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Your patient may benefit from an percutaneous achilles tendon lengthening procedure that will help reduce the strong plantarflexory force that contributes to the breakdown of charcot foot. Your patient may also need a plantar exostectomy of the first metatarsal head with removal of tibial and / or fibular sesamoid bones depending upon location of ulceration. The diabetic patient must have good blood supply to heal this procedure and should be performed only by a diabetic foot specialist who is skilled at performing these procedures. Hope this helps. Dr. Brian Richman DPM (Utah)

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Hello,

I don’t have any help for the orthotics part. However, I am battling a wound on a foot that sounds a lot like this right now. The patient was finally convinced to stay off her foot (NWB) and we are about to get it healed. Until this, she was continuing to lay down more callous than I was being able to keep scaled off .

Vicki, MSPT, CWS

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Dear Mr. Tabor,
How about referring to a physical therapist for
soft tissue and joint mobilization? I am not sure he will benefit from joint mob but I would think tissues are tight and when they are, we usually recommend stretching, mobilization prior to doing orthotics...maybe do contact
casting after a period of mobilization, then finally permanent orthotics. Hope this helps,
Maria Carunungan, DPT, CWS

Considering your mothers' age and not knowing her health status, I would try the most conservatively/aggressive approach. This also depends on the amount of pain your mother is having and if she/you are willing to consider the risks involved of surgery at her age. I have used electrical stimulation multiple times for aiding in chronic wound healing- mostly vascular and diabetic. There needs to be a 30 day period of no wound progress in order for reimbursement of ES from Medicare. We have used ES in the clinic and have also sent portable units home with the patients for daily use. This is a difficult case due to multiple factors. If there has been several attempts at changing wound care agents, then bypass is the only alternative for long term pain relief and resolution of wound.

Christine Walker LPTA, WCCS

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Hello. The electrical stimulation is used for different reasons in wound care. We can use the high volt pulsed current (HVPC) at
negative polarity which will help draw away infection and control edema...and with positive polarity will facilitate granulation with increased arterial flow. The HVPC has been researched and evidence supports its use especially for wounds who have not shown progress in 4 weeks. However, the use of e stim is not recommended for all wounds. If it is an arterial ulcer, bypass
may still be the better option as it will provide benefits for longer periods. If this is not considered, you may want to consult with a
physician about referring your mother to a vascular specialist to determine how severe the arterial insufficiency is. For the less severe
cases, would benefit from e stim, resisted exercises to encourage collateral
circulation...but for the more severe cases, it may be necessary to limit activity at the ischemic areas.
Hope this helps,
Maria Carunungan DPT CWS
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Hello,

Electric stimulation sometimes can help chronic wounds heal. However, the bypass would hopefully restore adequate circulation to the foot, and prevent recurrent wounds on her feet/legs. Your MD should describe to you the reasoning behind the recommendation for surgery; he or she should have done testing to confirm that your mother has poor arterial blood flow, and can discuss with you the options available. A certified wound specialist PT would know how to apply the e-stim to the wound.

Vicki, MSPT, CWS
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I am a fellow working at St. Francis Hospital Wound Clinic. I'm not familiar with  "electrostimulation," but what I would say about a wound with underlying arterial insufficiency is that there are some conservative measures that may help. First of all, an ischemic ("not getting enough oxygenated blood") extremity with a wound should be kept covered as much as possible. This will increase its temperature and improve blood flow, because even the slight loss of heat from uncovering a limb can cause constriction of blood vessels. A thick soft covering such as a "Rook boot" can improve the passive warming even more. The more time
the wound is kept covered/warm, the better.

Actively warming a wound site requires more care, because the risk of inadvertently
burning or injuring the skin is always possible. Thus, our clinic does not recommend heating pads, warm pools, etc. There is a special non-contact radiant heat bandage called Warm-Up Active Wound Therapy, by Augustine Medical Corp. It is a device approved by the U.S. Food and Drug Administration (FDA) that attempts to create a warm, moist environment for a wound. Unfortunately the device is temporarily
off the market, but some wound clinics may still have stocks in supply.

Hyperbaric oxygen may assist in increasing the development of new blood vessels
and improving healing. However, it may first be useful to have a measurement of the transcutaneous oxygen gradient (TCO). In this test, an electrode is placed on the skin and gently heated, and the flow of oxygen in the skin is measured.
The patient then receives pure oxygen by mask, and the resulting change in oxygen levels is assessed. Normal TCO for healthy people is about 55 mmHg (millimeters of mercury). If the patient's skin near the wound has a TCO of 40 or more, poor oxygen flow is unlikely to be the main problem. On the other hand, if it's less than 20, improving oxygenation is essential in order to achieve wound healing. If giving oxygen by mask does not improve the TCO score by more than a few points, it is unlikely that hyperbaric oxygen treatment will help, and surgery may be necessary to achieve healing.

I'd also make sure your mother has no evidence of nutritional deficiencies, which are common in the very elderly. Zinc, Vitamin A, and Vitamin C are all very important; you may want to try a multivitamin if nothing else.
Also make sure she's not on any medications that might impair wound healing, such as steroids or non-steroidal anti-inflammatories such as ibuprofen, aspirin, or related medicines (there are many of them).

-Rick Loftus, M.D.
Fellow in HIV Clinical Care
San Francisco General Hospital

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I am glad you asked. The lastest innovation for non-invasive wound healing is electromagnetic therapy (ET). CMS (Medicare) has just issued a ruling that ET is to be covered for stage III or IV chronic wounds that have not responed to 30 days of conventional treatment.

The only viable form of ET currently available is the Diapulse Wound Treatment System, which when applied correctly decreases swelling and increases blood flow. It is risk-free and treats through dressings and clothing. The human body does the rest on its own. Its use requires a prescription from a physician or podiatrist and it is now covered by Medicare.

For more information please go to http://www.diapulse.com/

Thomas A. Sharon, R.N., M.P.H.

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Please consider having a wound specialist check the wounds. Black tissue may be dead tissue which need to be removed as this
slows healing. Silver dressings are often effective in keeping infection in check. You may want to ask about these too. Hope this helps-
Maria Carunungan, DPT, CWS

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Using Betadine to dry them out and keep them stable might be helpful. Create an eschar. Management, not healing, sounds like the goal.

Renee C., MSPT, MPH, CWS
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Try a product called Tenderwet, you can obtain it through http://www.medline.com/ it will debride the necrotic tissue. I have used it on several patients with necrotic wounds and have gotten great results. They also have several other products that are great. On their web site they have a program where you can discribe the wound and they will give you suggestions on what to use.

Teresa Staggs, LVN

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Hello,

If this patient’s death is expected soon, the best option for this wound might be just cover it with a suitable dressing for drainage management and odor control as needed. I worked in Hospice for 4 years. Many times terminally ill patients develop wounds that are simply not going to heal under any circumstances due to poor nutrition, perfusion, etc. The unfortunate aspect of this is that they can be painful, and the sight or smell can be very troublesome to the pt and family. There are dressings available that contain materials like carbon that absorb odors. Also, if drainage is a problem, alginates and dry gauzes/abd pads absorb lots of drainage, and also may simply need to be changed often.

All that said, sometimes families need to feel that everything possible is being done for the patient. I will never forget the Hospice patient that took his last breath while I was debriding the leathery eschar from a small lateral malleolar pressure sore. His daughter demanded it be cleaned up and the MD therefore demanded I do it even though the Hospice nurse knew death was imminent. If this patient’s family is asking the wound be cleaned up, see if you can get a wound specialist to take a look. The silvadene you are using might be as good as anything at this point. It will keep the wound moist, and fight bacterial growth.

Vicki, MSPT, CWS

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Try web site http://www.nursingtips.zoomshare.com/

if not there you can request a search for the information

for now it is a free service

Staggs, LVN

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Generaly, LPN's or LVN's are license to perform all nursing procedures and tasks under the direct supervision of a R.N. In my opinion, you can best utilize LPN's to remain with a home care patient when continuous skilled nursing care is needed. Visits and wound measurements are okay but the key is "direct supervision". How that is interpreted is another matter. Does it mean that the RN has to be looking over the LPN's shoulder at all times? No. However, the supervising RN needs to be comfortable with being accountable for all of the LPN's actions.

Since you are involved heavily in chronic wound care at home, I would like to draw your attention to the latest CMS bulletin which states that electromagnetic therapy is covered by Medicare for stage III and stage IV wounds that have not responded to convention treatment for 30 days. For more info please go to http://www.diapulse.com/

Thomas A. Sharon, R.N., M.P.H.