What are the considerations for a right heel calcanectomy?

Right Heel Calcanectomy: Considerations and Indications

Partial calcanectomy should be considered as a limb-salvage procedure for patients with chronic heel ulcers, calcaneal osteomyelitis, or recalcitrant wounds that have failed conservative management, rather than proceeding directly to below-knee amputation.

Indications for Calcanectomy

Calcanectomy may be appropriate in the following situations:

• Non-healing ulcers on the heel that have failed conservative treatment 1
• Calcaneal osteomyelitis 2
• Chronic or recalcitrant heel wounds 3
• Pre-ulcerative lesions that fail to respond to non-surgical treatment 4

Patient Selection and Risk Stratification

Before proceeding with calcanectomy, careful patient evaluation is essential:

• Vascular assessment is critical - non-invasive vascular testing should be obtained in all patients to stratify amputation risk 2

• Consider revascularization if:

  • Toe pressure <30 mmHg or TcpO2 <25 mmHg 4
  • Ankle pressure <50 mmHg or ABI <0.5 4
  • Ulcer not showing signs of healing within 6 weeks despite optimal management 4

• Risk factors that increase odds of major limb amputation following calcanectomy:

  • Peripheral arterial disease (PAD) (OR 3.5) 2
  • End-stage renal disease (ESRD) (OR 2.8) 2
  • Diabetes mellitus (78.3% of calcanectomy patients) 2

Surgical Approach Options

Partial Calcanectomy

• Traditional approach for treating calcaneal osteomyelitis and chronic heel ulcers
• Limitations: May require closure under tension or secondary intention healing 3

Vertical Contour Calcanectomy

• Novel modification that improves soft tissue closure
• Addresses concerns of wound dehiscence and postoperative complications 3
• May be preferable when the proportion of bone resected is insufficient relative to wound size

Expected Outcomes

Based on recent evidence:

• Limb salvage rate: High (only 1 of 24 patients required below-knee amputation in one study) 1
• Wound healing: Variable, with some patients experiencing delayed healing or minor drainage 1
• Patient satisfaction: Generally high, with most patients satisfied with the procedure 5
• Functional outcomes:
  • Most patients require orthotics and external support 1
  • Pain is typically not a major problem post-procedure 1
  • Decline in ambulatory status is common (from 40.1% independent ambulation pre-surgery to 17.9% at follow-up) 2

Potential Complications

• Prolonged hospital stay 1
• Need for additional surgeries 1
• Recurrence of ulceration, especially in patients with impaired foot sensation 1
• Decline in ambulatory status 2
• Wound healing complications requiring additional interventions 2

Post-Operative Management

• Regular wound inspection 4
• Appropriate offloading to prevent recurrence 4
• Consider negative pressure therapy to help heal post-operative wounds 4
• Properly fitting therapeutic footwear with adequate support 6
• Regular follow-up to monitor for complications or recurrence

Alternative Approaches to Consider

Before proceeding with calcanectomy, consider:

1. Conservative management:

   • Debridement of necrotic tissue and surrounding callus 4
   • Appropriate antibiotic therapy for infection 4
   • Offloading with appropriate devices 4
   • Revascularization if indicated 4

2. Less invasive surgical options:

   • Digital flexor tendon tenotomy for pre-ulcerative lesions on toes 4
   • Orthotic interventions to reduce excess callus 4

Decision-Making Algorithm

1. Assess wound severity and presence of osteomyelitis
2. Evaluate vascular status and need for revascularization
3. Consider comorbidities (diabetes, PAD, ESRD) that increase amputation risk
4. Attempt conservative management for at least 6 months
5. If conservative measures fail and limb salvage is the goal, proceed with appropriate calcanectomy technique
6. Ensure comprehensive post-operative care including wound management and appropriate footwear

Remember that while calcanectomy has a high satisfaction rate and can prevent major amputation, patients should be counseled about the potential for prolonged healing time, need for additional procedures, and possible decline in ambulatory status.