Once an ulcer heals, the needs of the patient do not cease. Ulcer recurrence is a significant issue in high-risk patients. Accordingly, these panelists share their experiences and protocols, discuss patient education, and offer their thoughts on the role of surgical intervention along with a representative case study.
Once an ulcer heals, do you have a particular pathway that addresses prevention of ulcer recurrence? If so, please share your protocols including frequency of follow-up, any offloading or biomechanical measures, durable medical equipment (DME) advice, etc.
After an ulcer heals, Kazu Suzuki, DPM, FACFAS stratifies each patient by risk profile: low-, mid- or high-risk. He then schedules follow-up visits commensurate with that risk level and recommends one, two and six month follow-up intervals accordingly.
“This is much like a Doppler surveillance for peripheral arterial disease (PAD) after vascular intervention,” notes Dr. Suzuki. “You want to ‘survey’ the patient in a few weeks. Then, if everything looks good, you can extend the visit intervals slowly.”
Dr. Suzuki adds that implementation of patient education, offloading and DME is an ongoing process.
“At each visit, I check the patient’s shoes for wear, fit and cleanliness. I will make a comment on what I see, especially if the shoes are inappropriate in fit or materials,” says Dr. Suzuki. “It is very common for my patients to come in with three-year old shoes with the soles completely worn out as they may not see anything wrong with them.”
Mark Hinkes, DPM, FACFAS, FAPWCA also sees patients at progressing intervals after an ulcer heals. During these visits, he will order assistive technologies such as pressure mats or sensor-impregnated socks. He also orders two pairs of extra-depth, custom-molded or diabetic shoes, diabetic socks, braces for foot drop, offloading orthotics, canes, crutches, walkers or wheelchairs depending on the patient’s needs.
“I refer patients to a pedorthist for proper brace evaluation as well as shoe selection and fitting,” maintains Dr. Hinkes. “I also provide written instructions to the patient on the do’s and don’ts of foot care, emphasizing the need for foot inspection each morning and evening, and protecting the feet at all times.”
Chia-Ding Shih, DPM, MPH, MA, AACFAS advises providers to plan ahead when the wound is almost healed.
“It often takes some time for patients to receive a pair of diabetic shoes,” points out Dr. Shih. “There are also required documents and authorizations that take time. As a result, I frequently start the process by advising patients to get in touch with their certifying physician (i.e. primary care physician or endocrinologist). I also send the diabetic shoe prescription to an orthotist who will accept the patient’s insurance. This groundwork helps bridge the patient to fit his or her diabetic shoes as soon as the wound heals.”
He maintains that having a trustworthy orthotist whom you work well with is paramount as is being very clear and detailed in one’s diabetic shoe prescription.
Dr. Shih says he sees patients back in the office within two weeks of healing a DFU when the patient is transitioning to diabetic shoes. He finds that many patients develop new ulcers or reulcerate in this critical period. He stresses daily foot checks and after long walks as well. As with the other panelists, Dr. Shih will slowly transition to less frequent visits over time, tailoring visit frequency to the patient’s risk level and needs. He also encourages patients to regularly follow up with their primary care physician or endocrinologist for their diabetes management.
When it comes to new technology for daily monitoring, Dr. Shih is encouraged by this possibility but points out that many patients in the target population may not even know how smartphones work. He stresses that it is important to make sure the patient and/or family is capable of using the monitoring technology.
What type of patient or family education do you engage in, if any, regarding steps one can take at home to prevent ulcer recurrence?
Dr. Suzuki relates that his patient education also focuses on the limb-saving importance of daily foot checks, likening it to the importance of brushing one’s teeth daily.
“I may also mention the importance of daily walking for the sake of cardiovascular fitness and mental health. However, at the same time, I encourage limiting step counts as the skin breaks down after reaching a certain temperature, and every patient with diabetes should check the feet nightly before he or she goes to bed,” explains Dr. Suzuki. “There are a few high-tech devices to measure the skin temperature in this vein.”
Dr. Hinkes feels that patient behaviors are critical to keeping an ulcer site healed.
“I focus my energy on educating patients and their caregivers,” maintains Dr. Hinkes. “I review the chart, discuss the reason(s) why the ulcer initially developed and review what steps the patient could take to prevent a recurrence.”
He relates that controlling blood sugar, blood pressure, cholesterol and triglycerides along with smoking or vaping cessation are basic steps in this process. In order to account for what he calls the “wild card” of ulcer recurrence, patient behavior is a central tenet of success in this pursuit.
“Patients should ensure they are wearing properly fitting shoes, never walk without shoes and socks, keep their skin hydrated with moisturizing lotion and not perform ‘bathroom surgery’ on their feet,” says Dr. Hinkes. “Patients with diabetes should only have ‘medical pedicures,’ be certain that a foot bath is sterilized and that instruments are steam autoclaved and individually packaged.”
Dr. Hinkes relates that, in his experience, patients often lack diabetes education as a whole or have personal behavioral or psychological issues that preclude their ability to manage their diabetes and foot health. Once he identifies this issue, Dr. Hinkes says he will advise consultation with appropriate providers such as psychologists, nutritionists and diabetes educators.
Dr. Shih also utilizes a printed handout for patient education but personally delves into issues such as reviewing DFU pathophysiology, daily at-home care and the importance of timely and continued proper follow-up with all medical team members. He notes previous comparisons of DFU to cancer and likens patient and family education after ulcer closure to be similar to that for a patient in remission from cancer.1
“It is important to educate the patient and the family about close follow-up as the patient is now at high risk for DFU development,” says Dr. Shih.
Do you ever advise surgical intervention as a means of maintaining ulcer remission (i.e. muscle-tendon balancing, osteotomies, etc.) and if so, under what circumstances?
Dr. Suzuki often recommends hammertoe correction with flexor tendon release, especially for symptomatic toe tip calluses or toe tip ulcers. He also shares a bunionectomy can be useful when there is a resultant chronic ulcer. Dr. Suzuki also mentions the utility of tendo-Achilles lengthening for forefoot ulcers, especially when the physical exam reveals significant equinus.
Dr. Hinkes shares that he agrees surgical intervention for these patients can be beneficial for prevention of ulcer recurrence, especially when deformities are present.
Agreeing with the other panelists, Dr. Shih does pursue indicated procedures, especially in cases of underlying bony prominences and/or muscle imbalance. He says that patients with peripheral neuropathy are especially at risk in these cases.
Dr. Shih shares several points he considers when determining if surgical intervention is indicated for these patients. First, he assesses if the deformity in question is braceable. If so, he typically holds off on any prophylactic surgery. Additionally, it is crucial to know the patient’s vascular status as well as the patient’s baseline functional status prior to proceeding with any surgical intervention, according to Dr. Shih. If there are vascular concerns or if the patient is not ambulatory, he says the risks of such surgeries may not outweigh the potential benefit. Dr. Shih says it is also important in the evaluation to ascertain the patient’s hemoglobin A1c (ideally below eight to nine percent) and the status of any other comorbidities.
“I also encourage patients to stop cigarette smoking and enroll them in a smoking cessation program,” shares Dr. Shih. “Until the patient demonstrates that he or she can stop smoking for four weeks, I will hold off on prophylactic diabetic foot surgery.”
Lastly, he stresses that the provider must work to help the patient and family understand the goals, risks and potential complications of these surgeries along with assessing the patient’s ability to comply with postoperative instructions. This may include the ability to attend follow-up visits, maintain daily living activities and follow weightbearing instructions.
Can you share any particular patient cases regarding ulcer remission that stand out to you?
Dr. Shih shares a case of a 74-year-old male who lives alone and had a DFU under his left first metatarsal head. The patient has uncontrolled diabetes and a history of coronary artery disease, peripheral arterial disease (PAD) and end-stage renal disease. Dr. Shih initially saw the patient in January 2020 as an inpatient with acute on chronic osteomyelitis. Despite the odds, Dr. Shih says comprehensive care and a first metatarsal head resection led to healing of the ulceration.
“We high-fived,” says Dr. Shih. “The staff patted each other on the back because we saved his foot when he had already lost half of his other foot.”
As soon as the surgical site was nearly healed, Dr. Shih says he ordered extra-depth diabetic shoes with accommodative inserts for the patient. Unfortunately, Dr. Shih also points out that this was just as cities began to shut down due to the COVID-19 pandemic. Dr. Shih’s team checked in on the patient remotely and intermittently during this time. The patient said his foot was doing well and noted he had not yet put his shoes on but was working on it. Home health was also participating in the care of the patient due to a venous leg ulcer. The patient related that he would rather not come in for a checkup because it would take three buses to get to the clinic.
Dr. Shih shares his practice didn’t hear from the patient after April. However, in mid-August, they received an inpatient consultation for this patient for an infected DFU. Now there was an ulcer on the lateral fifth metatarsal head and plantar third metatarsal head of the left foot. The foot was red and swollen with purulent drainage from the fifth metatarsal wound. Surgical washout and antibiotics controlled the infection, but the patient still lost his fifth metatarsal head. Unfortunately, he also suffered a stroke during his admission and needed a carotid endarterectomy.
This patient’s story highlights a number of things, says Dr. Shih.
“High-risk patients with diabetes require close attention,” emphasizes Dr. Shih. “Without attentive follow-up, even just remotely, they can develop a foot ulcer in the blink of an eye. In the next second, the wound could become infected and they may lose a limb. Preventing DFU recurrence truly takes a team and a seamless process.”
Dr. Hinkes is a Diplomat of the American Board of Foot and Ankle Surgery. Dr. Hinkes is a Fellow of the American College of Foot and Ankle Surgeons, and the American Professional Wound Care Association. He is the author of “Healthy Feet for People With Diabetes” and “Keep the Legs You Stand On,” which are available at www.amazon.com. Dr. Hinkes has disclosed that he is the President and Chief Medical Officer of ePrevenir, Inc.
Dr. Shih is an Assistant Professor at the California School of Podiatric Medicine at Samuel Merritt University and a previous fellow with the Lawrence B. Harkless Fellowship in Limb Preservation at the University of Southern California. He is a Diplomate of the American Board of Podiatric Medicine and an Associate of the American College of Foot and Ankle Surgeons. He is attending staff at St. Mary’s Medical Center and California Pacific Medical Center in San Francisco.
Dr. Suzuki is the Medical Director of the Apex Wound Care Clinic in Los Angeles. He is also a member of the attending staff of Cedars-Sinai Medical Center in Los Angeles. He can be reached at Kazu.Suzuki@ cshs.org.
1. Boghossian J, Miller J, Armstrong D. Offloading the diabetic foot: toward healing wounds and extending ulcer-free days in remission. Chronic Wound Care Management and Research. 2017;4:83-88.