Creative Solutions for Foot Complications
July 2006 Issue
When the stakes are high and the odds are long, there are worse places to be than at the roulette table in Rick's Café Americain, Casablanca-after all, it is only money.
However, when the stakes involve the healing of a foot condition that has recently gone from bad to worse, one will soon discover it takes more than conventional methods to attempt to save it.
Roger Marzano, CPO, CPed, vice president of clinical services at Yanke Bionics, Akron, Ohio, shares his clinical experience and technical expertise concerning the application of orthotic devices that can arrest, accommodate, and better the odds of restoring non-traumatic, yet severe foot complications often due to diabetes.
The objectives are the same-reduce peak foot pressures-but the stakes increase in magnitude as complications increase. The last, best chance of fitting a patient with what most would say still resembles something familiar-looking involves adding additional orthotic modifications to custom-molded shoes to enhance and accommodate the foot's now limited function.
"For example," Marzano says, "you have a 350-lb. active, hardworking man, and his tarsal-metatarsal joints are breaking down and his foot is going into an early Charcot condition. A carbon-fiber insert placed under his orthotics will not prevent his shoe from bending, aggravating the problem. It can take up scarce room in there too. So we will insert and rivet a 1-in.-wide steel shank between the inner and outer shoe sole." He continues, "What makes it effective is the rocker modification added to the bottom of the shoe, but it is not a perfect solution: besides adding weight to the shoe, some heel slippage will result."
There are times when the answers are temporary and involve non-weight bearing on the affected side; the now more vulnerable wearer will be protected by an exoskeletal appliance against everyday obstacles. In those instances, Marzano will sometimes use a technique he picked up from a Chicago, Illinois, researcher who uses a roll of fiberglass casting bandage to keep a CAM walker on his patient's lower leg.
"The only difference between the total contact cast and a regular CAM walker is that the patient can remove the walker," Marzano says. "If we put them in it and use a fiberglass bandage to keep it on, they can't take it off.
"It is a great casting environment," he continues. "It is much less expensive than the cost of a total contact cast, and it is much less labor-intensive. The orthopedist will love you! This is going to be the wave of the future-physicians aren't well reimbursed for [total contact casts]."
Yanke Bionics is using the CAM casting technique for diabetic patients with severe complications such as foot ulcers, failed skin grafts, and Charcot foot injuries.
Skin Grafts: Low Success Rate
Plastic surgeons are getting involved in wound care centers at an increasing rate, but unfortunately the failure rate on skin grafts on the plantar surface of the foot is 35 percent, because skin is taken from another area of that body that is unlike the skin on the bottom of the foot. Often the healing of the skin graft adheres to the bony structures and the tendons underneath. That makes it very difficult to reduce shear. It is likely the grafted area will tear without that tissue mobility.
A pneumatic boot and fiberglass casting tape is sometimes used, since the compression of the boot's air bladder helps the healing process by reducing edema and lessening the already slight shocks in the casted environment. If necessary, the inner sole of the boot can be modified with an aperture relief underneath ulcerated areas and then recovered with the inner sole of the diabetic shoe insert to relieve the area of pressure.
Cautions with CAM Walker
"I put a heel lift in the patient's opposite shoe every time I fit a CAM walker," says Marzano. "I've seen patients come in with herniated spinal disks from wearing a boot for the 12 weeks of their Charcot episode. As soon as they got out of the boot, a diskectomy had to be done. Be very aware when fitting these boots: we should automatically build up the diabetic insert on the other side to protect the patient's back."
Gordon Zernich, CP, is employed at the Veteran Affairs (VA) Medical Center in Miami, Florida.