Nonhealing Diabetic Toe Ulcer

I received this patient as a second opinion for a nonhealing diabetic foot ulcer located at the bottom of the great toe and the patient had been treated for at least 4 months. Off-loading and local wound care was not sufficient and the wound would never completely heal. I had to consult a good friend who I trusted to have seen more of these then I had. There are many approaches to this problem and I wanted something very simple and we both agreed that an in-office flexor tenotomy was the way to go. This took no more than 5 minutes to perform, from sterile prepping to wound closure. After one week of the procedure, the wound healed. Although not pretty, both the patient and I are happy with the results. 

Things I learned from this case & hope residents (and aspiring medical students) take away from my posts:

- If the wound does not change or improve after a month of the same treatment, you must try a different approach. Don't be afraid to try something new. Of course, weigh the risk vs benefit to what you choose to do.

- Consult as many people as you need to, read as much as you can, and use all of your resources. Don't give up too soon!

- Be clear and honest with the patient. I often find myself saying "I am not sure if what I do will work perfectly, but we need to try something different because the current treatment is not working. I want you to get better and I'm sure you do too." If I sense the patient does not trust me (yes, it happens), I am more than happy to recommend other providers. I need the autonomy to do what is necessary but I also need the patient's cooperation and set the appropriate expectations. 

Naturally, when patients heal and they don't need me anymore, a piece of me is sad that I may never see them again. But  oftentimes, that is a good thing.