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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.

Aim: To explore factors associated with the presence of category I-IV pressure ulcers on the sacrum and heels., Design: Cross-sectional, secondary data analysis using data collected from the Landelijke Prevalentiemeting Zorgproblemen (LPZ) project, a multicentre prevalence study including nursing home residents and community care clients (N = 4,842) in the Netherlands in 2017., Methods: A single binary logistic regression model was designed to identify factors associated with the presence of pressure ulcers. Additionally, a multiple binary logistic regression model including modifiable explanatory factors associated with the presence of pressure ulcers was designed., Results: Impaired mobility, friction and shear (evaluated using the Braden Scale) are significantly associated with the presence of both sacral and heel category I-IV pressure ulcers. Incontinence-associated dermatitis is significantly associated with category I-IV sacral pressure ulcers., Conclusion: In pressure ulcer prevention, nursing interventions should focus on frequent repositioning and mobilization while avoiding exposure of the skin to friction and shear. The need to consider incontinence-associated dermatitis, incontinence and moisture as important factors in pressure ulcer risk assessment is confirmed., Impact: Pressure ulcers occur when skin and tissues are deformed between bony prominences and the support surface in a sitting or lying position. They are the result of a complex interaction between direct causal factors and a wide range of indirect factors. Recognition of these factors influences risk assessment guidance and practice. Knowledge of skin-specific factors at the patient level, modifiable by nursing interventions, enables a better targeted and tailored preventive approach., (© 2019 John Wiley & Sons Ltd.)

Heel pressure ulcer is a major complication in elderly hospitalized patients. The association with peripheral arterial disease (PAD) which is also a frequent disease in this population is poorly known. The aim of this study was to assess the prevalence of PAD and critical limb ischemia (CLI) in patients with heel pressure ulcer. Patients referred to the vascular medicine department for heel pressure ulcer from October 2014 to June 2015 were included in the study. The assessment of peripheral arterial disease was made with the results of ankle brachial index and/or doppler ultra sound of lower limb arteries. Toe systolic pressure and transcutaneous pressure (TcPO2) were also recorded, and the diagnosis of critical limb ischemia was made according to the TASC 2 criteria. The population was composed with 42 patients (women 43%, men 57%). The mean age was 81±11 years. Heel pressures ulcers were diagnosed in the following situations: lower limb fracture (31%), acute medical illness (21%), multiple chronic conditions (28%) and critical care unit hospitalization (7%). A peripheral arterial disease was present in 31 patients (73%), and a critical limb ischemia in 7 patients. For 18 patients, PAD was not known in their past medical history, and this was the case of 5 patients among those with critical limb ischemia. A revascularization was performed in 12 patients, and 5 patients undergo a lower limb amputation. 12 patients were died at 3 months. PAD is frequent among patients with heel pressure ulcer, and is often unknown. The functional and vital prognostic are poor, and the results of our study emphasize the importance of screening PAD in the evaluation of heel pressure ulcer risk.

Background: The evaluation and treatment of heel pressure injuries are a significant and expensive sequela of the aging population. Although the workup of patients with lower extremity tissue loss usually involves an assessment of the arterial blood flow by means of noninvasive vascular testing, the results may be misleading in patients with heel pressure injuries when the ankle-brachial index (ABI) does not provide direct information about perfusion of the rearfoot. The objective of this retrospective, observational investigation was to determine if noninvasive vascular testing provides accurate and reliable results in patients with heel pressure injuries., Materials and Methods: A retrospective chart review of 67 consecutive inpatients with 75 heel decubitus ulcerations was performed., Results: At least 1 noncompressible ankle artery was observed in 35 (46.67%) of the 75 feet. When at least 1 compressible vessel was present, allowing for calculation of an ABI (n = 49 feet), it was based on the posterior tibial artery in 23 (46.94%) feet and on the anterior tibial artery in 26 (53.06%) feet. In total, of the 75 feet with heel pressure injuries that underwent noninvasive vascular testing, a compressible posterior tibial artery allowing for calculation of an ABI as a direct measure of heel perfusion was observed in only 23 (30.67%) feet., Conclusions: The results of this study suggest noninvasive vascular testing may be inaccurate and unreliable in the majority of patients with heel pressure injuries.

Unlabelled: The aim was to investigate the effect of an early intervention, a heel suspension device boot, on the incidence of heel pressure ulcers among older patients (aged 70+)., Background: Pressure ulcers are a global healthcare issue; furthermore, the heel is an exposed location. Research indicates that preventive nursing interventions starting during the ambulance care and used across the acute care delivery chain are seldom used., Methods: A multi-centre randomized control study design was used. Five ambulance stations, two emergency departments and 16 wards at two Swedish hospitals participated. Altogether, 183 patients were transferred by ambulance to the emergency department and were thereafter admitted to one of the participating wards., Results: Significantly fewer patients in the intervention group (n=15 of 103; 14.6%) than the control group (n=24 of 80; 30%) developed heel pressure ulcers during their hospital stay (p=0.017)., Conclusions: Pressure ulcer prevention should start early in the acute care delivery chain to increase patient safety., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Unlabelled: Pressure ulcers represent a major current health problem and produce an important economic impact on the healthcare system. Most of studies to prevent pressure ulcers have been carried out in hospital contexts, with respect to the use of hyperoxygenated fatty acids and to date, no studies have specifically examined the use of olive oil-based substances., Methods and Design: Main objective: To assess the effectiveness of the use of olive oil, comparing it with hyperoxygenated fatty acids, for immobilised home-care patients at risk of suffering pressure ulcers. Design: Non-inferiority, triple-blind, parallel, multicentre, randomised clinical trial. Scope: Population attending Primary Healthcare Centres in Andalusia (Spain). Sample: 831 immobilised patients at risk of suffering pressure ulcers., Results: The follow-up period was 16 weeks. Groups were similar after randomization. In the per protocol analysis, none of the body areas evaluated presented risk differences for pressure ulcers incidence that exceeded the 10% delta value established. Sacrum: Olive Oil 8 (2.55%) vs HOFA 8 (3.08%), ARR 0.53 (-2.2 to 3.26) Right heel: Olive Oil 4 (1.27%) vs HOFA 5 (1.92)%, ARR0.65 (-1.43 to 2.73). Left heel: Olive Oil 3 (0.96%) vs HOFA 3 (1.15%), ARR0.2 (-1.49 to 1.88). Right trochanter: Olive Oil 0 (0%) vs HOFA 4 (1.54%), ARR1.54 (0.04 to 3.03). Left trochanter: Olive Oil 1 (0.32%) vs HOFA 1 (0.38%), ARR0.07 (-0.91 to 1.04). In the intention to treat analysis the lower limit of the established confidence interval was never exceeded., Discussion: The results obtained confirmed that the use of topical extra-virgin olive oil to prevent PU in the home environment, for immobilised patients at high risk, is not inferior to the use of HOFA. Further studies are needed to investigate the mechanism by which olive oil achieves this outcome., Trial Registration: Clinicaltrials.gov NCT01595347.

Aim of the Study: We examined the location-specific properties of pressure ulcers, focusing on depth and undermining formation, which are often unfavorable factors for ulcer healing., Methods: We conducted a retrospective observational study of 2 independent databases on pressure ulcers. Databases from a 200-bed hospital (database A) and a 300-bed hospital (database B) were collected during different time periods. Relationships between ulcer location, ulcer depth, and undermining formation were analyzed. All pressure ulcers were accurately diagnosed and classified according to their locations., Results: A total of 282 pressure ulcers in 189 patients from database A and 232 pressure ulcers in 154 patients from database B were analyzed. It was found that pressure ulcers primarily developed over the sacrum. Ratio of stages III and IV pressure ulcers was high in pressure ulcers of the foot, ankle, and crus on the lower leg. Among the deep pressure ulcers, undermining formation was frequently observed on the greater trochanter, ilium, and sacrum. In contrast, pressure ulcers of the foot, ankle, and crus did not exhibit undermining formation., Conclusion: Our results revealed marked differences in pressure ulcer properties depending on their location. Factors affecting depth and undermining of pressure ulcers appear to be related to anatomical and physical properties of the bone and subcutaneous tissue., (Copyright © 2013 Tissue Viability Society. Published by Elsevier Ltd. All rights reserved.)

The posterior aspect of heel is known as a particularly vulnerable site for pressure ulcer development, however, it is not well understood why this is so. This study was undertaken to identify the morphological characteristics of the skin over posterior aspect of heel in the context of pressure ulcer development. Human skin tissues were obtained from four different sites of the body of 4 aged subjects postmortem: posterior aspect of heel, plantar aspect of heel, sacrum and centre of gluteus maximus. The skin samples were processed for the examination using light microscopy and scanning electron microscopy. The posterior aspect of heel was characterized by a thicker epidermis, denser distribution and larger diameter of capillaries in the papillary layer, 3-dimensional architecture of collagen fibre meshwork in the reticular layer and elliptic adipose tissues situated perpendicularly to the skin surface being surrounded by thick collagen and elastic fibre septa compared to the sacrum. Given our observations in the papillary layer of the posterior aspect of heel, we assume that the tissue of this area may be less tolerant to ischaemia since the tissue has high metabolic demand to provide oxygen and nutrients to the epidermis which protects underlying tissue from external force. In addition, elliptic configuration of adipose tissues in the posterior aspect of heel situated perpendicularly to the skin surface may result in deep lesion if the forces applied exceed the tolerable level since the forces will be concentrated within the elliptic compartments., (Copyright © 2013 Tissue Viability Society. Published by Elsevier Ltd. All rights reserved.)

Heel pressure ulcers are the second most common site for pressure ulceration; although their assessment and treatment can be complex, and they often require additional consideration over and above core principles of pressure ulcer prevention and management. Recent international pressure ulcer prevention and treatment guidelines developed jointly in Europe and the USA have provided greater clarity by achieving international consensus on how to care for patients at risk of heel pressure ulceration, and also on the management of such patients if a pressure ulcer develops. Health professionals should embrace these guidelines and embed them in their everyday clinical practice and within local guidance and protocols to ensure that patients are provided with evidence-based care supported by international collaboration and agreement.

Aim: The aim of this study was to test the effectiveness of polyurethane foam in contact with the heel inside a plaster cast to decrease the rate of pressure sores in the population at most risk., Background: The rate of pressure sores caused by the plaster cast is reported to be 14-15% in the paediatric population, 33.3% in patients having undergone chemotherapy for bone tumours and 43% in orthopaedic patients who already have sore skin when the cast is applied (grade 1 lesion) to the heel., Design: Controlled clinical trial., Methods: From November 2007-January 2009, all consecutive subjects requiring lower limb casts having undergone chemotherapy and/or presenting heel soreness received polyurethane foam in contact with the skin of the heel before applying the cast. The results were compared with those of patients with the same risk factors but were not administered the foam and were enrolled from May 2005-August 2006., Results: In total, 156 patients were enrolled, 85 in the control group and 71 in the experimental group. In the experimental group, 2 of the 56 patients (3.6%) with sore skin developed a pressure sore compared with 21 of 49 (42.9%) in the control group without polyurethane foam (p < 0.0005). In the experimental group, one of the 24 patients (4.2%) patients undergoing chemotherapy developed a pressure sore compared with 18 of 54 (33.3%) in the control group (p = 0.005)., Conclusions: Placing polyurethane foam in contact with the skin of the heel inside a plaster cast prevents the formation of pressure sores., Relevance to Clinical Practice: This study provides evidence that using polyurethane foam to prevent sores even inside plaster casts in populations at most risk is a simple and cost-effective strategy and decreases the discomfort, pain and risks in these patients., (© 2011 Blackwell Publishing Ltd.)

Purpose: Heels are the second most common location for pressure ulcers, and their prevalence is increasing. The purpose of this multisite research project was to describe physical characteristics and medical history of patients experiencing heel pressure ulcers (PUs)., Subjects and Setting: The settings for this study were different healthcare settings (acute care, long-term care, and homecare) in North Carolina and Virginia, where member WOC nurses perform consultative services for patients with heel ulcers. Patients older than 18 years with a heel PU were included in the study., Methods: A data collection tool was developed by the authors. Participating members of the NC WOC Nurses Group identified 84 participants. Descriptive statistics were used to summarize the data by using proportions, means, standard deviations, and ranges., Results: Over half of the population had a palpable pedal pulse. Full-thickness PUs were found in 45% of the sample while 19% had suspected deep tissue loss. Subjects tended to be elderly and have low nutritional markers, high body mass index, multiple comorbid conditions such as diabetes mellitus, systemic infection, end-stage renal disease and peripheral arterial disease, as well as low Braden Scale scores., Conclusion: The study revealed important factors specific to heel PUs including advanced age, malnutrition, high body mass index, and multiple comorbid conditions. Further research is needed to further refine our knowledge of our factors associated with an increase likelihood of heel PUs. Our findings also point out the need for a tool specific for the evaluation of heel PU risk.

Objective: Pressure ulcers affect predominantly the elderly and nutritional status is a known risk factor. Guidelines on pressure ulcers provide recommendation on nutritional management. Ornithine alpha-ketoglutarate (OKG) is an adjuvant treatment in undernourished elderly patients or in patients with hypercatabolism states. It is a precursor of different amino-acids which play a role in the process of healing. The objective of the study is to determine the efficacy of OKG on pressure ulcer area reduction after six weeks of treatment., Design: Multi-centre, international, randomized, comparative, double blind, parallel groups, placebo-controlled study., Participants: 160 patients (ITT population) aged over 60 years with a heel pressure ulcer at stage II or III., Intervention: Patients received OKG (n=85) or placebo (n=75) once a day for 6 weeks., Measurements: Ulcer area was measured each week, using a tracer. The primary endpoint was the percentage reduction of the surface at the final visit: [(Wound areatn - Wound areat0)/ (Wound areat0)]., Results: At inclusion, ulcer area distribution deviated from normal distribution (median ulcer area OKG 6.6 cm(2), placebo 3.9 cm2, p=0.044, Mann-Whitney test). As healing is strongly related to baseline ulcer area, the abnormal distribution was a major bias. Therefore it was decided to perform the analysis on 2 sub-groups of patients according to the mean ulcer area, i.e. above or below 8 cm2. The mean wound area reduction for baseline area 8 cm2 no between group differences on either parameter was detected. When closure rate is considered, a significant difference in favor of OKG group is observed (- 0.07 cm2/day in the OKG group and - 0.04 cm2/day in the placebo groups respectively p=0.007, Mann-Whitney test). Thirty serious adverse events were reported in 28 patients (15 allocated to OKG and 13 to placebo). None of them was considered treatment related., Conclusion: This clinical trial supports a potential benefit of OKG 10g daily in the subgroup of patients with pressure ulcers

Heels are the second most common anatomical location for pressure ulcers. A combination of risk factors, including pressure, may cause ulceration. Heel pressure ulcers are a particular concern for surgical patients. A review of the literature, including poster presentations, shows that controlled clinical studies to assess the effectiveness and cost-effectiveness of available interventions are not available. Case series (with or without historical controls) as well as pressure ulcer guideline recommendations suggest the most important aspect of heel ulcer prevention is pressure relief (offloading). It also has been documented that the incidence of heel ulcers can be reduced using a total-patient care approach and heel offloading devices. Guidelines, observational studies, and expert opinion intimate that reducing heel ulceration rates can be expected to improve patient outcomes, decrease costs associated with their care, and avoid costs related to hospital-acquired pressure ulcers. The heel pressure ulcer prevention strategies reviewed should be implemented until the results of prospective, randomized controlled studies to compare the effectiveness and cost-effectiveness of these strategies are available.

Heel pressure ulcers are a major problem in healthcare today. They involve extended clinician time, patient discomfort, and increased healthcare costs. In an attempt to decrease the incidence of heel pressure ulcers in one long-term care facility, a 1-year program was implemented that involved residents of one long-term care unit. In addition to staff education and awareness interventions, residents' heels were assessed daily and heel pressure-relieving measures were implemented. Kites were used to identify pressure ulcer stage, photo posters helped staff visualize the stages of heel pressure ulcers, and pencils marked with "Float Heels" were used to remind staff of the importance of prevention. Ulcer incidence rates were calculated every month. All residents (n = 40, mean age 67 years) on the unit at the beginning of the program were followed for as long as they were in the facility. At the start of the program, 50% of residents were at risk for developing ulcers and 22.5% had a heel ulcer. While the at-risk profile of residents remained relatively unchanged, no new ulcers were documented during nine of the subsequent 13 months, with incidence rates in the other 4 months ranging from 2.6% to 9.1%. Program costs were minimal and the results seem to confirm previously published studies about the positive effects of a comprehensive approach to the pressure ulcer problem.

We obtained favorable results in reconstruction of the posterior heel with a lateral calcaneal V-Y advancement flap. This technique simplifies the operative procedure and eliminates the disadvantages of the original lateral calcaneal flap and its island version while retaining the advantages of these methods.