93: NEUROPATHIC ULCERATION

PATIENT STORY

A 58-year-old overweight diabetic man presented with bloody drainage from a callous on the plantar aspect of the right first metatarsophalangeal joint (MPJ) for approximately 1 week (Figure 93-1). He has a history of bilateral plantar first MPJ ulcers that healed with conservative treatment. He is a truck driver and wears custom-molded accommodative orthotics that are approximately 1-year old within work boots (Figure 93-2).

On physical examination, pedal pulses are palpable. The feet are warm and of equal temperature. Protective sensation is plantarly absent on testing with a 10-g monofilament. He has a planus (flat) foot type with limited first MPJ range of motion and mallet toe deformity (flexion contracture of the hallux interphalangeal joint) (Figure 93-3). Following debridement of hyperkeratotic tissue and cutaneous sanguinous drainage from the plantar aspect of the right first MPJ, a small surface area, full-thickness skin ulceration is identified (Figure 93-4). The wound base is granular and healthy with no signs of active infection. Treatment includes topical use of a hydrogel with silver (to address surface contaminants and facilitate moist wound healing) and a prescription for new orthotic devices. Due to the recurrent callous despite use of the orthotics, routine visits are recommended every 10 to 12 weeks for callous debridement and diabetic foot care. He is not interested in surgical correction of the abnormal mechanics in the forefoot (hallux malleus correction).

EPIDEMIOLOGY

• The incidence of diabetic ulcers in the United States is approximately 1.5 million¹ and this is expected to increase as diabetes increases.

• There are currently nearly 800,000 new cases of diabetes diagnosed every year, affecting approximately 6% of the population.¹

• Approximately 60% of all nontraumatic lower extremity amputations occur in diabetics.²

• Approximately 85% of diabetic lower extremity amputations are preceded by a foot ulcer.²

• Within 5 years of amputation, 28% to 51% of diabetic amputees undergo contralateral leg amputation.²

• 5-year mortality following bilateral amputation: 39% to 68%.²

• The direct cost of treating noninfected diabetic foot ulcers is more than $6 billion annually.³

ETIOLOGY AND PATHOPHYSIOLOGY

• Neuropathic ulceration is typically the result of repetitive, moderate soft tissue trauma in the setting of peripheral sensory neuropathy and abnormal foot ...