Previous history of ulcers on feet which were alleviated by introduction of Propet stretch shoes

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1 EDP- A case study for Vasyli medical trialling diabetic insole and Dr Comfort footwear BY SALLY LAXTON BAppSci(Pod) PODIATRIST- Knox Community Health Service EDP is a 68 year old female solid build Medical Hx Type 2 diabetes- on insulin Diabetic retinopathy Coronary artery disease Hypertension Hypercholesterolemia L 1 st bunionectomy June 06 Previous history of ulcers on feet which were alleviated by introduction of Propet stretch shoes Presented to clinic Sept 06 post L bunion surgery with ulcer under callus. With consultation with the client the decision was made to treat conservatively as Eclient wanted to avoid surgery due to post op infection in bunion. L 2 nd metatarsal head dropped post surgery. Orthotist had made insole which was thick and heavy and did not relieve pressure off 2 nd met head. (EVA with high Met dome and silicone cover.) Almost healed site many times with 10mm apertured felt padding but each time the padding is reduced the site breaks down again. Latest treatment. 15/5/08- Presented to clinic with a very sore foot - 1 -

2 4 photos Presenting problem 15/5/08-2 -

3 Post debridement- I love my job Re applied 10mm padding and reviewed in 1 week - 3 -

4 One week later!!!! 22/5/08 From this the wound continued to improve with weekly debridement of very thick, sometimes macerated callus and 10mm felt apertured padding, but the site never completely healed. Site always dressed with vacutex and allevyn dressings. Propet shoes had stretched and become quite floppy- purchased instride stretch shoes but client felt they were not as comfortable - 4 -

5 3/3/09 Central small fissure had opened further. Clinic notes were LN 5516 R 2nd toe improving RDNS dressing with bactigras and melolin. Dressing applied. L 2nd pl MPJ central area of ulcer larger, with cental shiny hypergran tissue in centre of wound. Debrided and dressed with iodosorb and vacutex and allevyn. Usual padding applied. R/v 7 days

6 10/3/09 LN 5529 L foot plantar ulcer not as deep with central granulating site. Padded as previously. Dressed with Betadine, vacutex and allevyn. Gave Evelyn new Vasyli diabetic orthotics. She said they felt very comfortable. R/v 7 days 17/3/09 S- Ulcer review and management. O- L plantar ulcer sub 3rd MPJ, associated callus and slight maceration from last visit. Granulating base. Ulcer R 3rd apex, base epithelialising. Exudate +++ P- Dressed R 2nd with bactigras and melolin. Dressed plantar wound with curasorb and vacutex. Applied plantar pad with cut out minus arch support. Secured with hypafix. Cut nails. 24/3/09 S- Patient states that L arch area is sore and has been red and hot. She describes the pain as a dull ache along with intermittent sharp stabbing pains which is present also at night. O- Wound L/F plantar aspect of 3rd MTPJ with surrounding maceration and callus. Area of hypergranulation tissue that is also macerated which has protruded through opening of wound. Wound margin decreasing. Wound R/F apex of 2nd digit with associated callus which is epithelising. P- Debrided callus. Made plantar cover with cut out and dressed wound firstly with bactigras and allevyn. Upon second visit d-filler was added and aqualcel AG and vacutex replaced bactigras. E- R/v 1/52. Patient advised to apply cold pack to arch and to report on pain levels at next visit as there is a suspicion of a charcot deformity. 31/3/09 S- Client had xrays taken of L foot, results coming in afternoon. Client not feeling as much pain. O&A- Bloody strike through on dressing, plantar L wound with minimal maceration compared to previous appointment and hypergranulation tissue is reducing in size. Small amount of surrounding HK. Took photo of wound, client consents to photos and also photos to be sent to matt from vasyli. Debrided surrounding HK. Applied plantar pad with cut out, d filler and met dome. Dressed wound with aquacel Ag and alleyvn, which client says district nurse applied 2 layers on previous dressing change. Secured with hypafix. 7/4/09 S- Client has x-rays. Dressing fell off night before. O&A- Xrays reveal L 2nd met has subluxed with no apparent met head, just shaft and a large calcaneal heel spur. L 2nd MTPJ wound less macerated and less callus build up. Minimal fluid present in wound. Applied plantar felt pads, Debrided callus, dressed with aquacel Ag and Allevyn. Debrided callus of R - 6 -

7 3rd apex. Debride callus on apex of R 1st, 2nd and 3rd and minimal callus plantar 5th MTPJ. Dressed apex with bactigras and melonin. RDNS to do dressing next Tues due to clinician holidays 7/4/09-7 -

8 Orthotics after 1 month - 8 -

9 21/4/09 S- Client has not been seen for 2 weeks over easter period and RDNS has been treating wound. Last dressing change revealed purulent exudate, client advised to see dr to get ABs. Client taking antibiotics still. O&A-L Plantar 2nd MTPJ wound with less maceration and less HK build up. Applied plantar felt pads, Debrided callus, dressed with aquacel Ag and Allevyn. Debrided callus of R 3rd apex. Debride callus on plantar heel B/F. Dressed apex with bactigras and melonin. Applied betadine to L arch area as there are signs of tinea. Fitted client for vasyli shoes, size Order form to be submitted to vasyli and client to pay when shoes arrive. Client interested in buying 2 pair. 28/4/09 O&A- No strike through on dressing. No maceration present. Less surrounding HK. Photo taken of wound. Wound decreasing in size. Tinea infection in L arch area better. Debrided surrounding HK. Applied felt met dome/plantar cover with cut out and d filler. Applied betadine to tinea infection. Dressed wound with aquacel Ag and melolin as wound does not require extra absorption from alleyvn. Client still interested in purchase 2 pairs on vasyli footwear

10 8/5/09 Delivered and fitted new Vasyli shoes. Annie 10W and Betty 10.5W. R/v 9 days 18/5/09 R 2nd apical callus reduced. L 2nd pl MPJ callus reduced. Small central area of callus in the fissure debrided. Eulactol cream applied. 10mm felt apertured pad applied with 7mm D filler and met dome. R/v 7 days Client is very happy with Dr Comfort shoes. Adv to wear all the time esp around the house instead of slippers. Client happy to comply. Client now being seen every 2 weeks instead of weekly 2/6/09 L pl callus reduced. Continues to improve becoming more like a corn and callus- some concern that 3rd met head is now prominent!! - to be monitored. 7mm felt apertured pl cover with 10mm met dome and D filler. R/v 2 weeks

11 16/6/09 Client : c/o no pain or discomfort. Very happy with footwear which is holding its shape well. Previous footwear deformed quite quickly. Caught a bus to the local shopping centre and walked a considerable distance. Client very happy to be returning to a more normal lifestyle Orthotics after 3 months

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14 Another set of new orthotics have been issued to the client so she can have them in a couple of pairs of shoes. Clinician concerns- 3 rd met area with an increase in pressure but interesting to see if the Vasyli Insoles reduce the sheer force so site doesn t breakdown Findings: There was a marked decrease in the amount of callus and maceration produced on wound site after the introduction of the Vasyli Diabetic orthotics complimented by the wearing of the Dr Comfort footwear Future: Clinician will gradually reduce the amount of padding over next 2 months. Increase time between visits. Client interested in purchasing some Dr Comfort runners as well Need to purchase new insole every 4-6 months?