the patient that this was a last ditch effort. Unfortunately the patient passed due to other issues so we haven't seen how these work out in ambulatory patients. Anyone have any experience with partial calcanectomy on ambulatory patients?

 

[ldsrmdude]

My program treats these similarly to what you guys have mentioned. Pretty much local wound care/offloading. Once calc osteo sets in we recommend BKA if the wound doesn't heal. We've tried a partial calcanectomy once recently. Pretty much told the patient that this was a last ditch effort. Unfortunately the patient passed due to other issues so we haven't seen how these work out in ambulatory patients. Anyone have any experience with partial calcanectomy on ambulatory patients?

We have a patient who I saw a few days ago who had a partial calcanectomy a few weeks ago. He's ambulatory in an offloaded CAM boot. Wound is healing nicely at this point. I think in the right patient it's reasonable to try a partial calcanectomy and either try to close the wound primarily or let it heal by secondary intention. With them being ambulatory, they'll need to be compliant with whatever offloading method you prefer.

 

[dyk343]

FHL transfer? Except now you have a ff ulcer.

 

[zane870]

We have some attendings that will at least attempt calcanectomies or partials. Most of the time though, it's an instant ortho consult.

 

[I post PRN]

We attempted a calcanectomy on a pt a few months ago....they are bilateral BKA now. Pt population sucks.

 

[PeaJay]

While I have limited experience, I think this could be an interesting read for the topic at hand.
http://www.ncbi.nlm.nih.gov/pubmed/?term=22835723
http://www.ncbi.nlm.nih.gov/pubmed/?term=22835723

 

[dyk343]

Vascular consult, external frame (Thought I would throw a new idea out there) vs TCC for complete offloading. Long term Abx. Cross fingers.

Once healed need to prevent re-occurrence.

.....+1 for PRAFO and true decubitus ulcers. Do Prevlon boots really help??? I've used them and was less than impressed. No real improvment in my limited experience.

....For calcaneal gait: http://www.ncbi.nlm.nih.gov/pubmed/20557812

...If Immobile calcenectomy vs BKA

Any other thoughts, opinions, treatments?

 

[AttackNME]

While I have limited experience, I think this could be an interesting read for the topic at hand.
http://www.ncbi.nlm.nih.gov/pubmed/?term=22835723

Steinberg mentioned at DFcon that being aggressive and taking more bone (i.e. near-total calcanectomy) did a little better than those where less bone were resected. He argued that he would also purposefully detach the Achilles tendon and just let it fly, he's had multiple patients have post-op fractures of the calc after resecting the plantar cortex and leaving the Achilles attached. The patients are then obligated to an AFO. He's working on publishing his series.

 

[PeaJay]

I look forward to reading Steinberg's finding and patient series.

I think the aggressive nature of bone resection in the mentioned article was more of a necessity for primary closure. The different flap techniques based on defect location provides an game plan on how to salvage an at risk extremity with better healing via primary closure.