Diabetic Foot Ulcers

Meetings of diabetologists justifiably occupy much time debating the management of ulcers of the feet, since a significant percentage of diabetics develop intractable ulcers leading to amputations.

These medical meetings correctly emphasise the importance of sensation loss and insufficiency of blood perfusion. However there is another necessary factor in the cause of foot ulcers, which is seldom discussed in these meetings, the abnormalities of alignment of the skeletal structures of the foot.  Examples are clawing, veering and rotation of the toes and dislocations of the toe joints. These cause dangerous high foot-pressure areas which are a necessary prerequisite for foot ulcers.

Such deformities worsen progressively[i], and once deformation has started ulceration in the insensate foot becomes inevitable with time. Therefore these abnormalities require correction immediately they appear, immediately the toes begin to claw, immediately the calluses show on the soles, and immediately any abrasions or corns appear on their feet.

Most non-diabetics with these foot deformities readily seek treatment because they are prompted by pain.

However, those who cannot feel do not complain, and so often progress to ulcers, with eventual loss of the foot by amputation

Naturally vascular supply surgery might also be necessary but, once the ulcers have appeared, other treatments like full contact casts, debridement of ulcers and bone, and various forms of direct application are all too little, too late, and often fail.

This is a tragedy because correction of the anatomical alignment of the forefoot (claw toes, hammer toes, “bunions”, corns calluses, metatarsal high pressure, and similar) can usually be easily, safely and permanently corrected by soft tissue releases. This reduces the incidence of ulceration dramatically and lessens the amputation rate.

Soft tissue realignment procedures are performed regularly on non-diabetics. Why then are they not performed in the far more urgent circumstances of diabetic sensation loss?

One reason is that podiatric and orthopaedic management commonly involves dividing and realigning perfectly normal bones, and often destroying perfectly normal joints. These procedures are dangerous (particularly in diabetics) because divided bones might not unite. Bones infected subsequent to surgical damage are exceedingly difficult to treat. Plates, screws, pins, spacers and Silastic hinges implanted in “conventional” surgery all increase the risks of infection. Further, bone surgery necessitates long periods of immobilisation which is detrimental to the physiology of the lower limb, producing yet another set of dangerous complications[ii]: Those without feeling run a high risk of abrasion by casts or other “immobilising” devices.

Clearly “conventional” surgery to bone is precluded in those without sensation or with complicated diabetes.

The belief that it is necessary to operate on bone has come about, and become entrenched dogma, because of irrationality. Bones cannot produce deformities and it is irrational to assault them. Deformities can only be caused by soft tissues pulling the bones into misalignment. The target for correction should therefore be the deforming soft tissues.

Because diabetologists have also been lead into this misapprehension they shy away from referring their patients for appropriate surgery, to the detriment of those who rely on their advice.

Soft tissue surgery is often performed successfully and safely on diabetics and those with sensory loss.

Leaving foot skeletal abnormalities in diabetics and sensory loss feet in the hope that complications will not occur is a misguided invitation to catastrophe.

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[i] For various reasons the skeletal deformities of the foot are far more common in diabetics and those with vascular and neurological disease.

[ii] These include oedema, deep vein thrombosis, fungal dermatitis and sensitivities to the contact material.

Diabetic Foot Ulcers

Meetings of diabetologists justifiably occupy much time debating the management of ulcers of the feet, since a significant percentage of diabetics develop intractable ulcers leading to amputations.

These medical meetings correctly emphasise the importance of sensation loss and insufficiency of blood perfusion. However there is another necessary factor in the cause of foot ulcers, which is seldom discussed in these meetings, the abnormalities of alignment of the skeletal structures of the foot.  Examples are clawing, veering and rotation of the toes and dislocations of the toe joints. These cause dangerous high foot-pressure areas which are a necessary prerequisite for foot ulcers.

Such deformities worsen progressively[i], and once deformation has started ulceration in the insensate foot becomes inevitable with time. Therefore these abnormalities require correction immediately they appear, immediately the toes begin to claw, immediately the calluses show on the soles, and immediately any abrasions or corns appear on their feet.

Most non-diabetics with these foot deformities readily seek treatment because they are prompted by pain.

However, those who cannot feel do not complain, and so often progress to ulcers, with eventual loss of the foot by amputation

Naturally vascular supply surgery might also be necessary but, once the ulcers have appeared, other treatments like full contact casts, debridement of ulcers and bone, and various forms of direct application are all too little, too late, and often fail.

This is a tragedy because correction of the anatomical alignment of the forefoot (claw toes, hammer toes, “bunions”, corns calluses, metatarsal high pressure, and similar) can usually be easily, safely and permanently corrected by soft tissue releases. This reduces the incidence of ulceration dramatically and lessens the amputation rate.

Soft tissue realignment procedures are performed regularly on non-diabetics. Why then are they not performed in the far more urgent circumstances of diabetic sensation loss?

One reason is that podiatric and orthopaedic management commonly involves dividing and realigning perfectly normal bones, and often destroying perfectly normal joints. These procedures are dangerous (particularly in diabetics) because divided bones might not unite. Bones infected subsequent to surgical damage are exceedingly difficult to treat. Plates, screws, pins, spacers and Silastic hinges implanted in “conventional” surgery all increase the risks of infection. Further, bone surgery necessitates long periods of immobilisation which is detrimental to the physiology of the lower limb, producing yet another set of dangerous complications[ii]: Those without feeling run a high risk of abrasion by casts or other “immobilising” devices.

Clearly “conventional” surgery to bone is precluded in those without sensation or with complicated diabetes.

The belief that it is necessary to operate on bone has come about, and become entrenched dogma, because of irrationality. Bones cannot produce deformities and it is irrational to assault them. Deformities can only be caused by soft tissues pulling the bones into misalignment. The target for correction should therefore be the deforming soft tissues.

Because diabetologists have also been lead into this misapprehension they shy away from referring their patients for appropriate surgery, to the detriment of those who rely on their advice.

Soft tissue surgery is often performed successfully and safely on diabetics and those with sensory loss.

Leaving foot skeletal abnormalities in diabetics and sensory loss feet in the hope that complications will not occur is a misguided invitation to catastrophe.

---

[i] For various reasons the skeletal deformities of the foot are far more common in diabetics and those with vascular and neurological disease.

[ii] These include oedema, deep vein thrombosis, fungal dermatitis and sensitivities to the contact material.

Weil, Weil, Weil!

 

In this website enquiries about the Weil Osteotomy  have been frequent. In this web-site (and in conferences around the world) I have asked the surgical community, both orthopaedic and podiatric, to explain how the Weil works. Just what does it do to correct pain? Despite many thousands of hits on my web-site no one has come forward with a valid explanation.

In the literature two pseudo-explanations are offered.

“Restoration of the metatarsal parabola”. Here it is reasoned that an unusually long metatarsal is responsible, particularly the second. It is claimed that the “normal foot” has the metatarsals forming a neat parabolic curve. Is there any evidence for that? Not that I can find. Foot shapes come in great variety. A lifetime of looking at feet has never revealed a “better” or “correct” shape.

Most feet function well for the first three-quarters of life, irrespective of significant variances. There is no hard evidence either that a “long” metatarsal is more prone to pain than a short one. What is true is that the second metatarsal often happens to be the first to become painful, and (by chance association) the second metatarsal also happens to be the longest.

But even if that association (long metatarsal = pain) should be correct, the argument immediately fails when Weil osteotomies are offered on multiple toes, or on a toe which is painful but with a shorter metatarsal.

The ultimate irrationality of this argument is that any given foot anatomy (perhaps with a long metatarsal, or with a “non-parabolic” shape) can function perfectly well for fifty or sixty years. When that foot becomes painful is it because the metatarsal is “long”?

Of course it is not – that metatarsal has had the same length all those years – not only that but it has functioned perfectly when the greatest loads have been on it, with youthful activity, running and jumping, pregnancies, and the rest. So some would try and make be believe that after half a century of service, a bone suddenly becomes “too long”! Really!

The other pseudo-argument promoting the Weil goes like this:

“When conservative modalities have been exhausted, you may consider over 20 surgical techniques, ranging from condylectomies to oblique osteotomies at the proximal, mid-shaft or distal metatarsal levels. Of these procedures, the Weil osteotomy has gained popularity, based upon the simple technique and stable fixation.”

This is another way of saying “If you are going to try something surgically try the easiest “something”.

“Try” is the operative word.

Ageing and orthopaedics

 

 

Excess mass. Many of the degenerative changes of ageing are associated with excess body mass. It is a common perception that as one ages body-mass should increase. At times I am told by my affronted patients “I have always weighed this much, since I was a youth. How can you expect me to weigh less now?”

 

Get older, thinner. The reality is that an “ideal” body weight, which is probably acquired at the end of growth should, with ageing, decreased progressively. The reasons are that there is a loss of both the weight of bone and the mass of muscle. Therefore if the bodyweight remains the same it must be because there is more fat.

 

The lungs and stomach. The vertebral column shortens was ageing, and therefore the volumes in both the abdomen and thorax decrease . If the same amount of fat (or progressively more fat) is compressed into the abdomen then the diaphragm will be lifted and the space in the thorax compressed. This may be one of the reasons why reflux oesophagitis increases with ageing, as does the hiatus hernia. Add to that decreases in respiratory capacity, often in lungs which are functioning sub-optimally, and one has extremely good reasons for reducing mass. Oesophageal reflux can cause further deterioration in the lungs, coughing at night and so the cycle continues.

 

Weaker body more load. Therefore we have the unsatisfactory situation with weaker muscles and more frail bones being expected to carry a far larger body-mass, comprising a primarily of fat.

 

Metabolic effects. Excessive fat is not innocuous, as it has a huge influence on the hormonal balance of the individual, including the factors that go to create a diabetes, and creating excess female hormone.

 

Weaker structural tissues. Structural tissues, such as ligaments and tendons  lose their mechanical strength with ageing. This is partly because the blood supply to those structures diminishes and partly because the reparative processes following minor injury are slower.

 

Exercise plays many roles in musculoskeletal health (as it does in the health of the entire biology).

 

Hormonal benefits of exercise. There are general effects of exercise, which stimulate the production of natural anti-inflammatory medication substances, natural antidepressants and natural analgesics. For those with aches and pains, as well as the sense of depression that inevitably accompanies the degenerative processes of ageing, these are exceedingly important.

 

Strengthening benefits of exercise. In more specific terms exercise will retain, or perhaps increase muscular bulk and strength, which is so vital in protecting the joints. The calorie burn will be the most effective way of reversing the ratio of fat to muscle.There is nothing better than low impact exercise (such as cycling and swimming) to stave off arthritic degeneration in the knee

Osteoporosis. Exercise is the most specific counter to osteoporosis.

 

What type of exercise? In the ageing body by far the most effective form of exercise is swimming. However, if an exercise program is to succeed, and for that matter if any exercise patterns are to succeed, it must be firmly scheduled, so that the exercise is consistent. Three times a week is probably ideal, with a necessary day of “recuperation” between each session.

 

Particular care with swimming. Those who have problems with the joints, particularly with the vertebral column, but also the large joints of the body, need to exercise particular care in swimming. A painful back or a dowager’s hump, and many forms of scoliosis can make it exceedingly hazardous to enter the water unassisted. It is recommended that swimmers with these problems should always be accompanied whilst in the water, at least in the beginning.

 

Swimming and Gym coaching. It is also recommended that a swimming coach be employed initially. Many elderly people will regard this advice with scorn, saying “that is for children and toddlers. I know how to swim”.
However this is not an appropriate answer. Anyone who wants to brush up their foreign language or musical instrument playing needs help as an adult. Perhaps even more important is the fine tuning of swimming skills, which will allow the swimmer a more effortless period of exercise, and  consequently a longer period of exercise. Ideally the aim is to churn through the water without significant tension or stress for forty or more minutes during the session.

 

Cycling is a realistic form of exercise, with great benefits, particularly, to the knee. This is because it develops the quadriceps and other muscles which control (and so protect) the knee joint. The loads on the lower limb during cycling are less than walking and running, whilst the range of movement is often more than walking. If there are disabilities in the knees which prevent adequate movement then the use of shorter pedals shanks can overcome the problem. Ideally, adjustable shanks could be used and as the range of movement in the knee increases, so the length of the shank can be increased.

 

Cycling has the advantage that one can listen to music, dialogue or watch television. Reading a book is not realistic because of the jolting and sweating.

 

Making exercise fun. This is an important aspect of exercise as a therapy. Exercise must be attractive, appealing and fun. If exercise is a drudge then enthusiasm will be lost rapidly and ultimately the endeavour will fail, leaving only a large burden of guilt.

It is therefore suggested that careful attention be given to the “fun” aspects of exercise. The iPod has created a new dimension of music and literary content, and it might be that the iPod should be bought before the exercise bicycle.

Real cycling is an option which can give much additional interest to exercise, as well as a social and even the travel aspects. Many people combine an exercise bicycle with the “real” bicycle, and so are able to enjoy summer but continue to exercise during winter.

 

The importance of the logbook. Another ploy which is useful in maintaining stimulus and interest is to keep a detailed exercise logbook. This logbook should include details of the period of the exercise, and if it’s possible to measure  (as  is possible on many types of exercise bicycles) the total calorie burn. The logbook should also include a daily resting pulse (before getting out of bed) and the pulse rates before and after exercise as well as weight daily.
There is a tendency to forget how one improves was exercise and therefore the recording of this will not only stimulate the aim to keep improving, but demonstrate the efficacy of past exercise.

 

What can you expect if you  lose weight by reducing calories?

 

A number of chronic illnesses can be reversed, sometimes completely, simply by calorie reduced loss of weight. These include:

Diabetes of maturity

High blood pressure

Gout

Lower limb arthritis

Reflux oesophagitis

Respiratory incapacity and breathlessness

Prevention of hernias, or recurrence of hernias

 

Possible improvements include:

 A longer life. People (and animals) live longer on restricted calorie diets.

Reduced sleep disturbance from oesophagitis, reflux pharyngitis or apnoea

Urinary incontinence

Cardiac failure

Chronic bronchitis

Chronic sinusitis

Shoulder pain (when this is caused by lifting the body weight out of chairs).

Low back pain and sciatica.

Painful feet

 

All these illnesses are frequently treated by long-term medication. It seems so simple to be able to effect an improvement with less or no medication, at less cost, more energy, and a better quality of life by weight loss and exercise. Surely you owe it to yourself to try?

Corns, Callouses and Bunions

The following appeared recently in Timesonline http://www.timesonline.co.uk/tol/life_and_style/health/article5675591.ece
“Corns and calluses are usually the result of a bone prominence rubbing against another bone, causing hard skin. You can get that corrected surgically, so the corn doesn’t come back. It is an easy condition to treat and you won’t have to spend the rest of your life visiting the chiropodist.
People are often badly advised on bunions – prominent and painful lumps caused by an outcrop of bone near the big toe joint. If you don’t get them treated surgically, there is a risk that your big toe will become less functional and your second toe overloaded. This can lead to hammer toes, a condition that makes wearing any footwear, not just fashion shoes, difficult.
Mark Davies is a foot surgeon and founder of the London Foot and Ankle Centre http://www.bofas.org.uk”

I can find little to agree with Mark Davies. Neither corns nor callouses are “the result of a bone prominence rubbing against another bone”. Corns are a response of the skin to abrasion against footwear and calluses are a complex (but easily corrected) foot-floor interface problem. A “soft corn” is unusual, but does result from follow pressure between the toes, almost always when there is an “osteophyte” (a small arthritic prominence from the joint) present.
“Bunions” are not caused by “an outcrop of bone”, and I invite anyone to demonstrate such an outcrop to me. “Bunions” are a prominence of an entirely normal metatarsal bone pushed into an abnormal position . Cutting a “bunion” away damages a normal bone and its benefit is short-term and mostly cosmetic. This destructive surgery usually causes long term problems in the great toe joint. The very structures which prevent the great toe from “veering” are destroyed by this procedure: shoul anyone therfore be surprised that cutting away “bunions” causes the great toe to veer even more?
Veering of the great toe is totally unrelated to “hammering” of the lesser toes, and therefore advising correction of a big toe on the basis that it will benefit the lesser toes is entirely incorrect. The abnormalities of the lesser toes are entirely independent of abnormalities in the great toe.  Lesser toe abnormalities will continue to progress regardless of what surgery is performed on the great toe.

Rethinking orthopaedic and forefoot surgery.

This post continues the page Stop! Wrong way! in relation to orthopaedic management

Deformities of the forefoot. These include “bunions”, Morton’s “neuroma”, clawed toes and “flat foot” (whatever that is intended to mean). It is unlikely that any group of elective procedures has been performed, in total ignorance of the causative factors, more often, by more people, in more ways, than various forms of surgery to the forefoot.

Fractures being “set” as soon as possible after the injury. This damaging policy produces significant, irreversible, complications. It will be addressed in a separate post on this site at a later date.

Finger-tip injuries. These common injuries produced a plethora of surgical treatments, from skin grafts and”rotational flaps” to “cross-finger flaps”. These required not-inconsequential surgery, sometimes under general anaesthetic, were expensive and incapacitating for various periods, and unnecessary. Harvest was taken from uninjured areas of the palm and other fingers, scarring those. The best results however have been shown to be obtained by doing nothing beyond usual wound care! The body’s capacity to heal itself at that site is not unexpected, being as easily and frequently injured as the fingers are.

“Traction” for so called “slipped discs” (mostly that diagnosis was incorrect, in the event). Tens of thousands of patient-days were lost by placing these unfortunates in hospital and attaching weights by cords to their legs, literally tethering them to their bed for days or weeks. This was entirely ineffective since the friction of the legs prevented transmission of any “traction” to the discs. The management was adversely effective, since most low back pain improves more rapidly with movement (ideally in water). Deep vein thrombosis would be expected to be increased by this form of immobility. I wonder how many died of resulting pulmonary embolisms.

 Osteomyelitis. Antibiotic usage and aggressive resection of bone is often counter productive and dangerous. The loss of the limb might result from some current management policies. This is addressed in a separate post on this site.

Is there a solution to my foot problem?

 

 

 

(Name withheld) Thanks again for your emails. In March this year, I had a Weil’s Osteotomy so as to correct my hammer toe which was the one next to my big toe and not the middle toe like the toe in your photograph. Since the first operation in March, then again in April, when they removed the screw as my body rejected it – it is now October, the toe is still very stiff and it is still floating (looking awful is the least). I saw a podiatrist a few times and he has now done a wedge on the middle toe next to the hammer toe which was operated on, he told me that all my body weight is now on the toe next to the operated toe, or something to that effect. The very worst of course for me is the hard lump/callous which is now underneath my foot, like a tight knot lump there and if I don’t wear an orthotic insole for walking, I’ve had it – even when I do wear one, the throbbing recurs. I can’t take pain tablets all the time, so I am just learning to live with it. After what I went through, if there is a solution?

Response: The Weil osteotomy is discussed in the pages

The patient in the picture which you refer to had four procedures before I got to see it. The second toe (next to the great) on the left had some kind of osteotomy, and was “floating” perhaps like yours. The third toe probably looks as your second toe did pre-operatively. The hard lump is a direct result of your toe abnormality, and can be predicted to worsen progressively unless surgically corrected. There is, very definitely, a solution. I look forward to seeing you and explaining the mechanism and background of your problem.