Vertical Contour Calcanectomy: Is it a Viable Option to Treat Infected Heel Ulcers in Patients with Diabetes and PAD?

13. August 2021
Jeff Hall, Senior Contributing Editor
While heel ulcers can be particularly challenging to treat and heal in patients with diabetes and peripheral arterial disease (PAD), an emerging surgical procedure may provide an alternative solution in this patient population.

In a recently published study in the Journal of Foot and Ankle Surgery, researchers found that nearly a third of patients with heel ulceration treated with the vertical contour calcanectomy had no wound recurrence, amputation or mortality one year after the procedure.1 The study authors also reported a 68.6 percent limb salvage rate at one year for the study’s 51 patients with a median age of 64.

John Steinberg, DPM, FACFAS, a co-author of the study, says the vertical contour calcanectomy facilitates wide resection of soft tissue and bone, and use of native adjacent tissues for full-thickness plantar closure.

Brian Lepow, DPM, DABPM, believes a benefit of the vertical contour calcanectomy is limiting tension along the posterior aspect of the heel, providing native tissue for robust coverage of the defect, thus facilitating easier wound closure and limiting future breakdown of the wound site.

“I believe this procedure presents an opportunity for a closer look at better management of patients with calcaneal wounds and osteomyelitis,” notes Dr. Lepow, an Assistant Professor at the Baylor College of Medicine, and the Founding Treasurer of the American Limb Preservation Society (ALPS). “These types of wounds pose a significant challenge for wound healing given the multiple comorbidities of this patient population, and their already severe decline, generally leading to the inability for the patient to properly offload the area. (The vertical contour calcanectomy) may provide an alternative to a more palliative care model versus major amputation with a reproducible procedure that allows for adequate healing and continued mobility.”

Dr. Steinberg says he considers the vertical contour calcanectomy to address infected heel wounds with osteomyelitis in patients who are in their 70s, 80s and 90s. This population usually does not respond well to proximal amputation, according to Dr. Steinberg, the Co-Director of the Center for Wound Healing at the MedStar Georgetown University Hospital in Washington, D.C.

For post-op care of patients who have the vertical contour calcanectomy, Dr. Steinberg emphasizes six weeks of non-weightbearing with splinting or casting. Then he has patients progress to walking in a Charcot Restraint Orthotic Walker (CROW) boot for six to 12 months with possible use of an ankle-foot orthosis afterward. In addition to offloading, Dr. Lepow says other keys to post-op care may include family support, rehabilitation and adequate follow-up monitoring of the surgical wound site.

Dr. Steinberg says the vertical contour calcanectomy is not an option in the absence of blood flow. Dr. Lepow notes he would not employ this procedure for patients who have severe deconditioning and/or those who have significant comorbidities and risk factors, including severe rigid contractures in the lower extremities, who clinically would benefit from a major amputation.

1. Cook H, Kennedy C, Delijani K, et al. Early clinical, functional, and mortality outcomes for heel ulcers treated with a vertical contour calcanectomy. J Foot Ankle Surg. 2021; S1067-2516(21)00252-0. doi: 10.1053/j.jfas.2021.06.015. Online ahead of print.

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