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Orthopaedics
Nonoperative Care and Footwear for the Diabetic Foot and Ankle Patient
Built from The Surgical Management of the Diabetic Foot and Ankle
What’s inside
11 sections · 125 slides
Overview
- Scope of this topic
- Key terms used throughout
Why the diabetic foot breaks down
- The normal gait cycle
- Effect of neuropathy on gait
- Diabetes as the leading cause of neuropathic joint disease
- Losses caused by diabetic nerve damage
- Cycle of neuropathic bone destruction
- Distribution of foot problems in diabetes
- Autonomic neuropathy and skin breakdown
- Deformities caused by motor neuropathy
- Aims of nonoperative treatment
Evaluation and diagnosis
- Typical clinical presentation
- History taking in the diabetic foot
- Social support in the treatment plan
- Components of the foot examination
- Semmes-Weinstein monofilament testing
- Pain as a marker of infection
- Assessment of distal perfusion
- Perfusion thresholds worth remembering
- Transcutaneous oxygen tension measurement
- Plain radiographs of the diabetic foot
- Radiographic patterns of neuroarthropathy
- Radiographic patterns of neuroarthropathy
- MRI in suspected osteomyelitis
- Labelled white cell and bone scanning
- Laboratory work-up
- Clinical rules for infection risk
- Two-hour bed rest test
Staging and classification
- Eichenholtz classification
- Eichenholtz stages I to III
- Stage I: development and fragmentation
- Early first tarsometatarsal disruption
- Stage II: coalescence
- Progressive medial and lateral column collapse
- Stage III: reconstruction and consolidation
- Tarsometatarsal fracture-dislocation at Eichenholtz III
- Effect of off-loading on outcome
- Anatomic classification of Charcot arthropathy
- Frequency of each anatomic type
- Type 1 tarsometatarsal involvement
- Tarsometatarsal joints
- Type 2 subtalar and transverse tarsal involvement
- Transverse tarsal and subtalar joints
- Type 3 ankle involvement
- Ankle joint involvement
- Types 4 and 5
Nonoperative foot care
- Goals of nonoperative management
- Reviewing an existing foot care programme
- Risk categories for failure of nonoperative care
- Category 0 and category 1
- Category 2 patients
- Category 3 patients
- Escalation of care across the risk categories
- Care of calluses and corns
- Limits of nonoperative callus management
- Routine toenail care
- Treatment of nail fungal infection
Shoewear and prescription footwear
- Importance of proper footwear
- Working with a certified pedorthist
- Objectives of diabetic footwear
- Rationale for reducing shock and shear
- Correct shoe fit
- Categories of prescription footwear
- Healing shoes
- Postoperative and forefoot unloader shoes
- In-depth shoes
- In-depth shoe with custom orthotic
- External shoe modifications
- Rocker bottom sole modification
- Orthoses and inserts
- Custom orthotic
- Custom-made shoes
- Custom extra-depth shoes with orthotic and rocker sole
Ulcer care
- From callus to ulcer
- Callus as a precursor to ulceration
- Treatment by ulcer size and depth
- Hydrocolloid dressings
- Platelet-derived growth factor therapy
- Limits of topical antibiotics
Total contact casting
- Total contact casting as gold standard
- Why minimal padding is used
- Benefits of the total contact cast
- Healing rates and recurrence
- Practical problems and contraindications
- Determinants of healing time
- Principles of cast application
- Sequence of total contact cast application
- Interdigital padding
- Dressing the ulcer and applying stockinette
- Felt padding of bony prominences
- Plaster of Paris layer
- Fiberglass shell and rocker sole
Immobilisation through the Charcot stages
- Principles of early immobilisation
- Initial management by injury pattern
- Immobilisation once swelling resolves
- Monitoring during early immobilisation
- Duration of restricted weight-bearing in stage I
- Stage II immobilisation
Charcot Restraint Orthotic Walker
- What the CROW device is
- Construction of the CROW
- Advantages of the CROW
- Charcot restraint orthotic walker
- Selecting patients for a CROW
- Ulcer size as the decision point
Long-term care and outcomes
- Clinical challenges in long-term care
- The multidisciplinary management team
- Roles within the care team
- Complications of nonoperative care
- Effectiveness of nonoperative management
- Place of nonoperative care
- Summary of nonoperative care
- References
- References (continued)
- References (continued)
- The Surgical Management of the Diabetic Foot and Ankle