Practice of Diabetology Carola Zemlin M.D., Wanzleben/Germany
58 years old, female, type 2 diabetes mellitus, duration of 22 years, dialysis since 1994 because of diabetic nephropathy, laser coagulated retinopathy, insulin therapy 3x normal at night NPH insulin, koronay heart disease, cardiac disrhythmia.
1992 resection of the 2nd left metatarsal bone because of a perforating ulcer of the foot; at that time this has healed completely. At 1998/05/05 first visit in our ambulance by reason of a 26 month old recurrent perforating ulcer of the right foot with projection to the 3rd metatarsal bone. Hitherto hospital stay 81 days without drastic improvement. No decompression measures took place. The amputation of the lower leg was advised.
Ointment containing chlorophyll, irrigation with H2O2 solution and hypertonic NaCl solution, antiseptic gauze. Change of dressing two times daily by nursing service, referral by dialysis practice.
Actual findings at 1998/05/05:
Distinct prominence of the forefoot, plantar, bilateral, claw toes, arterial pulses strong, dry and scaly skin, hypallaesthesia, sensibility for temperature and pain lapsed, no provocation of patellar and achilles reflex; indolent ulcus, plantar, 1.6 x 1.1 cm with an depth of 2 cm. The exploring forceps breaks into crumbled structures.
Fig. 1: findings at 1998/05/05
Fig. 2: Resection of bone and cartilage debris
Fig. 3: Control at 1998/07/07
Resection of bone and cartilage debris with bone curette and Luer´s bone nibblers, irrigation with Oxoferrin, inlay with a sterile LIGASANO® pack, cut to fit, which is changed once daily and soaked with Ringer´s solution, and over this a mull dressing. Because fixative bandages are not tolerated by the patient, we fix the dressing with hypoallergenic plaster.
Adequate instruction of the very cooperative patient, which on her part informs the nursing service; we provide her with sterile LIGASANO® packs (cut to fit, sterilised with steam and heat-sealed in our ambulance). Decompression: decompressive bandage shoe. During wound inspection at 1998/05/14 measurement for orthopaedic foot wear. Already in 1998/07/07 remains only a very plain wound.
Fig. 4: August 1998
Fig. 5: 1999/09/25
Closure since 1998/08/10. Until the complete healing 7 ambulant consultations. Supply with orthopaedic boots.
In september 1999 recurrence at the left foot, state after passing of a sequester. With Luer´s bone nibblers and a bone curette the same procedure takes place as in may 1998 at the right foot.
Wound inspection at 1999/11/04, the wound is highly granulated, the transition in the epithelisation phase is visible. The patient died in December 1999 from acute cardiac failure.
Study about the use of LIGASANO® white as initial wound dressing at foot disease caused by diabetics, of Carola Zemlin, M.D., internist/diabetologist. For the evaluation of the study please click here