How Long-Term Primary Podiatric Care Can Reduce Diabetic Pedal Complications

Author(s): 
Ronald Sage, DPM

Case Study: Underscoring The Impact Of Preventive Care Over Two Decades For A Woman With Type 1 Diabetes

The patient is a 62-year-old woman with type 1 diabetes, which is well controlled. She has received regular care at a podiatry clinic since 1989. She has received education about the importance of good control and the potential for foot complications. She is very attentive to her diabetes care.

   In spite of efforts to control her diabetes, she has a 45 pack-year history of tobacco use and continues to smoke on a limited basis to this day. She runs a part-time catering business and is active in community affairs so she spends a fair amount of time on her feet.

   As I previously noted, the patient’s podiatric care dates back to 1989 when she ulcerated her right fifth toe. She presented with an absence of pedal pulses and received a vascular consult. The vascular surgeon identified significant vascular disease and performed a femoral popliteal bypass. Her toe required amputation but healed uneventfully after the bypass.

   The patient started developing an ulcerating, painless callus under her first metatarsal head shortly after the toe healed. Conservative measures failed to resolve the callus so the surgeon performed a tibial sesamoidectomy. She healed and the callus resolved for a period of time. The callus eventually recurred within a year and ulcerated again. Treatment for the ulceration consisted of debridement, antibiotic ointment, gauze dressings and prescription footwear. It resolved within a month.

   Since that time, the patient has been wearing prescription shoes and orthotics, and has podiatric evaluation and management on a regular basis. Her visits include callus care every two to four weeks for the past 20 years. The frequency of her visits has depended on her activity level and the observed thickness of the keratosis along with evidence of intradermal hemorrhage or pre-ulcerative breakdown.

   If she goes more than three weeks without a podiatric visit, the first metatarsal callus ulcerates in spite of her constant use of prescription footwear. Without frequent callus care, prescription footwear and education about her foot risks, there is little or no question that she would develop serious ulceration, infection and possibly require amputation arising from this painless, chronic pressure keratosis.

   In addition to the aforementioned chronic plantar callus on the first metatarsal, the patient also has a stage 3 Charcot joint on her left foot and a third hammertoe with a chronic distal keratosis and history of ulceration. She has worn inlay depth shoes with custom multidensity accommodative insoles for nearly 20 years.

How The Podiatrist Addressed A Navicular Fracture Suffered By The Patient

In 2006, the patient sustained a minor left foot injury, which resulted in a relatively painless swelling across the top of the foot. She called for an office visit within 48 hours of the injury and presented the next day. An X-ray demonstrated a navicular fracture, which split the bone in two fragments. One of the fragments displaced dorsally and tented her skin, causing the swelling. Eventually, this tenting produced a 4 to 5 cm patch of ischemic necrosis.

   She clearly needed excision of the fragment and debridement of the necrotic tissue but she had non-palpable pulses. The patient had a collapsed arch, which was consistent with a diagnosis of Charcot joint. There were no plantar prominences. The podiatrist determined that the risks of an extensive reconstruction outweighed the potential benefit.

   Before undergoing any foot surgery, the patient received a vascular consult. She had extensive iliac occlusion on both sides and underwent an aortobifemoral bypass. Her peripheral circulation improved. The podiatric surgeon debrided the ischemic patch and excised the navicular fracture fragment.

   We subsequently utilized vacuum assisted closure and immobilized her foot in bulky soft dressings for approximately six weeks. She did not undergo any extensive reconstruction of her Charcot joint other than excision of the displaced fracture fragment.

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