Proven Strategies To Prevent Lower Extremity Amputation

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Emphasizing The Value Of Multidisciplinary Care

It is extremely beneficial to have close interaction with the patient’s primary care physician for help with diabetic control or management of other co-morbidities such as renal disease or congestive heart failure that could affect healing. It is also effective to have a dietitian both for diabetes management and increased protein intake to aid wound healing. If the patient has significant infection, infectious disease consultation may be appropriate. We work with all of these providers at our facility for comprehensive care of each patient. A multidisciplinary approach has been associated with better outcomes in treating diabetic ulceration since many health-related factors may affect wound healing.17-19

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Author(s): 
Monica H. Schweinberger, DPM

   If the patients’ vascular status is adequate, almost uniformly, we apply a Jones compression dressing to the affected extremity to control edema and provide some immobilization of the area.5 Offloading of the wound occurs with padding, surgical shoes, casts, crutches, walkers or wheelchairs. Most importantly, patients receive strict instructions limiting their walking to short distances (i.e. bathroom and back) with either partial weightbearing on the heel for forefoot ulcers or complete non-weightbearing. Research has shown non-removable offloading devices such as casts to be more effective than removable devices. This is likely due to forced adherence.6-7 Patients also get instructions to elevate the affected extremity consistently, limiting dependency on ambulation to 30 minutes at a time.

   The provider most often changes the dressings in the clinic each week, which has worked better than at home dressing changes in my patient population in almost every case. As a general rule, the wound care products one applies directly to the wound do not usually promote healing as much as strict offloading, elevation and compression when appropriate. We measure wound size and depth at each visit to determine if there is progress with the current wound care regimen. If not, we alter the treatment. One must question the patient at each visit about changes in activity, blood sugar and other factors to determine if other factors are preventing healing.

Pertinent Insights On Preventing Diabetic Ulcer Recurrence

After achieving healing, offloading with appropriate shoe gear, orthotics or bracing is imperative to help prevent recurrence. Several studies have shown some benefit in the prevention of re-ulceration with the use of therapeutic footwear.8 Researchers found this benefit was even more significant in those patients with severe foot deformity. I frequently utilize shoes with forefoot rockers to offload pre-ulcerative lesions plantar to the metatarsal heads. I also use orthotics with metatarsal pads and accommodation under the affected areas.

   Hastings and coworkers determined the ideal location for metatarsal pad placement to offload the forefoot at 6 to 11 mm proximal to the metatarsal head line.9 One can also sometimes add a 3 degree rearfoot varus or valgus wedge for additional offloading when a first or fifth metatarsal head pre-ulcerative lesion is present. I have found hallux interphalangeal joint pre-ulcerative lesions to be particularly difficult to offload. However, I have had some success preventing recurrence with a more distally placed rocker sole, starting at the base of the hallux in addition to an orthotic with a 3 degree rearfoot varus post. I will sometimes also use a forefoot varus post, a toe raise under the base of the hallux and accommodation under the pre-ulcerative area.

   In Charcot feet that do not have significant plantar prominence, I have used both Charcot restraint orthotic walkers and patellar tendon bearing braces successfully. In my experience, I have found that a patellar tendon bearing brace provides the best offloading for plantar heel pre-ulcerative lesions. The patients obviously have to wear the device at all times when on their feet to avoid recurrent ulceration.

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