A review of the surgical management of heel pressure ulcers in the 21st century

Abstract

Heel ulceration, most frequently the result of prolonged pressure because of patient immobility, can range from the trivial to the life threatening. Whilst the vast majority of heel pressure ulcers (PUs) are superficial and involve the skin (stages I and II) or underlying fat (stage III), between 10% and 20% will involve deeper tissues, either muscle, tendon or bone (stage IV). These stage IV heel PUs represent a major health and economic burden and can be difficult to treat. The worst outcomes are seen in those with large ulcers, compromised peripheral arterial supply, osteomyelitis and associated comorbidities. Whilst the mainstay of management of stage I-III heel pressure ulceration centres on offloading and appropriate wound care, successful healing in stage IV PUs is often only possible with surgical intervention. Such intervention includes simple debridement, partial or total calcanectomy, arterial revascularisation in the context of coexisting peripheral vascular disease or using free tissue flaps. Amputation may be required for failed surgical intervention, or as a definitive first-line procedure in certain high-risk or poor prognosis patient groups. This review provides an overview of heel PUs, alongside a comprehensive literature review detailing the surgical interventions available when managing such patients.

Keywords: Amputation; Angiosome; Calcanectomy; Heel ulcer; Pressure ulcer.

Figure 1

Operative management of a patient with large infected heel ulcer. (A) Debridement of the heel wound and creation of heel flap. (B) Daily debridement and irrigation of the wound. (C) Formation of granulation tissue. (D) Reconstructed heel created by suturing of heel flap to its bed (Reprinted with permission from reference 56).

Figure 2

Angiosomes of the foot and ankle, arising from the anterior tibial artery (ATA, one angiosome), posterior tibial artery (PTA, three angiosomes) and peroneal artery (PA, two angiosomes). The heel is supplied by branches of the posterior tibial and the peroneal arteries (Reprinted with permission from reference 78).