By: Normal A. Siddiqui, DPM, MHA
A 60-year-old female with a history of Type 2 diabetes, neuropathy and high blood pressure related that she had developed a non-healing sore after she noticed her “arch collapsed” a year earlier. She had seen multiple doctors but had not had any success healing her open wound. She was seen by the diabetic limb preservation team following her hospital admission for a foot infection. She explained that she had been told that having her leg amputated was a very real possibility if her wounds would not heal.
Reviewing her radiographs revealed that she had developed Charcot Joint in her ankle – a condition that can develop in patients with a positive history of diabetes and neuropathy, resulting in a loss of stability in the bones of the foot. Over time, the bones fracture and lose their normal shape, which results in pressure to the skin from uneven distribution of the individual’s body weight. After controlling the infection, the patient was given the option to heal her wounds surgically, since they had failed to heal using other methods over the course of a year.
An Ilizarov external fixation device was used to treat the complex foot wound. This device is a system consisting of rings and pins that is applied externally to a patient’s extremity. The device offloads the wound while simultaneously fusing the joints that are unstable. She underwent treatment for three months until the wound was healed and her unstable bones fused and achieved stability.
At the end of this treatment, the patient had no open wounds and was able to ambulate in a supportive diabetic shoe. She continues to be seen for routine followup, and has not developed a new ulceration. She was thankful that the diabetic limb preservation team was able to save her leg from amputation.
Discussion: Diabetic foot ulcers are one of the most common complications associated with patients with a history of diabetes. Studies show that 25 percent of diabetics will eventually develop a foot ulcer.1 It forms in a diabetic patient as a result of neuropathy, peripheral arterial disease or pressure. In many cases, it is a combination of these factors that cause the ulceration and prevent it from healing.
Non-healing ulcers or wounds present a significant medical challenge since studies have shown that 50 percent of diabetic foot wounds become infected and can lead to amputation at higher rates.2 Diabetic patients who undergo amputation have a much higher mortality rate than those without diabetes. These statistics are alarming, since the American Diabetes Association estimates 30 million people in the United States have diabetes.3 Numerous studies have shown that the direct cost of treating chronic diabetic wounds has increased to $13 billion in the United States annually.4
These statistics highlight the significant medical and public health burden that diabetic foot wounds pose to the population. The treatment to heal chronic foot wounds in a diabetic population is a multi-disciplinary effort requiring medical and surgical specialists. The Diabetic Limb Preservation team focuses on healing chronic non-healing diabetic foot wounds using advanced surgical and medical technology.
External fixation is one of the many surgical methods that are used when treating chronic wounds. Each patient is assessed for the specific cause that is contributing to a delay in healing and treated accordingly. Ultimately, wound healing has many factors. In the right patient, surgical reconstruction of the foot can be a powerful and effective method to prevent amputations associated with diabetic foot wounds. However, the goal for physicians must be on diabetes management and prevention so as to avoid the multiple systemic consequences that are associated with this terrible disease.
Noman A. Siddiqui, DPM, MHA, is division chief of Podiatry at Northwest Hospital, Randallstown, Md., and medical director, Diabetic Limb Preservation at LifeBridge Health. He can be reached at nsiddiqu@lifebridgehealth.org
1 Singh, Armstrong, Lipsky. J Amer Med Assoc 2005
2 Lavery, Armstrong, et al. Diabetes Care 2006
3 Diabetesatlas.org/American Diabetes Association
4 Rice, Desai, et al. Diabetes Care. 2014; 37:651-658
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