Diabetic feet #3

Diabetic feet #3

Molly Pitcher C.P.O.

Try contacting John Rahman at <Email Address Redacted> . He's an expert
re: diabetic feet.

I don't know, but I think a crow walker would be a good choice.
What you have I have to say is a case that is going to be a shipwreck soon.
Good luck, and remember this isn't about orthotic care alone, it is about
total system stress (systemic and mental attitude) . Put a quarter in the
pot at Santas departemtn store hang out, it may produce more positive results.
Happy Holidays!!!.

I understand the trouble and frustration that a patient with this kind of
condition can cause, especially when they seem to be non-compliant with
treatment modalities or changes in lifestyle.I worked for two years in the
Northern Territory of Australia, based in Darwin. We covered a very large
area, with a sparse population. The majority of our diabetic patients were
Aboriginal, who pose great problems in terms of compliance and lifestyle. We
had the most success with Total Contact Casts (TCC).
When I first arrived there, and I was told of the treatment I was highly
skeptical. Surely a fully enclosed cast would be the perfect breeding ground
for
infection, or worse still cause further ulceration. In fact we had some
outstanding results. Recalcitrant ulcers that had been present for months
were healing
in a period of 3-4 weeks. And not just surface layers,full granulation, so no
deep hole with thin skin prone to futher breakdown.Once the ulcers are healed
fully we then made soft
insoles and modified the shoes to reduce thepathological forces. This was a
relatively easy
process once the ulcer is healed and healed well. The process is quite
complicated, but in essence has been around for a very long time.
I can outline the process for you, but I think it would be best to contact
Professor Ian O'Rourke at the Royal Darwin Hospital. I am sure he will be
happy to give you all the information you require.(I left Darwin over a year
ago, and I am now in Japan...so I
might be a little rusty on the details.) Sorry, but I don't have an e-mail
address, but I am
sure if you do a search on any search engine forRoyal Darwin Hospital or
Territory Health Servicesyou should find some pointers in the right
direction.

Molly , I would definately try the CROW walker. You can take the cast over
minimal dressings and make the plastizote insole removeable so that you can
modify it to deweight the ulcered area. Then you do not need to worry about a
shoe either. She should be able to function without extra support if she was
able to do it with the AFO. Best of luck.

These patients are very difficult cases. A foot orthosis will help off load
pressure sensitive areas but it is only usually good if the area is not
ulcerated. The best approach is to try and solve the problem sequentially.
Firstly, address the ulcer and start the healing. You may have to use a
total contact cast or an off the shelf AFO with the removable honeycombed
sections that will allow complete non-weight bearing on the ulcer and
surrounding tissue.
If this works proceed to stage two, where the patient can attempt to return
to normal ambulation with the aid of either a custom moulded shoe or an extra
depth shoe and a custom made orthotic. The shoes need to be protective,
spacious and plastazote lined. They may also need external modifications, to
ensure pressure off loading, such as Rocker soles, Wedges, Flares,...
If the ulcer closes the patient can then graduate to wearing sensible shoes
(Spacious and Supportive) with an appropriate plastazote insert.
Healing these cases takes a long time and requires the patients full
commitment. Once healed, the feet need to be monitored daily to ensure that
there is no recurrence. If you have any questions please feel free to call
me,


I have had great success with total contact casts until complete healing of
the ulcers, then fitting with the AFO that you described. The person could be
put in one cast at a time, but I have personally applied the casts on persons
bilaterally with surprisingly good tolerance/success. If you don't know of
someone in your area who does this type of casting then perhaps if you
emailed your location, I could recommend someone.

Contact Nancy Elftman on the west coast. She is the expert. She is in the
registry.

I have had some success using a custom molded insole inside and
Air-Cast Diabetic Pneumatic walker. The insole must off load the ulcerated
area. The walker has a nice rocker sole attached.

If the patient is not compliant then the orthoses or shoes don't have much of
a chance. If you can get her to be at least agreeable to using a walker you
might have a chance. As far as the midfoot ulcer, at 4cm you now have to not
only unweight the ulcer but you may need to also unweight the foot. Is she
showing signs of Charcot?
Did her doctor attempt total contact casts? Crow walker might by you some
time but PTB orthoses might be just as effective if not more. Unfortunately
we all have that one horrible patient who's probably real nice but hates to
follow instructions.

You may try PTB orthoses, with solid ankles set at neutral or slightly
dorsiflexed. The shoes would need to be modified for SACH heel and rocker
bottom. I would not use PAFO's, but rather old style metal locked into ortho
shoes. This assumes the skin is still fairly good distal to the knee. Since
she
is non-compliant nothing may work but who's fault is that.