The DFU is healed, now what? Novel offloading techniques to prevent re-ulceration

Problem:  Diabetic foot ulceration (DFU) is a complication of diabetes that can lead to infection and/or amputation. DFU occurs in roughly 15 to 25% of patients with diabetes1. Recurrence rates for DFU is estimated as high as 40%2. Many of these patients have complex foot deformities or partial foot amputation. Offloading is an essential component of aftercare once a DFU has healed3. The authors present two novel approaches for offloading complex diabetic foot deformities with healed DFUs. Materials and Methods: Patient 1 is a diabetic male with an unstable Charcot foot and ankle deformity with history of DFU. Risk factors included diabetes, kidney transplant, neuropathy, CAD, and obesity. His DFU was treated with debridement, collagen, and total contact casting to closure. Long-term offloading was a significant challenge. The patient was placed in a modular patellar tendon brace/AFO to un-weight and immobilize his foot and ankle. Patient 2 is a diabetic male who required an atypical proximal foot amputation due to gangrene. A BKA was recommended which the patient refused. Risk factors included diabetes, neuropathy, PAD, osteomyelitis, CAD, and obesity. His DFU was treated with debridement, antibiotics, HBOT, collagen, and offloading to closure. Long-term offloading was a significant challenge. The patient was placed in a modified Charcot restraint orthotic walker (CROW boot) to accommodate his peg-leg foot deformity. Results: Two patients with a history of DFU and complex offloading issues are presented. Patient 1 had a very unstable Charcot foot and ankle deformity. A modular patellar tendon brace/AFO was used to offload and to un-weight and immobilize his foot and ankle. The patient remains closed and is a community ambulator. Patient 2 underwent an atypical proximal foot amputation after refusing a BKA. A modified CROW boot was used to offload a peg-leg foot deformity. The patient remains ambulatory and has not progressed on to a BKA.