The treatment and long-term care of diabetic feet is a major health concern because the path to a major lower-extremity amputation often involves an antecedent foot ulcer.
The findings of the study by Reiber and colleagues may be hard to generalize to the diabetic patients with recalcitrant foot ulcers who are often referred to orthopaedists. The inclusion and exclusion criteria permitted enrollment of patients with paronychial or other foot infections without ulceration as well as those with previous dorsal, medial, or lateral ulcerations that can be exacerbated by insert use, whereas they excluded many of the patients who are referred to orthopaedic surgeons for care.
The shoewear treatments were appropriate. When choosing an orthosis, however, most orthopaedists identify the area of high mechanical stress and try to off-load that area (e.g., by adding a metatarsal pad to off-load a forefoot ulcer); seek to achieve softer, thicker, shear-resistant interfaces through the use of a multilayered or multidurometer material; and intentionally incorporate patient-specific modifications that are consistent with the location and history of the ulceration and the findings of the clinical examination.
Not surprisingly, the authors found that nearly all of the ulcers occurred in the patients who lacked protective sensation (58%). Prevention of ulcers in this select group of patients with use of footwear and insert modifications remains a major challenge.
So what can we orthopaedic surgeons learn from this major clinical report? First, the popular belief that therapeutic shoes and inserts should be dispensed freely to all patients with diabetes is not supported by this study. Second, customized cork inserts fabricated with use of computer-aided design and manufacturing techniques offered no benefit. Third, these findings cannot be generalized to patients with Charcot deformities, amputations of multiple toes, or amputation of a ray. Further study of the use of multilayered or multidurometer inserts with patient-specific modifications, especially in patients with insensate or deformed feet, needs to be performed in a similarly well-controlled manner.