Q2: Neuropathic Foot: Ox Considerations Flashcards
Ulceration
Systemic Factors
- Hyperglycemia
- PAD
- Neuropathy
these issues are treated by physicians
Ulceration
Local Factors
- Hyperkeratotic lesions
- Foot deformity
- ROM limitations
- Improper Footwear
treated by orthotist, PT, woundcare team
Wound Classification Systems
Wagner: Grades 0 (best) to 5 (worst)
UTHSC-San Antonio: Stages A to D; Grades 0 to 3
Compromised Immunoresponse
Neuropathic Foot Challenges
Enables the spread of infection; tissue damage due to infection
Charcot Joint Neuropathy
Neuropathic Foot Challenges
Affects 1% of patients with peripheral neuropathy
Underlying causes - Combination
* Sensory neuropathy
* Normal circulation
* Preceding foot trauma
Warmth throughout the foot
Modified Eichenholtz - Stage 0
Classification of Charcot Joint Arthropathy
At risk foot and ankle (Pt. has diabetes and neuropathy)
Modified Eichenholtz - Stage 1
Classification of Charcot Joint Arthropathy
Developmental; presents with inflammation and some bone fragmentation
Modified Eichenholtz - Stage 2
Classification of Charcot Joint Arthropathy
Coalescence; swelling, warmth, and redness w/ large fragments fused together
Modified Eichenholtz - Stage 3
Classification of Charcot Joint Arthropathy
Reconstruction; continued resolution of inflammation
Best time for surgical fusion
Sanders & Frykberg - Pattern 1
Classification of Charcot Joint Arthropathy
IPJs & phalanges; MPJs & metatarsals
15%
Sanders & Frykberg - Pattern 2
Classification of Charcot Joint Arthropathy
LisFranc (Tarsometatarsal)
40%
Sanders & Frykberg - Grade 3
Classification of Charcot Joint Arthropathy
Naviculocuniform joint; talonavicular & calcaneocuboid joints
30%
Sanders & Frykberg - Pattern 5
Classification of Charcot Joint Arthropathy
Calcaneus
5%
Orthotist Role in Neuropathic Care
- Screen using the LEAP
- foot screening
- pt. education
- proper footwear
- offloading pressure areas
- self management of foot care (nails/dry skin)
NO active ulceration
Clinical Decision Making
long term maintenance justifies depth inlay shoes and inserts
* 1 pair shoes per year
* 1 pair insoles per 3 years
Prophylactic in nature for protection
Diabetic Insole
Interface Layer
Minimum 1/4” of Shore A35 material
*Ex. plastazote, P cell, J Cell
Diabetic Insole Materials
Support Later
Minimum 3/16” of Shore A40
durometer material
* EVA is most common
Diabetic Insole Materials
Poron
layered in between the interface and support layers for shock absorption
Acute Ulceration - Offloading Footwear
Clinical Decision Making
Offloading Footwear
(Darco Orthoheel, forefoot offloader, etc.)
*include aggressive shoe modifications that can impart discomfort, change moments about the lower limb joints and cause pelvic obliquity
Acute Ulceration - Total Contact Cast
Clinical Decision Making
Gold standard for neurapathic ulceration management
* can be casting or orthosis (walker boot)
* TCC must be changed regularly
* not necessarily part of O&P scope
Long Term Management - CROW
Clinical Decision Making
Charcot Restraint Orthotic Walker
* Bivalve design enable volume changes
* Include removable footbed for easy modification
* Appropriate during stage II or III of healing (modified Eichenholtz)
Long Term Management - Unweighting Ox
Clinical Decision Making
Extra depth footwear with diabetic insole
