Diabetic Foot Treatment

Diabetic pressure wounds are frequent on the feet of many neuropathic patients. Usually, if the arterial circulation is adequate, and the nutrition status is evaluated for protein intake, the final step is to offload the area. This is, in my experience, the most difficult part of wound care in our population. Everyone wants to stay active, and walking is a major component of this mentality. This picture is an example of a forefoot pressure ulceration, which is directly related to an equinus deformity combined with neuropathy in an insulin dependent diabetic female who has been to a wound care center for 2 years prior to my evaluation. After my initial screening protocol, which consists of taking an xray, listening to the arterial pulse with a hand held dopplar, and recording a HA1c value to determine longterm blood glucose control, I proceeded to the physical examination of biomechanics. In this case, the main issue was not an underlying bone infection, or ill fitting shoes (as she had custom shoes with offloading soft insoles already placed). A definitive diagnosis of "gastroc equinus" was diagnosed.

After a couple of weeks of continued debridements in the office the wound began to improve, but the central deepest portion was next to impossible to offload.

At this time, the patient was scheduled for an endoscopic gastroc recession, which is done with a 0.7 cm incision that heals in most cases after one week. This is a profound procedure which offloads the forefoot considerably, and in this case was the final step towards healing her wound. The patient also had a dermal skin graft application which also heavily increased the healing capacity of this particular wound.

There are numerous examples of how wound care can be performed by looking at the global picture in each patient. Sometimes the foot structure itself is the issue and needs reconstruction. Sometimes a bone infection is underlying, and excision of that portion of the bone is required, and even sometimes a leg needs more circulation requiring vascular interventions. Here at FFLC, we strive to be at the cutting edge of limb salvage, which may entail any number of procedures tailored to each individual patient. We work closely with the infectious disease and vascular surgeons to offer a team oriented approach to wound care. This allows rapid wound healing, and lowers the statistical possibility of deep seeded infections which can lead to amputations.

Each wound has a cause, and without a thorough examination, followed by extensive diagnostics and microbiologic cultures, many wounds will remain nonhealed. At FFLC, we offer comprehensive limb salvage efforts which transcend most private offices. We really do have the mindset of a wound care center. Weekly comprehensive debridements, Xrays on site, MRI and ABI testing nearby, and for the more complex wounds a reconstruction repitoire which may consist of internal and external fixation. We take limb salvage very seriously, and we all know that once a limb is lost, the statistics are not in a patient's favor for a 5 year lifespan afterwards in diabetic patients.

Dr. Brian Timm is a Certified Wound Care specialist and specializes in diabetic foot treatment. At the Family Foot and Leg Center, we have healed some very complex wounds that other centers give up on. Dr. Brian Timm is now officially the head of FFLC Advanced Wound Care Clinic.