There are a whole variety of procedures that might occur to treat something like a foot ulcer. In the case of an infection, that might be a more urgent kind of procedure that is done to drain the infection - to take out dead tissue. There are also types of procedures that are done to debride nonviable tissue - that's called wound debridement or cleaning up the wound. That can be done often in a clinic or in the operating room - depending on how extensive the debridement is necessary. There are other things that are done commonly like cutting into the bone and moving the bone so that deformity is not as present, causing the risk for developing an ulcer. So a procedure can be done that is reconstructive in nature that might change the way the foot hits the ground so that you're spreading force out over a larger area and reducing risk of a prominence causing a sore. The other thing that can be done is after a wound has been debrided and it's nice and healthy, then one can look from wound care to wound closure. A commonly performed procedure is some method to actually close the wound. A surgeon may choose to work with you to move skin over and that could be a rotational flap. They could take tissue from somewhere else in your body and put it on - rarely. That's called a flap and there's various kinds of flaps at various levels of fancy. Other things that can be done pretty commonly are taking skin from one area (like on your thigh) and then putting it onto your foot. That's called a split thickness skin graft and the skin graft can be taken from your thigh (it's a little bit like skinning your knee) and then just transferred to the back table in the operating room and the surgeons can manipulate that and spread it out a little bit so that it can have a little more surface area. Then, they can put that down on various parts of your foot to actually patch that area up if you have a big sore. So that's another thing that can be done as well that's done fairly commonly at a lot of a high-end limb salvage diabetic foot units.
There may be times when the best treatment is not to heal a wound, but rather to perform an amputation. Those amputations may come in different levels. They may be at the level of the foot or they may be above the foot. But understand that the clinician that's working with you is working with you to do the least amount to get you back to living your life the soonest. But: sometimes the best procedure is one that might be what we call a high level amputation (which is above the foot) and that procedure may be done because the doctor or the nurse or the therapist or all of that team believe that to get you back to living your life, that is the most effective way for rehabilitation or for healing or for both. So understand that that is the discussion going forward and most important is your decision because you have a say in this as well. I think you have the most important say in all of this because the goal for a lot of these things (especially for really complicated problems with a lot of tissue loss or a lot of infection or a lot of problems with blood flow) is: how can you get back to living your life the soonest? Sometimes that means a high-level amputation. It's not the most common, but it is sometimes the best option.
Now let's go through the treatments for the wound, the Ischemia, and the foot infection, specifically. First for the wound. If you have a wound that is not predominantly infected or ischemic, it's not what you put on these wounds that heals them - it's what you take off. What I mean is: the things that the doctor might do first is focus on what's called debridement of the wound - which means nothing more than trimming off what's dead and helping (just like pruning a tree) to do a little bit of good quality landscaping on the wound to allow that thing to be nice and healthy so that it can move on to healing. That's one thing you take off - what's not viable. They might take off callus, they might take off dead tissue in the middle or around the wound. That's number one. Number two: the other thing that we need to take off is the pressure or the weight and that can be done with various kinds of braces or casting or different types of what we call offloading technologies. The gold standard is what is called a total contact cast, and that's a technique where a doctor or a technician might actually put a special kind of cast around you that spreads the force out over the entire bottom of your foot and then even up the cast wall. That can be really, really effective. Other kinds of braces that you might get at a prosthetic shop can also help to do similar things, but the key thing is while you're in that, you need to be wearing it all the time for every step you take. Because if you take a step without that protection, it is - trust me - a step backwards.
We've talked about treating the wound. That's W. We've talked about treating the ischemia. That is I, or bad blood flow. Now let's talk about treating the FI, or the foot infection in WIFI. Now if you have an infection, the infection actually comes before a lot of the other things. It needs to be often treated first depending on its severity. The first thing your doctor will do is assess the severity of the infection. The second thing he or she will do is determine whether this is something that needs to be treated medically, surgically, or both. He or she may assess this with a culture to determine what kind of antibiotic to use. He or she may then either get you on an antibiotic or B, they may try to drain the infection or remove what is dead surgically. Those are things that are going to be assessed by your physician and a surgeon at the time of assessment of your infection. There is a whole host of therapies that are necessary at various times and a whole host of different kinds of antibiotics that are to be used. But the important thing to understand is that one goes from broad spectrum to narrow spectrum therapy. That is a principle of good quality infectious disease to be using the most targeted therapy possible. And then, for the surgical treatment to treat the infection, to get rid of the infection and to do as little as possible to get that patient living his or her life as soon as possible. So it is a surgical and medical combination that makes a big difference there for the foot infection. So now we've talked about wound and approaches to treating the wound and assessing it. We've talked about approaches to treating the ischemia or the bad blood flow. And we've talked about treating the foot infection. So those are your WIFI settings.
In terms of home remedies for the diabetic foot, there are likely a whole host of things that could be helpful. There is not a lot of evidence for treatment of various aspects of the diabetic foot in the home, but some things may be helpful. Let's start with things on the skin. There are different kinds of lotions and creams and oils that can be useful for the skin. If you are using something like a moisturizer for the skin, I like creams and oils more than I like things like lotions. The creams have some fat in them and obviously oils do as well and they stay around a little bit longer and they could really help to moisturize the skin. Your skin can (instead of being like a cracker) it can be a little more like a tortilla. You know that a Tortilla is way stronger than a cracker, and so too is that the case in the skin. That's what you want to work toward to make your skin a lot more moisturized and therefore stronger and less apt to crack and to develop a blister and a wound. There are a whole host of treatments for painful neuropathy - if you have pain like tingling or feeling like insects crawling on you or electricity or horrible burning at night. There are various therapies that may be useful that you can try at home. But before you try them, I really would urge you just to talk to your doctor so that you can go into this as a partnership because I think an open minded clinician working with you is a whole lot better than you just trying some kitchen chemistry on your own. I think the two can really be helpful. If you have a wound on your foot, there are many kinds of home remedies that people may talk about. But what I would urge you is to get in and see your doctor ASAP because these wounds - while they may not hurt you, because of the loss of the gift of pain with neuropathy and diabetes - they can kill you. I stress to you that instead of beginning a home remedy on a wound, that you get in to see your doctor. There may still be some remedies that may be really useful in the home that could help. But get in to see your doctor first and make this a partnership.
If you have a bigger wound, there are various types of technologies that might help the wound heal as well. Those include something called negative pressure wound therapy, which is a type of a foam that is attached to a vacuum that's attached to a computer-controlled the vacuum device that actually can help stimulate little baby blood vessels grow. Other things that might be put on that wound include types of tissue that's grown in the laboratory that could actually be applied, that can stimulate the wound, kind of like fertilizer might stimulate the wound. Other kinds of biotechnological devices that can be applied include technologies made from the amnion and chorion of the placenta. This is another type of technology that has been gaining popularity in certain circles as well. There are a host of other kinds of things like growth factors and other technologies that could be helpful. There's just too many to mention. But the important thing to understand: it is not what you put on these wounds that heals them - is what you take off. The things that we put on the wound are adjunctive that can help the wound heal a little bit faster, but not until we have focused on what I mentioned first, which is the good quality of debridement and the offloading and the protection.
We've just talked about treating the wound or the W of the WIFI. Now let's talk about the ischemia or the I in the Wifi. That's bad blood flow. Now, if you're determined to have some element of bad blood flow, then there are various things that the vascular specialist can do. He or she can treat you with what is called an endovascular option and that might include ballooning or stenting or removing clot from an area of stenosis or blockage. In many patients that's done right now around 60 to 70% of the time in high end units that are dedicated to amputation prevention. So that is often a first consideration by the physician or surgeon that is assessing you in that area. The other thing that can be done is what is called an open procedure. And this is done often for very significant blockages and more complicated problems where maybe you need to bring a lot more flow down to an area of tissue loss or it may just be particularly for you. And that is done by a vascular surgeon. He or she, then will bypass a big area of blockage just like they're bypassing an area of blockage in your heart. The only big difference is distance. There's a lot more distance here and there's a lot of technique involved there. So that is an area that is both life changing and exciting, especially for me because I get to watch it as an avid fan.
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