Inside Insights For Offloading Diabetic Neuropathic Ulcers

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Here is a close-up view of a neuropathic ulcer under the second metatarsal. Dr. Karlock says he is initially aggressive when it comes to offloading the plantar neuropathic ulceration. (Photo courtesy of Lawrence G. Karlock, DPM)
Dr. Karlock notes that most of the literature says 80 percent or more of neuropathic ulcers can be healed within a short period of time with TCC, but the time-consuming nature of the modality thwarts more mainstream use. (Photo courtesy of David G. Armstr
Converting a removable cast walker into an instant total contact cast may help facilitate easier application and increase patient compliance, according to Dr. Armstrong. (Photo courtesy of David G. Armstrong, DPM)
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Author(s): 
Clinical Editor: Lawrence Karlock, DPM

Q: How do you deal with the noncompliant patient?
A:
Dr. Kravitz says noncompliance is problematic not only due to the lack of consistent use of a removable cast walker, but is the “leading cause” of non-healing ulcers, according to much of the literature on the subject.
“Very few patients will adhere to an offloading regime if the offloading device is removable,” reemphasizes Dr. Armstrong. Citing a recent study involving sophisticated activity monitors that he co-authored in 2003, Dr. Armstrong notes that people with open plantar wounds only wore their removable cast walkers for 28 percent of the total activity they engaged in per day.3 However, he says this is not necessarily the fault of the patients but is more due to the fact that they don’t have the “gift of pain.”
Whether you are stern or take a more compassionate approach with noncompliant patients, it unfortunately doesn’t make much difference either way, according to Dr. Karlock. Dr. Kravitz says it’s important to get a patient’s family members or his or her caregiver involved.
“I explain to them the urgency of compliance and the need to follow instructions,” notes Dr. Kravitz. “I emphasize to the family members the possibility, if not probability, of total loss of the patient’s limb if he or she doesn’t comply (with the offloading regimen). I have found this to be the most effective way, by far, to deal with noncompliance.”
In his experience, Dr. Kravitz says if a family member or caregiver is not available, noncompliance will often continue to be a problem that compromises the patient’s long-term prognosis.
Dr. Karlock encourages thorough documentation of patient noncompliance.

Q: What “surgical offloading” procedures (i.e. osteotomies, etc.) do you employ?
A:
While there are a variety of approaches, Dr. Kravitz emphasizes that surgical offloading is very dependent on ulcer location and the structure of the foot. He adds that the patient’s long-term prognosis “is always improved when the surgeon has a thorough understanding of the biomechanics and the transfer of weightbearing forces that occur with any partial foot resection.”

Dr. Armstrong says he employs a number of prophylactic and curative procedures for this patient population. The most common “bread and butter” procedures include first MTPJ arthroplasties, panmetatarsal head resections, first metatarsal osteotomies and Achilles tendon lengthenings.
Dr. Kravitz says one should consider tendo-Achilles lengthening for recurrent forefoot ulcers or mid-foot Charcot, and in conjunction with transmetatarsal amputation and similar procedures.
“Reactive equinus is common among a significant number of these patients,” maintains Dr. Kravitz. “When this not addressed, it often leads to exacerbation of a Charcot problem and/or recurrent forefoot ulceration.”
Dr. Karlock commonly performs metatarsal basilar osteotomies for the plantar forefoot ulceration. He also emphasizes that he is a “big proponent” of midfoot exostectomies on the medial or lateral side in combination with a posterior Achilles/gastroc release for the broken down Charcot foot.
“I find that the success rate in curing these severe Charcot feet with midfoot exostectomies and appropriate custom-molded shoes and/or shoes attached to an ankle-foot orthosis (AFO) is highly rewarding,” claims Dr. Karlock. He adds that this approach also doesn’t have the risk of major midfoot and rearfoot reconstruction. Dr. Karlock says the only justification for reconstruction would be the “truly unbraceable foot” that is highly unstable with recurrent breakdown and ulceration.
In the realm of diabetic foot surgery, Dr. Armstrong adds that the emerging availability of a variety of traditional and hybrid external fixation devices in recent years has also helped in “temporarily or permanently holding positional correction.”

Dr. Armstrong is a Professor of Surgery, Chair of Research and Assistant Dean at the William M. Scholl College of Podiatric Medicine at Rosalind Franklin University of Medicine in Chicago. He is a member of the National Board of Directors of the American Diabetes Association.

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