In the last edition of Diabetes Digest (Young, 2013), I commented that I wanted to see similar studies to those of Routolo et al (2013) and Chantelau and Richter (2013), which investigated early interventions to minimise deformity in Charcot feet, being replicated. Remarkably, I did not have long to wait.
Parisi et al (their article summarised on the next page), however, took a different route. All of the participants had some X-ray change caused by Charcot neuroarthropathy in the early Eichenholtz stages I and II, and, rather than immobilise their patients in casts, Parisi et al opted for a walker boot and early weight bearing. This radical approach appears to have been successful, with only minor worsening of the radiographic findings and resolution of the clinical Charcot score, and without the issues of patient compliance and cast injuries that can plague the conventional total contact cast (TCC) route.
Some of the negatives of this particular study, such as a non-statistically significant worsening of the tarso-first metatarsal angle, might be explained by the size of the study (22 participants), but I would agree with the final conclusion of this paper that this “may therefore be a safe treatment option”. The lack of ulceration and infection is encouraging and, at least for those individuals for whom a TCC is not possible or desirable, may give clinicians an option for a less restrictive treatment.
Another article examining the possible early interventions to reduce reulceration is from the Amsterdam group of Bus et al (summarised alongside). They continue to publish excellent work on the utility of footwear and orthoses in the management of individuals with diabetic foot ulcers. Their latest research helps to explain why studies looking at shoes and insoles in some studies report significant reductions in recurrent ulceration, but real world case series continue to show high levels of recurrent ulceration despite patients being given shoes and preventative care. As their previous paper on shoe adherence, indoors and out, suggested, the provision of shoes alone will do little to improve outcomes for individuals with diabetes (Waaijman et al, 2013).
Even if the shoes are heavily customised, they will not prevent ulceration. Shoes, whether modified or not, will only reduce ulceration when they are worn. This is not a new message but it makes me think, perhaps we should take more notice of patient preferences when supplying shoes, which might be to make a bit of compromise on absolute off-loading efficacy in order to ensure that they are worn more of the time (or at all).
To read the article summaries, please download the PDF from the article options link at right.
