Review Question - QID 5790

This patient has a recalcitrant heel ulcer with visible bone (presumed osteomyelitis, OM). Partial calcanectomy (PC) and primary wound closure (or delayed primary closure)(often over a drain) is indicated. This maximizes the chance of healing while minimally changing oxygen expenditure and metabolic demand.

Heel ulcers with OM are difficult to treat. Skin grafts are not stable enough to withstand shear. Options include (1) below knee amputation (BKA) with the disadvantages of increased energy requirements and need for assistive devices, (2) debridement with free muscle flap, with the disadvantages of long recovery, donor site morbidity and footware fitting difficulties. The aim of a PC is debridement and tension-free primary wound closure (to prevent recurrent breakdown). Part (or all) of the Achilles insertion may need to be resected (and reattached). Healing will be delayed in patients with MRSA, poor nutrition (albumin <3g/dl), PVD and large ulcers with Wagner grade = 3.

Bollinger et al. reviewed 22 patients with heel wounds treated with PC instead of BKA. All patients healed their wounds although 12 had delayed healing (especially those with diabetes). They conclude that PC is a viable alternative for patients with large heel ulcers. They emphasize postoperative equinus splinting to prevent a calcaneus deformity

Smith et al. reviewed 12 patients treated with PC. Selection criteria include ABI >0.45, TcO2 of >28mmHg, albumin >3g/dL, TLC >1500. Wounds healed in 10 patients, and did not heal in 2 patients, necessitating BKA. They emphasize that free flaps are often impossible because of vascular disease or diabetes.

Figure A shows a large heel ulcer with exposed bone. Figure B is a lateral radiograph showing no gross osteomyelitic involvement of the calcaneus. Illustration A is a radiograph of the same leg after PC. Illustration B shows wound healing after PC. Illustration C shows the steps in a PC.

Incorrect Answers:
Answer 1: Wound closure should be by primary (or delayed primary) closure to prevent recurrent breakdown and re-infection.
Answer 3: Calcanectomy and talectomy is reserved for OM involvement of both talus and calcaneus and is not first line treatment in this case. Subtotal calcanectomy is superior to total calcanectomy because if provides a more stable foot.
Answer 4: Unlike in young patients, where early major amputation (BKA, Syme, AKA) offers the best functional outcomes, even a poorly functional salvaged limb can maximize ambulation and quality of life for sedentary, diabetic patients. BKA increases metabolic demand by up to 25-40%.
Answer 5: One of 2 vessels demonstrates a palpable pulse. Doppler examination reveals flow in both vessels. Revascularization is not a priority.