Newly revised to reflect the latest Standards of Care in Diabetes, this fourth edition of Clinical Care of the Diabetic Foot is an essential guide for all clinicians, healthcare providers, and educators who help people with diabetes avoid and manage this challenging complication. This new edition addresses the full scope of treatment, including:
Pathogenesis
Screening and Risk Assessment
Ulcer Assessment and Classification
Adjunctive Wound Therapies
Dressings and Local Wound Care
Charcot Foot
Soft Tissue Reconstruction
Infection
Peripheral Artery Disease
Remission
"Index", Clinical Care of the Diabetic Foot, Fourth Edition, David G. Armstrong, DPM, MD, PHD, Lawrence A. Lavery, DPM, MPH
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Note: Page numbers followed by an f refer to figures. Page numbers followed by a t refer to tables.
A
abductor digiti minimi (ADM) muscle flaps, 146, 147
abductor hallucis (AH) muscle flaps, 146–147
ABI. See ankle-brachial index acceptability, of footwear, 32–33
accessibility, of footwear, 33–34
acellular matrices, 89–91, 91t
Achilles tendon, 80
Achilles tendon equinus, 13
Achilles tendon lengthening (ATL), 197, 198–199, 199f
active adjunctive therapies, 88–96
acute kidney injury (AKI), 154
adherence
“forced,” 54, 58
to offloading devices, 54, 58, 59, 88
to wearing footwear, 34–36, 194, 204
adipofascial flaps, 147
adjuntive wound therapies, 85–96
active, 88–96
passive, 86–88
wound bed preparation for, 86
AI. See artificial intelligence
alginate dressings, 87t, 88, 108, 111t, 114t
American Association for Clinical Endocrinologists, 9
American Diabetes Association (ADA)
comprehensive foot exam developed by, 9
on footwear, 22
on LOPS diagnosis, 14
on screening, classification, and triage of patients, 182, 183t
on topical oxygen therapy, 95
amputations
in Charcot neuroarthropathy, 121–122, 133
foot infections and, 47
foot ulcer and, 1
incidence of, 179
mortality rate after, 179, 191
preventing (See foot care, targeted)
reducing number of, 1, 180
angiography, 174
angioplasty, 171, 175f
ankle equinus, 13, 134
ankle examination, 45
ankle reflexes, tests for, 15
ankle-brachial index (ABI), 16–17, 46
ankle-high offloading devices, removable, 59
ankle-pressure measurements, 169–170, 170f
anterior tibial tendon, 80
antibiotic resistance, 158, 159
antibiotics, 81, 154, 158, 159–161
antimicrobial dressings, 112t, 114–115, 114t
antipseudomonal penicillins, 160
antiseptic dressings, 112t
Apligraf®, 89, 90t
appearance, of footwear, 32–33
arterial flow, evaluation of, 45–46
arteriography, 172–173, 172f–173f
arteriolar occlusive disease, 168
arteriosclerosis obliterans (ASO). See peripheral artery disease
arthropathy. See Charcot neuroarthropathy
artificial intelligence (AI), 208
ATL. See Achilles tendon lengthening atrophic skin, 45
attractiveness, of footwear, 32–33
autolytic debridement, 86
autonomic neuropathy, 1, 4f, 44, 120, 123
B
bacteremia, 157
bacteria
and colonization, 155
diagnosis of infection with, 156
and wound healing, 72
balance
improving, 27t, 29, 55f
moisture, 106f, 108–110, 111t–112t, 114t
poor (See instability)
barefoot walking, 28
bespoke footwear. See custom-made medical grade footwear
bilobed flaps, 146
bioengineered products, 89–92, 90t
biofilm, 72, 74, 79, 158–159
BioSeed-S, 90t
biothesiometer, 15
bisphosphonates, 131–132
blades, surgical, 74
blisters, 43, 106
blood tests, 124, 134f, 154, 157t
blue dye, 74
bone(s)
debridement of, 81
infection in (See osteomyelitis)
bone biopsy
in Charcot neuroarthropathy, 125
in osteomyelitis, 154–155
bone stimulators, 132
Brannock device, 13
breathable materials, for footwear, 33
bunions, 13
burrs, cutting, 81
bypass, 171, 173–174, 173f
C
cadexomer iodine dressings, 87t, 114t
calcification of arteries, 45–46
calcitonin, 132
callus
in case study, 114–115
definition of, 24t
and foot ulcer, 2, 4f
and plantar pressure, 106
calor (heat), in inflammation, 205
carbapenem, 160
carbon reinforcement, of outsoles, 31
cavity wounds, 87t
Centers for Medicare and Medicaid Services (CMS), 115
cephalosporins, 159
charcoal dressings, 87t
Charcot, Jean-Martin, 119
Charcot in Diabetes United Kingdom (CDUK), 131–132
Charcot neuroarthropathy, 119–135
assessment of, 13
causes of, 5, 10f, 122–124
classification of, 127–130, 130f
diagnosis of, 12, 121, 124–126, 125f, 126f
early descriptions of, 119
imaging of, 127, 128f
management of, 131–132
mortality rate of, 122
predicting, 205
prevalence of, 121
risk factors of, 5–6, 121–122
surgical management of, 132–134, 133f, 134f
symptoms of, 6, 120–121
chemoattractants, 72
chisels, 81 chronic wounds
adjunctive therapies for (See adjuntive wound therapies)
appearance of, and dressings, 87t
debridement of (See debridement of diabetic foot)
definition of, 71
development of, 71–72
local care for (See local wound care)
preparing for reconstructive surgery, 144–145
treating cause of, 105–106
cigarettes, 107
claudication, 11t, 45
claw toes
in case study, 114–115
and foot ulcer, 2
clindamycin, 159
clinical trials/studies
on adjunctive therapies, 85
on bioengineered products, 89–92
on Charcot neuroarthropathy, 121
on debridement, 86
on electrical stimulation, 95
on fibrin multilayered patch, 92
on foot infections, 153
on footwear, 28, 34–36, 61
on growth factors, 93–94
on hyperbaric oxygen therapy, 94
on negative-pressure wound therapy, 93
on neurological assessment, 14, 16
on offloading devices, 54, 58, 60, 61–62
on plantar pressure monitoring, 202–204
on plantar temperature monitoring, 205–207
on sucrose octasulfate dressings, 92
on surgical treatments, 62–63, 198, 199, 200
on topical oxygen therapy, 94–95
CMS. See Centers for Medicare and
Medicaid Services collagen, 113t
collagenases, 72, 113t
colonization, definition of, 155
composite dressings, 112t
computed tomography (CT), 155
contact layer, under dressings, 112t
contamination, definition of, 155
continuous delivery of oxygen (CDO), 94
contralateral foot, footwear for, 29, 63
core needle bone biopsy, 125
cosmetic appearance, of footwear, 32–33
COVID-19 pandemic, 5, 18
crutches, 61–62
curettes, 74
custom-made insoles
definition of, 25t
for reducing plantar pressure, 31
custom-made medical grade footwear, 24t
cutting burrs, 81
“cytokine storm,” 123
D
debridement of diabetic foot, 71–83
autolytic, 86
definition of, 72
nonsurgical, 82, 86
and pain, 107
post care for, 82
repeat, 82
surgical, 72, 73–81, 75f–78f, 86
timing of, 73
for wound bed preparation, 86
debrider. See hydrosurgical debrider
debriding agents, 82
Defender Boot, 196, 196f
deformity. See foot deformity denosumab, 132
Dermagraft®, 89, 90t
dermatological assessment of foot, 12–13, 12t
DFU. See diabetic foot ulcer diabetes, overview of, 190
diabetic foot care. See foot care, targeted
diabetic foot exam. See foot examination
diabetic foot infections. See also foot infections
assessment for, 107–108
of bones (See osteomyelitis)
definition of, 155
risk of, 143
and timing of debridement, 73
diabetic foot ulcer (DFU). See also preulcerative lesions
adjunctive therapies for (See adjuntive wound therapies)
assessment of, 43–47, 107–108
case studies of, 108–115
classification of, 47, 48t–49t
consequences of, 191 (See also amputations; foot infections)
debridement of (See debridement of diabetic foot)
definition of, 43
depth of, 46, 47, 48t, 107
economic burden of, 191
foot care in (See foot care, targeted) footwear as cause of, 23
footwear for people with, 28–29
footwear for prevention of, 21, 25–28, 27t
“holiday ulcer,” 35
hospitalization risk with, 191
lifetime incidence of, 1, 21, 190
local wound care for (See local wound care)
location of, 46, 107, 195
mortality rate of, 191
offloading (See offloading)
pathways to, 3–5, 4f, 9–10, 10f
predicting location of, 195
prevention of, 3, 4f, 191 (See also foot in remission)
probability of healing from, 169–171, 170f
racial and ethnic disparities in, 191
reconstructive surgery for (See reconstructive surgery)
recurrence of (See recurrent foot ulcer)
remission from (See foot in remission)
risk classification for, 17, 17t, 22
risk factors of, 1–2, 10t, 22, 180, 190
sensation of, 44
severity of, 46, 191
size of, 46, 107
socioeconomic disparities in, 191
yearly incidence rate of, 21
diabetic neuropathic osteoarthopathy. See Charcot neuroarthropathy
digital flexor tenotomy, 63
digital health technologies. See
technologies, for patient
monitoring
dolor (pain), in inflammation, 205
donor tissue, 148
Doppler ultrasound, handheld, 45
dorsalis pedis pulse, 16, 45, 168, 169
double-Z-rhomboid flaps, 146
dressings, 105–116
alginate, 87t, 88, 108, 111t, 114t
antimicrobial, 112t, 114–115, 114t
antiseptic, 112t
cadexomer iodine, 87t, 114t
case studies of, 108–115
charcoal, 87t
choosing, 88, 108, 109, 115–116
composite, 112t
foam, 87t, 88, 111t, 114t
honey, 87t, 113t
hydrocellular, 87t
hydrocolloid, 87t, 111t
hydrofiber, 87t, 111t, 114t
indications for, 87t
low-adherent, 87
oxygen, 94
purpose of, 86
silver-based, 114t
of skin graft sites, 146
sucrose octasulfate, 92
superabsorbent, 111t
used in adjunctive therapies, 86–88
wet-to-dry, 82, 115
and wound-associated pain, 107
DRRAFT model, 181–182, 181t
dryness (skin), monitoring, 12–13
dye, blue, 74
E
education
about Charcot neuroarthropathy, 121
in foot ulcer prevention, 3
Eichenholtz classification of Charcot neuroarthropathy, 127–128
elastases, 72
Elastoplast, 56
electrical sagittal saw, 74
electrical stimulation, 95
endovascular therapy, 175
enzymatic debriding agents, 82
Epicel™, 90t
EpiCord®, 90–91
epidermal growth factor (EGF), 93–94
EpiDex™, 90t
Epifix®, 90–91, 91t
erythema, 156, 157t
ethnic disparities, in diabetic foot ulcer, 191
Eurodiale Study, 153
examinations. See ankle examination; foot examination; skin examination
excisional debridement. See surgical debridement
extensor digitorum brevis (EDB) muscle flaps, 146, 147
external fixation devices, 132–133, 133f
exudative wounds, 87, 87t, 88
F
fascia
debridement of, 80
healthy, 80
necrotic, 80
fasciocutaneous flaps, 147
FDA. See Food and Drug Administration felted foam, 60–61
femoral pulse, 168
Féré, Charles, 119
fibrin, 87t, 92
fibrin multilayered patch, 92
fibroin aloe gel films, 112t
films
fibroin aloe gel, 112t
semipermeable, 87
transparent, 87t, 112t
fixation devices, 132–133, 133f
flexor digitorum brevis (FDB) muscle flaps, 146–147
flexor tendon transfer, 62, 63 FLIR thermal camera, 205
fluoroquinolone, 159
foam, felted, 60–61
foam dressings, 87t, 88, 111t, 114t
Food and Drug Administration (FDA), 89
foot
Charcot (See Charcot neuroarthropathy)
debridement of (See debridement of diabetic foot)
ischemic, 2
pressure maps of, 3, 13–14, 193
proper measurement of, 13
warmth of, 2, 4f, 6
foot care, targeted, 179–185
DRRAFT model for, 181–182, 181t
interdisciplinary pathway to, 182–184, 183t
team approach to, 179–185, 180f
“toe and flow” model of, 184–185
foot deformity
assessment of, 13, 44–45
in Charcot neuroarthropathy, 122
definition of, 24t
and foot ulcer, 2, 4f
footwear for, 30, 31
surgical correction of, 200–201
foot examination
development of, 9
dynamic, 45
in foot ulcer prevention, 3
frequency of, 18
future perspective for, 18–19
importance of, 18
key components of, 11–17, 12t, 44–46
during remote patient monitoring, 18
risk classification based on, 17, 17t
static, 45
technologies for, 16, 18–19
foot in remission, 189–208
definition of, 24t
footwear for, 193–194
patient monitoring for, 201–207
reducing plantar pressures in, 191–197
surgical interventions for, 197–201, 199f
terminology of, 191
foot infections, 47, 153–161. See also osteomyelitis
assessment of, 154–155
classification of, 156–157, 157t
consequences of, 47, 153
definitions relating to, 155
diagnosis of, 47, 156
duration of therapy for, 160–161
incidence of, 153
microbiological diagnosis of, 156, 158
pain in, 47
treatment of, 158–160, 169
foot mats, smart, 205–206, 206f
foot pressure mats, 3, 13
foot ulceration. See diabetic foot ulcer footwear, 21–36
acceptability and stability of, 32–33
adherence to wearing, 34–36, 194, 204
advice on, 23
as cause of foot ulcer, 23
clinical trials on, 28, 34–36, 61
for contralateral foot, 29, 63
definitions related to, 22–23, 24t–25t
examining, 23, 45
felted foam pads for, 60–61
fitting for, 30–31
foot exam and, 13
for foot ulcer prevention, 21, 25–28, 27t
functional, 32
goals of, 29–34, 30t
ill-fitting, 23, 31
as lifelong necessity, 25
for offloading, 27t, 28–29, 61, 192, 193–194
patient monitoring with, 196–197, 196f, 197f
for people with foot ulcer, 28–29
for plantar pressure relief, 28–29, 31–32, 192, 193–194
prescription process for, 23–25, 26t
for preulcerative lesions, 22, 23, 27t, 28, 194, 195
replacement, reproduction, and accessibility of, 33–34
requirements for adequate, 29–34
success of, 36
“forced adherence,” 54, 58
foul-smelling wounds, 87t
free flaps, 148, 148f–149f
free tissue transfer, 148
F-Scan®, 197
full-thickness skin grafts (FTSGs), 145
functio laesa (loss of function), in inflammation, 205
functional footwear, 32
G
gamification, 208
gangrene, 73, 168, 175
gastrocnemius muscle, 13
gauze
dressings over, 87
mesh, 80
nonadherent, 112t
saline-moistened, 82
glycocalyx, 72
Grafix®, 90, 91
Graft-Jacket®, 91t
granulation tissue, 74, 79, 80, 86, 92, 110
great toe fibular artery flaps, 147
growth factors, 72, 93–94, 113t
H
half shoes, 57, 58, 59, 60
hallux, 15
hammertoes, 13
handheld Doppler ultrasound, 45
Harris mat, 13
HbA1c levels, 107
healability, 107
healing process, 71–72, 86, 107
heat, in inflammation, 205
heavily exuding wounds, 87, 87t, 88
hemoglobin spray, 94
higher cyclical pressure oxygen, 94
history, patient, 11, 11t, 43–44
“holiday ulcer,” 35
holistic management. See adjuntive wound therapies
honey dressings, 87t, 113t
128-Hz tuning fork, 15, 44
hydrocellular dressings, 87t
hydrocolloid dressings, 87t, 111t
hydrofiber dressings, 87t, 111t, 114t
hydrogels, 86, 87, 87t, 111t, 114t
hydrosurgical debrider, 74, 79
hyperbaric oxygen therapy (HBOT), 94
hyperglycemia, and wound healing, 184
hyperkeratotic callus, 114–115
I
ICF model. See International
Classification of Functioning, Disability, and Health (ICF) prescription model
ill-fitting footwear
checking for, 31
and sensory loss, 23
indoor shoes, 32, 34–35
infections
assessment for, 107–108
of bones (See osteomyelitis)
definition of, 155
in diabetic foot (See foot infections)
in local wound care, 105–106
of nail, 13
risk of, 143
of tendons, 80
and timing of debridement, 73
of wounds, 87t
inflammation
in healing process, 71
symptoms of, 205
infrared thermometry, in Charcot neuroarthropathy, 126, 126f, 131
insensitivity. See sensory loss inserts. See insoles
insoles
custom-made, 25t, 31
patient monitoring with, 202–204, 203f
room for, 31
instability
in Charcot neuroarthropathy, 122, 129
in neuropathy, 2
offloading devices and, 56, 57, 58, 63
surgery for, 132
instant total contact cast (iTCC), 56–57
instruments, surgical, 74, 81
Integra®, 89–90, 91t
interdisciplinary limb-salvage team, 179–185, 180f
interdisciplinary pathway, 182–184, 183t
International Classification of Functioning, Disability, and Health (ICF) prescription model, 25, 26t, 29
International Working Group on the Diabetic Foot (IWGDF), 22, 47, 54, 55f, 59, 95, 156
Ipswich Touch Test, 16
irremovable cast walker, 54, 56–57
ischemia
and arteriography, 172
and foot ulcer, 2, 10f
and timing of debridement, 73
J
joint arthroplasty, 62
joint mobility, limited. See limited joint mobility
K
knee scooters, 62
knee-high offloading devices
nonremovable, 54–57
removable, 58–59
L
large-fiber neuropathy, 44
lesions
definition of, 43
in foot ulcer (See diabetic foot ulcer)
preulcerative (See preulcerative lesions)
LeucoPatch®, 92
leukocytes, 92
ligaclips, 80
limb length discrepancy, 57, 63
limb loss. See amputations
limb-salvage team, 179–185, 180f
limited joint mobility
assessment of, 44–45
in Charcot neuroarthropathy, 122
definition of, 24t
liners. See insoles
local muscle flaps, 146–147
local random flaps, 146
local wound care, 105–116. See also dressings
case studies of, 108–115
determining healability in, 107
interdisciplinary approach to, 181, 182
long-term, 115–116
patient-centered concerns of, 106–107
treating cause of wounds in, 105–106
wound bed preparation in, 86, 105, 106f
long-term care, 115–116
loss of function, in inflammation, 205
loss of protective sensation (LOPS), 13, 17t, 183t
loss of sensation. See sensory loss
low constant pressure oxygen, 94
low-adherent dressings, 87
M
maggot therapy, 82
magnetic resonance imaging (MRI), 127, 129, 155
materials, for footwear, 33
matrix metalloproteases (MMPs), 92
maturation, in healing process, 71
Mayo scissors, 74
medial plantar artery flaps, 147
medical grade footwear
custom-made, 24t
definition of, 24t
prefabricated, 24t
Meggitt-Wagner classification, 47, 48t
mesh gauze, 80
metalloproteases, 72
metatarsal head(s), prominent
assessment of, 13
and foot ulcer, 2
metatarsal head resections (MHR), 62, 199–200
metatarsal osteotomy, 62
methylene blue dye, 74
microbiological tests, 156, 158
mild infections, 156, 157t, 159, 161
mitogens, 72
MMPs. See matrix metalloproteases moderate soft tissue infections, 156–157, 157t, 159, 161
moisture balance, 106f, 108–110, 111t–112t, 114t
Monckeberg medial calcific sclerosis (MMCS), 45–46
monofilaments, 14–15, 44
motor neuropathy, 4f, 44
MRI. See magnetic resonance imaging muscle(s)
debridement of, 81
healthy, 80
necrotic, 80
muscle flaps, local, 146–147
musculocutaneous flaps, 147
musculoskeletal assessment of foot, 12t, 13–14
N
nail dystrophy, 13
nail infections, 13
necrotic tissue, 72, 75f, 82, 87t, 158, 160, 169
negative-pressure wound therapy (NPWT), 80, 92–93
NERDS mnemonic, in diabetic wound care, 108–109
neuroarthropathy. See Charcot neuroarthropathy
neurological assessment of foot, 12t, 14–16
Neuropad®, 16
neuropathic pain, 107
neuropathy
assessment of, 44
and Charcot neuroarthropathy, 122, 124
diagnosis of, 2, 14
and foot ulcer, 1–2, 4f, 10, 10f, 44, 46
irreversibility of, 25
progressive, 25
symptoms of, 2, 44
and wound healing, 71
neurothesiometer, 15
neurotraumatic theory of Charcot neuroarthropathy, 122–123
neurovascular theory of Charcot neuroarthropathy, 122–123
nociceptive pain, 107
nonadherent gauze, 112t
noninvasive sweat indicator test, 16
noninvasive vascular testing, 169–171, 170f
nonremovable knee-high offloading devices, 54–57, 88
nonsurgical debridement, 82, 86
NPWT. See negative-pressure wound therapy
O
Oasis®, 91t
offloading, 53–64
adherence to devices, 54, 58, 59, 88
in Charcot neuroarthropathy, 131
and contralateral footwear, 63
definition of, 24t, 53
felted foam for, 60–61
flow diagram of options, 55f
footwear for, 27t, 28–29, 61, 192, 193–194
in healthy individuals, 192, 192f
nonremovable devices for, 54–57, 88, 192
purpose of, 88
removable devices for, 57–59, 88, 192, 199
surgical, 62–63
walking aids for, 61–62
in wound care, 88
128-Hz tuning fork, 15, 44
onychomycosis, 13
Orpyx LogR, 204
Orpyx Medical Technologies, 202–204, 203f
orthopedic footwear. See custom-made medical grade footwear
osteomyelitic bones, 81
osteomyelitis
acute kidney injury in, 154
antibiotics for, 81, 145
definition of, 144
diagnosis of, 144, 154–155
distinguishing from Charcot foot, 120, 125, 127–128
duration of therapy for, 161 imaging of, 114, 129
incidence of, 153
moderate, 157, 157t
severe, 157, 157t
treatment of, 144–145, 154, 160
outsoles
bending stiffness of, 31
carbon reinforcement of, 31
rocker, 31
oxygen. See hyperbaric oxygen therapy; topical oxygen therapy
oxygen dressings, 94
P
PAD. See peripheral artery disease
Page, Herbert W., 119
pain
in Charcot neuroarthropathy, 120
in foot infections, 47
in inflammation, 205
loss of (See sensory loss)
neuropathic, 107
nociceptive, 107
as warning sign, 5
wound-associated, 107
pamidronate, 131
paronchyia, 13, 156
passive adjunctive therapies, 86–88
patient history, 11, 11t, 43–44
patient monitoring
future of, 207–208
overview of, 18–19, 189, 201–202
plantar pressure monitoring, 196–197, 196f, 197f, 202– 204, 203f
plantar temperature monitoring, 204–207, 206f
PDGF. See platelet-derived growth factor
peak pressure relief, 31
pedal pulse, 16, 45, 168, 169
pedicled flaps, 147
pedorthic footwear. See medical grade footwear
penicillins, 159, 160
peripheral artery disease (PAD), 167–175
assessment of, 16–17, 45–46, 47, 49t
definition of, 45
and foot ulcer, 2, 16
incidence of, 45, 167
myths about, 168–169
noninvasive vascular testing in, 169–171, 170f
pulse palpation in, 169
revascularization options for, 171–174, 172f–173f, 175f
risk factors of, 167–168
symptoms of, 168
peripheral neuropathy
assessment of, 44
and Charcot neuroarthropathy, 122, 124
diagnosis of, 2, 14
and foot ulcer, 1–2, 4f, 10, 44, 46
irreversibility of, 25
progressive, 25
symptoms of, 2, 44
and wound healing, 71
peripheral pulse palpation, 169
peroneal pulse, 168
PET. See positron emission tomography
physical therapy, 184
pickups, 74
pied tabétique. See Charcot neuroarthropathy
pinprick sensation, 15
placental products, 90–92, 91t
plantar fad pad augmentation, 198, 201
plantar pressure
assessment of, 3, 13–14, 193, 194, 195
callus and, 106
definition of, 24t
and foot deformities, 13
footwear for reducing and redistributing, 28–29, 31–32, 192, 193–194
in local wound care, 106
natural offloading of, 192, 192f
offloading devices for relief from, 54–56, 58, 60, 88, 192
reducing, 191–197
surgical offloading for relief from, 62–63, 192–193, 197–201
technologies for monitoring, 196–197, 196f, 197f, 202– 204, 203f
tests for perception of, 14–15
plantar temperature monitoring, 204–207, 206f
plantar tissue stress (PTS), 191–197
platelet-derived growth factor (PDGF), 93–94
pneumatic sagittal saw, 74
Podimetrics Mat™, 205–206, 206f
polyneuropathy, 44
popliteal pulse, 45, 168
positron emission tomography (PET), 127
posterior tibial pulse, 16, 45, 169
postoperative foot care, 184
prefabricated medical grade footwear, 24t
prescription process, for footwear, 23–25, 26t
pressure, plantar. See plantar pressure pressure mats, 3, 13
PressureStat, 13
preulcerative lesions
causes of, 22
classification of, 48t
definition of, 24t
footwear for, 22, 23, 27t, 28, 194, 195
monitoring for, 5, 12
“probe to bone” test, 154
proliferation, in healing process, 71
proximal arterial occlusive disease, 168
Pseudomonas aeruginosa, 159, 160
PTS. See plantar tissue stress
pulse palpation, 169
pulse volume recordings, 170
pus, 114, 156, 158
R
racial disparities, in diabetic foot ulcer, 191
radiography
of Charcot neuroarthropathy, 120–121, 124, 125f, 127, 128f, 129
of osteomyelitis, 155
radionuclide isotope scans, 155
random flaps, local, 146
RANKL monoclonal antibodies, 131, 132
RCW. See removable cast walker reconstructive elevator, 144
reconstructive ladder, 143–144, 144f
reconstructive surgery, 143–150
soft tissue coverage options in, 145–148, 148f–149f
special considerations for, 149–150
team approach to, 145
recurrent foot ulcer
definition of, 24t
footwear for prevention of, 28
patient monitoring for, 204–207, 206f
prevention of, 190
rate of, 21, 22
redness
in Charcot neuroarthropathy, 120
in inflammation, 205
reflexes, ankle, tests for, 15
Regranex, 93
remission. See foot in remission
remission clinic, 183–184
remote patient monitoring (RPM)
future of, 207–208
overview of, 18–19, 189, 201–202
plantar pressure monitoring, 196–197, 196f, 197f, 202– 204, 203f
plantar temperature monitoring, 204–207, 206f
removable ankle-high offloading devices, 59
removable cast walker (RCW), 56, 58, 88
removable knee-high offloading devices, 58–59
removable offloading devices, 57–59, 88, 192, 199
renal disease, and foot ulcer, 2
renal replacement therapy, and foot ulcer, 11
replacement, of footwear, 33–34
reproduction, of footwear, 33–34
rest pain, 11t, 45
revascularization
assessing need for, 46
predicting likelihood of, 47
and timing of debridement, 73
revascularization options, 171–174, 172f–173f, 175f
reverse sural artery flaps, 147
rhomboid flaps, 146
risk classification, 17, 17t
rocker angle, 31
rocker outsole, 31
rongeurs, 74, 81
rotational flaps, 146
RPM. See remote patient monitoring
rubor (redness), in inflammation, 205
S
sagittal saw, 74, 81
saline-moistened gauze, 82 Sanders-Frykberg classification of
Charcot neuroarthropathy, 129–130, 130f
saw, sagittal, 74, 81
scooters, knee, 62
semipermeable films, 87
semisynthetic penicillins, 159
Semmes-Weinstein monofilaments, 14–15, 44
sensescent cells, 72
Sensoria Socks, 196, 196f
sensory loss, 121
assessment of, 14, 16, 44
and awareness of ulcer, 43–44
in Charcot neuroarthropathy, 5–6
and ill-fitting footwear, 23
and increased plantar pressure, 192, 192f
in neuropathy, 1–2, 43–44
sensory neuropathy, 4f, 43–44, 47, 120, 122–124
sensory tests, 14–16
severe soft tissue infections, 157, 157t, 159–160, 161
sharp-instrument debridement. See
surgical debridement
shoes. See footwear
silicone sheeting, 80
silver-based dressings, 87t, 108, 114t
single flaps, 146
single-photon emission computed tomography (SPECT), 155
single-use negative-pressure wound therapy (sNPWT), 93
Siren Diabetic Socks, 206–207, 207f
skeletal abnormalities, surgical
correction of, 198, 200–201
skeletal fragility, in Charcot neuroarthropathy, 122, 131
skin, debridement of, 79
skin examination, 45
skin grafts, 79, 80, 145–146, 147
skin hydration, monitoring, 12–13
skin mycosis, 43
skin substitutes, 89, 90t
skin temperature. See temperature
slippers, thin-soled, 28
Smart Boot, 196, 196f
smartphones/smartwatches, 196, 202, 204, 205
SmartSox, 197, 197f
smoking, 107
sNPWT. See single-use negative-pressure wound therapy
Society for Vascular Surgery, 47, 171
socioeconomic disparities, in diabetic
foot ulcer, 191
socks
patient monitoring with, 196–197, 196f, 197f, 206–207, 207f
walking in, 28
soleus muscle, 13
somatic neuropathy, 1, 4f
SPECT. See single-photon emission computed tomography
split-thickness skin grafts (STSGs), 145
stability
of footwear, 32–33
lack of (See instability)
Staphylococcus aureus, 158, 159
STONEES mnemonic, in diabetic
wound care, 105–106, 108
subcutaneous tissue, debridement of, 79–80
sucrose octasulfate dressings, 92
superabsorbent dressings, 111t
superficial wounds, 87t
sural artery flaps, reverse, 147
surgery, reconstructive. See
reconstructive surgery surgical blades, 74
surgical correction of skeletal
abnormalities, 198, 200–201
surgical debridement, 73–81, 75f–78f, 86
surgical instruments, 74, 81
surgical management, of Charcot neuroarthropathy, 132–134, 133f
surgical offloading, 62–63, 192–193, 197–201
SurroSense Rx, 203, 203f
sutures, 80
sweat indicator test, 16
sweating, in footwear, 33
swelling
in Charcot neuroarthropathy, 120, 124, 127, 131, 134f
in infections, 156, 157t
in inflammation, 205
systemic inflammatory response, 157
systolic toe pressures, 46
T
TAL. See tendo-Achilles lengthening
TBI. See toe-branchial index
TCC. See total contact cast
TCOMs. See transcutaneous oxygen measurements
technologies, for patient monitoring, 201–207
future of, 207–208
overview of, 18–19, 189, 201–202
plantar pressure monitoring, 196–197, 196f, 197f, 202– 204, 203f
plantar temperature monitoring, 204–207, 206f
telemedicine, 5, 18
temperature
elevated, 114, 120, 124, 126, 126f, 157t, 205
infections and, 156, 157t
inflammation and, 205
measuring, 13, 108, 114, 126, 131, 194, 202, 204–207
reduction of, 131, 132
TempStat, 18
10-g monofilaments, 14–15, 44
tendo-Achilles lengthening (TAL), 62 tendons
debridement of, 80
necrotic, 80
tenotomy, 62, 63
therapeutic footwear
clinical studies on, 61
definition of, 25t, 61
purpose of, 193
thermal necrosis, 81
thermography, 18, 205
thin-soled slippers, 28
tibial pulse, 16, 45, 169
tibial tendon, 80
tissue
debridement of, 73–80, 75f, 82
necrotic, 75f, 82, 87t, 158, 160, 169
tissues, necrotic, 72
tobacco, 107
“toe and flow” model, 184–185
toe-branchial index (TBI), 46
topical enzymatic debriding agents, 82
topical oxygen therapy (TOT), 94–95
total contact cast (TCC), 54–56, 88, 131
touch test, 16
transcutaneous oxygen measurements (TCOMs), 46
transepidermal water loss, 13
transmetatarsal amputation, 81
transparent films, 87t, 112t
transposition flaps, 146
trauma
and Charcot neuroarthropathy, 122, 123, 124
and foot ulcer, 3–5, 4f, 10f
tumor (swelling), in inflammation, 205
tuning fork, 15, 44
U
ulcer. See diabetic foot ulcer
ultrasound-based technologies, in debridement, 79
University of Southern California Limb Preservation Program, 184
University of Texas ulcer classification system, 47, 48t
U.S. Food and Drug Administration (FDA), 89
V
vacuum-assisted closure. See negative-pressure wound therapy
vascular assessment of foot, 12t, 16–17, 45–46
vascular disease
assessment of, 16–17
and foot ulcer, 10f, 16
vascular supply, in local wound care, 105
Vaseline mesh gauze, 80
Venturi effect, 79
vibration perception threshold (VPT)
testing, 15
VibraTip, 15
vibratory sensation, 15, 44
VIP mnemonic, in diabetic wound care, 105–106
visual impairments, 44
voice assistants, 208
V-Y advancement flaps, 146
W
walkers, 61–62
walking aids, 61–62
warmth, of foot, 2, 4f, 6
waveform analysis, 46, 169
weight-bearing activities, and diabetic foot ulcer, 195–196
wet-to-dry dressings, 82, 115
wheelchairs, 61–62
WiFi classification system, 47, 48t–49t
wound, chronic. See chronic wounds
wound assessment, 154
wound base, 72
wound bed preparation (WBP), 86, 105, 106f
wound closure, 71
wound edges, 72
wound formation, 71
wound healing process, 71–72, 86, 107, 184
wound-associated pain, 107
