What The Evidence Reveals About Midfoot Ulcers In Patients With Diabetes
Various authors have also reported major complications consisting of continued fracture and deformity, osteonecrosis, deep venous thrombosis and amputation.12-18
Early and Hansen reported on surgical reconstruction in 10 patients with midfoot Charcot and recurrent ulceration.19 The follow-up time was 28 months. Major complications included two patients with osteomyelitis requiring BKA and one postoperative death secondary to a myocardial infarction on postoperative day three. The remaining seven patients healed with minor complications occurring in only four patients (wound dehiscence in three patients and hardware failure without loss of correction in one patient).
Educating Patients On The Different Treatment Pathways And Associated Risks
The first encounter with a patient who has a midfoot ulceration should involve a frank discussion as to the poor prognosis associated with this ulceration. With this in mind, I discuss the following treatment pathways with the patient.
The first pathway involves patients going against the medical advice of conservative or surgical treatment recommendations, and continuing to self-treat their ulceration. It is important to tell patients that self-treatment will fail to heal the ulcer. If infection occurs, these patients will most likely require hospital admission with a high potential for lower extremity amputation.
The second pathway is conservative treatment consisting of non-weightbearing in a total contact cast followed by strict adherence to a lifelong routine of dedicated lower extremity hygiene, foot care, custom orthotics and the use of customized or custom shoe gear with or without adjunctive bracing. Patients choose this pathway knowing that the potential for ulceration recurrence, future surgical intervention and lower extremity amputation is high.
The third pathway is exostectomy followed by the aforementioned lifelong precautions. Patients choose this knowing that the potential for ulceration recurrence and lower extremity amputation is high.
The fourth pathway is partial amputation of the foot to eradicate the deformity that resulted in ulceration.
The fifth pathway is surgical reconstruction of the foot with education on the prolonged postoperative recovery course and weightbearing restrictions (six to 12 months), and the high risk of associated complications. Following this, patients take the same lifelong precautions and have the potential for lower extremity amputation I previously mentioned.
The sixth pathway is primary below-the-knee amputation.
No matter what treatment pathway the patient chooses, one should discuss the potential risks for significant complications to occur, primarily below-the-knee amputation. Physicians should also emphasize the importance of lifelong precautionary measures including a daily below-the-knee hygiene protocol, routine foot/nail/callus care and the use of proper orthotics, shoe gear and/or bracing.
Emphasizing The Need For Family Involvement And Multidisciplinary Teamwork
The treating physician should involve the patient’s family and support network in these discussions so they are also aware of what treatment entails. One should also discuss ease of accessibility of a wheelchair, walker, crutches, etc., in the patient’s home and potentially his or her place of employment. Does the patient need to use any stairs? Are all areas where the patient must go wheelchair accessible?
A consult to physical therapy can be beneficial in having these patients properly trained in the safe use of assistive ambulation devices to maintain their weightbearing restrictions safely. One should consider short postoperative hospitalization in patients who have extensive surgical intervention. Hospitalization ensures patient safety postoperatively and reinforces proper techniques for non-weightbearing and antithrombotic prophylaxis if patients use prophylaxis in the postoperative period.