by Al Kline, DPMP^1TP

Podiatry Internet Journal 2 (3):1

Plantar heel ulcers are common in the diabetic patient. Very often, the ulcers can become chronic and resistant to closure through conservative means. A case is presented describing the presentation, clinical work up and surgical management to promote closure of the plantar heel ulcer. The Midas Rex pneumatic burr is used to perform a plantar calcaneal saucerization and promote rapid closure of a chronic ulcer.

The Plantar heel ulcer is a problematic condition seen in the podiatric practice. It has been shown that dynamic pressure to at least 170 mmHg does not compromise tissue mechanical properties as much as static, or decubital pressure. [1] In the heel, since the skin is over a bone, cyclic and static pressures increase. This is also variable on the amount of fat pad protection in the area. When tissue function is compromised, interstitial fluid is disrupted, capillaries burst and lymphatic failure can occur, leading to ulcers through the skin. [1] Many times, early intervention and conservative care including debridement, off-loading and proper accommodation, can prevent ulcers.

There is also an increased incidence in reported heel ulcer encounters in hospital settings. [2,3] Many times, this is a complication of bed rest without the initiation of proper heel protection when patients are admitted. It is now our standard practice to place all high risk patients in heel protectors in the hospital setting.

Complicated ulcers will often lead to osteomyelitis of the calcaneus. Partial calcanectomy in the treatment of osteomyelitis is a common procedure. In the absence of bone infection, a limited calcanectomy still remains a viable option for surgery to promote closure of a persistent, draining ulcer. There are times when a patient can present after months or even years of antibiotic treatment, wound care and home health care and the ulcer simply will not close.

The large fat pad of the plantar heel can serve as an ideal medium for infection and abscess formation when the heel ulcerates plantarly. Although drainage procedures are an option in the treatment of plantar ulcers, many times infections can sequester and persist in the soft tissue. Cases such as these will contribute to a tremendous increase in the cost of healthcare. A case is presented that describes the need for surgical intervention after unsuccessful treatment of a heel infection after almost an entire year of antibiotics, wound care and home health care.

Case Presentation

A 70-year old female patient presented to us in November with a sinus-type ulceration to the bottom of the left heel. She had been undergoing local wound care and debridement by a podiatrist for the past year. Her wound care included local packing with plain gauze. She stated the ulceration began insidiously last year and she began seeking treatment in January 2006. She denied fever or chills.

FIGURE 1  This is a chronic heel ulcer with local cavitation and abscess formation superficial to the os calcis.  There is surrounding hemorrhagic keratosis.

FIGURE 2  There is purulent drainage on palpation.  This ulceration has been treated for over a year with antibiotics and local wound care.

Clinically, there was an open ulceration and surrounding hemorrhagic keratosis. (Fig. 1) There appeared to be cavitation of the ulceration with expression of purulent drainage. (Fig. 2) On probing, it did not appear to probe to the os calcis. She was allergic to sulfa drugs and had been on Cleocin for almost the past year. She had a medical history of heart disease, hypertension, anemia and stomach ulcers. She also had diabetes mellitus she claimed was under fairly good control. She has a coronary artery bypass with heart stent placement and carotid endarterectomy. Her quadruple CABG was performed in 1988.

She was taking Trental, Aspirin, Plavix, Toprol-XL, Isosorbide Mononitrate, Nexium, Humulin NPH, Nitroglycerin, Lisinopril and Lipitor. Interestingly, she had an incision and drainage procedure performed to her left lower leg for local cellulitis in November 2005, and has had a previous toe amputation to her third toe of the left foot about 10 years ago. In November 2005, her cardiologist reported an 80% lesion to her bypass graft. She underwent successful dilatation of the left anterior descending artery (LAD) and saphenous vein graft and has had no cardiac episodes since that time.

Physically, the patient was ambulatory and healthy in appearance. Her examination revealed fairly good palpable pulses with capillary refill to the toes. Her biomechanical examination revealed subtalar joint pronation with significant osteoarthritis and collapse of the midtarsal joints consistent with Charcot arthropathy. She had a narrow foot type and her gait evaluation exhibited plantar medial pressure to the heel. It was apparent that this ulceration was a result of her Charcot foot.

Her previous treatment included debridement and antibiotic therapy, bi-monthly podiatry visits with debridement, off-loading shoes and local wound care. By her sixth or seventh month of treatment, she began getting frustrated with her treatment and began to seek other alternatives to treatment. She presented to us from another city in Texas and agreed to stay with her daughter, who lived locally, to continue treatment. She was concerned about losing the leg and had heard about our services and success in limb salvage. She was very much interested in closing the ulcer, and getting back to her life, without risk of possible amputation.
Since the ulceration was cavitating and locally infected, I recommended hospitalization and further vascular and imaging including MRI with the premise of performing a local incision and drainage with surgical debridement. Our goals for this patient included resolving the heel ulcer, preventing recurrence and improving her biomechanical fault with custom diabetic shoes or walking braces once the ulcer is closed.

Nuclear Medicine and Radiographic Studies

FIGURE 3  Radiographs revealed a small heel spur and soft tissue inflammation, but no apparent disruption of the cortex to suggest osteomyelitis.

On initial office evaluation, we ordered radiographs to rule out osteomyelitis, abscess or gas. (Fig. 3) After the patient was admitted to the hospital setting, we immediately ordered an MRA to check the patient’s vascular status. This is indicated before surgery because of her history of vascular disease. An MRI was also ordered to rule out osteomyelitis of the os calcis. She was placed on NPO status and placed on Primaxin 1 gram IVPB every 12 hours. Standard admit orders were given. Heel protectors were placed, on admission, and within one day both the MRA and MRI were completed. Her surgery was scheduled the day following of her admission, and on the third day after her surgery, she was discharged to her daughter’s home.

FIGURE 4  The MRA is an important test to determine vascular perfusion to the extremities.  In this study, there was good run-off perfusion to both extremities.

An MRA was performed including views of the abdomen and both lower extremities. The study consisted of six sequences with 3D time-of-flight after 40 cc of ProHance injection. Images of the abdomen demonstrated moderate narrowing involving an accessory upper pole of the left renal artery. The abdominal aorta revealed no occlusion and only very minor plaques. No stenosis was seen in the common iliacs and external iliacs. The origins of the superficial femorals revealed no stenosis. The profunda arteries are open bilaterally, with the left side demonstrating more arteriosclerotic irregularities than the right. (Fig. 4) The trifurcation vessels on the right demonstrated a segmental stenosis throughout the leg with no significant occlusive lesion or high grade stenosis.

FIGURE 5  The repeat study of the left leg and foot revealed a small anterior tibial artery, open peroneal artery and posterior tibial artery. 

The left anterior tibial artery could be seen at its takeoff with marked arteriosclerotic changes involving the portion that was seen and was only noted in the proximal third of the left leg. The posterior tibial and peroneal arteries on the left were obscured by venous overlap. Due to the venous overlap and venous obscuration of the arterial bed, a repeat study of the left leg was done. The repeat study revealed a very small anterior tibial that demonstrated plaque disease and was very, very limited in its distribution. The peroneal was open and the posterior tibial artery was very bright and actually slightly enlarged when compared to the right. No significant stenosis was identified. (Fig. 5)

FIGURE 6  The MRI revealed an intact cortex of the calcaneus.  No abscesses or erosions were seen. 

MRI of the left Os Calcis was performed. Pre and post contrast imaging was performed using 40cc of ProHance injection. (Fig. 6) The inversion-recovery sequence showed no evidence of inflammatory bone disease. There was no evidence of cortical erosion. The precontrast T1 sagittal images revealed no abnormalities of the Achilles tendon or plantar fascia. There was a 1-cm cyst along the anteromedial aspect of the calcaneal cuboid joint. No abscess formation was identified.

This would suggest that the ulceration is primarily mechanical in nature and isolated to the fat pad of the heel. The MRA and MRI studies were discussed with the patient and daughter. Due to this long standing ulcer and no sign of osteomyelitis, an excision of the ulcer with partial plantar calcaneal saucerization was recommended.

Surgical Technique

FIGURE 7  After thorough debridement of skin, the incisional approach is to excise the ulceration and orient the incision along relaxed skin tension lines.

The patient was brought to the operating room the following day. Our surgical planning involved using the Midas Rex ® Legend Gold® pneumatic burr to decompress a small portion of the plantar os calcis. Surgical excision of the ulcer was planned with a linear type fasiotomy along the attachment of the plantar fascia to expose a portion of the plantar calcaneus. Prior to debridement, a small elevator was used to track the sinus and identify the areas of abscess. Due to her history of vascular disease, no tourniquet was used. When planning the incision to excise the ulceration, care was taken to plan an incision that would decrease any skin tension on closure; thus, the incision was made parallel to the skin lines along the heel. (Fig. 7)

 

FIGURE 8  (a) The ulcer was excised completely.  It was important to remove all necrotic tissue at this stage and lavage the region with antibiotic solution before incising the fascia to gain access to the os calcis. (b)  The fascia was then incised to gain access to the os calcis.

The incisional approach was made along relaxed skin tension lines that will result in the best cosmetic result. This also resulted in the most narrow and strongest scar line. The incision was made parallel to the dermal collagen bundles and deepened to the subcutaneous fat. We removed a large wedge of tissue with care taken to deepen this wedge down to the fascial layer of the plantar fascia. (Fig. 8a) A portion of this wedge was sent for surgical culture. It has been shown, in previous studies, the surgical biopsy performed in this manner will yield the most accurate results. Simply swabbing the ulcer will yield inaccurate results and superficial contaminates.

After the ulcer was excised, the region was copiously lavaged with an antibiotic solution. This was to make the surgical site as clean as possible before incising the fascia. After this was done, careful exposure of the plantar fascia was made. A controlled incision was made along the long axis of the plantar fascia. A small elevator was then used to dissect free the fascial attachment to the plantar os calcis region. (Fig. 8b) The insertion of the fascias is broad and extends both medially and laterally along the heel bone.

  

FIGURE 9  (a) The Midas Rex was introduced and the bone was easily removed with high-speed.  (b)  The bone surface after bone removal.  (c)  Closure of the surgical site.

After the fibers were carefully stripped free from the attachment, a small Midas Rex® acorn burr was introduced to remove a portion of bone. A small depression or saucerization was performed. The fascia was closed primarily and fitted nicely into the depression. (Fig. 9) The patient’s surgery was performed on a Tuesday and by Friday, she was discharged from the hospital setting. Her post-operative instructions included complete nonweightbearing and she remained on oral antibiotics for an additional 14 days.

Discussion

FIGURE 10  This patient had a chronic ulceration of the heel for almost 1 year before surgical intervention.  1 month after surgery, the ulcer was completely healed.

This case highlights the need for proper intervention when traditional conservative treatments do not resolve an ulcer in an appropriate period of time. This case also demonstrated diagnostic tests to rule out arterial disease and possible osteomyelitis in a long standing ulcer. In this case, careful patient selection and vascular evaluation resulted in complete closure of a long standing ulcer. After 1 month, this ulcer was now completely healed (Fig. 10). She was placed in a custom CROW device to accommodate her Charcot foot.

Conclusion

The health care costs for ulcer care are tremendous. This year alone the cost of treating pressure ulcers is estimated to be 11 billion dollars. Individual cases can range from 500 to 40,000 dollars. [2] Given the increased incidence of heel ulcers seen in the hospital setting, heel ulcers contribute a significant role in this expense. Hospital acquired heel ulcers actually increased from 19 percent in 1989 to 30 percent in 1993. [3] It is obvious that protocol should be initiated in these cases in an effort to decrease this complication and health care cost. There are times when ulcers can persist and a realistic time line should be established to promote closure. There are a host of modalities and treatments that should be initiated as soon as an ulcer presents. Patient selection is crucial to the successful outcome of these procedures. In the patient with good vascularity, a more aggressive surgical approach is recommended when a time-line has been met and ulcers don’t close or infections don’t resolve. It has been my experience that with proper conservative techniques in patients with good vascularity, most ulcers will close in a matter of 8 to 12 weeks. A progression of measurements and documentation showing ulcer closure is very important. If ulcer diameters don’t show improvement and ulcers begin to cavitate or worsen after 2 months of treatment, surgical intervention should be considered. This case highlights a typical condition where calcaneal saucerization and ulcer excision is indicated in a refractory ulcer of the plantar heel.

References

1. Esburg, et al: Mechanical Characteristics of Human Skin subject to static vs cyclic normal pressures. JRRD, Vol 36, No. 2, 1999.
2. Baycrest News Organization: Even Superman couldn’t win battle with pressure ulcers. On-line report.
3. Moore, J., Jensen, P. How to Manage Heel Ulcers In Patients With Diabetes. Podiatry Today, ISSN: 1045-7860 – Volume 18 – Issue 3 – March 2005 – Pages: 90-98.

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Address correspondence to:  Al Kline, DPM  3130 South Alameda, Corpus Christi, Texas, 78404.   E-mail: Al@Kline.net.

¹Private practice, podiatry staff Doctors Regional Medical Center, Corpus Christi, Texas  78411.

© Podiatry Internet Journal , 2007 

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