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Prevention of Diabetic Foot Ulceration

- See:
      - Charcot Changes in the Diabetic Patient
      - Diabetic Foot Menu
      - Pedorthic Footwear Association

- Discussion:
    - foot orthotics 
    - any diabetic patient who lacks protective sensation should have aggressive protective foot care;
    - diabetic foot should be protected by a padded foot cradle, & foot position should be turned frequently to prevent pressure ulcers;
    - recently it has observed that simple running shoes can predictably reduce plantar pressures in diabetic patients by 30%;
          - in contrast, tight leather Oxford shoes do little to reduce plantar pressure;
    - likewise, combination of padded socks and debridement of hyperkeratotic tissue may result in decreases of plantar pressure by 30%
    - 1st time ulceration w/ no bony prominences:
          - once the ulcer heals, need depth-inlay shoes with a custom accommodative foot orthosis (accomodate the foot deformity):
    - foot with bony prominences:
          - plastazote inserts is useful for diabetics w/ several bony prominences;
          - material is easy to mold and is fairly inexpensive; however, it tend to bottom out, requiring new orthosis w/in 3-6 months;
          - insoles should always be soft, but the material nearest the skin should be especially soft;
    - Charcot Restraint Orthotic Walker:
          - refers to a clam shell AFO which has the following characteristics:
                 - cast is made of the foot and ankle for a customized shell;
                 - mold is lined with perforated Plastazote (provides cushioning and ventilation);
                 - plantar surface of foot is lined with PPT which is a shock absorbing innersole which is removable;
                 - a rocker bottom sole facilitates gait (consider using lightweight EVA material);
                 - anterior and posterior shells are made with reinforced carbon fiber for strength;
          - ref: Charcot restraint orthotic walker.
    - debridement of ulcers;
          - combination of padded socks and debridement of hyperkeratotic tissue may result in decreases of plantar pressure by 30%;
          - hypertrophic ulcers should be debrided back to healthy skin margins over several office visits

The Use of Running Shoes to Reduce Plantar Pressures in Patients Who Have Diabetes.  

Objective evaluation of insert material for diabetic and athletic footwear.   

A technique for treatment of chronic plantar ulcer by saucerization and primary closure

The total-contact cast for management of neuropathic plantar ulceration of the foot.

Fractures associated with neuropathic arthropathy in adults who have juvenile-onset diabetes.

The diabetic foot: evolving technologies.

The effect of callus removal on dynamic plantar foot pressures in diabetic patients.   

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