Are Acellular Dermal Matrices Effective For Grade 0 Ulcers And Fat Pad Augmentation?

Author(s): 
Jodi Schoenhaus Gold, DPM, FACFAS

   Although some of these modalities have been marketed as cosmetic treatments, I have found positive outcomes with these products that have helped address a range of conditions from hallux valgus to hammered digit corns, facilitated relief of a heloma molle, provided padding over protruding hardware and offered heel pain cushioning.

   Most significant is the relief of pressure for previously ulcerated sites and in patients with diabetes who are at risk for further breakdown. When it comes to hemorrhagic calluses due to dermal capillary injuries, injection therapy can provide enough focal restoration that skin breakdown decreases.

   The benefit of injection therapy is that one can perform this in the office setting. Clinicians measure outcomes by patient feedback with decreased pain in sensate patients and clinical improvement in neuropathic patients. One can determine clinical improvement by performing follow-up peak pressure studies.

   Although these treatments are rewarding and fillers provide patients relief in their shoes, I have found limitations with injection therapy. The chemical compounds of the fillers break down over time with patients being able to obtain optimal relief for up to 10 months. Accordingly, there is a need for annual touch-up treatments. When it comes to radiopaque injectables like Radiesse®, which is made of calcium hydroxylapatite, one can see these products on X-ray migrate from their original injection locations.

   Furthermore, in patients with collagen disorders who have severe fat atrophy, fillers cannot provide the adequate fat restoration needed to provide desirable outcomes. Lastly, using these products for off-label indications can be cost-prohibitive.

Rethinking Our Approach To Grade 0 Ulcerations

Grade 0 ulcerations in patients with diabetic neuropathy are slightly more challenging because they typically do not have pain. The physician must educate the patient on the importance of addressing the pathology even though he or she may not feel a problem. While treatment options including padding and insoles are beneficial, they may be limiting and unrealistic on a daily basis. Granted, these traditional methods are standards in our profession but they fail to be more proactive at focusing on treatment of high-pressure areas with bone deformities. Until a patient presents with skin breakdown and the presence of Grade 1 ulceration, we typically sit and wait.

   We should not overlook patients who present in the Grade 0 class as treatment for these conditions can delay or even prevent a more serious condition such as ulceration, infection and amputation. Treatment of grade 0 ulceration is indicated in healthy individuals and more importantly in the high-risk patient.

   A more aggressive approach is required for patients who have severe fat atrophy and an inability to perform activities due to pain, hemorrhagic calluses, and blistering. Furthermore, individuals who have diminished sensation and neuropathy, high peak pressures and early skin breakdown need a more reliable and permanent solution. It is important to consider the varying degrees of peak pressure and load time on a given structure that can lead to skin breakdown, infections and ultimately amputations.

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