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This patient ,male ,45 years old ,diabetic on insulin therapy,, for more than 10/years, came to me for the c/o painless ulcer at his left foot ,under the plantar surface.This diabetic plantar ulcer is there for more than one year,which was non healing. He is active ,bread winner of the family, and is walking with same ulcer ,with daily dressing . The ulcer is ,5×5 CM in size .margin is callous, undermined edges,.No pus,or serous discharge, The ulcer is healthy,well dressed wound by the patient for the last one year. painless, In my 36 Years of professional life,never met such patient of having ulcer on the sole for such long duration . Discuss.1.What is the reason for non healing. 2.Not infected ,no discharge, healthy floor of ulcer bed .Discuss the reason . 3.Discuss points to promote the healing .

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Concluded answer

This is very simple that no doctor had advised for the last One year to take rest that can avoid load on the site of planter ulcer .Metatarsal head of great toe is the maximum weight bearing area ,on which if there is ulcer at sole , the common sense at least from the patient side should think till the wound heals one should know how avoid pressure on the sole wound. Now patient is bed ridden. would d is healing past.

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1. The wound is on the weight bearing area (head of 1st metatarsal) & the person has not been advised any offloading. 2. As he is regularly cleaning & dressing the wound the ulcer bed is clean. But as he don't know how to remove the callous undermined edge, the ulcer remains unhealed. 3. As you have already debrided the undermined callous Edge, it will help in healing. You can advise him offloading & apply Co-Mupimet granules to fill the wound bed with more granulation tissue but restrict the growth beyond the level of plantar skin surface.

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Perfect treatment. Very impressive work! Great appreciation from my side sir! 1. Dm neuropathy, sensory loss/poor glycemic control cause high affinity towards bacterial infection/pt may be using wrong footwear/pt habits of wound care and dressing 2. Make an x-ray to r/o if any deep pathology, or MRI scan suggested I think it's getting enough vascular supply.. because u mentioned it's healthy floor, if there's insufficient vascular supply, some of the part may turn ischaemic or gangrenous! 3. U can prescribe vit c for faster healing Collagen powder Placentrex ointment Protein rich diet

You well read the case. Rightly said ,good granulation ,healthy wound sign of Vascularity. Here patient put on load on metatarsal head of great toe,due to no pain ,he never permitted the granulation to cover the wound. Heel,strike ,mid stance ,toe off is the stages of walk .During toe walk ,metatarsal portion face more thrust on the ground ,particularly the great toe side make the pressure in the wound prevents the healing process.If pain is there his walking could have been prohibited by his cognitive control,which could help the wound to heal. After explained those steps to the patient he realised his mistakes of not taking rest,now he promised not to walk till wound heals. I will post the healed wound in due course .
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As it is a trophic diabetic ulcer. The best possible ways to hasten the healing are despite the best possible treatment you have done 1.Get a colour doppler study of lower limb vessels to assess vascular insufficiency or diabetic PVD - Tab cilostazol 100 mg B.D will improve the blood flow which will hasten healing 2.Weight bearing needs to be avoided for few days 3.Too frequent debridement should not be done .Just simple dressings and only occasional superficial debridement. Frequent debridement many a times destroys,the fresh granulation tissue 4.Don't use H2O2 which causes tissue injury in diabetics and even betadine. So don't use 5% betadine. 1 % betadine will be better 5.Protein supplements, Vitamin C , Zinc help healing. 6 A SSG is the last resort, but complete bed rest with no weight bearing for 3 weeks after grafting

Hydrogen peroxide ,irrespective of DM ,one can use it freely to clear the pus from cavity, fistula,sinuses as long there is slough ,pus ,are plenty .If every thing is getting cleared off ,granulation started growing then H2O2 should not used,this is the contraindication . Halogen family of iodide is the best germicidal best for purulent pus pouring wounds ,.Gauge with iodine is the best option to promote fast clearance of bacterial base of the wound . Two items what I mentioned is freely used for the last 4 decades for the wounds of foot with diabetics ,which gave good experiences for me.I have register of diabetic foot register ,shows more than thousand cases without amputation I had saved the legs. Saline wash too helped to promote the slough clearances .
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Congratulations! Your case has been selected as Case of the day and you have been awarded 5 points for sharing the case. Keep posting your interesting cases, Happy Curofying!

Diabetic foot with long standing ulcer sole though floor of the ulcer looks like healthy but there is no bleeding , skin margin also looks whitish due to lack of vascularity These diabetic ulcer painless due diabetic neuropathy due to sensory loss. The wound need to scrapped so that it bleeds , margin if the skin also need to be debribed Strict glycaemic control by insulin To allow to walk with pressure relieving chappal or shoes Pus for C/S and antibiotic accordingly Dressing daily or alt days until the wound is ready for either for rotation flap or full thickness skin flap to cover X-ray to see any Bonny involvement or not.

No pus ,so no culture. White margin is not due to poor vascular .It is because callous margin due to pressure. When floor is vascular ,why nor margin .It is callous.
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Diabetic TROPHIC ulcer, due to diabetic neuropathy. Its non healing is because of neuropathy. Whether non healing is caused by vascular insufficiency, need to be checked with arterial colour Doppler. Patient' s understanding of the problem, his efforts to keep it covered with dressings daily, has prevented infection and cellulitis. This is a lesson for the doctors to spend more time for patient education. Probably his diabetes is also under good control Suggestions Check on his diabetic status, and keep the control tight . Arterial colour Doppler, to check vascularity , Tab celestozole may be added Vit B1,B6,B12 , alpha lipoic acids can be helpful . DEBRIDEMENT, dressings with alginate dressings, skin grafting can be considered . Special footwear made of MCR

Celestozole ,alginate ,elaborate this molecule and its rationales
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Non healing diabetic ulcer debriment of ulcer excise callous part xray foot arteiogram to see arterial supply of foot may need vascular surgeon do collegen dressing amikacin & aug to continue regular dressing

When wound is healthy ,no discharge where is the question of antibiotics. if needed prophylactic oral simple antibiotics ate prepared .
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This is very simple that no doctor had advised for the last One year to take rest that can avoid load on the site of planter ulcer .Metatarsal head of great toe is the maximum weight bearing area ,on which if there is ulcer at sole , the common sense at least from the patient side should think till the wound heals one should know how avoid pressure on the sole wound. Now patient is bed ridden. would d is healing past.

This diabetic foot with no healing ulcer long standing It is peripheral neuropathic ulcer as pt is moving arround for ayear without pain So far healing is concerned needs insulin infiltration in wound with collegen dressings But important is off loading of weight with modified footwear Since he is breadwinner of family hence postponing the Amputation as long as possible but never on cost of his life hence right decision at right time.

Sir, amputation???
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Diaebtic foot with trophic ulcer. Need strict glycemic control. Off loading of weight Collagen dressing Arterial clolor Doppler to ch ck vascularity.. Co mupimet granules to enhance granlation..

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