Diabetic foot Reply#1
Molly Pitcher C.P.O.
Description
Collection
Title:
Diabetic foot Reply#1
Creator:
Molly Pitcher C.P.O.
Text:
Dear list, thank you to all who responded. I have included my answers in
several e-mails. Below is my original e-mail:
I am looking for some advice on handling a very difficult diabetic foot
situation.
>This is an oral-medicated diabetic with a three-year history of bilateral
midfoot ulceration. She was fitted with CMS's at some point but these offered
little support and that's how she came to my office.
On the right she is missing her great toe and first ray. On the left, she is
missing the great toe and the MT head. On WB she is in severe equinovalgus
with forefoot abduction. Her remaining digits on both feet are clawed and
rigid. Her feet can be ranged to a neutral position(MLplane) but her heel
cord is contracted. She is without sensation below her knees. She is fully
WB using no crutches, canes or WC. She is generally a household ambulator
but goes grocery shopping and drives. She is 5'10 and weighs 200 lbs. and
is gaining more weight. Presently she has a 4-cm ulcer on both feet, which
are sterile dressed daily and debrided weekly by an orthopedic physician.
>I fitted her with a custom AFO with a well molded and padded footplate
accommodating the heel cord contracture. She wore these inside a rocker
bottom cast shoe, which was the only shoe that would accommodate them. I
urged her to use crutches or a walker but she will not follow this advice.
The AFO's reduced the forefoot abduction and elevated the midfoot. Her gait
was well balanced in them but the ulcers did not improve and she is back in
Velcro shoes with about 7 lbs. of sterile dressings covering both feet.
There is no way for her to fit into the AFO's with the dressings.
>My question regards what to do next: Will any orthosis help if she is
unwilling to unload her feet? Do you try to mold around the dressings as
best you can or do you wait for healing to start another orthosis? I did not
use the CROW walker design but is there any chance for this to be successful
if she won't use some outside support? Would a cast boot help with a molded
foot plate? I appreciate any insight you can give me regarding this
difficult situation.
Replies:
>Not much you can do when they're non-compliant. Maybe try custom molded
plastizote inserts and an ortho wedge on the worst foot, and a Darco shoe on
the other. I think that one of the feet should be plantargrade for balance
etc.
The CROW is your best bet in my opinion. They are normally used in
my area without ambulatory aids. The problem is her noncompliance. A CROW
is removable. If she can be trusted to keep her appointments, total contact
casting would be the superior option.
Sounds like a very difficult case!!! We see many diabetic patients in our
practice, and usually, physicians will either use CROW walkers or CAM walkers
(i.e. 3D boots, etc. ) with a molded plastizote footbed (usually 3/4 to 1 in
thickness) until the ulcerations heal. I've casted for the CROW walkers
right over the dressings, because chances are they are going to have dressing
changes anyway and fluctuating edema.
I had a 45 year old female, very heavy, with Bilateral Charcot feet and
ulcerations on the plantar surface of her rocker feet. I was reluctant to
try CROW walkers on her, but the physician insisted. She was just casted for
regular custom molded shoes the other day and is doing VERY well. She was
reluctant at first, but was very compliant in using them and her improvement
showed it. Don't hesitate to try the CROW walkers. Sounds like its the only
way the open lesions are going to heal for you to move on.
Use a Full unloading PTB with a over sized Diab. shoe. If you want more info
send me a reply.
Sounds like a tough job. The only advantage of the CROW is that it allows
you to use much more padding than a standard AFO - thus you can give greater
relief for problem areas without worry about how it will fit into a shoe.
Sounds like this may be what you need to do for her.
I think I'd get the advice of the doc about whether you should wait for the
wound to heal before proceeding.
The crow works very well in this situation. We insure a sufficient relief is
made in the area required to unload the ulcerated area. It provides all the
protection and support needed to allow healing and still allow the person to
ambulate. Driving will probably be the main
complaint. Weekly follow-up is highly recommended. I use Saran Wrap to
protect the ulcer when casting. Sometimes I leave some of the bandage in
place as it will be there while the person is healing but this has not been a
problem.
i have a pt that has almost the exact same problems but mine is not diabetic
and is not gaining more weight what i suggest you try for her is the orthofix
walker from vacoped www.OPEDINC.com to see the uses and ease of the product
i have used this walker in the
past in conjunction with waiting for the ulcers to heel and have a good
succes rate with it instead of going to the CROW walker which can be at time
cumbersome to pt'
several e-mails. Below is my original e-mail:
I am looking for some advice on handling a very difficult diabetic foot
situation.
>This is an oral-medicated diabetic with a three-year history of bilateral
midfoot ulceration. She was fitted with CMS's at some point but these offered
little support and that's how she came to my office.
On the right she is missing her great toe and first ray. On the left, she is
missing the great toe and the MT head. On WB she is in severe equinovalgus
with forefoot abduction. Her remaining digits on both feet are clawed and
rigid. Her feet can be ranged to a neutral position(MLplane) but her heel
cord is contracted. She is without sensation below her knees. She is fully
WB using no crutches, canes or WC. She is generally a household ambulator
but goes grocery shopping and drives. She is 5'10 and weighs 200 lbs. and
is gaining more weight. Presently she has a 4-cm ulcer on both feet, which
are sterile dressed daily and debrided weekly by an orthopedic physician.
>I fitted her with a custom AFO with a well molded and padded footplate
accommodating the heel cord contracture. She wore these inside a rocker
bottom cast shoe, which was the only shoe that would accommodate them. I
urged her to use crutches or a walker but she will not follow this advice.
The AFO's reduced the forefoot abduction and elevated the midfoot. Her gait
was well balanced in them but the ulcers did not improve and she is back in
Velcro shoes with about 7 lbs. of sterile dressings covering both feet.
There is no way for her to fit into the AFO's with the dressings.
>My question regards what to do next: Will any orthosis help if she is
unwilling to unload her feet? Do you try to mold around the dressings as
best you can or do you wait for healing to start another orthosis? I did not
use the CROW walker design but is there any chance for this to be successful
if she won't use some outside support? Would a cast boot help with a molded
foot plate? I appreciate any insight you can give me regarding this
difficult situation.
Replies:
>Not much you can do when they're non-compliant. Maybe try custom molded
plastizote inserts and an ortho wedge on the worst foot, and a Darco shoe on
the other. I think that one of the feet should be plantargrade for balance
etc.
The CROW is your best bet in my opinion. They are normally used in
my area without ambulatory aids. The problem is her noncompliance. A CROW
is removable. If she can be trusted to keep her appointments, total contact
casting would be the superior option.
Sounds like a very difficult case!!! We see many diabetic patients in our
practice, and usually, physicians will either use CROW walkers or CAM walkers
(i.e. 3D boots, etc. ) with a molded plastizote footbed (usually 3/4 to 1 in
thickness) until the ulcerations heal. I've casted for the CROW walkers
right over the dressings, because chances are they are going to have dressing
changes anyway and fluctuating edema.
I had a 45 year old female, very heavy, with Bilateral Charcot feet and
ulcerations on the plantar surface of her rocker feet. I was reluctant to
try CROW walkers on her, but the physician insisted. She was just casted for
regular custom molded shoes the other day and is doing VERY well. She was
reluctant at first, but was very compliant in using them and her improvement
showed it. Don't hesitate to try the CROW walkers. Sounds like its the only
way the open lesions are going to heal for you to move on.
Use a Full unloading PTB with a over sized Diab. shoe. If you want more info
send me a reply.
Sounds like a tough job. The only advantage of the CROW is that it allows
you to use much more padding than a standard AFO - thus you can give greater
relief for problem areas without worry about how it will fit into a shoe.
Sounds like this may be what you need to do for her.
I think I'd get the advice of the doc about whether you should wait for the
wound to heal before proceeding.
The crow works very well in this situation. We insure a sufficient relief is
made in the area required to unload the ulcerated area. It provides all the
protection and support needed to allow healing and still allow the person to
ambulate. Driving will probably be the main
complaint. Weekly follow-up is highly recommended. I use Saran Wrap to
protect the ulcer when casting. Sometimes I leave some of the bandage in
place as it will be there while the person is healing but this has not been a
problem.
i have a pt that has almost the exact same problems but mine is not diabetic
and is not gaining more weight what i suggest you try for her is the orthofix
walker from vacoped www.OPEDINC.com to see the uses and ease of the product
i have used this walker in the
past in conjunction with waiting for the ulcers to heel and have a good
succes rate with it instead of going to the CROW walker which can be at time
cumbersome to pt'
Citation
Molly Pitcher C.P.O., “Diabetic foot Reply#1,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 5, 2024, https://library.drfop.org/items/show/215440.
