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I was wondering if you guys have some tried and tested ways for dealing with offloading bunion ulcers? Take a medial ulcer on the 1st MPJ on a foot with a prominent hallux abducto valgus. I would recommend accommodative footwear, where appropriate, such as the cosy feet shoes http://www.cosyfeet.com/susan-p-165.html Then use SCF bars proximal and distal of the dressing to help further offload. What about you?
Padding I have found useful (not sure if somebody has named it yet, if so I apologise),
The pad is adhered proximal to the MTPJ from the navicular along the medial side of the foot right up to the ulceration/pressure point. a u-cutout surrounding to offload.
Often the pad needs to be 2-2 1/2 layers thick to effectively prevent pressure from footwear.
If footwear is too occlusive to fit, which can often be a problem...then either get out of the court shoes! use post surgical shoe, or as LL said...fix the bunion!
Yes. The padding can also be adhered to the medial wall of the shoe and does not need to be taped to the foot.
I regard hydrogel discs and other gel paddings to be contraindicated since they can cause skin maceration and further breakdown. The need is to keep the wound dry.
This is no rant, but, i know the slightest suggestion of surgery would make some "high risk" Pod's cringe but we need to get real. Someone has a deformity, lets say they are diabetic, the deformity such as a prominent 1st met head is causing pressure and and such the medial eminence of the 1st mtpj / subluxed met is breaking down.
Now, even an orthopod can tell you that the deformity needs to be addressed. Of course this is a very easy statement and there are a number of considerations before knife is placed upon skin. Yes the surgical wound would probably need more attention than normal. Yes maybe the underlying systemic pathology may need to be brought under control prior to surgery, and essentially we are creating another wound, but at least the deformity has been reduced and we initially start with a clean surgical wound.
So hey, put that semi-compressed felt down and get the sagittal saw out!
I this case I don't think that surgery is warranted, and it's certainly not wanted by the patient. The main issue here was poor choice in footware which has been addressed. So I am just looking at off loading techniques in this case. But I do agree that surgery is an option that is some times over looked for HV.
So if any one does have some good offloading tips please do share, pictures most welcome .
This is no rant, but, i know the slightest suggestion of surgery would make some "high risk" Pod's cringe but we need to get real. Someone has a deformity, lets say they are diabetic, the deformity such as a prominent 1st met head is causing pressure and and such the medial eminence of the 1st mtpj / subluxed met is breaking down.
Now, even an orthopod can tell you that the deformity needs to be addressed. Of course this is a very easy statement and there are a number of considerations before knife is placed upon skin. Yes the surgical wound would probably need more attention than normal. Yes maybe the underlying systemic pathology may need to be brought under control prior to surgery, and essentially we are creating another wound, but at least the deformity has been reduced and we initially start with a clean surgical wound.
So hey, put that semi-compressed felt down and get the sagittal saw out!
George,
You're obviously enamoured with the knife. What you'll find is that the more you use it, the less you'll want to. Now, surgery has its place, but you can't set aside much of the conservative care you've learned just because you're happy with your new toy (I presume from your posts that you are just embarking upon your surgical career).
The reality of most cases where you'll see an ulcer overlying a bunion is that you're going to need to heal the ulcer BEFORE doing your elective surgery. If you do your surgery while there is an existing ulcer, especially in the presence of infection, you are in trouble. There are many other factors at play in a patient with an ulcer overlying the bunion. How's their vascular status? Medical history? I know you've alluded to the 'underlying systemic pathology needing to be brought under control prior to surgery' but I feel the point needs labouring.
I'd seriously recommend spending some more time with your colleagues working in 'high risk' work before you continue your surgical career. Everybody has a part to play in the management of the at risk or ulcerated foot. You can not make sweeping statements about single interventions being fit for every foot (or that could be read as such - I'm sure this was not your intention). You may have recently seen the article by the orthopod about surgery for corns in The Times. It's a blinkered way of thinking.
As podiatrists, we are best placed to manage all foot and ankle pathologies with the most appropriate intervention for the individual. It's a shame to limit yourself to only one of your possible options.
How about putting your saw down, getting to know your local high risk team so you can refer the patient to get the ulcer healed (for example in an offloading softcast with a cut-out and decent dressing regime) before then assessing them for surgery at a later date?
I've just saved you a law-suit. You can thank me in 10 years.
I used to work in a high risk team. As i've alluded to in my previous post, i understand the vast array of other considerations that need to be addressed.
And yes, the numerous conservative modalities do cover the gold standard. I also understand the need to heal the ulcer before surgical intervention (in chronic cases).
From my experience (i admit i don't have as much as the plethora of people on this forum), i believe surgical intervention is often overlooked in these cases, simply dismissed as being too risky.
Yes, i admit i probably am a bit knife happy, but i am all to aware of when not to operate.
Every foot is different, but as a sweeping statement yes, i would say surgery needs to be considered more often than it is.
Take a chronic lesser digit dorsal pipj ulcer, i think swaying towards surgery as a treatment option wouldn't be a bad thing!
I used to work in a high risk team. As i've alluded to in my previous post, i understand the vast array of other considerations that need to be addressed.
And yes, the numerous conservative modalities do cover the gold standard. I also understand the need to heel the ulcer before surgical intervention (in chronic cases).
From my experience (i admit i don't have as much as the plethora of people on this forum), i believe surgical intervention is often overlooked in these cases, simply dismissed as being too risky.
Yes, i admit i probably am a bit knife happy, but i am all to aware of when not to operate.
Every foot is different, but as a sweeping statement yes, i would say surgery needs to be considered more often than it is.
Take a chronic lesser digit dorsal pipj ulcer, i think swaying towards surgery as a treatment option wouldn't be a bad thing!
Fair enough George,
I hope your surgical successes reflect your choice for your patients. It's not so much chronic cases really, if you're going to do a rotation scarf on an acutely infected ulcerated bunion in a patient with an ABPI of 0.5 taking an Anti-TNF for their rheumatoid arthritis I'd worry. That's a more extreme example, but you get the point.
Surgical intervention is warranted in appropriate cases, but I consider it to be only one of the options we as podiatrists can offer. Sometimes it's under used, sometimes over. It's about striking a sensible balance really. I doubt anyone will get this balance right 100% of the time throughout their careers, but it's best to stray away from the extremes.
I'm impressed by your statement 'i am all to aware of when not to operate' - you're probably on your own there. Generally, most will be, but there is no 'black and white' when dealing with patients, only shades of grey (sometimes covered by just for men).
Bob i'm glad your impressed, no being serious, i didn't claim to forsee every future post operative complication, but i would hope that when there is an obvious contraindication to surgery present, i would notice.
Yes you are right, often it is not black and white, but surgery may still be considered, following further investigation, communication.
By acute i meant acute infection needing a surgical opinion (in terms of removal of osteomylitic bone), not the need for HV correction.
You do imply, that i would simply chop anything that walks through the door, i didn't say that, i am simply highlighting the fact that surgery is often overlooked.
As such your Rheumatoid Ischaemic patient would not be recieving a scarf, as it would probably lead to a BKA. Although they wouldn't be attending your clinic anymore
Bob i'm glad your impressed, no being serious, i didn't claim to forsee every future post operative complication, but i would hope that when there is an obvious contraindication to surgery present, i would notice.
Yes you are right, often it is not black and white, but surgery may still be considered, following further investigation, communication.
By acute i meant acute infection needing a surgical opinion (in terms of removal of osteomylitic bone), not the need for HV correction.
You do imply, that i would simply chop anything that walks through the door, i didn't say that, i am simply highlighting the fact that surgery is often overlooked.
As such your Rheumatoid Ischaemic patient would not be recieving a scarf, as it would probably lead to a BKA. Although they wouldn't be attending your clinic anymore
George,
I wasn't implying you'd chop everything that comes along, I was merely trying to give a bit more balance to your 'consider surgery more often' point. I think it was you that said you were 'knife happy'? My whole take on the situation is that (as podiatrists) we are best placed to offer a variety of APPROPRIATE interventions, from simple debridement/ offloading to surgery - which is great.
We're singing from similar songsheets, but I think delivery is important so as not to isolate the broad spectrum of our profession or reduce our patients' treatment options.
The best thing from my experience that you can do for medial ulcer of the first MPJ..avoid any pressure contact be it padded or not, if an urgent fix is needed nothing will beat a Balloon/Bubble which can be applied to the existing shoe in an hour...if you have the molded piece ready as we do Did one recently for a male client that was developing an ulcer on the lateral PIP of the 5th.... his gait changed to an abductory twist with a new prosthetic leg added.
in my idea; you have to identify the primary cause of the specific ulcer. is it only pressure and friction ulcer, getting infection? or additive poor vascularity for example. i manage with casting first with opened window for offloading and friction and also wound caring sometime simple wound care depending on type of the wound. if i find sign of good progression let it go on healing. talking to the patient we'll try conservative management first , after healing go on casting without window around 2weeks for scar maturation.total time period of 8 weeks in generally. putting on bunnion shoe with medial arch support and soft padding over the wound area . if it recur it may be need surgery, at least in the condition of superficial clean wound.
Ulcer on medial aspect of Bunion
Re: Ulcer on medial aspect of Bunion
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