Q2: Neuropathic Foot: Ox Considerations

Question 1

Ulceration

Systemic Factors

Answer 1

• Hyperglycemia
• PAD
• Neuropathy

these issues are treated by physicians

Question 2

Ulceration

Local Factors

Answer 2

• Hyperkeratotic lesions
• Foot deformity
• ROM limitations
• Improper Footwear

treated by orthotist, PT, woundcare team

Question 3

Wound Classification Systems

Answer 3

Wagner: Grades 0 (best) to 5 (worst)
UTHSC-San Antonio: Stages A to D; Grades 0 to 3

Question 4

Compromised Immunoresponse

Neuropathic Foot Challenges

Answer 4

Enables the spread of infection; tissue damage due to infection

Question 5

Charcot Joint Neuropathy

Neuropathic Foot Challenges

Answer 5

Affects 1% of patients with peripheral neuropathy
Underlying causes - Combination
* Sensory neuropathy
* Normal circulation
* Preceding foot trauma

Warmth throughout the foot

Question 6

Modified Eichenholtz - Stage 0

Classification of Charcot Joint Arthropathy

Answer 6

At risk foot and ankle (Pt. has diabetes and neuropathy)

Question 7

Modified Eichenholtz - Stage 1

Classification of Charcot Joint Arthropathy

Answer 7

Developmental; presents with inflammation and some bone fragmentation

Question 8

Modified Eichenholtz - Stage 2

Classification of Charcot Joint Arthropathy

Answer 8

Coalescence; swelling, warmth, and redness w/ large fragments fused together

Question 9

Modified Eichenholtz - Stage 3

Classification of Charcot Joint Arthropathy

Answer 9

Reconstruction; continued resolution of inflammation

Best time for surgical fusion

Question 10

Sanders & Frykberg - Pattern 1

Classification of Charcot Joint Arthropathy

Answer 10

IPJs & phalanges; MPJs & metatarsals

15%

Question 11

Sanders & Frykberg - Pattern 2

Classification of Charcot Joint Arthropathy

Answer 11

LisFranc (Tarsometatarsal)

40%

Question 12

Sanders & Frykberg - Grade 3

Classification of Charcot Joint Arthropathy

Answer 12

Naviculocuniform joint; talonavicular & calcaneocuboid joints

30%

Question 13

Sanders & Frykberg - Pattern 5

Classification of Charcot Joint Arthropathy

Answer 13

Calcaneus

5%

Question 14

Orthotist Role in Neuropathic Care

Answer 14

• Screen using the LEAP
• foot screening
• pt. education
• proper footwear
• offloading pressure areas
• self management of foot care (nails/dry skin)

Question 15

NO active ulceration

Clinical Decision Making

Answer 15

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

Question 16

Diabetic Insole

Interface Layer

Answer 16

Minimum 1/4” of Shore A35 material
*Ex. plastazote, P cell, J Cell

Question 17

Diabetic Insole Materials

Support Later

Answer 17

Minimum 3/16” of Shore A40
durometer material
* EVA is most common

Question 18

Diabetic Insole Materials

Poron

Answer 18

layered in between the interface and support layers for shock absorption

Question 19

Acute Ulceration - Offloading Footwear

Clinical Decision Making

Answer 19

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

Question 20

Acute Ulceration - Total Contact Cast

Clinical Decision Making

Answer 20

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

Question 21

Long Term Management - CROW

Clinical Decision Making

Answer 21

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)

Question 22

Long Term Management - Unweighting Ox

Clinical Decision Making

Answer 22

Extra depth footwear with diabetic insole