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The Foot in Diabetes - part 10

Tất nhiên, tất cả các mô mạch máu, bao gồm phức tạp sesamoid, sụn khớp còn lại, viên nang khớp và gân exor ¯, cũng như cancellous xương bị nhiễm bệnh, cần được loại bỏ (hình 19,8). Nếu vết thương là khu rừng đặc dụng ® ciently sạch vào lúc kết thúc của thủ tục, | International Consensus and Practical Guidelines 335 Appropriate footwear Inappropriate footwear is a major cause of ulceration. Appropriate footwear adapted to the altered biomechanics and deformities is essential for prevention. Patients without loss of protective sensation can select off-the-shelf footwear by themselves. In patients with neuropathy and or ischemia extra care must be taken with the fitting particularly when foot deformities are also present. The shoe should not be too light or loo loose see figure 4 . The inside of the shoe should be 1-2 centimeters longer than the foot itself. The internal width should be equal to the width of the foot at the site of the metatarsal phalangeal joints and the height should allow enough room for the toes. The fitting must be evaluated with the patient in standing position preferably at the end of the day. If the fitting is too tight due to deformities or if there are signs of abnormal loading of the foot e.g. hyperemia callus ulceration patients should be referred for special footwear advice and or construction including insoles and orthoses. Fig 4. The internal width of the shoe should be equal to the width of the foot. Treatment of non ulcerative pathology In a high risk patient callus nail and skin pathology should be treated regularly preferably by a trained foot-care specialist. If possible foot deformities should be treated non-surgically eg. with an orthosis . 336 The Foot in Diabetes Foot ulcer Foot ulcer A standardized and consistent strategy of evaluating wounds is essential and will guide further therapy. The following items must be addressed The cause of ulcer Ill-fitting shoes are the most frequent cause of an ulcer even in patienst with pure ischemic ulcers. Therefore the shoes should be examined meticulously in all patients. The type of ulcer Most ulcers can be classified as neuropathic ischemic or neuro-ischemic. This will guide further therapy. Assessment of the vascular tree is essential in the .