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how can i proceed with this
60 year old man with non healing ulcer
for a period of 2 years duration

suresh

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Hello Suresh,

Can you tell us more about the clinical and socioeconomic profile from this patient?

Regards,

dear javier ,

60 year old diabetic patient for 2 years duration, doing self dressing came for treatment.
pt was working as a security in private , at present he is not doing any work because of this. poor socioeconomic status pt
anything more..sir

Peripheral vascular disease? Other chronic complications? What kind of resources do you have available: drugs, human resources and orthotic supplies? What about patient's shoes?

As a general rule following the International Working Group on the diabetic foot practical guidelines, I would say (if there are not further chronic diabetes complications):

1. Glycemic management
2. Patient Education
3. Wound care: cleaning and dressings
4. Off-loading

But, I would need to know more about your resources for giving you a consistent advice.

It seems there is not infection, right? If the patient have been able to avoid infection by his own for 2 years and his condition it has not gotten worse, I am confident his heel ulcers can be heeled.

Also, you can download the Diabetic Foot Disorders Clinical Practice Guideline from ACFAS link here. It is a pretty good practice guideline.

Regards,

What dressings has been used with this patient historically? I have found that sometimes a wound becomes stagnent with its healing and changing the dressing to something different sometimes helps it on its way.

Does this patient wear shoes (sounds like a daft question but many of mine don't and judging by the colour of feet...)?

Has a referral been given to the dietician? If BSLs are high, you are fighting a losing battle.

__________________
Katherine
Tomorrow is promised to no man!
My location

Suresh

These are clean, neuropathic ulcerations. I would suggest this man probably has no peripheral arterial disease. Is the under lying cause leprosy or diabetes or similar?

The reason why they have occured under his heels is that he has a "calcaneal gait", possible due to excessive length in the posterior calf group - amongst other reasons. This is the opposite of most neuropathic patients, who exhibit high plantar pressures under the forefoot, and often may benefit from surgical lengthening of the tendo Achilles.

To heal these permanently you will need to offload the plantar aspect of the heel, and try to transfer weight-bearing forces into the midfoot and forefoot.

Depending on the resources available to this man, I would suggest some type of total contact casting to heal, then followed by shoes with a midfoot rocker and a custom orthotic to offload the heel.

I assume there is no infection in calcaneus...

LL