Heel Pressure Injuries: Consensus-Based Recommendations for Assessment and Management.

Significance: A systematic approach to develop experts-based recommendations could have a favorable impact on clinical problems characterized by scarce and low-quality evidence as heel pressure ulcers. Recent Advances: A systematic approach was used to conduce a formal consensus initiative. A multidisciplinary panel of experts identified relevant clinical questions, performed a systematic search of the literature, and created a list of statements. GRADE Working Group guidelines were followed. An independent international jury reviewed and voted recommendations for clinical practice. Consent was developed according to Delphi rules and GRADE method was used to attribute grade of strength. Critical Issues: The extensive search of the literature retrieved 42 pertinent articles (26 clinical studies, 7 systematic reviews or meta-analysis, 5 other reviews, 2 consensus-based articles, and 2 in vitro studies). Thirty-five recommendations and statements were created. Only 1 of 35, concerning ankle-brachial pressure index reliability in diabetic patients, was rejected by the panel. No sufficient agreement was achieved on toe brachial index test to rule out the orphan heel syndrome, removing dry eschar in adult patients without vascular impairment, and using an antimicrobial dressing in children with infected heel pressure injuries. Eleven recommendations were approved with a weak grade of strength. Experts strongly endorsed 20 recommendations. Offloading, stages I and II pressure injuries, and referral criteria were areas characterized by higher level of agreement. Future Directions: We believe that the results of our effort could improve practice, especially in areas where clear and shared opinions emerged. Barriers and limits that could hinder implementation are also discussed in the article.

Bumble Foot: A Rare Presentation of a Fusobacterium varium Infection of the Heel Pad in a Healthy Female.

Fusobacterium infection is common in herd animals and caged birds; the infection is typically referred to as "bumble foot" or "foot rot." These are opportunistic anaerobic bacteria that cause abscesses in the feet of animals that have developed inflammation in the foot pad secondary to the terrain. In humans, F. varium is known to cause abscesses associated with the oropharynx and gastrointestinal tract, also known as Lemierre's disease. The present study reports the case of a rare presentation of a F. varium soft tissue infection of the heel pad in a healthy young female with no associated oropharynx or gastrointestinal abscesses. Therefore, her presentation and disease course were similar to that described in herd animals. The patient was treated with 3 weeks of intravenous antibiotics, incision and drainage, and a gracilis free flap to the weightbearing surface of the right heel.

Shewanella putrefaciens, a rare cause of osteomyelitis.

Shewanella putrefaciens is a Gram-negative bacillus with a distinguishable characteristic of hydrogen sulfide production and routinely found in a marine environment. This organism has been cultured as a pathogen in a small number of soft tissue infections, but has rarely been the causative agent in osteomyelitis. This case report details calcaneal osteomyelitis due to S putrefaciens in a 77-year-old male with bilateral heel ulcerations and peripheral vascular disease.

Influence of osteomyelitis location in the foot of diabetic patients with transtibial amputation.

BACKGROUND: To evaluate the prevalence of osteomyelitis in different areas of the foot and the possible correlation between localization and outcome of major amputation. METHODS: From January 2008 to December 2010, a total of 350 diabetic patients were admitted to our diabetic foot unit for the surgical treatment of osteomyelitis. Osteomyelitis was diagnosed when both the probe-to-bone maneuver and plain radiography were positive. In all of these patients, osteomyelitis was confirmed by histological examination. RESULTS: Osteomyelitis was localized to the forefoot in 300 (85.7%) patients, to the midfoot in 27 (7.7%) patients, and to the hindfoot in the remaining 23 (6.75) patients. On average, foot lesions had developed 6.6 ± 5.6 months before admission to our unit. Transtibial amputation was performed in 1 (0.33%) patient with forefoot osteomyelitis, in 5 (18.5%) patients with midfoot osteomyelitis, and in 12 (52.2%) patients with osteomyelitis of the heel (χ(2) = 128.4, P < .001). Multivariate analysis showed the independent role that osteomyelitis in the heel region had in major amputation outcome (odds ratio 15.3; P < .001; confidence interval, 17.4-5336.0), dialysis treatment (odds ratio 6.3; P = .012; confidence interval, 2.5-1667.2), and leukocyte count greater than 10(3) mm(3) (odds ratio 2.25; P = .036; confidence interval, 1.1-76.6). CONCLUSIONS: We found a higher rate of transtibial amputation when osteomyelitis involved the heel instead of the midfoot or forefoot in diabetic patients. LEVEL OF EVIDENCE: Level III, retrospective comparative series.

Successful salvage therapy with Daptomycin for osteomyelitis caused by methicillin-resistant Staphylococcus aureus in a renal transplant recipient with Fabry-Anderson disease.

Daptomycin is licensed in adults for the management of Staphylococcus aureus methicillin-resistant infections, including bone and skin complicated infections. We describe for the first time its use in a renal transplant recipient for Fabry-Anderson Disease with right heel osteomyelitis. The patient was unresponsive to first-line Teicoplanin and second-line Tigecycline, whereas he was successfully treated with third-line Daptomycin monotherapy at 4 mg/Kg/qd for 4 weeks. Local debridement was performed in advance of each line of treatment.

Is heel prick as safe as we think?

Purulent lymphadenitis is rare in newborn and is associated with prematurity and invasive procedure. Neonatal staphylococcal infections due to skin interruption during intramuscular vitamin K administration and national metabolic screening programme (heel prick or Guthrie card test) have been already previously described. This is a report of a premature infant who developed an inguinal adenitis as a result of late complications from heel pricks. The diagnosis was made on clinical grounds and confirmed by ultrasound scans. Staphylococcus aureus was isolated. Bacteremia did not occur and the lymphadenitis had a complete resolution with antimicrobial therapy. The heel prick is a well-established procedure in neonatal practice, nevertheless it is not risk-free. The attention to signs of infections is important to avoid complications such as purulent lymphadenitis, abscess formation and septicemia. Best practice prevention and control in minimising the risk of infections are the most important intervention to prevent this complication.

Civilian gas gangrene: a clinical challenge.

Gas gangrene due to clostridia infections is commonly seen in war injuries and is much less commonly seen in civilian life. When such problems do occur, they present a challenge to the surgeon due to the associated high morbidity and mortality associated. A case is presented where a patient developed gas gangrene in a limb consequent to trauma that had been treated surgically. It is vital to make a correct diagnosis at the earliest to limit disease progression and to avoid complications.

Spontaneous calcaneal fracture after deep heel burns with diabetes.

Two patients with diabetes mellitus sustained spontaneous calcaneus fracture after deep heel burns. Both cases had avulsion type fracture of the os calcis. The authors discuss the incidence and possible etiology with literature review.