Offloading Difficult Wounds

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Wounds in the diabetic population represent a significant medical and economic burden. If foot pressures are to be reduced, healing to progress, and prevention of ulceration to be a realistic goal, offloading is imperative.

http://lowerextremityreview.com/article/diabetes-offloading-difficult-wounds

 

Hi, I thought this would be an appropriate thread to continue on with my question.

CC: A 76 y/o male presented for the first time to my podiatry clinic in Nov '10 with a long standing HX of R/ pl. 1st mpj ulcer. Duration of 5 years and previously being treated by GP, district nurse, surgeon for debridement but no off-loading. Had not seen a podiatrist before.

HPI:Ulceration came about because pt has osteoarthritis to L/knee and subsequently increased WB to R/limb to compensate for pain, therfore has increased his pl. pressure

PMH: Mild Parkinson's disease withy R/leg tremor (intermittent). No neuropathy. Walks with stick. Otherwise in good health.

PE: Gait: Pt has a heavy foot strike to R/leg with minimal heel contact and
slight supination midstance, with most pressure falling on his 1st mpj through midstance and toe off. Pt also retracts the hallux at the same time.

DT: When pt first presented to me, the wound was tested for; malignancy and diabetes - none of which were detected.

Treatment plan:
1) for the last five months pt has been attending fortnightly pod appts for debridement of callus peri-wound and offloading with 10mm scf, gradually reducing to 7mm in the last two months or so. DNS have been dressing changing in-between appts twice weekly. The offloading with felt has worked really well and wound closure is almost complete.

My question is:
I want to prescribe an orthotic for long-term off-loading but I am not sure how best to go about designing this device or what features to include to acheive this. My client has been assessed for a knee replacement but the surgeons won't operate until the ulcer heals so I don't want it to break down again.

Your advice/suggestions would be most appreciated. Thank you in anticipation.

 

Hi 2 Whiskers1

I would knock this off into another thread as a case presentation - I think it will probably be better responded to .

It's a nice topic, worthy of a discussion.

Just a few things to consider. Is the ulcer purely as a result of compressive force or is there a large element of shear involved?

If it is largely compressive force, what has allowed it to heal so far? Offloading yes but where has it offloaded to and how with reference to centre of pressure.

How might joint axis (sub talr joint)affect the kinetics and determine the forces through the foot and ultimately the ulcer

Are there any other factors affecting the distribution of pressure throughout the foot eg equinous at the talo crural joint

What other factors need to be taken into consideration when prescribing a pressure relieving orthosis if there is the requirement for an offload in the magnitude of 7mm.

Cheers

Robin

 

seems he has very little heel contact which is indicative of an equinas. Take a lateral of the ankle and see if it's rigid. (bony) If not, consider a TAL (percutaneous) to evenly distribute pressure over the plantar aspect of the foot. Othotics aren't going to help much. Many times wounds are not addressed according to plantar pressures and if a patient can undergo a surgery, by all means consider surgical intervention.

 

Patient who has had an ulcer for 5 years that has failed to heal with no offloading.

Felt offloading has reduced ulcer size(in addition to other factors, I'm sure) in 6 months.

Why are orthotics not going to help much?

 

In 6 months, is shouldn't be reduced. It should be healed. Orthotics control biomechanical function and area axis altering. The problem is a saggital plane contracture if there is very little heal contact. How is an orthotic going to control this saggital plane deformity? Heel lift. Ha. Felt is a pressure distribution modality

 

interesting reading?

Is this a pun? I didn't make any assumptions about the cause of the lack of heel contact. You may well be right, but you might be wrong?

I would have thought that any orthosis would accommodate the sagittal plane deformity(if present).

Does a heel lift in a patient with an equinous contracture not alter the ground reaction force at the foot/orthosis interphase?

Felt alters the ground reaction force at the foot/surface interphase. So do orthotics.

 

Here's the PE
Gait: Pt has a heavy foot strike to R/leg with minimal heel contact and
slight supination midstance, with most pressure falling on his 1st mpj through midstance and toe off. Pt also retracts the hallux at the same time.

I'll try to address your issues.

1. with limited heel contact, what's the contributing factor? Fixed equinas? Compound anterior and posterior or just ankle equinas? What else would limit heel contact? Of course it's equinas.

2. He has a supinated midstance. What's the foot supposed to do during midstance? It's indicative of a supinated foot with equinas and a plantarflexed MPJ, since that's where his ulcer is. Do orthotics control supinated feet well? If it is supinated, the foot is locked. How is your orthotic going to control this saggital plane deformity in a locked foot? Heel lifts increase forfoot pressures, much like high heel shoes do in women. So no, no pun.

3. Orthotics control saggital plane defomity by either lifting the heel to accomodate or stiffen the midtarsus by acting as a rigid strut to prevent midtarsal breaching. they aren't great controllers of saggital plane deformity other than addressing drive and drop of the navicular which in a supinated foot, like in this case, isn't happening.

4. In this case, the ground reactive force is altered by felt by being a dispersive for pressue. That's about it. Felt is a poor substance because it compresses and eventually looses it's value and will have to be replaced often. The best way, provided the patient is a surgical candidate, is to address the equinas which is causing excessive forefoot loading on a supinated foot with more than likely a plantarflexed 1st ray (im only assuming because of the location. If not, then you would get forefoot to rearfoot compensation and thus not have a supinated foot in midstance. Supinated feet are 1. influenced by the achilles which is a supinator of the foot and 2. the Peroneous longus which plantarflexes and stabilized the first ray and is also active in midstance phase of gate as a prepratory to propulsion)

5 months of felt is a long time. You can cut that down to one month to 6 weeks of healing time by reducing the saggital plane deformity by TAL. I've seen patients go from chronic wounds to full healing with very little future accomodation by just addressing saggital plane deformity by TAL. All this is moot if he's not a surgical candidate but wound trimming and felting is a long laborous process that will more than likely result in re-ulceration if you are not constantly accomodating this patient. Some patient's are like that as they are not a surgical candidate and it's what you HAVE to do. These patient's become life patient's and why not do the right thing and address the deformity and give the patient a plantigrade foot and accomodate with orthopedic shoes and inserts? I mean if all you can do is felt, then that's all you can do. Do yourself and the patient a service and address the deformity. If you can't then send to a DPM that is properly surgically trained to address deformity. A simple TAL percutanously done can be performed in about 20 minutes under local in an office setting. If one is not comfortable with that, then do it in the OR. The subject is offloading difficult wounds. Wound are present because of focal pressure. 5 months of felt is BARELY accomodating and not addressing the problem which is the mechanical component which in the case of a saggital plane defomity - orthotics help very little. Wounds that are difficult should only be difficult if there is vascular compromise in which surgical bypass is not an option. Otherwise, they dont' have to be difficult if you address the deformity.

 

For me,
1st With reduced heel contact and supination, l would increase the heel pitch slightly, by either orthosis or heel build up, to meet the heel and better distribution of the load, if the heel is up 10mm l would build up only 6mm to start with.

2nd A rocker sole with 20mm diameter hole in that sole under the 1st MPJ, not all the way through, a lateral flare might(?) be needed to stabilize.

3rd The obvious TCO

4th In-shoe pressure mapping to make sure l did it right or to make adjustments

Of course gait would need to be seen to be sure that all of this is right, hope that helps

 

delirious,

I don't have time to respond this right now but I'll just start by saying that you are making a recommendation to perform a surgical intervention based on scant information. I have recommended nothing, nor tried to push my view on an appropriate treatment plan as there is insufficient detail. I suggested considering several factors with regards to deciding on a treatment plan, conservative or otherwise.

Anyway, as I said, for a starter.....

Knee flexion contracture? Parkinsons, so could have spastic hamstrings that do not allow full knee extension in terminal swing?

You are making unwarranted assumptions Stating that the only reason for anyone to have limited heel contact is to have equinous is nonsense.

 

It's an open discussion. Im only stating from what was given. Really, I came to the forum to get a question answered about billing. You are right, there's lots of information that's not here but you know that. I know that. I've treated 60 patients so far this week and I'm not really wanting to dive into one more patient, so I went with what info was provided. I can assume anything but won't really know until I've had hands on. Even if we had all the facts, different docs see different things and what works in one mans hands may not work in mine and vise versa. I stick by what I said given the information provided, but this isn't a real life patient contact visit which of course would be a full history and physical. It's like asking about why your car is making a funny noise on the internet, WHO can diagnose the problem without hands on. Just saying. If there's more information provided, then maybe I will change my perspective. My point was to consider surgical options if the patient is a candidate. The DPM profession has grown through examination of all avenues of treatment, not just padding the problem to death. Yes I am making a recomendation, one can take it or leave it. It's just a recommendation based upon what little information there is and is by no means the end all treatment. It's just an observatoin and suggestion. Might I say the same about applying felt and an orthotic. One should probe deeper before just suggesting those. 6 of one half dozen of another.

If the patient had the things you mentioned, those would be obvious and pointed out. Why leave out the those contractures if they did exhist? Either they were overlooked, thought not important or not existant. Just like my assumption of equinas. Didn't say it exhisted but the clinical findings on the scant description leads to it. Doen't mean he has it.

PMH: Mild Parkinson's disease withy R/leg tremor (intermittent). No neuropathy. Walks with stick. Otherwise in good health.

 

Again, I didn't suggest anything, felt or orthotics. I asked the OP to consider several different factors. However, thanks for the advice that one should probe a little deeper

 

It's not advice, It just applies to the situation. It's obvious more informatin is needed, and I am by no means saying what needs to be done is ultimately surgical. Just one option to consider as well.

 

thx Delirious and RobinP for all your opinions, good food for though, great coverage quite a few options in offloading

 

Interesting discussion.

Delerious, I think you're partly right. The bit about possible options. I think you're wrong in the options you appear to write off.

The patient has parkinsons and balance issues (stick). Could be a tonal equinus. In which case the length of the ta is not so important as it's what it's doing. Given the nature of parkinsons and the difficulty it causes in adapting to new motor patterns, I would not be considering surgery until we'd exhausted all other options, which we've obviously not!

I'd agree that felt is a short term or stop gap solution at best and of it's not worked in 5 months it won't work in 6!

From what you say, delerious, I think you have a very different concept of orthoses to Robin and I. It's a geographical thing.

Boots n all made an excellant point about pressure mapping. This is exactly the sort of situation 4d vls is best at. I'd say in an ideal world that should be the first thing we did.

But based on the information at hand, I'd go with either David's suggestion of a big ass rocker sole with a cavity or a darco forefoot sandle with a window. AND felt. Lots and lots of felt. 20 mm whole foot with filled In arch.

Or TCC. That would be good.

That would heal it in THREE weeks, (less than a tal). As long as we're prophesiing.