Yeah, you are already behind the 8 ball when you have any sort of deep wound or any plantar wound... probably already osteo or well on the way if capsule/bone or even plantar muscle is exposed. If it "heals" with a scar, they are ultra high-risk, though. Offloading fast and well asap on first presentation of wound is what matters, debride helps a bit, PO abx for cellulitis... goops and fake grafts or dressings couldn't matter less. I only use topicals to help dry or wet it (usually alcohol perimeter, dry gauze or betadine wet-to-dry to dry it... or baci or mupi or some oint to wet a very dry wound). Inf Dz will laugh in our face if you start talking what abx creams for what pathogens, swab culturing chronic wounds, lol. HBO is also fake as can be... waste of the limited time most wound/amp pts have left.
Top strategy is always prevention. If you have a pt with a DM ulcer who doesn't have DM shoes, you messed up (unless new pt, of course):
Get them all shoes even if they have no wound but any callus, PAD, neuropathy or any deformity (basically just follow research/MCR quals).
Get them custom DM insoles if they have any significant neuropathy or deformity.
Get them custom DM insoles with filler if they've had any more than partial digit amp (for non-DM amps TMA/ray also).
If they have any plantar hemorrhagic callus or superficial ulcer, obviously Rx DM shoes and insoles or new ones, but since that will take awhile, they need something that day. I agree. I have memory foam pre-fabs in my office (I just eat the minimal cost... they save a lot of limbs), or the pt should have their DM shoes and insoles to add to. Add a met pad, dancer pad, etc to their DM liner, one you give, tennis shoe foam or cardboard liner insole, etc. A surgical shoe with its foam base or with the memory foam insole in it or pad added can help too. Flexor tendonotomy for tuft of lesser toe ulcers asap (I usually tell them it's and idea and do it next f/u). I don't find CAM boots or TTC too useful for typical DM ulcers... but I do the CAMS occasionally.
Frankly, I'm also just way too busy for TTC... but it's worth a shot if you have the time and resources and think it'll slow them down. OWL boots are under-utilized and ok if you have a medial or lateral or posterior heel wound or forefoot wound, but you need both a fairly compliant pt and an excellent orthotist who can get them in quick, and like CROW, they're one of those things where the wound might heal or they might have osteo by the time the DME is done and ready for the pt to wear. I try to mostly do stuff that's fast and they might comply with. I did a "Scotch Cast" (Armstrong pub about CAM with fiberglass roll around the straps so they can't take it off), and the pt went for second opinion elsewhere. A lot of things seem ok in a conference or rep pitch or might work on paper (or get green paper for the doc), and that's why I think so many DPMs bumble with futile wound care. Patients aren't stupid. They make bad choices, but they choose for them self. They usually got the way they are by being stubborn and liking Coke and Hersheys and smore and Crocs, and they aren't going to 180 spin now.
For the compliance part, I start talking about "blood positioning" and amputation... some will listen, some won't. Sadly, your best hope with some is that a family member 'gets it' and helps them out... because the pt might have neuropathy between the ears. Follow-up goes to weekly or even bi-weekly for plantar ulcers (I don't trust hardly anyone to change their own wound or post-op dsg). Some phrases that tend to work for me:
"The infection has already taken the tissue, we are just removing it try to save the rest."
"Many, many people have walked right by you on the street missing a toe/foot/leg/etc. You didn't even know because they had a filler/prosthesis and walked pretty regular. You can do just as well if you make your appointments and rehab after the surgery."
"The MRI/XR/culture is clear that the bone has become poisoned." (take any subjective or emo out of it)
"You risk falling into a bad cycle of bandage visits, antibiotics that will hurt your kidneys eventually, and still needing an amp."
"You can take a bit of time to think if you wish. I have been down this road and know where it ends. I want you to have something left to walk on."
CROW for is obvious gold standard for any Charcot or highly likely warm midfoot ("stage 0").... CAM is the stop-gap until CROW is made. I Rx CROW (and custom shoes) for any past Charcot that don't have one... never know when it'll activate again. If it was a rectus foot capsulitis (not stage 0), and you were wrong, no harm done. Again, 99% screwed if you get behind on Charcot and the varus or rocker deformity collapse has begun. Ulcerated Charcot foot for me is TAL +/- amp if a functional shape salvage is available (hallux amp, midfoot fusion, etc), CROW until they get BKA, rarely a hero recon (usually just terrible, horrible, hopeless OR candidates for many reasons).
I am super aggressive with amps. That is the best way to heal and "offload" most deep or plantar DFUs... and get a good deep culture if needed for mop-up abx. I do most of them elective... tell them it can be that way, or they will get amp of more tissue via ER a bit later and also might go into the surgery sick and septic. And I tell the patients I don't take ER call either. 🙂
I do them early and often for any osteo or ulcer that doesn't respond very fast to good offloading. I will take partial digits (try to leave at least half of prox phalanx), first ray, fifth ray, fourth and fifth ray... otherwise it's TMA. After that is not an option, BKA city. You need something that absolutely gets source control of osteo, ends up DURABLE and easy for a filler insole. That's the goal. They all get custon insoles with filler started as soon as incision and edema allow ~1-2months post. If they don't get filler or understand it's a lifelong need after ray or TMA, you wasted their time and your own.
I used to try first and second ray or 345, but they will ulcer or fracture the remaining adjacent met even with a good filler (some barefoot is inevitable, and just won't work with neuropathy). Ditto for single or multiple met head resections or central ray resects... dumb AF unless it's a veeery minimal ambulator who will crump soon. Met head resects in anyone young-ish or active just creates transfer or crazy toes that will ulcerate elsewhere. Likewise, digit amps across the board (MPJ level) never work... some Gen or Vasc surgeons seem to try that (I sure hope no DPMs!), and I convert them when they start having calluses or ecchymosis despite custom fillers. It's not functional.
Gas is nothing to mess with... need to go highly proximal. Goal is simply to prevent BKA. I have a few I should have taken more, none I think I overdid it. My research in residency confirmed that. I put vanco dry powder in any osteo or gas infected amp. If there is any gas or puncture or anything that compromises your plantar TMA flap skin or intrinsics, you can try open amp and IV abx for a couple days, but it's usually game over... tell pt Vasc Surg will do well for them and move on to the next chart.
Dumb stuff we shouldn't have learned except for boards trivia: the Choparts, Pirgoff, Lisfranc, etc level amps are stupid... "can" vs "should." They don't work for functional ambulation for any amount of time, and they don't work even with the best or orthotist AFO magic afterward. Not at all functional or easy to make filler for. Even assuming you get the great AFO or filler, they will absolutely still go into varus and equinus and get BKA or worse very soon if you can't save the TA and pero brevis insertions (and fix any equinus with gastroc - more commonly need TAL in diabetics). Again, people don't wear the filler and shoes around the house. Trying to do the Chopart, etc with tendon transfers or doing heroic Charcot recons are even dumber than doing the bad non-functional amps without the fluff added on. But some people don't want that cash register to shut off and will graft and debride hopeless amps, or some 'super surgeon' types have to learn the hard way or try to get their RRA numbers for boards or their residents with futile recons and non-functional proximal amps and flaps, I suppose?
...Help who you can, the rest will get their amp. There are some people who are just busy or their PCP didn't explain their DM meds well, and sometimes they will wake up and live a good life after first ray amp or TMA and shoes afterwards. But those sub-cuboid, sub 5th met base, calc osteo, draining central met head to capsule, etc are done for. The nibbled digits with non-functional "Franken-foot" amps are a nightmare of ongoing wound care, bandages, antibiotics, etc by VA docs who don't get it or DPMs trying to "keep the patient." They will get a TMA or BKA, and they will be better off breaking the weekly visit and ongoing major problems cycle. Those patients who have had 5 foot amputations, 10 foot hospital admits, dozens of PO abx, and years of wound care and wound center are sad. Many are actually refreshed when you explain a plan to actually eradicate deformity and osteo, go on with their life with much fewer foot visits. Even if they "heal" non-functional amps, they're going to recur. It wastes the time of the pt, orthotist, family, transportation, other docs, treating doc, and tons of other people and resources. It is no small wonder that 99% of MDs don't want to do this "limb salvage" work and pretend to not understand it. I am so glad that wound/amp is ~10% of my practice now and not a third or half as at prior offices. I believe I do it well and it is technically not hard, but it doesn't pay well and it takes extensive conversation and babysitting of aftercare do well (many post-op visits, Rx DME, coordinate with ID and Vasc and PCP, etc).
Don't worry too much about it, tho. Fix who you can and consider the rest a win if they get ray/TMA + TAL and custom DM shoes instead of BKA. 👍
