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
Proven Strategies To Prevent Lower Extremity Amputation
Patients with significant deformity and adequate vascular status may benefit from surgical correction to reduce pressure and avoid re-ulceration.10 Surgery ideally happens after the wound has healed but can sometimes occur to promote healing in situations in which local wound care has not been completely effective. For distal and dorsal toe ulcers in relatively flexible hammertoe deformity, percutaneous tenotomy (with a local anesthetic for the patient) works well to correct deformity.11 One can often perform the procedure safely and achieve good results, even in elderly patients with multiple comorbidities. Other standard or minimal incision procedures include bunionectomy, proximal interphalangeal joint arthroplasty or fusion, metatarsal osteotomy, midfoot or rearfoot fusion, and even Charcot reconstruction on a case-by-case basis.12
One must critically evaluate the patient’s health status and ability to adhere with postoperative instructions in order to select the best procedure for the patient. Researchers have reported that tendo-Achilles lengthening and gastrocnemius recession reduce pressure on the ball of the foot and aid with ulcer healing and prevention.13 When performing a tendo-Achilles lengthening, take care to avoid over-lengthening in order to prevent plantar heel ulceration in the neuropathic foot.13-14
Routine follow-up of patients with a history of ulceration has been critical in maintaining long-term healing.15 Some may develop calluses in the area of their previous ulcer that need periodic debridement to avoid re-ulceration, even with the use of appropriate footwear. Periodic replacement of therapeutic shoe gear, orthotics and bracing is important in order to maintain appropriate support and protection of the patient’s feet. Researchers have shown that patient adherence to wearing prescribed footwear at home is poor.16 We repeatedly give written as well as verbal foot care instructions to patients through our clinics in an attempt to improve adherence. Pamphlets are also available in the waiting rooms at our outside clinics for patient education.
I will admit that wound care is extremely labor intensive with frequent, long visits required to provide appropriate care. Even with the significant emphasis on wound management at our facility, we are not always successful in healing wounds or maintaining healing without amputation. There is no magic involved in healing diabetic foot ulcers but most ulcers will respond to a standard protocol of basic wound care strategies in combination with comprehensive, multidisciplinary patient management.4,17-18
Dr. Schweinberger completed a limb preservation fellowship at Madigan Army Medical Center in Tacoma, Wash. She currently works in the podiatry department at the VA Medical Center in Cheyenne, Wyo.