Conservative Management to Restore and Maintain Function in Limb Preservation Patients Tyson Green, DPM Department Chair Imperial Health Center for Orthopaedics Lake Charles, LA Founder & Medical Director Christus St. Patrick Wound Care Center Lake Charles, LA Residency Director Christus St. Patrick Podiatric Medical & Surgical Residency Lake Charles, LA Team Physician McNeese State University Lake Charles, LA
Disclosures None
Literature Review Goal of diabetics: maintain independence at all costs and not be wheelchair dependent (Buzato 2002) Patient s less likely to achieve preoperative mobility if: > 65 years old Alcoholic HTN Depression (Norvell 2012) Rates of contralateral limb amputation are high and predicted by: Renal disease Atherosclerosis Atherosclerosis plus diabetic neuropathy (Glaser 2013) Life expectancy decreases with each subsequent segment amputated (Mayfield 2001) Toe<foot<lower leg< knee/thigh Limb length directly related to life expectancy
Literature Review In cases of BKA, will patient wear prosthesis? Relative energy cost (rates of oxygen uptake divided by maximum aerobic capacity): 42% for unilateral BKA 63% for unilateral AKA (Reiber, et al. 2002) Large VA study revealed only 9% of AKA patients and 34% of BKA patients used prosthesis (Humphrey, et al. 1996). Numbers are improving 64% of BKA patients used their prosthesis (Evans, et al 2011) Success heavily relies on aggressive physical therapy, patient education, interaction with prosthetists Reiterates need for successful offloading prior to reaching level of BKA
Literature Review How Effective is Orthotic Treatment in Patients with Recurrent Diabetic Foot Ulcers? Fernandez, et al. JAPMA 2013 117 diabetic patients prescribed therapeutic insoles and footwear based on detailed biomechanical study All had hx of foot ulcers, none had previous orthotic management Before treatment Ulceration rate: 79% Amputation rate: 54% 2 year follow up Reulceration rate: 15% Amputation rate: 6% Peak plantar pressures reduced significantly (p<0.5) in those who did not reulcerate Sick leave reduced from 100% 26%
The Neuropathic Foot Will occur in 13-68% of diabetics (van Dieren et al., 2010) Affects sensory, motor, autonomic components (Shenoy, 2012) Loss of protective sensation Intrinsic muscle dysfunction Anhydrosis Above lead to bony deformities and increased plantar pressures resulting in skin breakdown (Boulton et al., 2005) Repetitive mechanical stress (pressure) during gait believed to be primary cause of most diabetic ulcerations. DPN reduced joint ROM, active muscle power and changes in gait (Andersen, 2012) 1 st MPJ main site of biomechanical dysfunction leading to increased plantar pressures promoting ulceration (Turner et al., 2007)
Gomes et al., 2011 Kinematics DPN patients exhibited greater hip flexion in comparison to health controls (HC) Also exhibited reduced hip extension, knee flexion and knee extension Both maximum ankle PF and DF were significantly reduced.
Clinical Biomechanics Meta-analysis Majority of studies reported DPN patients: Slower cadence Shorter strides Longer stance phase Higher maximum support moment Combination of extensor moments at hip, knee, and ankle
Offloading devices Acute vs longterm setting Acute Surgical shoe Forefoot offloading shoe Total contact cast Longterm Custom orthotics Shoe fillers, offloading modifications Custom shoes CROW boot With advances in components, modifications able to be made to both groups
Goals of Offloading Reduce or disperse plantar pressures Stabilize foot Reduce shear forces Maintain compliance Easy to apply Satisfying appearance Allow patient to maintain lifestyle and decrease hindrance
Orthotics Must offload current deformity Disperses plantar forces Best when multilayered
Materials Ethylene vinyl acetate (EVA) Poron Plastizote Cork Urethane polymer Polyethylene
Literature Review The Physical Characteristics of Materials Used in the Manufacture of Orthoses for Patients with Diabetes Paton et al. FAI 2007 Purpose: To investigate the physical properties of materials used to fabricate orthoses designed for the prevention of neuropathic diabetic foot ulcers. Methods: 15 commonly used materials: 4 various specs of Poron, 3 densities of 12mm EVA, 12mm low-density plastazote, two depths of Cleron, PPT, and MaxaCane Evaluated for density, resilience, stiffness, static coefficient of friction, durability, and compression. Results: Best dampening materials were Poron 96 (6mm) and Poron 4000 (6mm) Best for motion control: High-density EVA and Lunacell Nora EVA
Shoe fillers: Partial 1 st ray
Shoe filler Extremely helpful postoperatively Further stabilizes foot in shoe after 1 or more forefoot amputations by filling the void Allows for shoe of similar appearance of contralateral foot to be worn
Shoe filler: TMA
Shoe fillers: TMA 52F diabetic with left TMA
Rocker Bottom Sole Assist in restoring normal motion Best way to offload forefoot Place apex proximal to area of concern Creates a mild midstance assisting in restoring gait Must capture deformity Temporary Permanent
Forefoot Offloading Shoe Plantar Pressure Relief in the Diabetic Foot Using Forefoot Offloading Shoes Bus, et al. Gait and Posture. 2009. Purpose: Assess the offloading efficacy of four different forefoot offloading shoe models in comparison with a cast shoe and a control shoe Methods: 24 patients- all neuropathic diabetics at high risk for plantar ulceration In-shoe pressures were measured during walking in all 6 footwear conditions Peak pressures, pressure-time integral, and force-time integrals were calculated Load transfer diagrams developed to assess the footwears MOA Walking comfort measured via VAS Results: Peak pressures and pressure-time integrals at metatarsal heads and hallux were significantly reduced by 38-58% in all models vs control 20% less than cast shoe 40% of forefoot load transferred to midfoot. VAS in FOS 2.7-5.9 Control shoe 8.2 Cast shoe 6.8
Acute setting offloading
Offloading Shoe
Patient Example 46M with chronic right heel ulceration Progressed to OM of calcaneus Confirmed via MRI and bone biopsy Extremely active patient Works 40-50 hours per week Many outside activities, small children
Heel Offloading Boot
Longterm offloading example Recurrent ulceration under plantarflexed 3 rd metatarsal head
Longterm offloading example
Longterm Offloading
Acute stage Charcot foot
Stage II Charcot foot Stage II Charcot with maximal ankle DF
Stage II Charcot foot with chronic ulcer
Charcot Restraint Orthotic Walker (CROW) Increases stability and support of Charcot deformity Fully enclosed, clam-shell device made of plastic or fiberglass Custom molded to patient s foot Rocker-sole assists in forward propulsion Allows for even distribution of force/stress throughout foot, including deformities
CROW
Thank You
Conservative Management to Restore and Maintain Function in Limb Preservation Patients Tyson Green, DPM Department Chair Imperial Health Center for Orthopaedics Lake Charles, LA Founder & Medical Director Christus St. Patrick Wound Care Center Lake Charles, LA Residency Director Christus St. Patrick Podiatric Medical & Surgical Residency Lake Charles, LA Team Physician McNeese State University Lake Charles, LA